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2019 HSR&D/QUERI National Conference Abstract

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1013 — Veteran and VHA Staff Perspectives on Discussing Lethal Means Safety in Primary Care Settings

Lead/Presenter: Steven Dobscha,  COIN - Portland
All Authors: Dobscha SK (HSRD Center to Improve Veteran Involvement in Care (CIVIC)), Clark, KD (HSRD Center to Improve Veteran Involvement in Care, CIVIC), Karras E (VISN-2 Center of Excellence for Suicide Prevention) Simonetti JA (VISN-19 Mental Illness Research, Education, and Clinical Center) Kenyon E. (HSRD Center to Improve Veteran Involvement in Care, CIVIC) Gerrity M (Oregon Health and Science University)

Means safety (MS) counseling, which aims to reduce suicide risk by limiting access to lethal methods (e.g., firearms) by at-risk patients, is considered an important element of effective suicide prevention programs. Half of patients who die by suicide are seen in primary care clinics in the month prior to death, where MS counseling is rarely delivered. The aim of this project was to assess acceptability and identify facilitators of staff-initiated brief MS discussions in VHA primary care settings with Veterans with elevated suicide risk.

Four listening sessions were conducted with Veterans (n = 70), and four with primary care providers (PCPs), nurses, and other staff (n = 70). Additional individual interviews were conducted with six Veterans and five PCPs. A grounded theory approach was used to analyze the data. This project was designated a quality improvement project by the VHA Medical Center where it was conducted.

Veterans and staff agreed that discussing MS is within the purview of primary care and may be beneficial for patients with elevated risk (such as indicated by a positive depression screen). Staff felt that a team approach to MS discussions would be optimal due to competing demands on PCPs. Veterans supported a team approach because staff other than PCPs may have greater rapport or contact with the Veteran than PCPs. Both Veterans and staff felt there were opportunities to link MS discussions with VHA's new Whole Health approach. Both groups felt that initiating MS conversations by asking Veterans directly about firearm ownership may not be an effective strategy because it is a sensitive topic and may be perceived as a threat to 2nd amendment rights. Indeed, Veterans acknowledged that they may not truthfully disclose firearms ownership. Veterans reported they would feel more comfortable discussing MS if 1) the rationale for discussing firearms was provided; 2) they understood legal consequences of disclosure; and 3) conversations were personalized and conducted in a patient-centric manner.

It is acceptable to staff and Veterans to discuss MS in primary care. Staff and Veterans share multiple perspectives on MS and MS discussions.

Study results are being used to develop and disseminate a training program and supplementary written materials to facilitate brief MS discussions in VHA primary care clinics.