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Adapting to Context: Implementing an Evidence-Based Suicide Prevention Intervention During the COVID-19 Pandemic

Key Points

  • Caring Contacts is an evidence-based suicide prevention intervention that entails sending short, caring messages to Veterans at risk of suicide.

  • The QUERI PII’s launch of Caring Contacts coincided with the start of the COVID-19 pandemic, resulting in the need for flexible and adaptable implementation.

  • The original goal of Caring Contacts has now been accomplished; 20 facilities across 11 VISNs have implemented Caring Contacts. Additional settings have also launched Caring Contacts programs.

  • While implementation progress occurred in unexpected ways due to the COVID-19 pandemic, it is clear the use of Caring Contacts has increased among high-risk Veterans.

Caring Contacts is an evidence-based suicide prevention intervention that consists of sending brief, caring messages to people at risk of suicide at regular intervals, usually over the course of a year. It is recommended by clinical practice guidelines but has not been widely implemented. The QUERI-funded Partnered Implementation Initiative (PII) “Implementing Caring Contacts for Suicide Prevention in Non-Mental Health Settings” that aimed to improve implementation concluded at the close of fiscal year 2023.

The QUERI PII started with a one-year planning and pilot phase followed by a longer phase to allow for implementation across multiple Veterans Integrated Service Networks (VISNs). The timeline of the initiative’s spread phase coincided with the onset of the COVID-19 pandemic, and with changes in both the popularity of Caring Contacts and in VA requirements related to its implementation. We share here more about the research and implementation teams’ experience of those significant context changes.

The PII began with a one-year planning and pilot phase in collaboration with VISN 16 and the Central Arkansas Veterans Healthcare System (CAVHS) in 2019. During that year, the team conducted qualitative interviews with stakeholders about adapting and implementing Caring Contacts for Veterans in emergency department (ED) and urgent care center (UCC) settings. Using that data, the team worked with an advisory board of stakeholders and experts to adapt Caring Contacts and develop implementation materials. A successful pilot was conducted at CAVHS with facilitation used to support implementation. The team mailed Caring Contacts to 475 Veterans following an ED visit in the first year of the pilot. Qualitative interviews indicated that Veterans appreciated receiving Caring Contacts. One Veteran said, “I appreciate them sending the cards out though to check on me because, you know, I have (had) several suicidal attempts. That made me feel good, that ‘Hey, I’m being thought about’.”1 Following the pilot, the initiative expanded to 10 additional VISNs, for a total of 20 facilities. Facilitation was used to support implementation in each facility.

Facilitation was originally planned to include in-person site visits to allow for better facilitator understanding of the context, recipients, logistics, and setting as well as to foster rapid relationship building. Launch of the spread phase coincided with the onset of the COVID-19 pandemic and therefore the in-person component of facilitation was removed. In addition to changing the facilitation approach, the onset of the COVID-19 pandemic had a significant impact on the targeted settings: emergency departments and urgent care centers.

Facilities had agreed to participate in the initiative prior to the grant submission and therefore significantly ahead of the pandemic. Facility interest in implementing Caring Contacts at the launch of the spread phase varied greatly. Some facilities indicated that due to the pandemic, they were either unable to add any new service, or were too short-staffed to participate. Other facilities were more enthusiastic, noting that they were concerned about increased risk of Veteran suicide due to the pandemic and the challenges of social distancing. Caring Contacts presented a relatively low-burden intervention that allowed facilities to reach out to Veterans over the course of a year without additional in-person interaction.

Facilitators experienced multiple unique challenges due to the COVID-19 pandemic but were ultimately able to design strategies to minimize and overcome these obstacles. Facilitators initially found it challenging to gather site-specific information and build rapport without the opportunity for in-person site visits. By design, EDs and UCCs provide unscheduled care, with high variability in peak times of demand. Thus, at times, it was difficult for facilitators to schedule meetings with leaders, clinicians, and champions at the sites without the option of an in-person visit. Many sites (and facilitators) struggled with the rapid switch to virtual applications for components of their jobs.

The pandemic also impacted onsite personnel who had been identified as the Caring Contact Champions and Specialists; as facilities struggled to provide care for COVID-19 patients, these personnel experienced shifts in assigned duties, increased patient caseloads, and re-assignment to different sections or wards. The initiative experienced a high level of turnover, especially among the specialists. Over time, facilitators identified successful strategies to address these unique challenges. These strategies included decreasing length and frequency of routine contacts, increasing flexibility in scheduling, providing shelf-ready and user-friendly materials, creating pre-formatted written standard operating procedures, incorporating flexibility into processes to allow for appropriate site-level modification, integrating the need for the site to train multiple back-up specialists in anticipation of turnover, and initiating routine yet unscheduled check-ins via Microsoft Teams messaging.

Two additional strategies proved critical. First, facilitators recognized that implementation during the pandemic would be slower and less linear than at other times. Second, facilitators realized the value of building personal relationships to support all healthcare professionals via informal and unstructured contacts. For example, facilitators took the time to understand the site’s specific COVID-19 patient load and adapted facilitation strategies and expectations as those factors fluctuated.

In addition to the impact of the COVID-19 pandemic on implementation, the popularity and requirements regarding Caring Contacts in VA changed over the course of the project. Initially, Caring Contacts was chosen as an evidence-based intervention that had historically experienced low uptake. As the project progressed, Caring Contacts became more popular in VA. Prior to the initiative, Caring Contacts had been recommended for additional outreach for Veterans identified as being in the highest tier of predicted suicide risk by REACH VET. However, given low use of Caring Contacts, a subsequent project to centralize sending Caring Contacts on behalf of clinicians resulted in higher utilization.2 Later, the Surgeon General recommended considering use of Caring Contacts for crisis lines and VA undertook an initiative to send Caring Contacts to Veterans Crisis Line callers who were VHA users and who self-identified. This work is being evaluated by another QUERI-funded project led by Dr. Mark Reger. The Veterans Crisis Line used a centralized mailing service to do this and in the first 12 months, VA sent Caring Contacts to more than 100,000 Veterans.3 More recently, policy changed to require that Veterans be sent Caring Contacts following deactivation of their high risk for suicide flags in the electronic health record. Given the extent and potential benefit of sending Caring Contacts for this population, VA centralized and implemented this intervention nationally starting in 2023.

When we first started implementation, Caring Contacts was still a relatively new intervention. Many VA sites expressed enthusiasm. The first sites we worked with were eager to have a new way to reach out to Veterans who may have been more isolated due to COVID-19. Once other Caring Contacts initiatives described above started, implementation planning at sites changed to include decisions about 1) whether to incorporate tracking of other Caring Contacts programs into the process, and 2) whether to send Caring Contacts from more than one initiative (e.g., from the ED and REACH VET).

As a QUERI PII, the primary goal of this project was to increase the use of an evidence-based suicide prevention intervention among Veterans at risk of suicide. This goal has been accomplished and 20 facilities across 11 VISNs completed facilitation and implemented Caring Contacts. In addition, the attention on Caring Contacts and QUERI funding to support its implementation and evaluation has resulted in implementation of Caring Contacts in other settings and using different approaches (i.e., centralizing with a mailing service).

As is common in implementation work, the progress occurred in unexpected ways and in different settings, but it is clear the use of Caring Contacts has increased among high-risk Veterans. The dedication and ability of all team members to rapidly adapt to changing and challenging contexts resulted in enhanced implementation and increased utilization of this life-saving intervention.

  1. Landes, SJ et al. “Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results from a Type 2 Hybrid Effectiveness-Implementation Pilot Study,” Front Psychiatry 2021;12, 746805.
  2. Reger, MA et al. “Implementation Strategy to Increase Clinicians’ Use of the Caring Letters Suicide Prevention Intervention,” Psychological Services 2022 Mar 14;online ahead of print
  3. Landes, SJ et al. “Qualitative Evaluation of a Caring Letters Suicide Prevention Intervention for the Veterans Crisis Line,” Psychiatric Services 2023 May 24; online ahead of print.

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