Practice Facilitation to Enhance Implementation of a Pediatric Suicide Prevention Care Pathway

Project Summary Abstract
Suicide is a leading cause of death in youth across the United States. Approximately 80% of youth who
die by suicide interface with the medical system in the year preceding their death. Primary care practices
(PCPs) serving youth are well positioned to detect patients at risk for suicide and intervene, and widely
accessible toolkits are available for practices to use. However, effective ways to impact providers’ skills in
actually implementing a clinical pathway to manage at-risk patients remain underexplored. Indeed, training
without applied practice and support is likely insufficient to significantly impact these skills in the long term and
less likely to improve patient outcomes. Practice facilitation is a powerful way to transform clinical practice,
develop provider skills, and improve patient outcomes. Our team trains PCPs in the NIMH youth suicide
prevention care pathway and, in addition, assists them in integrating the pathway into routine care with
longitudinally with feedback, implementation support through practice facilitation and data collection. However,
there is limited evidence for the effects of supplemental supports, such as practice facilitation or coaching, on
primary care providers’ adoption of and competence in suicide risk assessment and management. Thus,
guided by the combined Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM)/Practical
Robust Implementation and Sustainability (PRISM) framework, this cluster-randomized trial will compare the
impact of practice facilitation added to didactic suicide prevention training based on the NIMH youth suicide
prevention care pathway (TO+PF) versus training only (TO). In this pilot type 3 hybrid effectiveness-
implementation trial, Pediatric and Family Medicine practices in our practice-based research networks will be
randomized to TO+PF or to TO. Providers in clinics randomized to the TO+PF arm will also receive practice
facilitation for 6 months, involving monthly individual check-ins which include: 1) clinic- and provider-level data
review of adoption data for the five components of the NIMH youth suicide prevention care pathway, 2) clinical
coaching around implementing the different components of the pathway, and 3) logistical coaching in
identifying multilevel contextual barriers (organized in PRISM domains) to implementation and strategies to
overcome them. At the clinic/provider level, we will assess feasibility, acceptability, effectiveness, adoption,
fidelity and implementation and all contextual barriers that emerge. At the patient level, we will follow youth
assessed at intermediate or high risk and their family for 6 months following screening, collecting data on
attempted suicides and suicide ideation as well as emergency room and behavioral health provider visits. The
outcomes will provide preliminary support for a subsequent fully-powered type 3 hybrid effectiveness-
implementation trial of the model, assessing its reach, effectiveness, adoption, implementation, and
maintenance, with the goal of promoting broad implementation in diverse clinic contexts.

Grant Number: 5R34MH132832-02
NIH Institute/Center: NIH
Principal Investigator: BRUNO ANTHONY