4 - (IOP 19) Assessing the Quality of Lethal Means Counseling Documentation in the US Veterans Health Administration

Lethal means counseling (LMC) is an evidence-based intervention during which clinicians assess patients’ identified methods for suicide and their access to these methods, and collaboratively discuss strategies to reduce access (Rowhani-Rahbar et al., 2016; Spitzer et al., 2024). LMC has been widely implemented throughout the US Department of Veterans Affairs (VA) clinical sites via the provision of the Safety Planning Intervention (SPI: Stanley & Brown, 2012), which incorporates LMC as the sixth step of the intervention.

However, despite LMC being widely implemented, there is a paucity of research about the quality of LMC as delivered in real-world clinical settings. The aims of this study were to 1) describe the characteristics and quality of a representative sample of LMC action plans documented in safety plans delivered across six VAs and 2) examine differences in quality ratings based on patient sociodemographic characteristics and the clinical setting in which the intervention was conducted.

A total of 910 LMC action plans that were documented on written safety plans were extracted from the medical record across six VAs selected to be diverse across geography, rurality and facility complexity. Coders rated the overall quality of the LMC documentation using a rating system adapted from the Safety Planning Intervention Scoring Algorithm for Veterans Affairs (SPISA-VA; Brown & Stanley, 2022). Quality ratings ranged from 0 (documentation did not include content relevant to LMC) to 3 (high quality). The ICC for 88 triple-coded LMC action plans was .91, indicating excellent reliability.

On average, the quality of LMC action plans was low (M=1.29, SD=0.86). Steps to reduce firearm access were documented 54% of the time, with only firearms reduction steps (and none related to other means) documented 38% of the time. Steps to reduce access to medications/drugs and other means were documented 20% and 14% of the time, respectively. In 25.8% of safety plans, clinicians documented that the patient had access to firearms, but there were no action steps to reduce firearm access documented. LMC action plans were rated higher for male versus female patients and for outpatient versus residential or acute care settings.

In this first study to examine quality of LMC action plans as implemented across a large healthcare system, the average quality was low. Documentation of plans tended to be vague, or reviewed previously completed actions, instead of focusing on a specific plan for lethal means access reduction. Findings indicate clinician awareness of firearm risks, with less discussion about access to and reduction of other means. These findings have important implications for clinician training to improve the quality of LMC in routine clinical practice. Future work should also include the development of implementation strategies to improve quality.