Hotline Imminent Risk SS_revised_final

The Substance Abuse and Mental Health Services Administration’s (SAMHSA), Center for Mental Health Services (CMHS) is requesting Office of Management and Budget (OMB) approval for a new data collection, the Networking Suicide Prevention Hotlines – Evaluation of the Lifeline’s Policies for Helping Callers at Imminent Risk (NEW) (see attachment A). CMHS is requesting OMB approval of the data collection under SAMHSA’s Networking and Certifying Suicide Prevention Hotlines grant program, which established the National Suicide Prevention Lifeline (“Lifeline”).

The program is operated under authorization of Section 520A of the Public Health Service Act (42USC290bb-32.) Each year, beginning with the 2001 appropriations bill, Congress directed that funding be provided for the Suicide Prevention Hotline program. In addition to the Suicide Prevention Hotline program, funds have been continually allocated for the evaluation of the program.

This is a new request for approval; however this evaluation is the next in a series of efforts previously reviewed and approved by OMB (OMB No. 0930–0274) to evaluate crisis hotline practices, protocols and outcomes. The Evaluation of the Lifeline Policies for Helping Callers at Imminent Risk is a data collection activity that will be implemented to evaluate the management of imminent risk callers by hotline counselors and counselor adherence to Lifeline Policies and Guidelines for Helping Callers at Imminent Risk of Suicide.

A total of eight centers will participate in this evaluation. SAMHSA is requesting OMB review and approval of the National Suicide Prevention Lifeline--Imminent Risk Form (see attachment B).

SAMHSA funds a National Suicide Prevention Lifeline (“Lifeline”) Network, consisting of toll–free telephone numbers that route calls from anywhere in the United States to a network of local crisis centers. Since its inception, the Lifeline” has received more than two million calls.

The crisis centers answering these calls provide invaluable services for callers who are and are not at imminent risk. Previous evaluations of SAMHSA’s hotline initiatives have demonstrated that callers experienced a reduction in hopelessness and suicidal intent; however, results revealed that 43% of suicidal callers, who completed follow-up assessments, experienced some recurrence of suicidality (ideation, plan, or attempt) since their crisis call (Gould et al., 2007) and only 22.5% of suicidal callers had been seen by the behavioral health care system to which they had been referred (Gould et al., 2007). In response, SAMHSA funded an initiative to offer and provide follow up to all Lifeline callers who reported suicidal desire during or within 48 hours before making a call to Lifeline in which counselors at participating centers used motivational interviewing/safety planning and case management techniques to enhance follow-up and assist in keeping callers safe after the call and before they were seen by a health care provider.

Previous hotline evaluations have shown that large numbers of callers have significant histories of suicidal ideation and attempts (Kalafat et al., 2007). While not every caller is at imminent risk for suicide, crisis hotlines will typically provide referrals to mental health and other services, and also will advise the caller that they may call back if they are in crisis or have additional needs. For those at imminent risk for suicide, emergency intervention is frequently initiated and may result in a psychiatric hospitalization or other acute mental health service provision.

The Lifeline has recently developed the Lifeline Policies and Guidelines for Helping Callers at Imminent Risk of Suicide. The guidelines are comprised of two policies: (1) telephonic practices and (2) establishing and maintaining collaborative relationships with local crisis and emergency services. In addition there are nine supporting guidelines to assist crisis centers. These guidelines focus on three core areas:

The use of active engagement, which requires that callers are actively engaged in the process of ensuring their own safety, that there is collaboration between the caller and hotline staff, and that the least invasive approach is taken to ensure a positive outcome;
The use of active rescue, which requires that staff take all action necessary to secure the safety of a caller and initiate emergency response without the callers consent if they are unwilling or unable to take action on their own behalf; and
A focus on collaboration with other community crisis and emergency services and the establishment of working relationships with entities that can serve to assist in the ongoing safety of the caller.

This initiative is in keeping with SAMHSA’s Strategic Initiatives, which are designed to reduce the impact of substance abuse and mental illness on America’s communities. Specifically, Strategic Initiative Goal 1.3 addresses the emphasis on suicide prevention, “prevent suicides and attempted suicides among populations at high risk, especially military families, youth, and American Indians and Alaska Natives.” Objective 1.3.2 states “increase public knowledge of the warning signs for suicide and actions to take in response.” The following two action steps relate specifically to the Lifeline and its services: (1) to increase the visibility and accessibility of suicide prevention services in States, Territories, Tribal entities and communities, and work to ensure the National Suicide Prevention Lifeline program is adequately funded, and (2) to increase awareness of suicide prevention and the suicide hotline among populations at higher risk for suicide, especially military families, Tribes and youth with a focus on racial and ethnic minorities and LGBT youth. It is also in keeping with SAMHSA’s Strategic Initiative 7: realizing an integrated data strategy and a national framework for quality improvement in behavioral health care that will inform policy, measure program impact, and lead to improved quality of services and outcomes for individuals, families, and communities.

SAMHSA is requesting approval for data collection associated with the Networking Suicide Prevention Hotlines—Evaluation of the Lifeline Policies for Helping Callers at Imminent Risk. The purpose of this evaluation is to collect data, using an imminent risk form, to inform the network’s knowledge of the extent to which counselors are aware of and being guided by Lifeline’s imminent risk guidelines; counselors’ definitions of imminent risk; the rates of active rescue of imminent risk callers; types of rescue; barriers to intervention; and the circumstances in which active rescue is initiated, including the caller’s agreement to receive the intervention. To capture differences across centers, the form also collects information on counselors’ employment status and hours worked/volunteered, level of education, license status, training status, source of safety planning protocols, and responsibility for follow up. This new data collection activity is distinct from the Crisis Center Survey data collection, which targets the entire network of crisis centers and focuses on a different domain of questions (specifically, the makeup, strengths, and needs of crisis centers). The information gathered from the Crisis Center Survey cannot provide a profile of imminent risk callers or details about interventions with imminent risk or third party callers.

The Need for Evaluation

Evaluation data provide the information necessary for shaping and influencing program and policy development through the systematic analysis and aggregation of information across the components of large-scale initiatives, thus contributing to an understanding of overall program effectiveness. With a comprehensive assessment of counselor implementation of imminent risk and active rescue protocols, efficacy, and outcomes of hotline services, counselor effectiveness can be monitored and adapted as needed, and ways in which program activities can be improved or differentially targeted can be identified. The evaluation will also assess whether a center’s follow-up practices have an impact on rates of active rescue and profiles of individuals considered to be at imminent risk.

A2. Purpose and Use of Information

The Lifeline seeks to instill hope; sustain living; and promote the health, safety, and well-being of the callers and community members it serves. Preventing the suicide of callers is the primary mission of the Lifeline; thus, all staff must act to secure the safety of callers determined to be attempting suicide or at imminent risk for suicide.

The data to be collected will contribute to the evidence-base of suicide prevention hotlines. Through this effort, SAMHSA will enhance the efficacy and accountability of crisis intervention services, and ultimately optimize public health efforts that prevent suicidal behavior. More immediately, this effort will assess the knowledge, actions, and practices of counselors to aid callers who are determined to be at imminent risk for suicide and who may require active rescue. The information will be compiled in a report for SAMHSA, which may choose to disseminate it. The specific areas of contribution for the Evaluation of the Lifeline Policies for Helping Callers at Imminent Risk efforts are detailed below.

SAMHSA can use the results from the evaluation to develop policies and provide guidance regarding the handling of imminent risk callers to the Lifeline. Information and findings from the evaluation also can help SAMHSA refine the guidelines for imminent risk callers, if deemed necessary, to promote the systematic implementation of guidelines across crisis centers.
Findings from the evaluation can be used by crisis centers to improve their services, assess the ability of counselors to implement the guidelines, and retrain crisis counselors in center processes and functions related to imminent risk. Centers also can use the information gathered to better identify imminent risk callers and improve their services and outcomes.
The research community, particularly the field of mental health services research, will continue to benefit in a number of ways from the information gathered. First, evaluation of the implementation of the guidelines adds significantly to the developing research base about the use of hotline services. Second, the focus on imminent risk callers allows researchers to examine and understand the actions taken by counselors to aid imminent risk callers, as well as to assess the need for active rescue. Finally, the analysis of evaluation data helps both researchers and service providers improve the delivery of crisis hotline services to imminent risk callers.

Clearance is being requested for the National Suicide Prevention Lifeline—Imminent Risk Form, which will be completed by hotline counselors based on the information discussed during crisis calls with imminent risk callers. No direct data collection will occur from imminent risk callers.

Questions on the National Suicide Prevention Lifeline–Imminent Risk Form examine whether the crisis counselor is following Lifeline’s guidelines for helping callers at imminent risk of suicide and assess the counselor’s experience and training. This protocol directs the counselor to note the following:

Counselor information (employment status, hours worked/volunteered per week, number of imminent risk callers per week, level of education, license status, training status, source of safety planning protocols, and responsibility for follow up)
Line called (Lifeline or center line)
If person is a repeat caller (if known)
Demographic information of the imminent risk caller
Ratings on the suicidal desire and suicidal intent of callers
Suicidal capability and history of risk behaviors (e.g., suicide attempt, violence, substance abuse, sleep problems)
Protective factors/buffers (e.g., social supports, sense of purpose)
Intervention type either agreed to by caller (e.g., take actions on his/her own behalf to immediately reduce imminent risk, get rid of lethal means) or taken by counselor (e.g., send public safety officials for safety check, send mobile crisis unit)
Barriers to getting help for caller at imminent risk
Steps taken to confirm emergency contact was made and when emergency contact was not made

New York State Psychiatric Institute, Department of Psychiatry of Columbia University serves as the Institutional Review Board of record for the Evaluation of the Lifeline Policies for Helping Callers at Imminent Risk.

A3. Use of Information Technology

National Suicide Prevention Lifeline--Imminent Risk Forms will be completed by trained crisis workers in hard copy. Counselors will complete the form for imminent risk callers during or after the call based on information provided by the caller. There is no direct data collection involved and callers will not be asked to answer the questions on the form. Forms will be transferred via standard mail or fax to the evaluation team where they will be entered into a secure database.

A4. Efforts to Identify Duplication

The information will be collected only for the purposes of this program and is not available elsewhere.

A5. Involvement of Small Entities

The information collected will not have a significant impact on small entities.

A6. Consequences if Information Is Collected Less Frequently

The current application represents a one-time data collection effort.

A7. Consistency With Guidelines of 5 CFR 1320.5

This information collection fully complies with 5 CFR 1320.5 (d) (2).

A8. Consultation Outside the Agency

SAMHSA published a 30-day notice in the Federal Register on Monday, October 3, 2011 (FRN Volume 76, No. 191), after receiving no public comment on the 60-day notice previously published.

Directors and representatives to the National Suicide Prevention Lifeline Steering Committee provided feedback to the evaluation design and data collection instrument. These steering committee members have been involved in related hotline evaluations.

A9. Payment to Respondents

There will be no payment to respondents.

A10. Assurance of Confidentiality

All reports and publications from data collected on imminent risk callers will include only group-level analyses that fully protect the privacy of individual participants, and no data have been or will be stored with identifying respondent information. Due to the anonymity of the callers and the nature of the data collected, a certificate of confidentiality was deemed unnecessary by the evaluation team in collaboration with the IRB of record.

The names of counselors who complete imminent risk forms will be included on forms sent to the evaluation team, but their names with be replaced with an ID number, following routine practice recommended by the IRB of record. The names are included temporarily so that the evaluation team is able to contact counselors if information is missing or internally inconsistent. Because the forms include information already available to supervisors through their own routine quality control monitoring, do not request personal information about counselors, do not identify imminent risk callers, and will be used to provide feedback to counselors on performance when necessary, the provision of confidentiality has been deemed unnecessary.

Data from hard-copy forms will be entered into a secure database by the evaluation team and hard copies will be stored under lock and key in the PD’s office; only the PI, PD, and Database Administrator/Data Analyst will have access to those files. All files will be destroyed at the end of the project.

A11. Questions of a Sensitive Nature

The items included on the imminent risk form, while related to a sensitive topic, will not be asked directly of callers, but filled in by counselors during calls or after the completion of the call. Therefore, the counselor will be discussing sensitive issues with the caller as a function of the crisis call. Counselors will not be asking sensitive questions as a function of the evaluation. The content of the form includes dimensions such as suicidal desire, intent, capability, protective factors, interventions, barriers to getting help, and steps taken with a person at risk. The answers to these questions will be used to understand and assess the actions taken by counselors in response to imminent risk callers.

A12. Estimates of Annualized Hour Burden

Table 1 shows the annualized burden associated with the evaluation, which will occurs across two years, the period for which OMB clearance is being sought.

An average of 45 counselors at each of eight centers will interact with imminent risk callers for a total of 360 respondents per year of data collection. It is expected that a total of 1,440 imminent risk forms will be completed across the two year data collection period, which is equal to 720 annual responses from the 360 respondents.

During the first imminent risk form completion only, counselors will complete 10 questions about their experience and training in addition to information about the person at imminent risk. Therefore, the burden associated with the first imminent risk form completion is 17 minutes, while the remaining three completions of the form are estimated at 15 minute burden. Together, when averaged across the four-form completions, the imminent risk form burden is 15.5 minutes.

Table 1. Evaluation of Imminent Risk—Estimated Annual Burden Across One Year of Evaluation

Instrument	Number of Respondents	Responses / Respondent	Total Responses	Hours per Response	Total Hour Burden	Hourly Wage Cost	Total Hourly Cost
National Suicide Prevention Lifeline— Imminent Risk Form	360	2	720	.26	187	$19.88^*	$3,718

Instrument

Number of Respondents

Responses /

Respondent

Total Responses

Hours per Response

Total Hour Burden

Hourly Wage Cost

Total Hourly Cost

National Suicide Prevention Lifeline— Imminent Risk Form

360

720

.26

187

$19.88^*

$3,718

*Assuming mean hourly wage of mental health counselors taken from U.S. Department of Labor, Bureau of Labor Statistics, May 2010 National Occupational Employment and Wage Estimates. http://www.bls.gov/oes/current/oes_nat.htm#21-0000

A13. Estimates of Annualized Cost Burden to Respondents

The respondents will not incur any capital, startup, operational, or maintenance costs.

A14. Estimates of Annualized Costs to the Government

SAMHSA has planned and allocated resources for the management, processing, and use of the collected information in a manner that enhances its utility to agencies and the public. Including the Federal contribution that funds the grantees participating in the evaluation, the contract with the evaluator, and Government staff to oversee the evaluation, the annualized cost to the Government is estimated at $208,741. These costs are described below.

Approximately $116,700 per federal fiscal year for each of two years has been planned to fund grantees participating in the Evaluation of Imminent Risk, of which 10% can be dedicated to evaluation which results in an estimated annualized grantee evaluation cost of $11,670. Awards or plans for future awards have been made to cover the evaluation in the annualized cost of $194,671. An estimated 72 hours per year of a senior GS-14 level federal staff member will be required for oversight to the evaluation efforts for an annualized cost of $2,400.

A15. Changes in Burden

This is a new data collection.

A16. Time Schedule, Publication, and Analysis Plans

Time Schedule

The time schedule for the evaluation is summarized in Tables 2. A 2-year clearance is requested for this project.

Table 2. Time Schedule

Activity	Timeline
Receive OMB approval for study	October 1, 2011
Data collection period	December 1, 2011 – November 30, 2012
Analysis complete	April 2013
Final report written	September 2013

Publication Plan

A final report will be submitted to SAMHSA with anticipated subsequent dissemination to other interested parties, such as researchers, policymakers, and program administrators at the Federal, State, and local levels. Although not required under the evaluation contract, it is also anticipated that results from this data collection will be published and disseminated in peer-reviewed publications such as Suicide and Life Threatening Behavior.

Data Analysis Plan

SAMHSA expects to be able to answer the following questions from this evaluation:

What is the extent to which counselors are aware of and being guided by Lifeline’s imminent risk guidelines?
How do counselors across and within centers define imminent risk? Are counselors’ definitions of imminent risk impacted by their training histories?
What are the rates of active rescue of imminent risk callers and the types of rescue?
What are the circumstances in which active rescue is initiated, including the caller’s agreement to receive the intervention and the extent to which counselors’ experience, including their training histories, influences the rates of active rescue among callers at imminent risk?

Statistical Analyses

The descriptive analyses of the imminent risk forms will primarily use frequency distributions and counts from items in the form, including: counselor information, caller demographics; suicidal desire; ability to control suicidal thoughts; suicidal intent; plan to kill self; history of suicide attempt, violence, substance abuse, and sleep problems; and protective factors such as social supports and sense of purpose. Frequencies will also be derived as to the type of interventions, need for active rescue, and barriers to getting help for caller.

Statistical analyses will take into account the hierarchical structure of the study design (i.e., callers within eight different crisis centers). Clustering of observations within the site will be handled primarily using fixed effects methods. Random effects models are likely to be biased by failing to account for all site level influences. Nevertheless, alternative random effects models will be utilized and goodness-of-fit tests implemented using the Hausman method (Greene, 2000).

A17. Display of Expiration Date

The expiration date for OMB approval will be displayed on the imminent risk form, which approval is being sought.

A18. Exceptions to Certification Statement

This collection of information involves no exceptions to the Certification for Paperwork Reduction Act Submissions. The certifications are included in this submission.

Statistical Methods

B1. Respondent Universe and Sampling Methods

There are over 150 crisis centers in the Lifeline network. This evaluation is designed to identify and work with eight of those centers. The determination of the necessity of surveying eight centers results from a power analysis for clustered designs, conducted by Dr. Roger Vaughan, professor in the Biostatistics Department at Columbia University, demonstrates that only under the most optimistic circumstances (e.g., Intra Class (center) Coefficients (ICCs) of 0.0 or 0.01) would two centers per arm provide sufficient power. Please note that based on earlier hotline evaluation (Gould et al., 2007), it would be anticipated that the ICCs would be likely to be 0.03 or 0.05 in the study under review. The second reason not to choose k=2 per arm is that any proper statistical model would most likely fail to converge if trying to estimate the ICC with only four centers. Simulation studies (Murray et al) demonstrate clearly that k=e8 is really a minimum for estimation. Four of the eight centers in the Evaluation of the Lifeline Policies for Helping Callers at Imminent Risk have been selected from a pool of crisis centers currently funded under the Crisis Center Follow-up Grant Program, a supplemental grant program of the Lifeline. Crisis centers involved in the grant program receive specific training in follow-up techniques to use with callers at imminent risk. This will enable the evaluation to examine whether centers’ familiarity with follow-up yields different types and rates of interventions with imminent risk callers. Four additional centers have been recruited from centers attending the SAMHSA-funded Crisis Centers Conference in July 2011 in Baltimore Maryland. The additional centers have been selected from those that have not been engaged in follow-up with callers. These centers may have already successfully participated in evaluation activities in the past, but this was not a criterion for selection. Centers have been selected to represent a cross-section of the Lifeline network. Eligible calls will include those involving imminent risk, as identified by individual counselors using the Lifeline Policies and Guidelines for Helping Callers at Imminent Risk of Suicide.

B2. Information Collection Procedures

Data for the evaluation will be collected during imminent risk calls to the eight participating crisis centers. Counselors are trained in the guidelines for imminent risk callers and will complete imminent risk forms based on the discussion with the caller. The counselor will not ask questions from the form, but will complete the form based on the information discussed with the caller. For standard collection of these data across sites, the National Suicide Prevention Lifeline—Imminent Risk Form was developed.

Table 3 summarizes the information collection procedures for the imminent risk form.

Table 3. Procedures for the Collection of Information

National Suicide Prevention Lifeline—Imminent Risk Form
Indicators (Counselor) Employment status of counselor Counselor start date Average number of hours per week Average number of weekly suicide calls Level of education Licensure status ASIST status Other safety planning training status Sources of protocols used Follow up responsibilities	Indicators (Person at Imminent Risk) Demographic information of the imminent risk caller Line called (Lifeline or center line) If person is repeat caller (if known) Ratings on the suicidal desire and suicidal intent of callers Suicidal capability and history of risk behaviors (e.g., suicide attempt, violence, substance abuse, sleep problems) Protective factors/buffers (e.g., social supports, sense of purpose) Intervention type either agreed to by caller (e.g., take actions on his/her own behalf to immediately reduce imminent risk, get rid of lethal means) or taken by counselor (e.g., send public safety officials for safety check, send mobile crisis unit) Barriers to getting help for caller at imminent risk Steps taken to confirm emergency contact was made and when emergency contact was not made
Data Source(s): Counselors	Data Source(s): Counselors handling imminent risk calls
When Collected: One time during first imminent risk call	When Collected: At time of the call to the crisis hotline or after the call has been completed

B3. Methods to Maximize Response Rates

The National Suicide Prevention Lifeline—Imminent Risk Form will be implemented by all counselors in each of the eight centers as part of their job responsibilities. It is expected that counselors will complete imminent risk forms for 100% of callers who are at imminent risk for suicide. Initial questions about counselor training and experience will be completed only once during first imminent risk call.

B4. Tests of Procedures

The National Suicide Prevention Lifeline—Imminent Risk Form has been reviewed by experts in the fields of suicide prevention and mental health and piloted to determine burden levels.

B5. Statistical Consultants

The evaluator has full responsibility for the development of the overall statistical design and assumes oversight responsibility for data collection and analysis for the evaluation. Training and monitoring of data collection will be provided by the evaluator. The following individuals are primarily responsible for overseeing data collection and analysis:

Madelyn S. Gould, Ph.D., M.P.H.

Professor,

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5329

Jimmie Lou Munfakh, B.A.

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5482

Marjorie Kleinman, M.S.

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5959

Alison Lake, M.A.

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-6714

The SAMHSA project officer responsible for receiving and approving deliverables is:

Richard McKeon, Ph.D.

Center for Mental Health Services

SAMHSA

1 Choke Cherry Road, Room 6-1105

Rockville, MD 20857

240-276-1873

References

Gould, M.S., Kalafat, J., Harris–Munfakh, J.L., and Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 2: Suicidal callers. Suicide and Life–Threatening Behavior, 37(3), 338–352.

Kalafat, J., Gould, M.S., Harris–Munfakh, J.L., and Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 1: Nonsuicidal crisis callers. Suicide and Life–Threatening Behavior, 37(3), 322–337.

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