Tuolumne County Suicide Prevention Strategic Plan

IntroductionWhen any health condition occurs at significantly higher rates in one population than another it becomes a matter for study and possible community concern. Whether lung cancer in smokers or immune deficiency in intravenous drug users, a presumption exists that there is an unrecognized reason for the anomaly. The goal of subjecting such a phenomenon to study is to institute measures to prevent suffering.

In 2006, the incidence of suicide in Tuolumne County nearly doubled. Tuolumne County has rated among California counties with the highest rates of suicide in recent years. In fact, virtually all counties in California with a population under 60,000 register the highest suicide rates. Recognizing the scope of this tragedy, multiple local agencies, coalitions, government entities and private citizens formed a Suicide Prevention Task Force in 2007 to analyze the factors that increase the risk of suicide and to identify protective factors that might mitigate that increased risk so that tangible steps might be taken to reverse the trend. This Suicide Prevention Strategic Plan is the product of that effort.

Suicide prevention campaigns have been guided by the plans of national and state experts. In 2001, the National Academy of Sciences published the Institute of Medicine’s report, Reducing Suicide: A National Imperative. In 2008, the California State Department of Mental Health released its draft California Strategic Plan on Suicide Prevention. However, these excellent documents provide only a framework for activating local resources. The job of implementing the recommendations of such research falls upon the local jurisdictions and is dependent upon the cooperation of agencies and, more importantly, the community itself.

The Tuolumne County Strategic Plan for Suicide Prevention follows the Strategic Directions of the California plan. Specifically addressed are Training, Prevention/Intervention, Community Education and Monitoring and Surveillance to assure accountability. The Appendices list information about various evidence-based programs and community education proposals which will be implemented to seek to prevent suicide during the three year planning period and beyond.

While this Strategic Plan takes into consideration the financial cost and demonstrated benefit of each suicide prevention program proposed herein, Tuolumne County acknowledges that there is an unmeasurable cost to a community when a member contemplates suicide, and a community-wide wound inflicted by the completion of suicide. It is therefore the hope of the Suicide Task Force that the steps outlined in this plan will not only accomplish the goal of reducing suicide in our

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community, but also address those issues which underlie the social and psychological causes of suicidal ideation and shed light on the reasons why suicide is so prevalent in rural communities, so that benefits can be universally shared.

OverviewTuolumne County has consistently registered some of the highest rates of suicide in California. In 2006, an analysis of multiple factors correlating with higher suicide rates in counties throughout California was undertaken. This study confirmed relationships between social, mental health, and demographic risk factors for suicide and highlighted the problem facing rural counties. With funding from a local community foundation and encouraged by the mobilization of multiple local agencies, organizations and community members, a Tuolumne County Suicide Prevention Task Force (SPTF) was launched in January, 2007, to coordinate local suicide prevention activities. In August, 2008, the SPTF convened to further consolidate a strategic plan for suicide prevention. This Strategic Plan is the product of that effort.

Suicide Rates and TrendsThe overall rate of suicide in California between 1999 and 2005 averaged 9.3 suicides per year per 100,000 persons. The average rate for the United States during this period was 10.7 with an overall slight trend upwards.1 Suicide rates for states considered rural, based upon percentage of population living in metropolitan areas,2 average 50% higher than urban states. The rate of increase in suicide rates between 1999 and 2005 for rural states has been three times that of urban states.3

Suicide death rates are thought to be underestimated from death certificate data because of the extensive criteria that must be met in order to convincingly certify that a death was intentional. The test for suicidal intent is often not met in such cases as overdose deaths or suspicious motor vehicle accidents, particularly when a note is not left by the victim. A “suicide note” from the victim is found in fewer than 50% of suicides.4

Tuolumne County experienced a suicide rate in 2006 that was nearly double the county average (See Figure 1). This upward trend simultaneously raised concern from various local agencies, coalitions and government entities, resulting in individual and formal meetings on the

1 Surveillance for Violent Deaths – National Violent Death Reporting System, 2005; MMWR, Department of Health and Human Services, CDC, Vol.57, No. SS-03, April 20082 Bowers, D.E and Reeder, R.. Rural Conditions and Trends, United States Department of Agriculture, Economic Research Service, Vol. 9, No. 1, 1998.3 CDC. Web-based Injury Statistics Query and Reporting System (WISQARS™). Atlanta GA: US Department of Health and Human Services, CDC 2008. Available at http://www.cdc.gov/ncipc/wisqars/default.htm 4 Goldsmith, S.K. et al., Reducing Suicide: A National Imperative, Institute of Medicine, The National Acadamies Press, Washington D.C., 2002.

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subject of suicide prevention. State and regional resources were consulted to assist with evaluating the scope of the trend for Tuolumne County and for other rural counties throughout the state. Resulting from this preliminary research, funding was procured in January, 2007, from the Sonora Area Foundation, a local community foundation, and a community wide task force was convened to share local data and begin planning to address suicide prevention.

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Task Force attendees included individuals from Public Health, Law Enforcement, Behavioral Health, Board of Supervisors, schools, the Office of Education, local hospital, medical practitioners, non-profit agencies, emergency medical response, service clubs, senior support agency, faith-based organizations, probation, Human Services, child development, recreation and community members, some with personal experience with suicide in their families.

Mission StatementThe mission statement of the Suicide Prevention Task Force is:

“to coordinate the planning, implementation and monitoring of projects throughout Tuolumne County that prevent and reduce the risk of suicide

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incorporating the core values of integrity, accountability, compassion, collaboration and professionalism.”

The No Wrong Door philosophy represents the coordination of efforts by local county agencies, community based organizations, educational institutions, businesses and community members to ensure that anyone exhibiting suicidal behavior is helped immediately, regardless of where they initially present. This goal will be met through a variety of community-wide trainings, some focused on specific populations, some for the general public, in order to open dialogue and raise awareness about risk factors, protective factors and warning signs of suicide.

The Tuolumne County Suicide Prevention Task ForceQuarterly meetings were conducted between August, 2007, and September, 2008. Projects throughout the community that targeted suicide prevention were presented, cataloged, and included in a resource directory so that participants could network with similar assets. Community presentations were conducted to raise awareness through multiple venues, including radio, newspaper and slide presentations. Mental health crisis resource cards were printed and distributed, and the local crisis response telephone line supervised by the Behavioral Health Department was reinforced. Screening programs for depression were launched at the local college and at the annual Health Fair. In early 2008, the Prevention and Early Intervention Coordinator from the Behavioral Health Department was made available to the Task Force to assist with further program development.

In September, 2008, an annual meeting of the Task Force was conducted for the purpose of preparing a county-wide Strategic Plan for Suicide Prevention. The four strategic directions recommended by the California Strategic Plan on Suicide Prevention were used as a framework: 1) Development of a Suicide Prevention system, 2) Training and Workforce Enhancements 3) Community Education, and 4) Monitoring and Surveillance for Effectiveness. A format was recommended in which age-specific groups would consider evidence-based programs and practices for each of these strategies that could address the needs of four different age group populations: 1) Youth (18 years and under), 2) Young Adult (16-24 years), 3) Adult (25-60 years), and 4) Older Adult (over 60 years).

After age-specific concerns were addressed by these age-group subcommittees, the groups were rearranged to coincide with the model for the strategic plan that had been proposed. Five subcommittees contributed materials for inclusion into the strategic plan through the subcommittee chairpersons, in the realms of training, prevention,

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intervention, community education, and monitoring/surveillance. These submissions were compiled into this Strategic Plan for the community.

Suicide Prevention Task Force Subcommittees The SPTF was divided into subcommittees in order to address different components of the plan.

Training: The purpose of the Training Subcommittee was to identify suicide prevention trainings that impact all sectors of Tuolumne County. The committee’s task was then to identify the target audiences and the community groups/agencies/service organizations/churches from which individuals could be selected to train as trainers for the range of suicide prevention training programs.

Prevention Subcommittee: The Prevention Subcommittee was asked to comprehensively assess existing county suicide prevention services and identify gaps. The committee would then develop a local suicide prevention action plan based on the assessment. The goal of this committee long term was to coordinate efforts by local county agencies, community based organizations, educational institutions, businesses and community members (using a “No Wrong Door” philosophy) to ensure that anyone exhibiting suicidal behavior is helped immediately, regardless of where or when they initially present.

Intervention Subcommittee: The Intervention Subcommittee’s purpose was to assess existing county suicide intervention services and identify major gaps, then develop local suicide intervention strategies based on this assessment.

Community Education Subcommittee: Broad goals for the Community Education Subcommittee included the development of a plan to increase awareness of suicide, educate the community about suicide, encourage and invigorate the community to act to address suicide, and de-stigmatize depression and suicide. Desired outcomes for this committee included: to identify target audiences to educate by age group, identify means, strategies and venues to educate, determine the cost of strategies, and to determine timing and frequency of education strategies

Monitoring and Surveillance Subcommittee: The purpose of this committee was to assure community-wide system accountability through monitoring and surveillance of the incidence of suicide. By identifying data sources for potential gaps in the community system the Monitoring and Surveillance Committee ultimately seeks to maximize system effectiveness.

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Regional and Local Risk AnalysisIdentifying specific causal relationships between factors that either impart an increased risk of suicide or provide protection from suicide has been an elusive goal. The 2002 Institute of Medicine report points out that “lack of longitudinal and prospective studies are a critical barrier to understanding and preventing suicide.5” Nevertheless, designing a strategic plan for suicide prevention demands that specific goals be considered, and that these goals be specific to the target population.

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Data collection regarding the incidence of suicide in rural California was initiated by the Tuolumne County Health Department in early 2006. This data was presented to the California Rural Health Policy Council in September, 2006. Subsequently, a research project was launched under funding by the Tuolumne County YES Partnership and the Sonora Area Foundation to analyze risk factors for rural counties in California that correlated with suicide, with a particular focus on factors that might respond to local suicide prevention interventions.

In this cross-sectional observational study,6 suicide rates in California counties for the period 2002-2004 were compiled. Explanatory variables

5 S.K. Goldsmith et al., Reducing Suicide: A National Imperative, Institute of Medicine, 2002, The National Acadamies Press, Washington D.C.6 Stolp, S.T. and Stolp, CW. Social Variables and Suicide Risk in Rural California Counties, pre-publication copy, 2009

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previously recognized as correlating with higher suicide rates were identified from prior research and collected for each California county. These data were used to estimate a series of ordinary least squares (OLS) regression models of suicide rate as a function of measures of Violence, Macroeconomic Conditions, Firearm Availability, Mental Health Status, Substance Abuse, Poverty, Ethnic Composition, and Rural-Urban Characteristics.

The strongest explanators of suicide rate related to the Violence, Mental Health, and Substance Abuse models. Rural-Urban Characteristics and Ethnic Composition were strong predictors of suicide rate, while rural proximity to an urban setting attenuated the effect of rurality on increasing suicides. Firearm Availability also directly correlated with suicide rate, albeit weakly.7 The Macroeconomic and Poverty models evidenced no meaningful explanatory power relating to suicide rates. Television viewing, as a measure of social isolation, was found to lack correlation with suicide rates, although viewing data was only available for county clusters and conclusions about correlations with television viewing rates only speculative.

The second source for data regarding local suicide risk is gained from the conduction of psychological autopsies. Confidential Law Enforcement and Behavioral Health agency reviews of cases provide valuable insights into individual risk factors. While such data remains strictly confidential, recognizing such factors provided critical insight into potential system improvements and confirmed that the suicide indicators identified in the earlier research were locally relevant.

Risk Factors and Protective ProcessesPrevention programs are designed specifically to promote the reduction of risk factors and processes, and to enhance protective factors and processes.8 Both risk and protective factors operate in multiple life domains. These include individual, family, school, peer, and community, as well as workplace and society. Further, risk and protective factors vary with the age and developmental stage of the individual9. The California Strategic Plan on Suicide Prevention specifically emphasizes the importance of age-appropriate suicide prevention planning in Core Principle 6: “Employ a life span approach to suicide prevention.”10 Each 7 It should be noted, however, that 85% of completed suicides for Tuolumne County in 2006 involved firearms. 8 Hawkins J D, Catalano R F, Miller J Y (1992). Risk and Protective Factors for Alcohol and Other Drug Problems in Adolescence and Early Adulthood: Implications for Substance Abuse Prevention. Psychological Bulletin, 112(1), 64-105.9 Report To Congress On The Prevention And Treatment Of Co-occurring Substance Abuse Disorders And Mental Disorders, Substance Abuse and Mental Health Services Administration, U.S. Depart. Of Health and Human Services 200210 California Strategic Plan on Suicide Prevention, California Suicide Prevention Plan Advisory Committee, California Department of Mental Health, April, 2008

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developmental phase brings new tasks to be accomplished; just as each individual is continually changing and evolving, risk and protective factors emerge and disappear over time or, if present for a long time, may express themselves differently11. Thus, prevention programs must be matched to the appropriate developmental stage of the individuals for which they are designed.

Protective factors proposed by Surgeon General David Satcher in 1999 that afford protection against suicide include effective and appropriate clinical care for mental, physical, and substance abuse disorders; easy access to a variety of clinical interventions and support for help seeking; restricted access to highly lethal methods of suicide; family and community support; support from ongoing medical and mental health care relationships; learned skills in problem solving, conflict resolution, and nonviolent handling of disputes; and cultural and religious beliefs that discourage suicide and support self-preservation instincts.12

Risk factors that correlate with high suicide rates include, previous suicide attempt; mental disorders—particularly mood disorders such as depression and bipolar disorder; co-occurring mental and alcohol and substance abuse disorders; family history of suicide; hopelessness; impulsive and/or aggressive tendencies; barriers to accessing mental health treatment; relational, social, work, or financial loss; physical illness; easy access to lethal methods, especially guns; unwillingness to seek help because of stigma attached to mental and substance abuse disorders and/or suicidal thoughts; influence of significant people—family members, celebrities, peers who have died by suicide—both through direct personal contact or inappropriate media representations; cultural and religious beliefs—for instance, the belief that suicide is a noble resolution of a personal dilemma; local epidemics of suicide that have a contagious influence; isolation, a feeling of being cut off from other people.13

Age Specific GoalsSociological factors that influence the occurrence of suicide are different for different age groups. The factors listed in Figure 3 are recognized as

11 Mrazek PJ and Haggerty RJ 1994, Reducing Risks for Mental Disorders: Frontiers for PreventiveIntervention Research, National Academy Press, Washington DC12 The Surgeon General’s Call To Action for Suicide Prevention, U.S. Department of Health and Human Services, 1999, Washington D.C.13 The Surgeon General’s Call To Action for Suicide Prevention, U.S. Department of Health and Human Services, 1999, Washington D.C.

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valuable considerations for evaluating suicide prevention activities in specific age groups.141516

Figure 3

Age Group Goals and Objectives

5 – 11 years  Institute protective factors through skill building in listening, coping, self esteem, problem solving, conflict resolution. Begin dialogue regarding mental health issues, substance abuse.

12 – 18 years Increase protective factors through open dialogue with trained personnel describing the risks and signs of suicidal behavior; increase skills in problem solving, conflict resolution, self esteem, resiliency; reduce isolation, alienation, oppression; address issues specific to culture, gender, sexual orientation, gender identity; increase safety by providing crisis and ongoing assistance and support.

Age 18 – 60 Enhance protective factors by reducing isolation, strengthening community involvement, educate regarding substance abuse and mental/physical health;  increase safety by providing crisis and ongoing assistance and support; address specific needs of transitional age youth.

Age 60+ Increase protective factors through identifying isolated individuals and reducing isolation; educate regarding aging and mental/physical health issues; increase safety by providing crisis and ongoing assistance and support; address age-specific challenges of depression, substance abuse and alienation, strengthen connections back to the community and/or faith-based groups.

Strategic Plan Structure and Coordination with Other PlansThe overall structure of the Tuolumne County Suicide Prevention Strategic Plan follows the four Strategic Directions of the California Strategic Plan for Suicide Prevention, except that Strategic Direction 1, “establishing a system of suicide prevention,” is divided into Prevention activities and Intervention activities. There are therefore five strategic directions in this plan, one correlating with each of the subcommittees earlier described. For the purposes of this plan, “intervention” activities are defined as responses to people in acute suicidal crisis, including the process of evaluating individuals suspected of actively seeking to end their lives.

Bringing specific attention to the intervention component of the strategic plan will highlight these crisis services. Public review of the basic plan will 14 The Surgeon General’s Call To Action for Suicide Prevention, U.S. Department of Health and Human Services, 1999, Washington D.C.15 The Effectiveness of Universal School-Based Programs for the Prevention of Violent and Aggressive Behavior, MMWR, Department of Health and Human Services, CDC, Vol.56 No. RR-7, August 200716 Kushner, H.I. and Sterk, C.E., The Limits of Social Capital: Durkheim, Suicide and Social Cohesion, American Journal of Public Health, American Public Health Association, Vol. 95, No. 7, July 2007

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thereby identify universal entryways available to those requiring emergency suicide prevention services.

The 2001 National Strategy for Suicide Prevention17 provides guidance for evidence based practices that have been successful in other settings. The goals recommended by the national plan have been incorporated into components of our local program and are cited when they are specifically addressed.

Planning PeriodThis Strategic Plan is to be implemented over a three year period, as follows:

Year One……………April, 1 2009 to June 30, 2010Year Two……………July 1, 2010 to June 30, 2011Year Three…………July 1, 2011 to June 30, 2012

It is recommended that the SPTF begin to renew this planning effort 30 months following the date of implementation of this plan.

Through the deliberations of the coordinating agency, the committees and subcommittees described below, modifications of this plan may be made. Keeping the community-wide suicide prevention effort a dynamic process will allow each segment of the program to adapt to the needs of the community. It is also important that adequate support and time be dedicated to projects in accordance with the project-specific scientific evidence to allow the benefits to be captured.

DefinitionsFor uniformity of interpretation, the following definitions are used for the terminology in this Strategic Plan.

Community Education: General education, awareness and stigma reduction campaigns for the general population regarding behavioral health care and suicide prevention. This is consistent with the concept of “universal prevention.”18

Core Programs: Programs for which funding and implementation will be sought in year one of the three year strategic plan.

17 National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Dept of Health and Human Services, Public Health Service, 200118 Gordon, R. (1987), ‘An operational classification of disease prevention’, in Steinberg, J. A. and Silverman, M. M. (eds.), Preventing Mental Disorders, Rockville, MD: U.S. Department of Health and Human Services, 1987.

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Expanded Programs: Programs which are expected to be implemented in years two or three of the three year strategic plan. Expanded programs may be moved up to year one through the actions of the Core Committee if funding is procured earlier and a need is identified.

Evidence-based Programs: Programs for which studies have been performed and reviewed that statistically demonstrate or strongly suggest effectiveness in diminishing the risks and/or incidence of suicide when they are implemented in a population.

Fidelity of Implementation: Indication that resources are locally available and appropriate to allow the implementation of a program in the manner in which the program was originally designed. As an example, a plan designed for urban populations may not be appropriate for implementation in a rural setting like Tuolumne County.

Gatekeeper: A person trained to assist an individual who presents as a suicide risk to enter the local system of care where further help can be received.

Intervention: Recognizing the multiple areas of overlap between Prevention and Intervention, “intervention” was defined as the following: the immediate steps/activities taken to prevent suicide by intervening at the time of crisis; the imminent act of preventing a suicide- including a mental health evaluation for danger to self (5150 evaluation) transport and hold; the point when someone is recognized as immediately at risk; the 5150 evaluation is generally the cut off point when actions move from prevention to intervention; the initial assessment is the “grey zone” between prevention and intervention.

Prevention: Any action or program designed to prevent suicide by modifying risk factors and protective factors.

Train-the-Trainer Instruction: Programs designed to train individuals to become proficient in training other people, using a particular curriculum.

Programs and ProposalsThis portion of the strategic plan is divided into three sections: 1) Current Programs for Training, Prevention, Intervention and Community Education in suicide prevention which are already in place, 2) Newly proposed Training, Prevention and Intervention Programs, and 3) Newly proposed

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Community Education projects. The newly proposed programs are listed in charts in the Appendices. Core Programs are those which are planned for implementation in year one, and the Expanded Programs are those which are planned for implementation in years 2 or 3. Appendix A lists the Core Programs and Appendix B the Expanded Programs for the Training, Prevention and Intervention section, and Appendix C shows both Core and Expanded programs for Community Education.

1) Current Programs for Training, Prevention, Intervention and Community EducationIn preparing the Three Year Strategic plan it was decided to first assess and identify (as well as acknowledge) the current ongoing suicide prevention programs being accomplished locally. These programs are currently being funded by county departments, local agencies, law enforcement, faith-based organizations, the local hospital, local media, schools and service clubs. The Suicide Prevention Task Force convened over a 12 months period to share local data, compile as list of current programs, and monitor the cross-agency efforts identified below. Ongoing funding and operation of these programs by the current funding sources is encouraged.

Amador-Tuolumne Community Action Agency: Friday Night Live activities and programs offered throughout the year at schools and local venues, addressing issues such as suicide, substance abuse, family involvement and general health.

Behavioral Health Department: Operates the county behavioral health services program, which includes the Crisis, Assessment and Intervention Program (which includes a 23-hour bed patient assessment program), Outpatient Behavioral Health Services, and a Crisis Assessment Team that evaluates patients in the local hospital emergency department.

Columbia College: Provides depression screening and licensed counseling services through the student health program on campus.

Dawn’s Light Center for Children and Adults in Grief: This local non-profit agency provides Suicide Loss Support Groups, several Children’s Grief Groups, and offers the Yellow Ribbon Suicide Prevention Program and Yellow Ribbon Cards. This agency also provides grief management and suicide prevention presentations to various local groups, including some schools.

Law Enforcement, including the Tuolumne County Sheriff’s Office (TCSO), the Sonora Police Department and the California Highway Patrol: Many calls from the public require assessment by Law

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Enforcement, particularly coming in to the TCSO dispatching center, to determine the risk of suicidality. The TCSO averages one to two calls per day requiring an assessment of suicide risk.

Mountain Women’s Resource Center: Provides teen violence and bullying prevention training in local schools and for community groups.

Tuolumne County Office of Education (TCOE) and YES Partnership “Understanding And Preventing Suicide” Brochure: A three-fold brochure developed as a student senior project and sponsored by the Office of Education and the YES Partnership, describing signs of suicidal risk and providing education about effective interventions to prevent suicide. This has been distributed at schools and health fairs.

TCOE and Local Schools: Provides the Jason Foundation Suicide Prevention Program at two local high schools. An ongoing Challenge Day program is underway at local high schools to improve social skills and prevent bullying behavior. Other selected promotional programs for mental health are offered at various local schools, kindergarten through 12th grade.

Rotary Club Crisis Resource Cards: Over 10,000 resource cards have been printed and distributed to local county agencies, businesses, churches and schools providing numbers and websites to access suicidal or other mental health crisis services.

Rotary Club Safe Place Projects: Projects that are currently underway include the Community Dog Park, Columbia Elementary Sports Park, Sonora High Track lights, and the Sonora library new childrens' reading room. Rotary is also supporting Dawn's Light Sonora High Grief Group, and coordinating community projects with the Tuolumne County Recreation Department.

Recreation Department Crisis Resource Cards: This “accordion card” directory is an updated edition, entitled “HELP Make the Call.” It is an extensive resource for youth and includes emergency numbers for various health crises, including suicidal ideation. These cards have been widely distributed.

Recreation Department Youth Services Directory for CommunityThe “Youth Services Directory” booklet was published by the Tuolumne County Youth Services Directory Committee with a large number of local resources to enhance the quality of life for local

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youth. The “Youth Services Directory” is available and has been distributed.

Senior Outreach Activities, including the Senior Center, Area 12 Agency on Aging, Social Security offices, Veterans Services, Senior Ombudsman, “Golden Age Partners,” Senior Peer Program, Catholic Charities and Meals on Wheels: Each of these programs offers preventive health services with varying amounts of training in suicide prevention throughout the county.

Visiting Nurses Association/Hospice Program: Provides an annual “Coping With the Holidays” program, teen grief support at local high schools, and ongoing grief support groups in Tuolumne and Calaveras Counties.

2. Training, Prevention and Intervention Programs

Core ProgramsThe Core Programs for Training, Prevention and Intervention represent programs recommended for funding in year one of the Strategic Plan and are listed in Appendix A.

The Suicide Prevention Task Force identified critical core programs and proposals for inclusion in the Suicide Prevention Strategic Plan in the realms of training, prevention and intervention that could be implemented in the first year of the three year Strategic Plan if funds were made available. Note that a brief description for each identified core proposal is included in the following chart, as well as target audience, age groups to benefit from proposal, outcomes, annual costs, an agency that could provide oversight of the proposal, identified in-kind contribution or cash available from a sponsoring agency and what level of priority the proposal would have in the first year. Please refer to the “Training, Prevention and Intervention Core Proposals” chart for Year One, Appendix A.

Expanded ProgramsThe Expanded Programs for Training, Prevention and Intervention represent programs recommended for funding in years two or three of the Strategic Plan, and are listed in Appendix B.

These represent programs and strategies that were important and yet not feasible to implement until years two and three – either due to costs for the program, level of priority and/or ability to implement if funds were to become available. Note that in this chart a brief description was included, as well as target audience, age groups to benefit from proposal, outcomes, annual costs, a possible agency

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that could provide oversight of proposal, and any identified in-kind contribution or cash available from a sponsoring agency. Please refer to the “Training, Prevention and Intervention Expanded Proposals” chart for Years Two and Three, Appendix B.

3. Community Education ProgramsA Community Education Committee was formed in order to determine how best to communicate, build awareness and encourage groups, organizations, companies, and individuals to act and engage in suicide prevention, training and intervention A list of strategies was developed for the universal dissemination of education, awareness and stigma reduction campaigns for the general population relating to suicide prevention. Please refer to the “Community Education Core and Expanded Proposals” chart, Appendix C.

Prioritizing ProgramsThe Suicide Prevention Task Force chairpersons from the five subcommittees (Training, Prevention, Intervention, Community Education, and Monitoring and Surveillance) decided upon a set of criteria for prioritizing programs identified as being Core Proposals. Programs were then prioritized in accordance with these criteria, with #1 assigned for top priority, #2 for second and #3 for third, so that the Task Force could prioritize which proposals to implement first based upon the availability of funds in year one.

Criteria for Inclusion Into The Strategic PlanPrograms were prioritized according to the following criteria:

No Wrong Door : Each program was evaluated on its potential to support and achieve the community goal of “No Wrong Door.”

Age-Specific Goals : See Figure 3 Evidence-based Documentation : Whether specific programs

designed to promote protective factors and diminish risk factors for suicide can actually diminish the occurrence of suicide in rural California counties is a question that largely remains unanswered. Programs that focus on improving general coping skills and resiliency show promise for suicide prevention. However it is difficult to demonstrate efficacy in experimental models for suicide prevention, in part because of the low base rate of completed suicide, the short duration of implementation and assessment in most studies, and the insufficient power generated by the complexities of county-based data.19 The Tuolumne County Strategic Plan for Suicide Prevention can serve as part of the rigorous analysis that is required in order to establish the generalized effectiveness of various suicide prevention programs.

19 S.K. Goldsmith et al., Reducing Suicide: A National Imperative, Institute of Medicine, 2002, The National Acadamies Press, Washington D.C.

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Relevant to Local Risk Analysis : The risk analysis conducted for California counties in 2006 and 2007 suggests that substance abuse, firearm availability, racial demographics (higher suicide rates for Native American and White residents) and rural location are significant predictors of high suicide rates in rural counties like Tuolumne County.20 Psychological autopsy data confirmed local relevancy of these risk factors. Mental health care for low income populations was also a fairly strong predictor, but otherwise, mental health factors weakly correlated with suicide rates. The rate of completed suicide was highest for males and for those over 70 years of age and those 35 to 44 years of age, similar to the bimodal occurrence of suicide nationally (See Figure 2). Firearms were used in 85% of suicides in Tuolumne County in 2006.

Fidelity of Implementation : Whether specific suicide prevention programs can be broadly applied to regions like Tuolumne County is an important consideration. Considering local resources and capacities may render it difficult to reproduce experimental conditions in Tuolumne County, or programs may have been designed for urban settings inapplicable to the needs of Tuolumne County.

Cost/Benefit Assessment : Ultimately, a cost-benefit analysis of each program is a necessary consideration.

Monitoring and SurveillanceFor the purposes of monitoring the community for suicidal incidents and system utilization, a monitoring and surveillance plan was developed. Six different data sources will provide a Monitoring and Surveillance committee with statistical information regarding incidents of intentional self-injury or suicidal events. The Monitoring and Surveillance committee will meet quarterly. In all cases, strict patient confidentiality is observed and data reviewed only in an anonymous fashion to identify potential trends over time. Trends to be monitored may include gender, age, race, residence and method. Data sources include the following.

1) Law Enforcement Child Death Review Team: As required by Section 11166.7 of the Penal Code, the Tuolumne County Sheriff’s Office (TCSO) provides oversight for the local Child Death Review Team. An annual report is prepared of the review of all deaths in the county of people under 25 years of age. This team meets in an ad hoc fashion and tracks suicide deaths in the county. Members include the Sheriff/Coroner's Office, Probation, Public Health, Behavioral Health, District Attorney's Office, Victim/Witness, Child Welfare Services, California Highway Patrol, and the Sonora Police Department. Data is shared with the Monitoring and Surveillance committee only as trend data and not specific to any one case.

20 Stolp, S.T. and Stolp, CW. Social Variables and Suicide Risk in Rural California Counties, pre-publication copy, 2009

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2) Public Health Death Certificate Review: The Health Officer reviews all local death certificates each month and provides consultations for deaths that occur with suspicious medical circumstances. Specific attention is paid to identify cases of so called “passive suicide,” in which a death may have been due to intentional overdose with prescription medications or noncompliance with medical recommendations. Ongoing surveillance for suicidal deaths is conducted and overall rates shared with the Monitoring and Surveillance Committee.3) Hospital-based E-Code monitoring: The International Classification of Diseases maintains a series of Supplemental Codes, called “E-codes,” to modify a diagnostic code for patients seen. E-codes 950 through 959 identify “suicide and self inflicted injury,” including poisoning. Sonora Regional Medical Center will provide monthly rates of E-codes 950-959 for patients seen in both outpatient and inpatient sites, allowing a way to monitor for suicidal attempts without fatal outcomes. The data is entirely anonymous.4) Behavioral Health Psychological Autopsies: Patients followed by the Behavioral Health Department undergo case review under a Quality Improvement Program. Part of case reviews include psychological autopsies of cases with unfavorable outcomes, including suicide or suicidal attempts. While specific case information is strictly confidential, trends as they relate to suicide prevention are shared in the setting of the Monitoring and Surveillance committee.5) Statewide Statistical Section: Statewide data is gathered from the Department of Public Health Statistical Section to monitor for regional suicide trends.6) Data specific to Screening Campaigns: Periodic screening for depression may be conducted at the annual Health Fair or Columbia College. The results of such screening may be shared to provide insight into local trends for depressive illness or suicidal ideation.

Structure of Strategic Plan OversightThis Strategic Plan will be implemented under the following organizational structure.

Strategic Plan Coordinating AgencyGiven the large number of recommended strategies and projects, a monitoring/coordinating entity, the Coordinating Agency, will be sought to assume responsibility for implementation, coordination, project management and overall supervision. A Request For Qualifications (RFQ) will be drafted to solicit bids and the successful organization be awarded a contract in the range of $50,000 to $80,000. The successful bidder will have primary responsibility to:

1.      Monitor the projects to ensure identified outcomes are achieved. Project status reports from the project contractees will be received by this agency.

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2.      Organize materials to present to a Core Oversight Committee (COC described below) composed of volunteers from the Suicide Prevention Task Force (SPTF).3.      Prepare an annual report for submission to the entire SPTF.4.      Oversee and implement the Community Education component of the Strategic Plan. Money will be set aside from the $50,000 to $80,000 funding pool to pay for brochures, posters, calendars, etc.

Core Oversight CommitteeThe Suicide Prevention Committee will reform in early 2009 as the Core Oversight Committee (COC) with 6 to 8 members to provide overall responsibility for implementation of the Strategic Plan strategies and projects. This committee will include key individuals involved in each of the five Strategic Plan components – suicide prevention, intervention, training, community education and monitoring. The COC will have the primary responsibility for overseeing the contractor who will be charged with implementation and monitoring of the strategies and projects. The COC will meet with the contractor on a quarterly basis. It is the intention that the Community Education and Monitoring and Surveillance committees will continue to meet between 2-4 times annually to be a resource to the Core Oversight Committee and contracted Coordinating Agency. The COC will also be responsible for ensuring the ongoing development of the Strategic Plan over time.

Community Education CommitteeThe Community Education Committee will meet 2 to 4 annually to provide support to the Core Committee and Coordinating Agency.

Monitoring and Surveillance CommitteeConsisting of members from the TCSO, Public Health, Behavioral Health, and the SPTF, for a total of no more than six members, the Monitoring and Surveillance Committee will meet quarterly to review data from the sources noted earlier in this plan. A report will be prepared and provided to the Core Committee annually.

Fundraising CommitteeA small development/fundraising committee is being formed to begin work to seek grants from a range of funders in Tuolumne County and California in particular. It should be noted that $10,000 of the contract amount ($50,000 -- $80,000) will be set aside to cover fundraising costs in year one of the Community Education projects and strategies.

Funding and estimated CostsThe estimated costs to implementing all programs listed in the core proposal chart for year one are estimated at $245,400 total, not including the costs of coordination and fundraising.

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Proposals given a #1 priority are estimated to cost $36,000, #2 priority proposals are estimated to cost $199,400, and #3 priority proposals are estimated at $10,000.

The Tuolumne County Behavioral Health Mental Health Services Act (MHSA) Prevention and Early Intervention(PEI) funds of $40,000 will be available to use for training costs each year for a four year period.

Funds totaling approximately $205,400 will be sought to support the additional programs for the first year of the Strategic Plan. In Year Two and Three, the expanded proposals are estimated to cost up to $301,055 (ongoing costs).

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