The Suicide Prevention Council requested formation of a Suicide Fatality Review. A Suicide Prevention Coordinator, an Epidemiologist and a Medicolegal Death Investigator (MDI) developed a novel Suicide Fatality Review (SFR) process. For more information please visit

State: OR Type: Model Practice Year: 2019

Washington County Public Health had two goals for the proposed practice: Form strong community partnerships for suicide prevention Reduce the suicide rate in Washington County There were five objectives of the proposed practice: Form a Suicide Prevention Council with membership across all stakeholders in the county, including suicide survivors, private businesses, faith representatives, and other government agencies, to form and guide a strategic plan for suicide prevention Develop and implement a Suicide Fatality Review process Collect specific and actionable individual suicide risk factor and circumstance information from each suicide Use the individual risk factor information to determine location-based suicide touchpoints for rapid, data-driven Question, Persuade, Refer (QPR) trainings For evaluation purposes, record the number of people trained with a suicide prevention technique and reports of interventions The suicide prevention work in this practice involved a novel internal collaboration in the development of a data collection instrument. This practice also included two significant and separate community partnership based committees: the Suicide Prevention Council, and Suicide Fatality Review. In early 2012, when preparing the epidemiological portion of the county's Community Health Needs Assessment (CHNA), suicide was noted as an area of concerning trend from the data perspective. County administration agreed that initiating suicide prevention work was necessary and the county applied and was awarded the Garrett Lee Smith Grant. In 2014 and 2016, through major regional CHNAs, suicide was identified as a top health issue by through community focus groups and the population-level data. As a result, a Community Health Improvement Plan (CHIP) committee was formed to develop and implement goals and strategies for suicide prevention at the county and was known as the Suicide Prevention Council. To recruit membership from a diverse array of stakeholders, multiple major community events were held throughout the county to announce the launch of the Suicide Prevention Council and other CHIP committees. Hundreds of organizations and individuals were invited to attend and learn about the selected priority areas, such as suicide prevention. At those meetings, organizations were able to self-select for participation in any or all of the committees. If a known stakeholder was not able to attend any of the launch parties, a personal invitation was extended verbally and in writing by the county. These efforts culminated in the following organizations being represented on our Suicide Prevention Council: Community members Beaverton School District Local school district Boys and Girls Club After school program Cedar Hills Local government Clackamas County Local government Hillsboro Education Center Center for autism teacher training Hillsboro School District Local school district Inukai Boys and Girls Club Local after school program LifeWorks Northwest Community-based mental health and addiction agency Lines For Life Regional non-profit dedicated to preventing substance abuse and suicide Lutheran Community Services Faith-based organization Metro West Ambulance Ambulance and emergency medical services provider Multnomah County Local government NW Regional Education Service District Provides access to services for Oregon children and families Oregon Department of Human Services Oregon state's principal agency for helping Oregonians achieve wellbeing and independence Oregon Pediatric Society The state chapter of the American Academy of Pediatrics Pacific University Counseling Higher education institution Polk County Local government Portland Veterans Administration Local Veterans Administration's healthcare provider Sherwood School District Local school district Sunset High School Local high school Teens Finding Hope A small non-profit organization dedicated to providing resources and encouragement to teens and their families affected by depression. Tuality School District Local school district ???????Washington County Programs Crisis Team Crisis mental health assessments for Washington County residents Developmental Disabilities Provides services coordination for individuals with developmental disabilities in Washington County Disability, Aging, and Veterans Provides programs and services to maintain and enhance the quality of life to assure that basic needs are met for Washington County seniors, veterans and people with disabilities Medical Examiner's Office Provide medical-legal investigations of all sudden or unexpected deaths in Washington County Mental Health Response Team Sheriff's Office program providing crisis and mental health services Mental Health Services Assures quality, collaborative, person-centered services for Washington County residents Public Health Local public health department working to protect the public's health and achieve health equity through prevention, regulation, and education. As shown above, the Suicide Prevention Council includes representations from a wide array of local private, non-profit, government and healthcare organizations. Although school districts and educational groups are well represented on the council, the research aspect often represented by academia in these councils is instead performed by county epidemiologists with masters and doctoral-level qualifications as one would expect from academic research. All community partners are volunteers. At each meeting, feedback is solicited from councilmembers about missing partners who should be at the table but isn't? If missing organizations are identified as key stakeholders, the councilmember with the best partnership with the organization commits to reaching out to inform the organization about the Suicide Prevention Council. Finding the missing voices through existing community partnerships furthers the objectives and goals of the practice by helping to ensure all voices are heard and all stakeholders are engaged and present so that suicide prevention and intervention practices will be as successful as possible. The Suicide Prevention Council tackles education, training, stigma, and awareness by uniting community partners in conversation and engaging with county-level suicide risk factor data. The vision of the Council is "Zero is possible.” Soon after the Suicide Prevention Council was established, the council considered what sub-groups were necessary, and a formal recommendation was made to create a Suicide Fatality Review. The purpose of the Suicide Fatality review would not be to perform psychological autopsies, or to mirror child fatality review, but to thoroughly assess suicides in Washington County to better identify potential systems improvements that could be implemented by organizations at the table, or others. Unlike the Suicide Prevention Council, Suicide Fatality Review covered extremely sensitive, identified and confidential information. Because of the need to have permission from the next of kin for each organization to share information at Suicide Fatality Review, active recruitment for Suicide Fatality Review members was only pursued with agencies that would have relevant information or insight to share and would not merely be an observer. Medicolegal death investigators identified agencies that provide information to them during a death investigation. The county suicide prevention coordinator was well versed in the local organizations that interact with suicidal individuals as part of their standard operation. All these organizations were invited to an initial meeting to determine if the organizations would be a good fit and to consider who was missing. Law enforcement suggested asking the Federal Bureau of Investigation and the District Attorney as they have access to information that local law enforcement does not. Multiple organizations suggested recruiting a member from the local Veteran's Administration. After two years of Suicide Fatality Review, we have the organizations below actively participating: Community members Cedar Hills Hospital Addiction and recovery healthcare provider Federal Bureau of Investigation Federal law enforcement Health Share of Oregon Local coordinated care organization Lifeworks Northwest Community-based mental health and addiction agency Lines for Life Local crisis line MetroWest Ambulance Services Ambulance and emergency medical services provider Multnomah County Aging and Disability Services Local government National Alliance on Mental Illness The local chapter of a national mental health organization Providence Inpatient Psychiatric Services Inpatient services Sherwood School District Local school district Tualatin Valley Fire and Rescue Local fire organization Universal Health Services Hospital management company Veteran's Administration Healthcare System Local Veterans Administration's healthcare provider Washington County Programs Crisis Team Crisis mental health assessments for Washington County residents Developmental Disabilities Provide services coordination for individuals with developmental disabilities in Washington County Disability, Aging, and Veterans Provides programs and services to maintain and enhance the quality of life to assure that basic needs are met for Washington County seniors, veterans and people with disabilities District Attorney's Office The chief prosecutor for the local government Epidemiology Program Serve the research, analytics, informatics and data needs for Washington County Fire Chaplains Provides an effective solution to the intentional and purposeful provision of holistic care to department members, their families, and command as well as on-scene support for community residents during and after an incident. Medical Examiner's Office Provide medical-legal investigations of all sudden or unexpected deaths in Washington County Mental Health Response Team Sheriff's Office program providing crisis and mental health services Mental Health Services Washington County provider of mental health services Sheriff's Office Local law enforcement organization Councilmembers of both the Suicide Fatality Review and the Suicide Prevention Council often take information from the meetings back to their organizations and make internal policy changes. Washington County Public Health creates an annual report about prevention successes in the previous year to be shared with the Suicide Prevention Council to reinforce the positive impact these volunteers are having on our residents. Independent of but concurrently with the formation of the Suicide Prevention Council and Suicide Fatality Review, and in a genuinely unusual collaboration, epidemiologists partnered with MDIs by shadowing them at death investigations to understand what information is available that could inform suicide prevention efforts. Timeline of notable events that led to the development of this practice: 2010-2012 Garett Lee Smith Grant to support suicide prevention work 2012 Suicide vignette in Community Health Needs Assessment 2012 Designated suicide prevention coordinator - unfunded 2012 Suicide Prevention Council formed 2012-2014 Epidemiologists shadow medicolegal death investigators 2013 Suicide Prevention Council recommends the formation of Suicide Fatality Review 2014 Data collection instrument for suicide risk factors developed and surveillance begins 2014-2019 Garett Lee Smith Grant Received 2014 Regional Community Health Needs Assessment identifying suicide as a priority issue 2015 Medicolegal death investigators retrospectively fill out data collection instrument for previous two years of suicides 2015 Dedicated suicide prevention coordinator 2015 Promote Zero Suicide initiative and technical consult adopted by Washington County 2016 Community Health Needs Assessment again identifies suicide as a priority issue 2018 County Suicide Surveillance System evaluated against the National Violent Death Reporting System 2018 Epidemiologist and medicolegal death investigators win national Susan P. Baker Public Health Impact Award for novel collaboration Startup funding: Work to put all aspects of this practice in place was unfunded and functioned as in-kind until a full-time suicide prevention coordinator was funded in 2015. The majority of the startup work was the time needed for recruiting community partners (1-3 months), ensuring the process is approved by legal counsel (3-4 months), training MDIs and epidemiologists on the data collection instrument (4h meeting) and setting the meeting schedules for Suicide Prevention Council and Suicide Fatality Review (2h a month). Now that all documents, policies, procedures, have been developed, the cost to start this project would be minimal. Humboldt County, California has recently fully adopted the practice, in consultation and with on-site training from the Washington County epidemiology program, and reports minimum in-kind time for the Coroners, suicide prevention coordinator and epidemiologist. Funding maintenance: All members of Suicide Fatality Review participate on a volunteer basis for 3 hours every other month All members of Suicide Prevention Council participate on a volunteer basis for 2 hours every other month The suicide prevention coordinator is grant funded at $80,000 per year, plus benefits, for five years Epidemiologists spend 4 hours per month on data merging and analysis and creating reports The Medicolegal Death Investigator who leads Suicide Fatality Review spends 4 hours a month contacting families for permission to review cases and preparing for the next Suicide Fatality Review (i.e., sending out the Consolidated Risk Assessment Profiles for cases to review and talking with the other investigators about their cases that will be reviewed) Washington County's four medicolegal death investigators each spend approximately 15 minutes a month filling out the data collection instrument Biannually the agencies in Suicide Prevention Council and Suicide Fatality Review are evaluated, and recruitment efforts are initiated by the suicide prevention coordinator as necessary.
There were five objectives of the proposed practice: Form a Suicide Prevention Council with membership across all stakeholders in the county, including suicide survivors, private businesses, faith representatives, and other government agencies, to form and guide a strategic plan for suicide prevention Develop and implement a Suicide Fatality Review process Collect specific and actionable individual suicide risk factor and circumstance information from each suicide Use the individual risk factor information to determine location-based suicide touchpoints for rapid, data-driven Question, Persuade, Refer (QPR) trainings For evaluation purposes, record the number of people trained with a suicide prevention technique and reports of interventions Evaluation of meeting objectives In 2012, Washington County formed a Suicide Prevention Council with diverse membership (as shown in the Community Partnership section of this practice). Although the Suicide Prevention Council had a slightly smaller membership in 2012 than in 2014 and today, we are proud to report we have representation from nearly 30 organizations. The charter and mission of the council remains to inform and guide the suicide prevention strategic plan for Washington County and to instruct on training locations for county resources. Although Washington County cannot speak to the actual number of individuals positively influenced by this practice, we can reflect on the numbers available. Since its inception in 2014, the Suicide Fatality Review committee has reviewed 88 cases and has recommended 50 system-level interventions based on these reviews. Year to date in 2018, the county has already received 17 authorizations from next of kin with 22 additional letters out awaiting a response. The Suicide Fatality Review process is thriving beyond expectations and has more cases with consent to review than can be reviewed in an entire year. The objective of developing and implementing a Suicide Fatality Review was met. Regarding suicide prevention training performed in the county, 2,728 individuals attended suicide prevention training with roles spanning from social workers, family members, coaches, and veterans (see Table 1 below). Additionally, 844 people have received QPR training, with 34% of attendees identifying their role in the community as a "family member" (see Table 2 below). Recording the number of people trained, their roles, and the type of training received meets objective five, which is record the number of people trained with a suicide prevention technique and reports of interventions. While training is a critical component of evaluating the county's reach, the true measure of success is the known interventions with suicidal residents. As stated previously, in the calendar year 2018, the county has received over ten reports of successful interventions from community members trained in QPR. Meaning, QPR trained community members and business staff had the courage to ask a complete stranger if they were thinking about hurting themselves, and the person said yes. The QPR trained folks reported following their training and getting the person in need on the phone with the crisis line and staying with them until a safety plan was made. Death certificate data has been the only source for suicide data for decades, which is not particularly useful for actionable prevention steps. Death certificate data is limiting not only because it usually takes years for data to become available but also because death certificates do not record important aspect of decedents' socio-economic and health information. While Oregon participates in the National Violent Death Reporting System, capacity at the state severely restricts our access to timely, county-level data. For this reason, epidemiologists in Washington County initiated the current practice of the Suicide Consolidated Risk Assessment Profile form to allow for real-time suicide surveillance data to bring the relevant stakeholders together to tackle the problem of suicide and to ultimately reduce the suicide rate. The objective of collecting specific and actionable individual suicide risk factor information was achieved through the SCRAP form. Additionally, using this individual risk factor information to instruct locational QPR trainings was done repeatedly and successfully – achieving the fourth objective. Process measures Throughout the development of the SCRAP form, constant feedback was requested and received from medicolegal death investigators on how to improve the form. This included having the risk factors listed in the way that they usually are asked in an investigation; instead of the way an epidemiologist might like them. The investigators also requested additional variables from their lived experience of completing decades of death investigations in Washington County. These variables and open text box they requested turned out to be critical components of our prevention efforts. Feedback from Suicide Prevention Council members was requested on at least a yearly basis – asking what could be improved about the process, meeting, and administrative aspects of the practice. Outcome measures In addition to the number of trainings listed below in Tables 1 and 2, there were other outcome measures. One such outcome is the determination that imminently suicidal pet-owners sometimes surrender their beloved animals to the local shelter to ensure that they are cared for before ending their lives. Equipped with this information, the suicide prevention coordinator, upon recommendation from the Suicide Prevention Council, sought to train local shelter staff to recognize signs of mental health crisis using QPR and how to connect folks to the appropriate resources. Other suicide touch points have been identified through the novel data collection, and training programs with similar goals have been carried out benefiting hotel staff, law enforcement, hospital staff, and many others to improve the local suicide prevention capacity. Another example of policy change outcome from this practice relates to eviction notifications. Epidemiologists identified eviction in the two weeks prior to death as a risk factor present in 20% of suicides from 2014-2016. This information was presented to the local law enforcement agency who served the eviction paperwork to identify a possible prevention opportunity. After just one meeting, law enforcement now has crisis line information included with all eviction paperwork and the sheriff now requires a member of the mental health crisis response team to go out with the deputy to serve the paperwork. Although we do not have direct evidence of the effectiveness of this policy change, we have had a drop in suicides with an eviction crisis from 20% pre-intervention to 10% post-intervention. Short-term results Elements of this practice have been presented at numerous national conferences, including the Council for State and Territorial Epidemiologists (CSTE) conference multiple times, and the National Association of Medical Examiners (NAME). Many local, and numerous state jurisdictions have either fully adopted or are in the process of adopting this practice. The chief epidemiologist for Washington County has given over 20 presentations on this practice to medical examiner/coroner and public health groups both inside and outside the United States. The SCRAP form alone has been requested and sent out over 300 times in the past year. The striking difference in accuracy of risk factors for the same 212 Washington County suicides surveyed with SCRAP form versus the National Violent Death Reporting system is pending publication in a leading forensic pathology journal. There indeed is no comparison for the accuracy and speed of the actionable suicide risk factor information proposed in this practice. Public health entities such as Humboldt County California and New York State have requested multi-day in-person training for their death investigators and public health staff to implement this practice. North Dakota's entire medicolegal community was recently provided hour-long live webinar training from Washington County. Utah has implemented the SCRAP form as their organization is fortunate to have an epidemiologist in their medical examiner office. Even the Centers for Disease Control and Prevention has indicated interest in this data collection practice. Media interest in this prevention work has spanned from the local paper in Washington County to National Public Radio. County epidemiologists, medicolegal death investigators, and our suicide prevention coordinator have received many requests from jurisdictions across the country to provide in-person or online trainings about how to implement this practice, further demonstrating the value and utility of this practice for other local health departments. Some jurisdictions have even adapted the SCRAP form and Suicide Fatality Review to other public health issues, such as opioid overdose deaths. This level of national interest, in and of itself, is a clear indicator of the utility of this practice and its potential to revolutionize the process of suicide surveillance and prevention. This past October, our practice was presented at the National Medical Examiners (NAME) conference in Florida and was awarded the highly competitive Susan P. Baker Public Health Impact Award, for highlighting the visible impact on improving public health outcomes of our practice. The fact that this award came from the forensic medical community was highly encouraging. It's relatively easy to convince public health staff to work on prevention efforts that they may not see the results of for decades. It's not so easy to ask death investigators to fill out yet another form, complete another piece of work, attend another committee for free with no understanding of the actual difficulty of the nature of the ask of them. After shadowing investigators to hundreds of scenes, epidemiologists clearly understood the consequence and impact of asking a family in complete crisis, yet another invasive risk question. I am so sorry for the loss of your child, did John Doe experience any abuse or neglect in his previous 17 years?” The additional asks of the death investigators were given serious consideration and required approval from not only the State Medical Examiner but the medicolegal death investigation team themselves. Endorsement from the sole association for the forensic medical community now meant this practice would be likely to be more accepted by medical examiners and coroners across the country. After the NAME conference, the hundreds of information requests came from the death investigation community asking how to connect with their public health colleagues to start this work – a service we were more than happy to provide. Long-term results This practice has already produced encouraging long-term system change outcomes in the few years since its creation, including the examples mentioned above involving innovative prevention interventions with our county animal shelter, our county eviction notification procedure and real-time postvention efforts, mainly related to youth suicides. These are tangible improvements of the process by monitoring deaths at the local level which contributed to improving the completeness, quality, and timeliness of available suicide surveillance data for use in rapid, targeted, and localized intervention. These examples highlight how this practice has improved health outcomes for our community and improved the number of effective, evidence-based suicide prevention efforts in our community that are specifically addressing the needs of our residents. Pending any unexpected events in the next 12 days, in the calendar year 2018, Washington County will have the lowest suicide rate it's had in ten years. Another long-term result of this practice is that it improves awareness and accessibility of suicide prevention by engaging both professional stakeholders in public health, healthcare providers, law enforcement, as well as members of the public. Having all of these experts and partners in the same room together and having them share information that is then brought back to their organizations to promote innovative change, has had a motivating impact for other organizations. It has been shocking to present the suicide risk factor data and the recommended system interventions from the fatality review to the council, and immediately have councilmembers self-identify in an intervention and say That's my organization's touch point. I can do that. I will do that.” And the change is made. If you give your stakeholders an option for a specific action that will likely save lives, it is surprising how quickly even large organizations can make interventions happen. Modifications to practice based on findings As the practice has been in place for multiple years, we have modified our practice over time and have future planned changes. Modifications include: Find new exciting ways to keep community volunteers in the Suicide Prevention Council and Suicide Fatality Review Continue to have a medicolegal death investigator and at least one epidemiologist involved in Suicide Fatality Review to ensure data completeness and integrity. The same epidemiologist who performs data collection should present it to the Suicide Prevention Council. The SCRAP form has been completely modified to an online version based on feedback from the MDIs about the need for a more user-friendly version of the form. This modification also eliminated data entry for the epidemiologists. The new version can be found here: The county does not have formal representation from a Tribal or Native organization, and there has been difficulty recruiting membership in some religious and cultural organizations due to belief systems surrounding suicide There is an annual report now created to provide feedback to volunteers on the committees about the impact of their work All of these contributions demonstrate this practice's evident contributions to improving suicide prevention in Washington County, starting from incorporating previously inaccessible socio-economic and risk factor data to better inform prevention efforts, to the dissemination of these data to relevant stakeholders' with the expertise to make evidence-based prevention recommendations to address the needs of our community. Most importantly, this practice has demonstrably saved lives. The value of the years of work from the hundreds of people that went into achieving this outcome, visibly manifesting into pride in our committee members, our internal programs, and community members is immeasurable. Table 1: Class type of non-QPR suicide prevention training, count of attendees, and self-identified role of those attending, 1/1/2015-11/16/2018 (n=2,728) Class type # of classes # attending Adult Mental Health First Aid 16 293 Applied Suicide Intervention Skills Training 26 653 Counseling on Access to Lethal Means 4 88 Question, Persuade & Refer 56 1411 Youth Mental Health First Aid 7 132 Special Presentation (Joiner) 1 151 110 2728 Role Count % Mental Health Professional 302 27% Other 239 21% Educator 165 15% Social Services Provider 144 13% Youth Services Provider 52 5% Health Care/Services Provider 45 4% Multiple 38 3% Family Member 36 3% Volunteer 35 3% Aging Services Provider 20 2% Clergy/Pastoral 16 1% Sheriff/Police/Corrections 13 1% Housing/Housing Services Provider 10 1% Veteran/Military Service Member/National Guard 5 0% Coach 4 0% 1124 100% Table 2: Summary of the role of the individuals who completed QPR Training between 1/3/2016 and 11/6/2018 (n=844). Role % Family Member of Suicide Victim 34% Educator 26% Social Services Provider 15% Mental Health Professional 8% Volunteer 7% Sheriff/Police/Corrections 5% Youth Services Provider 5% Health Care Provider 4% Veteran/Military 2% Housing Services Provider 1% Clergy 1% Firefighter/EMS <1% Other 13%
Please enter the sustainability of your practice Now that Suicide Prevention Council, Suicide Fatality Review, and the associated data collection process are established in Washington County, sustainability has happened organically and has remained unaltered for two years. Since 2015, the county has been fortunate to have a grant funded suicide prevention coordinator to take on the role of scheduling meetings, reaching out to community partners and keeping the practice moving forward. However, before the county had this position, this administrative work was completed by adding this portfolio of work to an existing mental health staff member's workload. Suicide Prevention Council is the largest suicide prevention group in the county, to the point that other smaller suicide prevention coalitions ended and joined the Washington County Suicide Prevention Council. Community partners are at the table because they want action, results, and training they can take back to their practice or organization for adoption in the vein of the collective impact model. The council and the county continue to see the communitywide impact these committees are having on suicide prevention. Lessons learned from developing this practice Involving county legal counsel from the beginning is critical. Each state/jurisdiction has different laws and interpretation of those laws regarding information sharing and consent. Make sure to test your legally-approved documents with a handful of community members to see if they are understandable. Legally okay does not mean it's understandable to your community. Medicolegal death investigators are invaluable to understanding risk factors for suicide and have the most access to the current, relevant factors associated with a death. They are the ultimate frontline staff. Access to community-specific suicide risk factor data for our county has allowed us to pursue novel prevention strategies not available in the literature, such as interventions at animal shelters, during eviction notifications and in the timely postvention of near real-time identified clusters Organizations can have rapid turnover and it's important to retain institutional memory of the process, goals and objectives. Keep excellent meeting notes as they will be helpful references later. When beginning Suicide Prevention Council, each organization set their own goals for the council and summarized their organizations internal suicide work. Reviewing these goals at least yearly and assessing progress is a helpful and centering practice. Lessons learned from engaging community partners in collaboration for the Suicide Prevention Council and Suicide Fatality Review Ensure the committees are co-chaired by a community member Community partners want specific, objective, strategic guidelines, a charter, and actions when voluntarily joining a committee. Specific co-facilitation of meetings with partners reporting back successes related to the council's work are important. Washington County hosts and facilitates the Suicide Prevention Council, but we the county is not the leader. Recognize and respect all the partners at the table – no one knows their community better than they do. Each agency is likely to have a different priority population for suicide prevention. Keep the meetings such that the strategies and training are adaptable to as many populations as possible. For example, research shows after a suicide attempt, sending a thinking of you” follow up postcard dramatically lowers suicide risk. These are interventions that can be applied broadly. Be trauma informed and mindful. Understand that most people at the table will have direct experience with suicide and it can be traumatizing for others when personal experiences are shared. Have self-care or resiliency activities built into the agenda. Keep Fatality Review meetings to two hours and review no more than five cases to ensure members are able to stay engaged and are not emotionally exhausted by the process. Feedback loops for community participants are critical. Partners need a safe way to express concerns with issues that arise during council meetings and meaningful ways to express opinions and concerns to improve the committee processes. Medicolegal death investigators, due to the extremely traumatizing nature of their work, may not be aware of the trauma experienced by others from reviewing a case. It's important to have a coordinator that can balance self-care with the need to process the heart-wrenching information reviewed. This practice in its entirety is an example of how postvention becomes prevention. Our prevention efforts have gone in directions we would have never expected. If an organization is willing to function outside the proverbial box, the creativity fostered can yield creative interventions that work. Cost/Benefit Analysis In 2014, after the first full year of the Suicide Prevention Council, members of the committee were asked to confidentially report in an online survey whether they saw value in continuing. All organizations reported somewhat valuable or fully valuable” when asked of the value of the Suicide Prevention Council. When asked in an open-text field why or why not” is the committee valuable, the overall theme was members felt the group was making a collective difference, that they could take what they learned back to their organizations to make change, and reported enjoying forming new partnerships with others at the table. This confirmed what the county had suspected – community members are fully committing time and energy to suicide prevention of their own volition. This simple evaluation functioned as our cost benefit analysis. Our community partners at the table see a value in these meetings and we, as the county, will continue to support the work with in-kind staff time and a grant-funded Suicide Prevention Coordinator. Sustainability Plans With reports spreading of successful interventions from organizations that were trained by Washington County in Question, Persuade, Refer (QPR) based on the council's recommendations, there has been a considerable rejuvenation of energy and commitment in the council and Suicide Fatality Review. Without demonstrated value of the effectiveness of some portion of the council or the fatality review, it's unclear how long community committee members would wish to stay involved. As the five-year grant cycle is coming to an end, Washington County Public Health has proposed to make the Suicide Prevention Coordinator a full-time permanent position. Other county staff members who participate voluntarily, and have for multiple years, plan on continuing the work. Not only will this work be sustainable at the county, but the county has trained multiple jurisdictions (counties and states) across the country on how to implement a Suicide Fatality Review and Suicide Prevention Council.
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At a NACCHO conference