Promoting suicide prevention in hospitals: Evidence and incentives
Suicide is one of the leading causes of death in the United States, with over 49,000 deaths by suicide in 2023 alone, a trend that shows no sign of abating.
自杀是美国的主要原因之一，仅 2023 年就有超过 49,000 人死于自杀，这一趋势没有减弱的迹象。
Many of these deaths occurred within reach of the health care system: approximately 13 to 30% of individuals who die by suicide had an inpatient stay or emergency department visit in the month before their death .
其中许多死亡发生在医疗保健系统的范围内：大约 13% 至 30% 的自杀者在死前一个月曾住院或急诊科就诊。
1 R esearch has identified four core practices through which hospitals can reduce this risk—formal safety planning, lethal means counseling, warm handoffs to outpatient care, and follow-up contact after discharge—each with demonstrated potential to reduce suicidal behavior and improve care transitions.
1 研究确定了医院可以降低这种风险的四种核心做法——正式的安全计划、致命手段咨询、温暖的门诊护理交接以及出院后的后续联系——每一种都被证明有可能减少自杀行为和改善护理过渡。
Yet only 8% of accredited hospitals have implemented all four concurrently.
然而，只有 8% 的认可医院同时实施了这四种措施。
This gap reflects neither a failure of clinical knowledge nor a lack of evidence, but a misalignment of incentives: Hospitals bear the costs of implementation, while the financial benefits accrue largely to insurers.
这种差距既反映了临床知识的失败，也反映了缺乏证据，而是激励措施的错位：医院承担实施成本，而财务收益主要归保险公司所有。
Payers, therefore, hold the leverage to close this gap.
因此，付款人拥有缩小这一差距的杠杆作用。
Health plans and payments overseen by the Centers for Medicare and Medicaid Services (CMS) alone account for nearly half of hospital revenues , a share large enough to move hospital behavior nationwide and one that reaches the resource-constrained hospitals least able to fund these practices on their own.
仅由医疗保险和医疗补助服务中心 (CMS) 监管的健康计划和支付就占医院收入的近一半，这一份额足以在全国范围内改变医院的行为，并且能够惠及资源有限、最无力自行资助这些业务的医院。
We propose fidelity-based quality process metrics for each of the four recommended practices—assessing the timing and completeness of safety planning and lethal means counseling, administrative readiness and completion of warm handoffs, and the timing, modality, and consistency of follow-up contacts—rather than metrics tied to downstream clinical outcomes.
我们为四种推荐实践中的每一种提出了基于保真度的质量流程指标——评估安全计划和致命手段咨询的时间和完整性、行政准备和温暖交接的完成，以及后续联系的时间、方式和一致性——而不是与下游临床结果相关的指标。
Payment should then be linked to these measures in a way that rewards both progress and performance: Hospitals would earn payments for improving, but the largest rewards would be reserved for reaching meaningful standards of care, with higher payments for the practices that are hardest to implement because they extend beyond the hospital’s walls.
然后，报酬应与这些措施挂钩，以奖励进步和绩效：医院将因改进而获得报酬，但最大的奖励将保留用于达到有意义的护理标准，而对最难实施的做法则给予更高的报酬，因为它们超出了医院的范围。
Because hospitals begin at widely different levels of capacity and adoption, these incentives should be introduced gradually.
由于各医院的能力和采用水平在起步阶段存在很大差异，因此应逐步引入这些激励措施。
Payers should start with bonus-only payments that build participation and infrastructure, later transitioning to a two-sided risk model in which hospitals equipped to take on that risk face financial consequences for underperformance alongside bonuses for strong performance.
付款人应从建立参与和基础设施的纯奖金付款开始，然后过渡到双边风险模型，在该模型中，有能力承担该风险的医院面临绩效不佳的财务后果，同时因绩效出色而获得奖金。
Both stages draw on approaches already in use in Medicare through the Center for Medicare and Medicaid Innovation (CMMI) and in state Medicaid programs, such as Colorado’s.
这两个阶段都借鉴了医疗保险和医疗补助创新中心 (CMMI) 以及科罗拉多州等州医疗补助计划中已经使用的方法。
Suicide is one of the leading causes of death in the United States, with over 49,000 deaths by suicide in 2023 alone, a trend that shows no sign of abating.
自杀是美国的主要原因之一，仅 2023 年就有超过 49,000 人死于自杀，这一趋势没有减弱的迹象。
Reducing these deaths is a recognized public health priority, and interventions have been studied across the care continuum to identify the most effective points of impact.
减少这些死亡是公认的公共卫生优先事项，并且已经对整个护理过程中的干预措施进行了研究，以确定最有效的影响点。
Hospitals are particularly well-positioned to help, given that approximately 13 to 30% of individuals who die by suicide had an inpatient stay or emergency department visit in the month before their death, and 36 to 86% in the year before their death.
医院特别适合提供帮助，因为大约 13% 至 30% 的自杀者在死前一个月曾住院或急诊科就诊，而这一比例为 36% 至 86% 在死前一年曾住院或急诊科就诊。
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Hospitals represent one critical, but underutilized, intervention point in the continuum of suicide prevention.
医院是自杀预防过程中一个关键但未得到充分利用的干预点。
Emergency department (ED) visits for suicide attempts and intentional self-harm nearly quadrupled between the early and late 2010s, rising from 1.43 million to 5.37 million over the course of the decade, and individuals who present following a suicide attempt face a 30-times greater risk of subsequent suicide death .
2010 年代初期和末期，因自杀未遂和故意自残而到急诊室 (ED) 就诊的人数几乎翻了两番，在这十年间从 143 万增加到 537 万，而自杀未遂后就诊的个人随后自杀死亡的风险增加了 30 倍。
Even among those with a known suicide attempt, only 55% received any inpatient or outpatient mental health care in the same year.
即使在那些已知有自杀企图的人中，也只有 55% 的人在同一年接受过住院或门诊心理健康护理。
Hospitals are thus a critical setting for high-risk individuals , presenting after a suicide attempt, self-inflicted injury, or suicidal crisis, and potentially, those whose risk has not yet been identified.
因此，医院对于高危人群（在自杀未遂、自伤或自杀危机后就诊）以及潜在风险尚未确定的人群来说是一个至关重要的场所。
Despite this, hospitals have been slow to adopt evidence-based practices that could meaningfully reduce harm during and after these encounters.
尽管如此，医院在采取基于证据的做法方面进展缓慢，这些做法可以有效减少这些事件期间和之后的伤害。
Universal suicide risk screening is widely recommended , and roughly two-thirds of Joint Commission–accredited hospitals report hospital-wide screening protocols.
普遍建议进行普遍的自杀风险筛查，大约三分之二的联合委员会认可的医院报告了全院筛查方案。
However, adoption of the full complement of recommended practices remains to be fully embraced.
然而，仍需充分接受采用完整的建议做法。
A growing body of research and clinical guidance, complemented by the Zero Suicide framework and the Joint Commission’s National Performance Goals (NPGs), has identified four core practices for hospital-based suicide prevention:
越来越多的研究和临床指导，辅以零自杀框架和联合委员会的国家绩效目标 (NPG)，已经确定了医院自杀预防的四个核心实践：
Each practice has demonstrated the potential to reduce suicidal behavior and improve care transitions.
每项实践都证明了减少自杀行为和改善护理过渡的潜力。
Yet only 8% of accredited hospitals responding to the Joint Commission’s 2022 survey had implemented all four practices concurrently.
然而，在联合委员会 2022 年调查中，只有 8% 的认可医院同时实施了所有四种做法。
The economic realities of how hospitals are paid and how quality improvement is financed limit hospitals’ ability to adopt best practices in suicide prevention.
医院如何支付费用以及如何为质量改进提供资金的经济现实限制了医院采用自杀预防最佳实践的能力。
Quality improvement is costly, and the primary financial benefits of better suicide prevention and care accrue largely to insurers rather than to the hospitals bearing the costs of implementation, for example, through reduced readmissions or fewer return ED visits.
质量改进的成本高昂，更好的自杀预防和护理的主要经济利益主要归于保险公司，而不是承担实施成本的医院，例如，通过减少再入院或减少急诊室的回访次数。
This misalignment of incentives appears to have constrained the voluntary adoption of these suicide prevention practices in hospitals and suggests that goodwill and clinical guidance alone are insufficient levers to drive systemic change.
这种激励措施的错位似乎限制了医院自愿采用这些自杀预防措施，并表明仅凭善意和临床指导不足以推动系统性变革。
Yet some hospitals continue to provide this care despite the absence of financial benefit, reflecting health system leaders’ enduring commitment to patient safety.
然而，尽管没有经济利益，一些医院仍继续提供这种护理，这反映了卫生系统领导者对患者安全的持久承诺。
That commitment should be applauded, but it clearly does not motivate the majority of hospitals to adopt the recommended practices.
这一承诺值得赞扬，但它显然并没有促使大多数医院采取推荐的做法。
Well-designed financial incentives can align a hospital’s economic interest with evidence-based patient care.
精心设计的财务激励措施可以将医院的经济利益与基于证据的患者护理结合起来。
The leverage to create such incentives is challenging, but the potential exists across the payer landscape.
创造此类激励措施的杠杆作用具有挑战性，但整个付款人领域都存在潜力。
Commercial insurers, state Medicaid programs, and the federal government all hold financial relationships with hospitals that could be tied to suicide prevention performance—and health plans and payments overseen by the Centers for Medicare and Medicaid Services (CMS), spanning Medicare, Medicaid, and the Affordable Care Act (ACA) Marketplaces, alone account for nearly half of hospital revenues , a share large enough to affect hospital behavior nationwide.
商业保险公司、州医疗补助计划和联邦政府都与医院保持着可能与自杀预防绩效相关的财务关系，而由医疗保险和医疗补助服务中心 (CMS) 监督的健康计划和付款，涵盖医疗保险、医疗补助和平价医疗法案 (ACA) 市场，仅占医院收入的近一半，这一份额足以影响全国医院的行为。
This analysis explores how payers and hospitals can be engaged as active partners in promoting hospital adoption of suicide prevention best practices through fidelity-based quality metrics and payment arrangements that create real financial incentives for implementation.
本分析探讨了付款人和医院如何作为积极的合作伙伴，通过基于保真度的质量指标和支付安排，促进医院采用自杀预防最佳实践，从而为实施创造真正的财务激励。
Rather than focusing on any single payer type, we examine what hospitals should be doing, why current incentive structures have failed to get them there, and what payers could do to close that gap.
我们不关注任何单一的付款人类型，而是研究医院应该做什么，为什么当前的激励结构未能实现这一目标，以及付款人可以采取哪些措施来缩小这一差距。
The paper is organized into the following sections: We first provide background on the best practices in hospital-based suicide prevention and hospitals’ fidelity to them.
本文分为以下几个部分：我们首先提供有关医院自杀预防最佳实践的背景以及医院对这些实践的忠诚度。
We outline the economic considerations shaping hospitals’ engagement with these practices, followed by a discussion of quality metrics and payment strategies to incentivize hospital participation.
我们概述了影响医院参与这些实践的经济因素，然后讨论了激励医院参与的质量指标和支付策略。
We close with a brief comment on the role of health plans and the federal government as payers.
最后，我们对医疗计划和联邦政府作为付款人的作用进行简短评论。
Efforts to standardize suicide prevention in health care settings have increasingly coalesced around a common framework called Zero Suicide , and from that framework, a specific set of evidence-based practices has emerged as the core of what hospitals should be doing in their EDs and inpatient units to reduce suicide risk before, during, and after discharge.
医疗保健机构中标准化自杀预防的努力越来越多地围绕着一个名为“零自杀”的共同框架，从该框架出发，一套特定的循证实践已成为医院在急诊室和住院部应采取的措施的核心，以降低出院前、出院期间和出院后的自杀风险。
The Zero Suicide framework emerged from a partnership between the National Action Alliance for Suicide Prevention, the Suicide Prevention Resource Center, and other national suicide prevention experts, inspired by the Perfect Depression Care initiative at Henry Ford Health System in Michigan in the early 2000s.
零自杀框架是国家预防自杀行动联盟、自杀预防资源中心和其他国家自杀预防专家之间合作的成果，其灵感来自于 2000 年代初密歇根州亨利·福特卫生系统的完美抑郁症护理计划。
The Perfect Depression Care initiative produced notable results: Henry Ford achieved an 80% reduction in suicides, including an 18-month period between 2009 and 2010 with zero suicides—a statistically significant decrease that occurred even as Michigan’s overall suicide rate climbed.
完美抑郁症护理计划取得了显著成果：亨利·福特的自杀率降低了 80%，其中 2009 年至 2010 年的 18 个月期间自杀率为零——尽管密歇根州的总体自杀率攀升，但统计上的显着下降却发生了。
Zero Suicide became the first and most widespread model for quality improvement in suicide prevention at the health care organization level, targeting system-wide cultural and structural change rather than individual clinical behavior.
零自杀成为卫生保健组织层面自杀预防质量改进的第一个也是最广泛的模式，其目标是系统范围的文化和结构变革，而不是个人的临床行为。
Its foundational premise is that suicide deaths among patients receiving care are preventable, and that achieving that goal requires a “whole-organization” commitment: standardized, evidence-based behavioral health protocols, a trained workforce, and continuity of care across the entire process of treatment and discharge.
其基本前提是接受护理的患者自杀死亡是可以预防的，实现这一目标需要“整个组织”的承诺：标准化、循证的行为健康方案、训练有素的劳动力以及在整个治疗和出院过程中的连续性护理。
The framework has since been adopted as a guiding model by the Substance Abuse and Mental Health Services Administration (SAMHSA) , has informed the Joint Commission’s NPGs on suicide prevention, and is now being implemented , to varying degrees, across a growing number of health care organizations in behavioral health programs, general and psychiatric hospitals, primary care settings, and health plans.
此后，该框架已被药物滥用和心理健康服务管理局（SAMHSA）采纳为指导模型，并已向联合委员会的 NPG 提供有关自杀预防的信息，目前正在不同程度地在越来越多的医疗保健组织的行为健康项目、普通医院和精神病医院、初级保健机构和健康计划中实施。
Zero Suicide operationalizes this commitment to suicide prevention in health care systems through seven elements—Lead, Train, Identify, Engage, Treat, Transition, and Improve—that together address both administrative infrastructure and direct clinical care.
零自杀通过七个要素（领导、培训、识别、参与、治疗、过渡和改进）落实了医疗保健系统中预防自杀的承诺，这些要素共同解决了行政基础设施和直接临床护理问题。
This analysis focuses on one element, Transition, or discharge planning, which encompasses the four evidence-based practices noted earlier.
本分析重点关注一个要素，即过渡或出院计划，其中包含前面提到的四种基于证据的实践。
These practices are relevant across the full continuum of suicide prevention care but are particularly critical at points of highest acute risk, including discharge from inpatient psychiatric units and EDs following a suicide attempt or crisis.
这些做法与自杀预防护理的整个过程相关，但在最高急性风险点尤其重要，包括在自杀未遂或危机后从住院精神科病房和急诊室出院。
Gaps in hospital implementation are well-documented and are the focus of this analysis.
医院实施方面的差距有据可查，也是本次分析的重点。
Four practices sit at the center of this analysis: safety planning, lethal means counseling, warm handoffs to outpatient care, and follow-up contact.
本分析的核心有四种做法：安全计划、致命手段咨询、温暖的门诊护理移交以及后续联系。
Recommended by The Pew Charitable Trusts and the Joint Commission and grounded in the Zero Suicide framework, each has a substantial evidence base supporting its effectiveness in reducing suicidal thoughts and behavior , yet most hospitals consistently underdeliver on each .
由皮尤慈善信托基金和联合委员会推荐，并以零自杀框架为基础，每一项都有大量的证据基础支持其在减少自杀想法和行为方面的有效性，但大多数医院在每一项方面始终表现不佳。
The sections below review the evidence for each practice and document the gap between what research recommends and what hospitals currently provide—a gap that structured payment incentives could help close.
以下各节回顾了每种做法的证据，并记录了研究建议与医院目前提供的服务之间的差距——结构化的支付激励措施可以帮助缩小这一差距。
Safety planning is a brief, collaborative intervention in which a clinician and patient work together to create a prioritized, written set of coping strategies and sources of support to be used during and after a suicidal crisis.
安全计划是一种简短的协作干预措施，临床医生和患者共同制定一套优先的、书面的应对策略和支持来源，供自杀危机期间和之后使用。
It has become one of the most widely recommended brief interventions for individuals identified as at risk across inpatient, emergency, and outpatient settings.
它已成为针对住院、急诊和门诊中被识别为高危人群最广泛推荐的简短干预措施之一。
Safety plans incorporate elements of several evidence-based suicide risk reduction strategies, including access to lethal means reduction, brief problem-solving and coping skills, social and emergency crisis support, and motivational enhancement for continuing behavioral health treatment.
安全计划纳入了几种基于证据的自杀风险降低策略的要素，包括减少致命手段、简短的问题解决和应对技巧、社会和紧急危机支持以及增强持续行为健康治疗的动机。
A 2022 systematic review of 26 studies across general adult and veteran populations found that these safety planning interventions were associated with improvements in suicidal ideation and behavior, decreases in depression and hopelessness, reductions in hospitalizations, and improvements in treatment attendance, with qualitative studies further confirming their acceptability and feasibility across a range of clinical settings.
2022 年对一般成年人和退伍军人群体的 26 项研究进行的系统回顾发现，这些安全计划干预措施与自杀意念和行为的改善、抑郁和绝望的减少、住院次数的减少以及治疗出勤率的提高有关，定性研究进一步证实了它们在一系列临床环境中的可接受性和可行性。
Research shows that higher-quality safety plans, administered by trained staff and tailored to the individual at risk, are associated with reduced likelihood of hospitalization in the year following safety planning.
研究表明，由训练有素的工作人员管理并针对面临风险的个人量身定制的更高质量的安全计划与安全计划后一年内住院可能性的降低有关。
Yet studies have found that safety plans in practice are frequently incomplete or insufficiently personalized.
然而研究发现，实践中的安全计划常常不完整或不够个性化。
One inpatient study found that mandating safety plans without accompanying training and implementation support was not sufficient to ensure quality.
一项住院研究发现，在没有附带培训和实施支持的情况下强制执行安全计划不足以确保质量。
Safety planning is also most effective when paired with follow-up during and after discharge that updates the plan, supports engagement with outpatient care, and identifies social contacts that a patient can reach out to when experiencing suicidal ideation after the visit— a combination that has been shown to decrease the likelihood of subsequent suicide attempts and inpatient psychiatric hospitalizations.
安全计划与出院期间和出院后的随访相结合也是最有效的，该随访更新计划，支持门诊护理的参与，并确定患者在就诊后出现自杀意念时可以联系的社会联系人——这一组合已被证明可以降低随后的自杀企图和住院精神科住院的可能性。
Lethal means counseling consists of a conversation between a clinician and a patient, and ideally their support network, aimed at reducing access to firearms, medications, and other highly lethal means during periods of elevated suicide risk.
致命意味着咨询包括临床医生和患者之间的对话，最好是他们的支持网络，旨在减少在自杀风险升高期间获得枪支、药物和其他高度致命手段的机会。
It can be administered in under five minutes by any trained health care worker.
任何经过培训的医护人员都可以在五分钟内完成注射。
The intervention may be incorporated into safety planning or delivered on its own.
干预措施可以纳入安全计划或单独实施。
However, while lethal means reduction is embedded as a core component of safety planning, it warrants particular attention as a clinical practice in its own right, given the strength of the supporting evidence and the high frequency with which it is omitted or insufficiently addressed in safety plans.
然而，虽然减少致命手段是安全计划的核心组成部分，但考虑到支持证据的强度以及在安全计划中被忽略或未充分解决的频率，它本身作为一种临床实践值得特别关注。
The case for lethal means counseling rests on two intersecting bodies of evidence: that restricting access to lethal means reduces suicide rates at the population level, and that the window between suicidal crisis and attempt is often extremely short.
致命手段咨询的理由取决于两个交叉的证据：限制获得致命手段可以降低人口水平的自杀率，并且自杀危机和自杀企图之间的时间间隔通常非常短。
International studies have demonstrated that overall suicide rates drop when access to commonly used, highly lethal methods is reduced.
国际研究表明，当使用常用、高致命性方法的机会减少时，总体自杀率就会下降。
Among survivors of nearly lethal suicide attempts, 24% reported taking less than five minutes between the decision to attempt and the actual attempt.
在几乎致命的自杀未遂事件的幸存者中，24% 的人表示从决定尝试自杀到实际尝试自杀之间的时间间隔不到五分钟。
Additionally, studies consistently find that the interval between the emergence of suicidal thoughts and an attempt can be ten minutes or less , leaving little time for intervention once a crisis has begun.
此外，研究一致发现，自杀念头的出现和自杀企图之间的间隔可能只有十分钟或更短，一旦危机开始，就几乎没有时间进行干预。
Reducing access to lethal means during a moment of acute crisis can therefore be lifesaving, and evidence suggests that if a favored method becomes less available, individuals do not reliably substitute another method.
因此，在严重危机时刻减少致命手段的获取可以挽救生命，而且有证据表明，如果一种偏爱的方法变得不再可用，人们就不会可靠地替代另一种方法。
The transition from inpatient or emergency care to outpatient behavioral health treatment is among the highest-risk periods for individuals who have experienced a suicidal crisis.
对于经历过自杀危机的个人来说，从住院或急诊护理到门诊行为健康治疗的过渡是风险最高的时期之一。
In the first week after discharge from inpatient psychiatric care, suicide death rates are approximately 300 times higher than that of the general population and may remain elevated for up to three months post-discharge.
在住院精神科护理出院后的第一周，自杀死亡率比普通人群高出约 300 倍，并且可能在出院后长达三个月内保持较高水平。
Rather than providing a referral contact at discharge and leaving individuals to navigate the barriers of outpatient care on their own, a warm handoff directly connects the patient with their next provider before discharge and establishes a relationship with the receiving provider while the patient is still in a supported care environment.
温暖的交接不是在出院时提供转诊联系人并让个人自行克服门诊护理的障碍，而是在出院前直接将患者与其下一个提供者联系起来，并在患者仍在支持的护理环境中时与接收提供者建立关系。
Research supports the importance of this transition : brief interventions that include care coordination have been shown to reduce subsequent suicide attempts for individuals who presented with suicidal thoughts or behaviors in an ED or other medical setting.
研究支持了这一转变的重要性：事实证明，包括护理协调在内的简短干预措施可以减少在急诊室或其他医疗环境中出现自杀想法或行为的个人随后的自杀企图。
Separately, one study examining Medicaid-enrolled youth across 33 states found that timely follow-up treatment that can be promoted by warm handoff interventions—specifically, seeing a mental health provider within seven days of discharge from inpatient psychiatric care—was associated with meaningfully reduced suicide risk.
另外，一项对 33 个州参加医疗补助计划的青少年进行调查的研究发现，通过温暖的交接干预措施可以促进及时的后续治疗——具体来说，在住院精神科护理出院后 7 天内去看心理健康服务提供者——与显着降低自杀风险相关。
The evidence for warm handoffs is compelling and backed by a large body of literature showing that patients who receive one, along with other transitional interventions, are significantly more likely to attend their first outpatient appointment or follow-up treatment.
温暖交接的证据令人信服，并得到大量文献的支持，表明接受热交接以及其他过渡干预措施的患者更有可能参加第一次门诊预约或后续治疗。
The need for this practice to improve continued patient engagement with care is reinforced by data on post-discharge follow-up: fewer than half of patients discharged from EDs for a mental health crisis successfully transition to outpatient care, with high rates of ED readmission.
出院后随访数据强化了这种提高患者持续参与护理的必要性：因精神健康危机而从急诊室出院的患者中，只有不到一半成功过渡到门诊护理，且急诊室再入院率很高。
A warm handoff directly targets this gap by reducing the logistical and psychological barriers between discharge and first outpatient contact.
热情的交接通过减少出院和首次门诊接触之间的后勤和心理障碍来直接解决这一差距。
The National Action Alliance for Suicide Prevention’s best practices guidance recommends that inpatient providers secure an outpatient appointment for their patient within 24 to 72 hours of discharge, initiate direct personal contact between the patient and the receiving outpatient provider before discharge, and proactively work with the patient and family to identify and resolve logistical barriers such as transportation, childcare, and insurance before the patient leaves the inpatient setting.
国家自杀预防行动联盟的最佳实践指南建议，住院服务提供者应在患者出院后 24 至 72 小时内为其安排门诊预约，在患者出院前与接收门诊服务提供者建立直接的个人联系，并在患者离开住院机构之前主动与患者及其家人合作，找出并解决交通、儿童保育和保险等后勤障碍。
Follow-up contact involves reaching out to individuals by phone or other means within the days and weeks following hospital discharge to assess ongoing risk, offer support, and help address barriers to accessing outpatient care.
后续联系包括在出院后的几天或几周内通过电话或其他方式与个人联系，以评估持续风险、提供支持并帮助解决获得门诊护理的障碍。
Follow-up contact, ideally continuing until the patient attends their first outpatient appointment, is supported by evidence as a component of reducing subsequent suicide attempts and improving treatment engagement.
后续联系最好持续到患者第一次门诊预约为止，这是有证据支持的，可以作为减少后续自杀企图和提高治疗参与度的组成部分。
A collection of research indicates that active follow-up contact interventions are effective in reducing the risk of a repeat suicide attempt within six months.
一系列研究表明，积极的后续接触干预措施可以有效降低六个月内重复自杀企图的风险。
The National Action Alliance for Suicide Prevention’s best practices guidance recommends a follow-up call within 24 to 48 hours of inpatient discharge, weekly telephone contact until the patient attends their first outpatient appointment, and ongoing caring contacts—brief, encouraging messages to the patient that do not require a response.
国家自杀预防行动联盟的最佳实践指南建议，在患者出院后 24 至 48 小时内进行后续电话联系，每周进行一次电话联系，直至患者第一次门诊就诊，并持续进行护理联系——向患者发送简短、鼓励性的信息，无需回复。
Outpatient providers should reach out to confirm the first appointment if it is more than 24 hours after discharge, and written protocols should govern follow-up on missed appointments, escalating from telephone contact to mobile crisis outreach and, where risk indicators warrant, emergency welfare checks.
如果出院后 24 小时以上，门诊服务提供者应主动联系以确认首次预约，并应制定书面协议来管理错过预约的后续行动，从电话联系升级到移动危机外展，并在风险指标允许的情况下进行紧急福利检查。
Research supports extending these contacts over longer periods: one study found that the rate of suicide attempts was 33% lower among individuals who received up to three follow-up contacts compared with those who received none.
研究支持延长这些接触时间：一项研究发现，与没有接受过三次后续接触的人相比，接受最多 3 次后续接触的人的自杀企图率降低了 33%。
Follow-up contact should also help ensure that patients maintain contact with health care providers and support promptly attending a scheduled outpatient appointment.
后续联系还应有助于确保患者与医疗保健提供者保持联系，并支持及时参加预定的门诊预约。
A large population-based cohort study using data of over 76,000 patients discharged from psychiatric inpatient care in South Korea found that earlier outpatient appointments were significantly associated with lower suicide risk, with patients seen within seven days showing meaningfully reduced risk across diagnoses, including depression, schizophrenia, and bipolar disorder, relative to patients not receiving care within 30 days.
一项基于人群的大型队列研究使用了韩国超过 76,000 名从精神科住院治疗出院的患者的数据发现，较早的门诊预约与较低的自杀风险显着相关，相对于 30 天内未接受护理的患者，在 7 天内就诊的患者显示出各种诊断的风险显着降低，包括抑郁症、精神分裂症和双相情感障碍。
A combined safety planning and structured follow-up contact intervention tested across nine Veterans Affairs EDs was associated with 45% fewer suicidal behaviors over a six-month follow-up period and more than double the odds of attending at least one outpatient mental health visit compared with usual care.
与常规护理相比，在 9 个退伍军人事务部 ED 中测试了一项综合安全计划和结构化后续接触干预措施，在六个月的随访期内自杀行为减少了 45%，并且与常规护理相比，参加至少一次门诊心理健康就诊的几率增加了一倍多。
A review of eleven empirical studies found that repeated follow-up contacts are associated with reductions in suicidal behavior.
对十一项实证研究的回顾发现，反复的后续接触与自杀行为的减少有关。
Taken together, these four practices form an important part of an evidence-based continuum of care that addresses suicide risk not as a single clinical event but as a sustained process requiring attention from the moment of identification through the critical weeks following discharge.
总而言之，这四种做法构成了循证连续护理的重要组成部分，该护理将自杀风险视为一个持续的过程，从识别时刻到出院后的关键几周，都需要关注，而不是作为单一的临床事件。
Yet despite this clear evidence base, hospitals have struggled to implement these practices consistently and at scale.
然而，尽管有明确的证据基础，医院仍难以持续、大规模地实施这些做法。
This implementation gap is not due to a failure in clinical knowledge or evidence but largely reflects the structural and financial realities hospitals navigate.
这种实施差距并不是由于临床知识或证据的失败造成的，而是在很大程度上反映了医院所面临的结构和财务现实。
Hospitals bear real costs in training staff, embedding protocols, and sustaining follow-up infrastructure, while the financial benefits of better suicide prevention care accrue largely to insurers through reduced utilization.
医院在培训员工、嵌入协议和维持后续基础设施方面承担实际成本，而更好的自杀预防护理的经济利益主要通过减少利用率而为保险公司带来。
The data on current hospital practices make this misalignment concrete.
当前医院实践的数据使这种不一致变得具体。
Existing evidence suggests that about 13 to 30% of individuals who die by suicide had an inpatient stay or ED visit in the month before their death; moreover, in the year before death, these figures rise to about 36 to 86% of individuals.
现有证据表明，大约 13% 至 30% 的自杀者在死前一个月曾住院或急诊室就诊；此外，在死亡前一年，这一数字上升至约 36% 至 86%。
3 It is for this reason that increasing health system fidelity to the use of evidence-based practices aimed at suicide prevention is so important.
3 正是出于这个原因，提高卫生系统对使用旨在预防自杀的循证做法的忠诚度非常重要。
According to the Joint Commission, suicide prevention best practices in hospital settings should include suicide screening, formal safety planning, warm handoff to outpatient care, follow-up with patients after discharge, and lethal means counseling.
根据联合委员会的说法，医院环境中预防自杀的最佳做法应包括自杀筛查、正式的安全计划、热情地移交门诊护理、出院后对患者进行随访以及致命手段咨询。
In several recent studies, the Joint Commission collected data on its accredited hospitals to better understand how often providers are engaging in these practices.
在最近的几项研究中，联合委员会收集了其认可医院的数据，以更好地了解提供者参与这些实践的频率。
4 Overall, suicide screening is the most prevalent practice, with about 80% of hospitals reporting universal screening and 65% of hospitals having implemented protocols for positive screens and risk assessments.
4 总体而言，自杀筛查是最普遍的做法，约 80% 的医院报告进行了普遍筛查，65% 的医院已实施积极筛查和风险评估方案。
However, this still leaves about one in five hospitals that do not screen all patients, most often due to insufficient resources to adequately address patients who ultimately screen positive for suicide risk.
然而，仍然有大约五分之一的医院没有对所有患者进行筛查，最常见的原因是资源不足，无法充分应对最终筛查出自杀风险呈阳性的患者。
Beyond screening, there is significantly less uptake of the additional four best practices.
除了筛选之外，其他四种最佳实践的采用率也明显减少。
In fact, only 8% of Joint Commission-accredited hospitals meet full criteria for implementing all recommended suicide prevention activities at the time of patient discharge.
事实上，只有 8% 的联合委员会认可的医院符合在患者出院时实施所有建议的自杀预防活动的全部标准。
Separately, 28% of hospitals developed a plan for lethal means counseling, 30% made follow-up contact, 37% provided warm handoffs to outpatient care, and 61% implemented formal safety planning.
另外，28%的医院制定了致命手段咨询计划，30%的医院进行了后续联系，37%的医院向门诊护理提供了热情的交接，61%的医院实施了正式的安全计划。
However, only about 19% of hospitals that completed safety planning included all eight recommended components, which involve processes such as documenting warning signs and coping strategies, identifying people and settings that can provide distraction from suicidal thoughts or offer help during a crisis, and developing a plan for lethal means safety.
然而，只有约 19% 的医院完成了安全规划，包括所有八个建议的组成部分，其中涉及记录警告信号和应对策略、识别可以分散自杀念头或在危机期间提供帮助的人员和环境以及制定致命手段安全计划等流程。
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Although hospitals are not engaging in suicide prevention practices broadly, individual hospitals and health systems are acting as leading examples for risk reduction.
尽管医院没有广泛参与自杀预防实践，但个别医院和卫生系统正在成为降低风险的领先典范。
Intermountain Health , a nonprofit system with 34 hospitals and 400 clinics across six states in the Mountain West, is one such example.
Intermountain Health 是一个非营利系统，在西部山区的六个州拥有 34 家医院和 400 家诊所，就是这样的一个例子。
Through its participation in the Suicide Care Collaborative Improvement and Innovation Network, a collaborative learning initiative led by the Zero Suicide Institute in partnership with The Pew Charitable Trusts, Intermountain Health worked to strengthen suicide prevention training for staff and improve care transitions for discharged patients.
通过参与自杀护理协作改进和创新网络（由零自杀研究所与皮尤慈善信托基金合作领导的一项协作学习计划），Intermountain Health 致力于加强对工作人员的自杀预防培训，并改善出院患者的护理过渡。
The system had already integrated suicide risk screening and assessment into routine behavioral health care and hired behavioral health navigators to follow up with patients within three days of discharge.
该系统已将自杀风险筛查和评估纳入常规行为健康护理，并聘请行为健康导航员在患者出院三天内进行随访。
System data show that between 58% and 66% of patients in behavioral health settings are now seen for a follow-up visit within seven days of discharge, well above the national average of 27 to 48%.
系统数据显示，目前有 58% 至 66% 的行为健康患者在出院后 7 天内接受随访，远高于全国平均水平 27% 至 48%。
Through the initiative, Intermountain Health also improved collaborative safety planning, setting a goal that 60% of patients at risk for suicide would complete a safety plan before discharge and meeting or exceeding that target in eight of ten months tracked.
通过该举措，Intermountain Health 还改进了协作安全计划，设定了一个目标，即 60% 有自杀风险的患者将在出院前完成安全计划，并在跟踪的 10 个月中有 8 个月达到或超过该目标。
Intermountain Health does this in an environment where many of these services are not reimbursable and roughly 30% of patients at the implementation site are on Medicaid.
Intermountain Health 是在许多此类服务无法报销的环境中开展这项工作的，并且实施地点大约 30% 的患者接受医疗补助。
Yet health system leaders have remained committed because they believe this care is the right thing to do and that it makes a meaningful difference for patients and their families.
然而，卫生系统领导人仍然坚定不移，因为他们相信这种护理是正确的事情，并且它对患者及其家人产生了有意义的影响。
While there is evidence showing that these practices are likely to be cost-effective from a societal perspective—meaning that the broader economic and social benefits, including those that accrue to parties beyond the patient and provider, are achieved at a cost that compares well to other uses of funds—they may add to a particular hospital’s costs.
虽然有证据表明，从社会角度来看，这些做法可能具有成本效益，这意味着更广泛的经济和社会效益，包括患者和提供者以外的各方所获得的利益，其成本与其他资金用途相比相当不错，但它们可能会增加特定医院的成本。
These societal benefits include , for example, reduced emergency visits to other hospitals and clinics, along with fewer deaths by suicide and the disruptive impacts such deaths have on families and communities.
这些社会效益包括，例如，减少对其他医院和诊所的紧急就诊，减少自杀死亡人数以及此类死亡对家庭和社区的破坏性影响。
In some cases, for EDs, some of these practices may be reimbursable.
在某些情况下，对于急诊室来说，其中一些做法可能是可以报销的。
That is less likely for inpatient units, which are typically paid via a bundled case rate (a fixed payment for the entire inpatient stay) or a bundled day rate (a fixed payment per day of care).
对于住院病房来说，这种情况不太可能发生，因为住院病房通常通过捆绑病例费率（整个住院期间的固定付款）或捆绑日费率（每天护理的固定付款）来支付。
The findings concerning hospitals’ fidelity to the four recommended practices represent a classic misalignment of incentives: the entity that incurs costs (in this case, the hospital) is not always the one that captures the financial benefits (which often accrue to insurers or society at large through avoided future utilization and mortality).
关于医院对四项推荐做法的忠诚度的调查结果代表了一种典型的激励错位：产生成本的实体（在本例中为医院）并不总是获得经济利益的实体（通过避免未来的使用和死亡率，通常为保险公司或整个社会带来经济利益）。
Under existing payment arrangements and legal processes, there is a complex array of incentives that are likely to affect hospital decisions regarding which practices to adopt.
根据现有的支付安排和法律程序，存在一系列复杂的激励措施，可能会影响医院关于采取哪些做法的决定。
Here we briefly summarize some of those incentives.
在这里，我们简要总结了其中一些激励措施。
First , there are downstream costs that are frequently incurred by a hospital .
首先，医院经常产生下游成本。
E ven under bundled payments, hospitals often bear some financial risk , such as readmissions and repeat ED visits .
即使实行捆绑支付，医院也常常承担一些财务风险，例如再次入院和重复急诊就诊。
That is, higher- quality safety planning and follow-up can reduce short-term revisits .
也就是说，更高质量的安全规划和后续行动可以减少短期重访。
Some payment systems penalize readmissions within a 30-day window.
一些支付系统会对 30 天内的重新入院进行处罚。
In addition, e ffective discharge planning can prevent complications or crises that prolong inpatient stays.
此外，有效的出院计划可以预防并发症或危机，从而延长住院时间。
If a significant share of hospital revenues stems from risk-based contracts where the hospital shares responsibility with payers for the cost and quality of care , hospitals do internalize some of the sa v ings from reduced future utilization .
如果医院收入的很大一部分来自基于风险的合同，其中医院与付款人分担护理成本和质量的责任，那么医院确实会将未来利用率减少所节省的部分费用内部化。
Therefore , while the full societal benefit is n’t captured, a slice of it can be , especially as payment models shift toward risk-sharing.
因此，虽然无法获得全部社会效益，但可以获得其中的一部分，特别是当支付模式转向风险共担时。
A second class of incentives is less direct : t hose related to liability and risk management.
第二类激励措施不太直接：与责任和风险管理相关。
Suicide after discharge is a major source of malpractice claims.
出院后自杀是医疗事故索赔的一个主要来源。
Demonstrating use of evidence-based practices , such as the four recommended practices , can reduce legal exposure or strengthen defense s .
展示基于证据的实践的使用，例如四种推荐的实践，可以减少法律风险或加强辩护。
Hospitals often view these practices as a form of risk mitigation investment, even if they are not directly reimbursed.
医院通常将这些做法视为风险缓解投资的一种形式，即使它们没有直接报销。
A “softer” set of incentives concern s reputation and community expectations .
一套“较软”的激励措施涉及声誉和社区期望。
Hospitals, especially nonprofits, have incentives tied to community benefit obligations ( although these are weakly enforced in most states ) , brand trust and public perception , and relationships with local providers (physicians) and stakeholders.
医院，尤其是非营利组织，其激励措施与社区福利义务（尽管在大多数州执行不力）、品牌信任和公众认知以及与当地提供者（医生）和利益相关者的关系相关。
Preventing highly visible adverse events like suicide aligns strongly with these pressures.
预防自杀等高度可见的不良事件与这些压力密切相关。
However , this reputational incentive is blunted by low public awareness: it is not widely known how often suicide follows a recent hospital encounter, nor that most hospitals have yet to implement the practices shown to reduce that risk.
然而，这种声誉激励因公众意识较低而受到削弱：人们并不知道最近在医院发生自杀事件的频率有多高，而且大多数医院尚未实施可降低这种风险的做法。
Greater public visibility into how much more hospitals could do could strengthen reputational pressure to adopt the se practices.
提高公众对医院还可以做多少事情的了解可能会增强采取这些做法的声誉压力。