MCW Comprehensive Injury Center - Community Academic Partnerships

Each day across the United States, an average of 20 veterans or active military members die by suicide. In Wisconsin, the most recent report on the impact of suicide found that from 2013 to 2017, veterans accounted for almost one out of every five suicide deaths.

“It’s a significant number – and we know that there may be even more deaths by suicide of people with prior military experience that the data we have isn’t capturing,” said Brian Michel, director of prevention services at Mental Health America of Wisconsin and program director of the R&R House, a peer-run respite for veterans that will open this fall.
For Michel and his colleagues working in prevention, good data is critical, helping to produce a comprehensive picture of an issue and identifying where to take action.

“We really need to better quantify and describe the burden of veteran suicide in Wisconsin,” said Sara Kohlbeck, assistant director of the Medical College of Wisconsin’s (MCW) Comprehensive Injury Center, and one of the lead epidemiologists on the recently published “Suicide in Wisconsin: Impact and Response” report released by the Wisconsin Department of Health Services, Mental Health America of Wisconsin, and the MCW Comprehensive Injury Center.

The report uses current data to paint a picture of the burden of suicide across the state, and calls for a comprehensive approach to prevention that includes improved data in critical areas.

Together, Michel and Kohlbeck are working to do just that by gathering a network of partners across the state to build evidence that will help shape efforts to prevent veteran and active-military deaths by suicide. The collaborative project, called “Remembering the Lost,” will begin in October 2020 with the support of a $399,771 AHW grant.

The project adds to the more than $1.8 million AHW has invested in community-led approaches to preventing death by suicide in Wisconsin, and is one of seven funded through an AHW grant opportunity designed to help community-academic partnerships gather data to inform policies, programs, and practices that can improve health in Wisconsin.

“If we can improve data, identify gaps in the systems, and understand the life circumstances that are contributing to death by suicide among veterans, we can then push prevention and help upstream so that people aren’t even getting to the point of suicidal ideation, suicide attempts, or death by suicide,” said Kohlbeck.

The project will combine novel approaches, including working with Wisconsin’s medical examiners and coroners to identify opportunities to standardize data collection of veteran status, map available support services with access points and eligibility requirements to understand strengths and gaps in how veterans may access services, and conduct interviews with friends and family to examine the psychological and socioeconomic factors in the lives of veterans before their deaths.

Alongside that work, they will make a unique comparison in cases: Looking at the veteran’s discharge status.

“Making a comparison between folks who were honorably discharged and those with other discharge ratings may help us identify an important gap in information,” said Kohlbeck, who noted that a veteran’s discharge status impacts the services and health care they have access to within the Veterans Administration.

“National statistics show that about 14 of the 20 veterans that die by suicide each day are not enrolled in VA health care. The big question is: Why?” said Michel. “Were they not eligible? Did they choose not to go to the VA because of a bad experience? Had they sought care, but it wasn’t what they were looking for? The path to navigate veterans benefits is complex and can be even more challenging for those living with suicidal ideation.”

Understanding this information will help Michel, Kohlbeck, and their team identify gaps in what resources and health care are currently available.

“Ultimately, the long-term goal is to prevent suicide among veterans,” said Kohlbeck. “Suicide is 100 percent preventable.” If you or someone you know needs help, support is available.

The National Suicide Prevention Lifeline is available at 1(800) 273-8255 (TALK). For service members, veterans, and their families needing non-crisis support, call the R&R House Warmline at (262) 336-9540.

View a list of Wisconsin County Crisis Lines.

In the Fox Valley region of Wisconsin, suicide rates have increased 66% over the last decade. Suicide rates are highest among middle-age men, individuals in certain professions, veterans, and the LGBT community. Local health and behavioral health care systems lack the tools and capacity to properly manage patients who are at risk for suicide. In addition, nearly 50% of mental health care providers in the region feel they lack adequate training to manage suicidal patients.

Through this award, project partners aim to reduce the rate of suicide in the tri-county region by implementing a Zero Suicide framework to improve the ability of the health care systems beyond psychiatry, as well as and non-clinical systems, such as workplaces, to support individuals in crisis and prevent suicide.

Community partners:
NEW Mental Health Connection's Zero Suicide Initiative, Samaritan Counseling Center, Zero Suicide Initiative, Ascension, ThedaCare, UW-Madison Division of Extension Winnebago County.

Project Updates:

• Created the Early Warning System, real-time monitoring of law enforcement calls for service related to suicidal ideation and attempts, mental health crisis and completed suicides, and was initiated due to anecdotal evidence of an increase of calls to law enforcement for mental health/suicide crises after the COVID-19 pandemic hit.
• Formed collaborative partnerships with local law enforcement, County Crisis Services, and Coroner’s Office.
• Formed a multi-disciplinary steering committee who developed what the ideal system response to mental health/suicide crisis could look like-less transactional and more humanitarian .
• Innovated during COVID through the creation of the ideal system response which includes recommendations for mobile crisis; the hiring of a Mental Health Navigator to manage tracking/scheduling of same/next day appointments with community mental health providers; recommendations for Emergency Department workflow redesign as it relates to treating mental health/suicide crisis; involvement and inclusion of certified peer specialists and utilization of peer run respite instead of inpatient treatment as the only option.

Suicide remains a major public health issue. In 2015, 874 Wisconsinites died by suicide. Fond du Lac County's suicide rate has been higher than the Wisconsin rate, and this project aims to reduce suicide among all Fond du Lac residents with a targeted effort to reach men in the middle years. Project partners will implement policies and practices in health and behavioral health care organizations and select non-clinical settings to impact working-aged adults, especially middle-aged men, and reduce the rate of suicide and self-injury in Fond du Lac.

Community partners:
Mental Health America of Wisconsin, Agnesian HealthCare, Envision Greater Fond du Lac, Fond du Lac County Veterans Service Office, Fond du Lac County Department of Community Programs, Marian University.

Project Updates:
Hosted two-day training with nearly 50 attendees representing 18 local organizations, including institutions of higher learning, school districts, county agencies, and direct care/support organizations. Evaluation results indicated that 93.3% of participants felt they had a better understanding of how to develop a comprehensive, system-wide approach to suicide care in their organization as a result of the training.

The Comprehensive Injury Center (CIC) partners with community-based coalition to reduce underage drinking and its consequences in La Crosse County.

Between 1998 and 2008, nine young men drowned in the nearby Mississippi River as a result of alcohol overuse with BACs as high as 0.41 (5 times the legal limit). The Changing the Culture of Risky Drinking Behavior Community Coalition is a community-academic partnership between the Injury Research Center (IRC) and the La Crosse Medical Health Science Consortium (LMHSC). LMHSC is a partnership of two medical systems and three schools of higher education formed in response to those drowning deaths.Changing the Culture of Risky Drinking Behavior

In 2007, the LMHSC-IRC community-academic partnership received a planning grant from the Medical College of Wisconsin’s Healthier Wisconsin Partnership Program (HWPP) to assess the community's culture and develop a strategic plan for addressing alcohol-related injury and death among 12-24 year-olds. This grant led to the Coalition’s initial formation. The planning grant resulted in a report on the burden of alcohol-related injury in La Crosse County, a compilation of community assets for alcohol-related injury prevention, and a Strategic Plan that identified underage access and binge drinking as the major issues leading to the prevalence of injury in the community.

In 2009, the same year that La Crosse County ranked 4th worst in the state for binge drinking among 18-25 year olds, the community-academic partnership received 3 years of funding from the HWPP to focus on reducing underage access to alcohol. Activities led to changes in alcohol-related practices in La Crosse County such as best practices being adopted by community festivals, more alcohol servers seeking and receiving training in Responsible Beverage Service, additional alcohol compliance checks by law enforcement, parents of at-risk youth attending Strengthening Families sessions with their children and learning about safer practices related to alcohol in the home, and youth getting involved in alcohol awareness in their schools and communities.

In 2012, the community-academic partnership will continue its work with an additional 5 years of funding from the HWPP to create a sustainably safe environment for alcohol consumption. This will be accomplished through improvements in the delivery of evidence-based practices such as Responsible Beverage Service training and the Parents Who Host Lose the Most campaign; changes in local alcohol licensing policies; practices on college campuses, in taverns, and at festivals; and education for current and future leaders in community collaboration. The IRC’s assistance and experience with alcohol policy change, evaluation, and dissemination, will help lay the groundwork for permanent changes in the culture of risky drinking behavior of La Crosse County. The IRC is also helping to develop models of success that can be replicated in communities across the state and nation.

No greater tragedy exists than the loss of a child; an event that often can be prevented. Each year, more than 600 deaths occur to children under age 18 in Wisconsin. Over one-quarter of these deaths are due to injury. Child death review (CDR) teams are multidisciplinary groups of experts charged with determining all risk factors and circumstances leading to the child’s death in an effort to generate recommendations for preventing future deaths. In 2008, Keeping Kids Alive in Wisconsin received a three-year implementation grant from the University of Wisconsin Partnership Program to begin building a sustainable CDR program in each of Wisconsin’s 72 counties. Grant partners include Children’s Health Alliance of Wisconsin, Wisconsin Department of Justice, Wisconsin Department of Health Services and the Injury Research Center at the Medical College of Wisconsin.

Keeping Kids Alive in Wisconsin had three objectives:

• The first objective was to provide assistance to 30 Wisconsin counties to develop CDR teams. Over the course of the grant, 39 CDR teams were created or restructured, while an additional 14 counties expressed interest in implementation.

• The second objective was to facilitate data collection and participation in the National Case Reporting System for Child Death Review. Over 70% of teams entered data into the system.

• The final objective of the project was to develop recommendations and establish governing policy and sustainability for implementation by state leaders for a model CDR system in Wisconsin. To address implementation barriers reported by local teams, partners created a legislative framework to enable formation of local CDR teams. This framework is currently at the Legislative Reference Bureau for drafting The Injury Research Center was instrumental in achieving all three objectives by developing webinars and training tools to facilitate data entry and improve data quality, as well as working with local teams in using data to create recommendations for prevention. The grant allowed partners to build a comprehensive CDR program that enabled local communities to learn from child deaths and use meaningful data as a catalyst for prevention.

The Injury Research Center was instrumental in achieving all three objectives by developing webinars and training tools to facilitate data entry and improve data quality, as well as working with local teams in using data to create recommendations for prevention. The grant allowed partners to build a comprehensive CDR program that enabled local communities to learn from child deaths and use meaningful data as a catalyst for prevention.

One issue that emerged at both the national and state levels during the grant period was infant safe sleep. Over half of child deaths in Wisconsin occur in those aged less than one year. Of those infant deaths in the Case Reporting System, one-third were classified as “sleep-related”. Fetal Infant Mortality Review (FIMR) is a review process which focuses on infant and stillbirth deaths. Like CDR, FIMR teams review risk factors and circumstances surrounding the infant death in order to prevent future deaths. In 2011, the partners convened with the Milwaukee County Fetal Infant Mortality Review Team leadership to develop Preserving Infant and Child Health. The goal of this project was to build upon the success of Keeping Kids Alive and reduce the burden of infant and child mortality utilizing both the FIMR and CDR processes in five pilot counties across the state. FIMR and CDR currently exist as two separate review systems, lacking formal collaboration and communication. The combined use of FIMR and CDR in counties could have a greater chance for improving health outcomes for problems like unsafe sleep environment deaths. The partners received three years of funding to implement Preserving Infant and Child Health from the University of Wisconsin Partnership Program in 2012.

Collaborative effort of the Comprehensive Injury Center (CIC) and Kenosha County Division of Health increases education and awareness to prevent suicide.

Suicide was the second leading cause of injury death in Kenosha County according to the Injury Research Center’s 2006 Burden of Injury in Wisconsin report. This, in addition to a sudden increase in adolescent suicides, led Kenosha County to form a suicide coalition with guidance from the Injury Research Center at the Medical College of Wisconsin through the Wisconsin Injury Prevention Coalitions (WIPC) project funded by the Healthier Wisconsin Partnership Program in 2005. The project worked to reduce the burden of unintentional and intentional injuries in Wisconsin by facilitating the translation of injury prevention research into the implementation of evidence-driven, community-based programs and policies. The academic and state health department partners supported local health department-based community coalitions through technical assistance, best practices guides, evidence-based research, and direct consultation in all aspects of coalition development and management, as well as development, implementation, and evaluation of the program, policy, or practice. In turn, coalitions identify priority areas of injury to address based on community priorities and resources and then select and implement an evidence-based Kenosha County Suicide Prevention injury prevention program. The Kenosha County Suicide Prevention Coalition was one of the five coalitions funded as part of this project.

At the conclusion of The WIPC project, the Injury Research Center and the Kenosha County Division of Health collaborated to further develop suicide prevention in Kenosha County. The result was an initiative to prevent suicide and non-fatal suicide attempts through increased education and awareness and decreased access to lethal means. This three-year project was funded by the Healthier Wisconsin Partnership Program in 2008. Successes of the initiative include coalition growth, resource development, coordinated mental health services, initiation and sustainability of Question-Persuade-Refer trainings and the implementation of several means restriction activities through community agencies and emergency departments. As a result, suicide rates in Kenosha declined from 18.51 in 2007 to 11.01 in 2009. The rate of ED visits in 25-64-year-olds decreased significantly in Kenosha during 2008-2009 compared to the remaining WI counties. Data analysis for the second half of this project is forthcoming to see if these promising results were sustained over time.

While the proportion of suicides involving firearms was lower in Kenosha than Wisconsin for 2005-2009, the proportion of suicides involving poisoning was higher in Kenosha than Wisconsin for the same time frame. Additionally, unintentional poisoning moved from the 4th leading cause of injury deaths in Kenosha County in 2006 to leading cause of injury death in Kenosha County in 2011 according to the Injury Research Center’s Burden of Injury in Wisconsin reports. In light of this new data, the partnership developed three new objectives: Prevent access to methods of self-harm, with a focus on poisoning; Expand prevention efforts through coalition expansion and formation of a suicide death analysis review team; and Increase identification, referral and treatment of persons at risk for suicide and self-harm. The partnership received an additional five years of funding from the Healthier Wisconsin Partnership Program to begin work on these objectives in 2012.