Suicide Prevention Toolkit for Rural Primary Care Practices

Primary care providers have an important role to play in suicide prevention. View Toolkit welcome letter to primary care providers.

This Toolkit can be used by all primary care providers, including those in non-rural settings. It contains tools, information, and resources to implement state-of-the art suicide prevention practices and overcome barriers to treating suicidal patients in the primary care setting. You'll find assessment guidelines, safety plans, billing tips, sample protocols, and more.

The Toolkit was developed by the Suicide Prevention Resource Center (SPRC) and the Western Interstate Commission of Higher Education (WICHE) Mental Health Program. The materials offered through this website may be reproduced for use within your practice. Further distribution without the express consent of the Suicide Prevention Resource Center is prohibited.

In addition to this web-based version, the Toolkit is also available as a free PDF, and as a printed booklet available for $25 through the WICHE Mental Health Program. Call 303-541-0311 or contact Jenny Allen ( for more information.

1. Getting Started

As a provider of primary care services you are in a unique position to prevent suicides among your patients. Research tells us that people who die by suicide are more likely to have seen their primary care provider shortly before their death than any other health care professional.

At any given time, between two and four percent of your patients are having thoughts of suicide. They may come to your exam rooms presenting with many different concerns, but the one they may not be telling you about could be the one that will kill them – unless you and your staff are prepared.

Quick Start Guide
Start your suicide prevention journey by checking out the Quick Start Guide. It will walk you step-by-step through the process of seamlessly integrating suicide prevention into your practice.

Office Protocol Development Guide 
Your practice can soon have systems in place that will allow you to intervene effectively without significantly disrupting the flow of patients. After you have familiarized yourself with the entire toolkit, use the Office Protocol Development Guide to establish the roles and responsibilities, as well as the procedures you will follow when your find that a patient is suicidal. If everyone in the clinic knows what he or she is expected to do, the process will be smoother than you might expect

Primary Care Suicide Prevention Model 
This is a one-page overview of the suicide prevention model promoted by this Toolkit. It summarizes the actions needed in the preparatory phase, lists ongoing prevention activities for the clinic and presents a flow chart of the prescribed intervention for patients at heightened risk for suicide.

2. Educating Clinicians and Office Staff

The educational section of this toolkit contains a primer presented in five modules. The first two modules are background material that may be of interest to the entire staff. The third module provides an understanding of general prevention practices that should be implemented to maximally benefit the entire patient population. Modules 4 and 5 are designed to educate clinicians for the specialized suicide prevention roles they will play. Module 4 provides the information necessary to evaluate patients who may be at heightened risk for suicide and to make a clinical assessment of that risk. Module 5 discusses interventions that may be necessary to protect patients from intentionally harming themselves, up to and including making arrangements for involuntary hospitalization. Additional educational resources can be found in the Patient Education Tools/Other Resources section of this Toolkit.

Module 1 – Prevalence and Comorbidity
This one-page learning module summarizes the magnitude of the suicide problem in the U.S. and describes how the vast majority of those cases are associated with one or more mental health or substance abuse problems.

Module 2 – Epidemiology
This one-page learning module summarizes the epidemiology of suicide attempts and suicide deaths in various demographic groups.

Module 3 – Prevention Practices
This four-page learning module discusses general practices that can be incorporated into primary care settings to lower the risk of suicide across their entire patient population. This module should be read and discussed by the entire primary care staff.

Module 4 – Suicide Risk Assessment
This five-page learning module presents a methodology for gathering information about a patient's suicidal thoughts and plans and an approach for assessing the level of suicidal intent. It concludes with pointers for clinical decision making regarding the assessment of risk.

Module 5 – Intervention
This five-page learning module discusses a range of patient management approaches that can be implemented in the primary care setting according to the level of risk.

Click here to download the entire primer in one document.

3. Developing Mental Health Partnerships

The strong association between behavioral health problems and suicide suggests that the majority, though not all, of the patients you evaluate for suicide risk is also in need of mental health care. In many rural areas, accessibility to specialized mental health treatments is limited. Regardless of how far away the nearest mental health care may be, ongoing communication between the primary care provider and mental health clinicians is a key to achieving treatment success. When comprehensive treatment is delivered to patients, recovery becomes an achievable goal in most situations.

Additional resources related to developing these partnerships are available in the Patient Education Tools/Other Resources section of this Toolkit.

Mental Health Outreach Letter
To help build strong, collaborative partnerships between primary care and mental health practices, this Toolkit includes a draft Outreach Letter. This letter may be modified to fit your personal style and circumstances and then sent to providers of mental health services to whom you expect to refer patients.

SAFE-T Pocket Card
This pocket card, designed by mental health experts for mental health professionals contains a guide for assessment of and intervention with potentially suicidal patients and may be included with the outreach letter. You can download the card from the URL above; however, if you would like to order additional professionally printed and laminated, pocket-sized copies of the card, they are available by visiting the SAMHSA Publication Ordering website at:

4. Patient Management Tools

Many concrete and easy-to-use tools are available to assist you and your staff in preventing suicide. This section includes pocket-sized tools to facilitate assessment and intervention with at-risk patients in the office, as well as templates for helping to ensure the patients' safety outside of your office. Also included in this section is one strategy for carefully tracking the status of patients at heightened risk for suicide, an important component of effective suicide prevention.          

Primary Care Pocket Guide
The Pocket Guide for Primary Care Professionals provides a summary of important risk and protective factors for suicide, questions you can use in a suicide assessment, and a decision tree for managing the patient at risk for a suicide attempt. The card is designed to be printed on both sides and folded in quarters to fit easily in the pocket. Additional hard copies are available for $1 each, minimum order of 10, through the WICHE Mental Health Program.

Safety Planning Guide
The pocket-sized safety planning guide reminds clinicians of the most important points to cover in collaboratively developing a safety plan with a patient. The guide was adapted from content developed by the Department of Veterans Affairs.

Patient Safety Plan Template
The Patient Safety Plan Template is filled out collaboratively by the clinician and the patient and then used independently by the patient to help ensure their safety in their day-to-day lives. The Safety Planning Guide (listed above) can be used as a source of questions to ask to facilitate development of the Safety Plan.

Crisis Support Plan
The Crisis Support Plan is used by the patient and the clinician to enlist social support from a trusted friend or relative should a suicide crisis recur. It explains roles that supportive individuals can take to help protect the person at risk for suicide and serves as an informal contract that the designated support person will fulfill these roles. Active support of a friend or loved one is among the strongest protective factors against suicide.

Patient Tracking Log for Patients at Heightened Risk
Patients at risk for suicide should be tracked and contacted periodically to monitor their suicide risk. The period immediately following a suicide crisis, especially after an attempt or hospitalization, is marked by extremely high risk for a suicide attempt. Regular, frequent contacts with these patients, even a brief check-in by phone, can be very protective. This log is one of many approaches that may be taken. Patient record flags may also be used to color code files to designate elevated suicide risk.

5. Billing Tips, State Resources and Policy

Policies, billing procedures, and referral procedures related to suicide prevention in primary care vary significantly across states. Understanding how to bill for mental health services in primary care, how to obtain higher levels of care for individuals at risk for suicide, and where to find information relevant to your state is critical. Learning to successfully navigate these processes will reduce the barriers to mental health service provision within your setting and will enhance your ability to partner with mental health treatment centers when crisis services are needed.

Tips and Strategies for Billing
This brief module provides strategies that billing personnel within primary care practices may use to increase their success in obtaining reimbursement for mental health services.

Template for State Specific Resources and Policy
This template may be used as a guide to direct providers and staff to state-specific behavioral health resources and policies. It includes suggestions for locating information regarding crisis services and inpatient mental health care.

6. Patient Education Tools/Other Resources

This section contains two types of resources: Public Awareness Tools and Additional Resources. Public Awareness Tools are provided to help increase awareness in patients, families, and communities about suicide. Increasing awareness is an important component of addressing the problem of stigma associated with suicidality. The Additional Resources offer more information on suicide prevention and primary care-related topics for providers, patients, families, and community members.

Public Awareness Tools

Catalog of public awareness posters and brochures
This section lists materials you may find useful for posting in your office to promote suicide prevention awareness or for making available to patients in need of information about suicide.

Additional Resources