Implementing the NIMH Clinical Pathway in Rural Appalachian School-Based Health Clinics

Rural Appalachian youth are at disproportionately high risk for suicide and experience significant barriers to health care access. School-Based Health Centers (SBHCs) have the potential to address suicide risk among this underserved population by providing routine evidence-based suicide risk screening, assessment, and

follow-up. The NIMH Clinical Pathway is an evidence-based suicide risk detection and management program that has been found to be effective at addressing suicide risk among urban youth. However, the feasibility and impact of the NIMH Clinical Pathway have not been evaluated in rural Appalachian SBHCs, who face unique

contextual, resource, and cultural barriers to implementation. To address this health care disparity, we propose a pilot hybrid effectiveness-implementation type-1 study that will use mixed methods and a stepped wedge design to adapt, implement, and evaluate the NIMH Clinical Pathway in two SBHCs located in rural

Appalachia. This study will gather data regarding the specific needs of rural Appalachian youth and providers in the SBHC setting, use a Quality Improvement (QI) approach to modify the pathway and tailor implementation, and gather preliminary data on the effectiveness and sustainability of the modified pathway. Data, training

materials, and implementation strategies developed can be disseminated to practices throughout rural Appalachia and will be used to support a future R01 trial of the NIMH Clinical Pathway in these Appalachian settings. This study has the following three aims: Aim 1: To adapt the NIMH Clinical Pathway and tailor implementation to address the unique needs of the rural

Appalachian SBHC care setting and gather preliminary data on its feasibility, appropriateness, and acceptability. Aim 2: To examine the preliminary effectiveness of the adapted NIMH Clinical Pathway compared to Treatment as Usual (TAU) on overall screening and detection rates as well as service and patient outcomes for

youth identified as at risk for suicide. Hypothesis 2a: Overall proportions of screening will be significantly higher during the intervention phase than during TAU and risk detection rates will increase. Hypothesis 2b: Youth receiving the modified NIMH Clinical Pathway will show improvements in service and

patient outcomes (safety planning, follow-up visits, suicidal ideation/behavior, depression, and safety plan/acute care usage) compared to TAU. Aim 3: To identify barriers to and facilitators of implementation and sustainability of the adapted NIMH Clinical Pathway in the rural Appalachian SBHC setting.

This innovative pilot study will address a critical health care disparity by identifying strategies to increase the widespread adoption of an evidence-based suicide prevention program for rural Appalachian youth.