HC-4230 Final

Policy Implementation Plan

for

Graduate Certificate

Healthcare Policy and Regulatory Leadership

Ashley Erin Anderson

University of Denver University College

June 3, 2018

Faculty: Tiffani Lennon, J.D., L.L.M.

Director: Bobbie Kite, PhD

Dean: Michael McGuire, MLS

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Policy Implementation Plan

HB 18-1177 – Youth Suicide Prevention

Developed for:
Office of Suicide Prevention
Colorado General Assembly
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Table of Contents

Introduction and Legislation Background ………………………………………………………………………………… 4

Stakeholders and Engagement Strategies ……………………………………………………………………………….. 5
Objectives and Measurable Outcomes ……………………………………………………………………………………. 6
Evaluation Tools ……………………………………………………………………………………………………………………… 9
Cost Efficiency Analysis ………………………………………………………………………………………………….….…… 12
Looking Forward ………………………………………………………………………………………………………..………….. 15
References ………………………………………………………………………………………………………………………..…… 16
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Introduction and Legislation Background

Between 2010 and 2015, there were 5,881 suicides in Colorado. 835, or 14%, of suicides
were committed by children and young adults between the ages of 10 to 24 (Colorado
Suicide Data Dashboard, 2017). The number of suicides continues to rise every year, and in
2015 and 2016, suicide was the leading cause of death among the same age group.
According to a 2013 Healthy Kids Colorado survey, 21.1% seriously considered or actually
attempted suicide, in the 2015 survey, that number rose to 25.3% (Office of Suicide
Prevention, 2017).

HB 18-1177, Youth Suicide Prevention, was introduced in response to the increase in

suicides by children and young adults, which continues to grow at an alarming rate.
Comprised of three main elements, the overall goal of this legislation and implementation
plan is to reduce the number of suicide attempts and suicides among 10- to 24-year-olds
living in Colorado.

The first component of HB 18-1177 is the development and implementation of a statewide

youth suicide prevention training program. This program is directed towards adults who
have regular interaction with children and young adults, but who have not received any
training specifically regarding youth mental health or suicide awareness and prevention.

The second component of HB 18-1177 is conducting a statewide awareness campaign,

promoting youth suicide prevention resources, including targeted outreach highlighting the
crisis hotline and website.

The third component of HB 18-1177 expands access to mental health treatment. The
current age of consent for outpatient psychotherapy services, without parent or guardian
notification, is 15 years old. Upon passage of HB 18-1177, the age of consent will be
lowered to 12 years old.
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Stakeholders and Engagement Strategies

Numerous stakeholder groups have been identified; those who may be directly or indirectly
affected by the implementation of HB 18-1177, as well as those who will be instrumental in the
execution of the implementation and further management of the enacted legislation. Early
identification of these groups has allowed for relationship building, feedback and input to be
obtained, and increased engagement, support, and “buy in” (D’Angelo, Pullman, and Lyon,
2015) for successful implementation.

The following is a non-exhaustive list of stakeholders for HB 18-1177, Youth Suicide Prevention:
 Children and Young Adults (10-24 years of age) living in Colorado
 Adults living in Colorado, who are non-mental health professionals and regularly
interact with children and young adults (“Gatekeepers”)
 Mental health professionals
 Non-profit organizations focused on mental health and suicide awareness and
prevention
 Elementary, Middle, and High Schools in Colorado
 Digital and Traditional Media Outlets
 Graphic design and print services
 Office of Suicide Prevention staff
 Colorado General Assembly legislators and staff
 Office of Vital Statistics
 Law enforcement and medical examiners/coroners
 Rocky Mountain Crisis Partners staff and volunteers
 Colorado Youth Advisory Board
 Youth Suicide Prevention Workgroup of the Suicide Prevention Commission

Stakeholder engagement is critical for implementation to be successful.

To ensure that stakeholders remain involved in the implementation and continue to be

engaged and supportive of the process, communication channels should be open and utilized
on a regular basis. At a minimum, there should be a quarterly video conference, to report on
the progress being made and share statistics that have been collected, and to discuss
opportunities for improvement and address any issues or problems.
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Objectives and Measurable Outcomes

In order to complete the three primary elements of HB 18-1177, several smaller objectives have
been identified. These objectives have clearly defined, measurable outcomes that build upon
each other to ensure thorough, successful implementation and results.

Objective #1: Approve a Youth Suicide Prevention Training Program/Course and Organization to
Administer Program
A number of suicide awareness and prevention training programs currently exist, however none
of them are specifically focused on both youth suicide and with a target participant of
“gatekeepers.” The Office of Suicide Prevention, in collaboration with stakeholders, will develop
an evidence-based program; information from courses designed by Mental Health First Aid,
American Foundation for Suicide Prevention, and Sources of Strength can be included and
modified as needed. The final training program must include measures to ensure longevity,
such as a connecting with a support network, additional resources and ongoing learning
opportunities, and routine follow-up communication (Donald, Dower, and Bush, 2012;
Shtivelband, Aloise-Young, and Chen, 2015).

A single non-profit organization, that operates statewide and specializes in youth mental health
and/or suicide awareness and prevention, will be chosen to conduct the “gatekeeper” training
courses. This organization will receive annual funding to cover staff and expenses related to
course administration (Colorado General Assembly, HB18-1177, 2018). A formal evaluation
process will take place to determine which organization is best suited for implementation.
Organizations will be evaluated based upon their length of history within Colorado, local and
regional affiliations, experience with conducting training classes, willingness to participate in
creation of additional resources and attend stakeholder events, size of staff and volunteers, etc.

Objective #2: Schedule “Gatekeeper” Youth Suicide Prevention Training Courses

In order to ensure that the training program courses are available statewide, Colorado will be
divided into regions, following the boundaries for State Senate districts. The non-profit
organization should schedule at least one course, preferably two, per month in each of the 35
regions. Each training course offering should seat a minimum of 13 participants and a maximum
of 30-45 participants. A combination of evening and weekend sessions should be available, in
order to draw maximum attendance.

Measurable Outcomes: Program Interest – Course Registration – Actual Attendance

Objective #3: Develop Youth-Friendly Website with Suicide Awareness and Prevention
Resources
In Colorado, searching online for help in a crisis or for informational resources regarding mental
health and suicide awareness and prevention yields a variety of sites, but none are tailored
specifically towards youth and young adults. Existing sites are often hard to navigate, or contain
extraneous (though important) information, including research articles and statistics.
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The Colorado Department of Public Health and Environment will coordinate with the Colorado
Youth Advisory Board and the Youth Suicide Prevention Workgroup of the Suicide Prevention
Commission, to develop a youth-friendly, bilingual website (Colorado General Assembly, 2018;
Colorado Legislative Council Staff, 2018). The site should include easy to find and plain-language
information resources, available in text, audio, and video formats. Multiple links to crisis hotline
services, including the chat and text functions, should be highlighted on every page, and
directly integrated when possible.

In order to boost clicks, views, and visits, part of the awareness campaign should be allocated
to website redirects, keyword and search term sponsored links.

Measurable Outcomes: Unique and Repeat Clicks and Views (IP Addresses), calculated monthly
and annually – Time Spent on Site – Resource Views and Downloads

Objective #4: Increase Text-Based Crisis Hotline Services

In an effort to appeal to younger users, and their preferred method of communication, the
crisis hotline will expand their text-based services. Currently, chat and text messaging with crisis
hotline staff is only available during limited hours and certain days of the week. Implementing
HB 18-1177 requires doubling the of text-based services, and increasing the staff that covers
those services, so that they can be accessed by those in need 24 hours a day, 7 days a week
(Colorado General Assembly, 2018; Colorado Legislative Council Staff, 2018).

Measurable Outcomes: Calls Received – Texts Received – Chats Initiated – Duration of

Interaction – Day and Time of Calls/Texts/Chats

Objective #5: Plan, Coordinate, and Execute Statewide Awareness Campaign

Awareness campaigns for other state-funded initiatives have typically been planned and
financed in two-year phases (Colorado Legislative Council Staff, 2018). Working in conjunction
with stakeholders, legislators, and local and regional media outlets, as well as with new media
and digital media consultants, a 24-month campaign should be outlined. The awareness
campaign will have two target audiences, children and young adults and “gatekeepers,” and
different approaches to outreach for each. The emphasis will be on the training program
availability for “gatekeepers,” while the promotion of the crisis hotline and resource website
will be the primary focus of youth outreach.

Radio, print media, and television should include advertisements targeted towards
“gatekeepers,” while advertisements targeted to children and young adults should be on digital
and new media platforms, such as pre-play ads on Pandora, Spotify, YouTube or in-game ads on
mobile applications. Paid social media advertisements should also be included in the awareness
campaign plan, with microtargeting to ensure maximum exposure to both “gatekeepers” and
youth target audiences. Additional awareness efforts can come from free media, such as social
media posts crafted for maximum organic engagement, or op-ed articles in local and regional
digital and print newsletters, magazines, or newspapers.
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Measurable Outcomes: Email Opens – Video Views & Shares – Article Views & Shares – Post
Views, Likes, & Shares – Link Clicks – Program Registration – Website Referals
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Evaluation Tools

Gatekeeper Behavior Scale

 The Gatekeeper Behavior Scale was designed to measure the effectiveness of gatekeeper
training programs (Albright, Davidson, Goldman, Shockley, and Timmons-Mitchell, 2016),
and it can serve two functions in evaluating the effectiveness of the implementation of the
Youth Suicide Prevention legislation.

First, when designing the suicide prevention training programs, the Gatekeeper Behavior
Scale should be utilized to critique possible methods and tools and determine which would
have the greatest impact and longevity, conveying information in the best possible way.

Second, the Gatekeeper Behavior Scale should be utilized in follow-up surveys that
participants in the training program take immediately following the conclusion of the
course, as well as six-month and at least one year after. These follow-up surveys, with
questions sampled from the Gatekeeper Behavior Scale, will help evaluate the longevity of
the training program, which is a crucial measure of its effectiveness (Albright, Davidson,
Goldman, Shockley, and Timmons-Mitchell, 2016; Shtivelband, Aloise-Young, and Chen,
2015; Strunk, King, Vidourek, and Sorter, 2014).

Data Collection
 Colorado Violent Death Reporting System
 Standardized Suicide Death Investigation Form
The Office of Vital Statistics has collected data on the number of suicides, including
demographics and detailed information related to methodology, etc., over several previous
years. This information will continue to be collected and entered into the system and
dashboard, and can be analyzed and compared, as the implementation of the legislation
progresses, to evaluate its effectiveness. If the legislation has its desired impact, there will be a
significant decrease in the number of suicides of people between ages 10 to 24 years old.

Additionally, the standardized Suicide Death Investigation Form has been introduced to coroner
and medical examiner’s offices, as well as law enforcement agencies, as a way to regulate the
information that is collected regarding suicides and ensure that it is more consistent (Office of
Suicide Prevention, 2017). Promoting the use of this form will help increase the accuracy of the
data that is collected.

 Rocky Mountain Crisis Partners (RMCP)

RMCP is currently responsible for the statewide suicide prevention hotline, as well as for
fielding calls from Coloradoans to the National Suicide Prevention Lifeline (Rocky Mountain
Crisis Partners, 2016). In addition to providing the staffing resources for the hotline and
assisting callers, they will be responsible for collecting data related to the hotline. There is some
data that is already being collected, such as the number of calls to the hotline, and again, this
will be used to establish a baseline for prior to the legislation’s implementation and should
continue to be collected after the implementation occurs. However, there is additional
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information that should be collected as well, some general demographic information and some
of which will be in the form of survey questions (but all will only be asked if appropriate, after
help has been administered and the imminent crisis has been addressed).
 How many calls to the hotline?
 Where/How did you hear about the hotline?
 Have you called the hotline before?
 Have you sought help outside the hotline?
 Have you utilized any of the suggested resources?

 Training Program Non-Profit Organizations

Data collection in regards to the training program participants will not be quite as in-depth or
large-scale as the other components. Information will need to be tracked on how many people
were given information about the availability of the training program opportunities (including
contacts through the advertising campaigns), the number of people who sign up and register
for a training course, and the number of people who actually attend and participate in the
training program course. There may be a significant drop off between the number of people
who are aware of the program and those who register, or the number who register may be
high, but very few actually attend, and that would be problematic, and a sign that there would
need to be a change in the implementation of that component, in order to increase its
effectiveness.

Surveys and Questionnaires

 Conducted before awareness campaign starts, and again after, over predetermined periods

 Surveys of general population, grouped by state senate districts, to give regional breakdown
of results and analysis
 Smaller than Congressional districts, but larger than state house districts

 Surveys of children and young adults, ideally conducted in person (paper or digital) at
schools, grouped by school district
 Able to be broken down further, by schools or grade level, for further analysis and
comparison

 Representative samples, randomly chosen, and called to participate in the survey – will
need to call several times the number of participants needed, in order to get a large enough
response rate

 Survey regarding about public attitudes about mental health and suicide awareness and
prevention (Kohls, Coppens, Hung, Wittevrongel,l Van Audenhove, Koburger, Arensman,
Szekely, Gusmao, and Hergel, 2017)
 Responses can be used to help evaluate the public’s response to the awareness
campaign, as well as what informational resources should be highlighted
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Surveys and questionnaires will be conducted by a variety of stakeholders. The non-profit

organization conducting the training program will distribute and collect the survey immediately
after the course concludes. The follow-up survey will be conducted by the Office of Suicide
Prevention. School employees and staff will be utilized to assist with distributing and collecting
surveys from their students (with district and/or parent approval). The staff and volunteers at
Rocky Mountain Crisis Partners will be responsible for obtaining responses from surveys and
questionnaires pertaining to their services.

All the responses and information received from survey responses will be collected, analyzed,
and circulated in reports by the Office of Suicide Prevention.
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Cost Efficiency Analysis

Allocated and Estimated Funding

2018-2019 FY 2019-2020 FY
Public Awareness Campaign* $600,000 $600,000
Training Contractors $54,000 $54,000
Website Development & $25,000 $3,000
Maintenance
Crisis Hotline Contractor Staff $400,000 $400,000
Personal Services (CDPHE $18,838 $20,550
Staff)
*Funding for Public Awareness Campaign removed from final Fiscal Note, will need to be financed through
alternative sources

Training Program Cost Efficiency

According to the Fiscal Note for H.B. 18-1177, it will cost approximately $54,000 annually to
fund the staff, materials, and other miscellaneous costs associated with providing suicide
prevention courses to the community.

For the purposes of ensuring the program is implemented statewide, training regions will be
divided along the 35 State Senate district boundaries. Each region will have approximately
$1,543 to utilize for the training courses each year, or approximately $130 per month.

Mental Health First Aid Colorado currently offers suicide prevention and mental health
awareness courses, similar to what this legislation requires. Most courses are provided free of
cost to participants, but of the course options that require a payment, fees range from $5 to
$20 per person. These fees cover the cost of the workbook, and often go towards lunch, snacks,
or beverages during the training session (Mental Health First Aid Colorado, 2018).

The training program course provided through the non-profit chosen for H.B. 18-1177 will offer
a break for participants to bring their own meals/snacks and/or the opportunity for them to
retrieve their own lunch, allowing those funds to be redirected to cover the cost of materials
and staff.

If each training region offered at least two courses per month, and each course had at least 13
participants, the cost per participant would be approximately $.63 per hour. For larger course
sizes, up to a maximum of 30 participants, the cost per participant would be approximately $.27
per hour.

The funding allocated does not provide much coverage in the way of covering materials, travel,
and wages for training staff. One the schedule has been determined, and quotes are received
from local union printing organizations for course materials, additional funding from private
sector organizations or grants, will need to be obtained, in order to subsidize the operational
costs.
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Crisis Hotline Cost Efficiency

Rocky Mountain Crisis Partners, the organization responsible for staffing the Colorado Crisis
Services hotline, handled approximate 90,000 calls, chats, and texts during the 2015-2016 fiscal
year (Rocky Mountain Crisis Partners, 2017), and average 5,900 calls per month between March
2015 and May 2016 (Colorado Health Institute, 2016).

During the 2015-2016 fiscal year, according to their annual report, Rocky Mountain Crisis
Partners had $3,021,692 in program expenses. According to the most recent fiscal note, RMCP
has an annual budget of $2.2 million for their 54 current staff members and the services they
provide (Colorado Legislative Council Staff, 2018).

The fiscal note states that, in order to expand the text-based services of the crisis hotline, both
text and chat functions, an additional 7 staff members must be hired, and allocates an
additional $400,000 in funding to cover their salaries and expenses (Colorado Legislative
Council Staff, 2018).

Based off the 2016 annual report figures, it cost approximately $25 per crisis line interaction
(including follow-ups), and each staff member handled approximately 2,250 interactions.
90,000 calls, texts, and chats, 35% (31,500) had scheduled follow ups (121,500 total estimated
interactions) (Rocky Mountain Crisis Partners, 2017).

With the allocated funding for text-based service expansion, an additional 16,000 interactions
(approximately) will be covered, at current cost levels. ($25 per interaction). Since text-based
interactions may not be as critical, last as long, be as in-depth, or require as much additional
follow-up, estimates for price per interaction can be lowered by one third to one half. Based on
those estimated cost-levels, the text-based funding allocation can cover between an additional
23,880 interactions (one-third lower, $16.75 per interaction) and an additional 32,000
interactions (one-half less, $12.50 per interaction). The 7 new hires, dedicated staff to the text-
based services (Colorado Legislative Council Staff, 2018), will handle an estimated 2,286-4,571
interactions per person annually.

After speaking with Josh Larson, the Clinical Operations & Quality Assurance Specialist for Rocky
Mountain Crisis Partners, by phone, additional information was obtained. In 2016, a total of
147,404 contacts were handled by the state-funded crisis line, text, and chat services, and in
2017, that number increased to 170,558 contacts. Those numbers represent both incoming and
outgoing interactions. RMCP expects the number of contacts in 2018 to increase as well.

Based on those statistics, the price per interaction significantly decreased, to approximately $17
in 2016 and $15 in 2017. In an immediate crisis, or for short-term assistance, the cost per
interaction is significantly lower than outpatient or inpatient treatment, and substantially lower
than the cost of an emergency room visit (National Institutes of Health, 2017). Utilizing the
crisis hotline services, either voice or text-based, should not be a replacement for long-term
mental health treatment services.
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Website Cost Efficiency

Unfortunately, information regarding the number of monthly and annual visitors to the
Colorado Crisis Services website was not available. (Ricki, the contact that has that information
for RMCP was out of the office during the time of inquiry.)

A similar website, with the goal of decreasing the number of suicides among working age men,
www.mantherapy.org, did provide such information to the Colorado Office of Suicide
Prevention Annual Report. During the 2016-2017 fiscal year, there were 12,052 visitors to the
site from Colorado, and site visits averaged approximately 3.5 minutes (Office of Suicide
Prevention, 2017).

With $25,000 allocated for the creation of the website, and an annual maintenance and upkeep
budget of $3,000 (Colorado Legislative Council Staff, 2018), it is possible to approximate the
cost per visit and cost per minute on site. If the youth-friendly website required by the
legislation receives an average of, 15,000 to 20,000 visits per year, it would cost $1.25 to $1.67
per visit in the first year, and $.15 to $.20 per visit the following year. If visitors spend an
average of 3 to 5 minutes on the site, that would equal approximately 45,000 to 100,000
minutes spent on the site, with an estimated cost of $.25 to $.56 per minute in the first year,
and $.03 to $.07 per minute the following year.
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Looking Forward

Like all public policies and legislation, frequent evaluation and adjustments will be necessary for
long-term success. Continuation of the preventative elements that comprise HB 18-1177
requires proven impact and positive change, which will also improve the odds for sustained
funding.

During the initial phase of the implementation, funds have been allocated through government
resources, primarily the General Fund, but not every objective can be met within the funds
provided (Colorado Legislative Council Staff, 2018). Outside resources will have to be utilized,
such as applying for grants from federal government and private benefactors, to cover the
remaining expenditures.

Evaluations and measurements should be conducted on a routine basis, monthly at a minimum,

and then quarterly and annually. Stakeholders should be brought in to give feedback, opinion,
and advice on elements that have been enacted, and suggestions for further work.

If the implementation the prescribed programs and objectives are successful, and there is a
measured decrease in the instances of suicide attempts and suicide among children and young
adults in Colorado, this legislation and its execution could serve as an example and/or pilot for
similar legislation in other states or even at a federal level. Successful implementation tactics
could also be applied to other suicide prevention initiatives for other demographic groups.
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References

"2016 Annual Report." Rocky Mountain Crisis Partners.

http://www.metrocrisisservices.org/library/FY_2016_Annual_Report.pdf.

Albright, Glenn L., Jesse Davidson, Ron Goldman, Kristen M. Shockley, and Jane Timmons-
Mitchell. 2016. "Development and Validation of the Gatekeeper Behavior Scale." Crisis: The
Journal of Crisis Intervention and Suicide Prevention, 37(4), 271-80. doi:10.1027/0227-
5910/a000382.

Calear, Alison L., Philip J. Batterham, and Helen Christensen. 2014. "Predictors of Help-seeking
for Suicidal Ideation in the Community: Risks and Opportunities for Public Suicide Prevention
Campaigns." Psychiatry Research, 219(3), 525-30. doi:10.1016/j.psychres.2014.06.027.

Colorado Department of Public Health & Environment. Office of Suicide Prevention. Office of
Suicide Prevention Annual Report 2016-2017.2017.
https://www.colorado.gov/pacific/sites/default/files/PW_ISVP_OSP-2016-2017-Legislative-
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Colorado General Assembly, Youth Suicide Prevention, HB18-1177 (2018)

http://leg.colorado.gov/sites/default/files/documents/2018A/bills/2018a_1177_01.pdf

Colorado Legislative Council Staff. HB18-1177 Fiscal Note.

(1) http:/leg.colorado.gov/sites/default/files/documents/2018A/bills/fn/2018a_hb1177_00.pdf
(2) http:/leg.colorado.gov/sites/default/files/documents/2018A/bills/2018a_1177_eng.pdf
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Ramchand, Rajeev, Lisa H. Jaycox, and Patricia A. Ebener. "Suicide Prevention Hotlines in
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"Suicides in Colorado: An Overview." Colorado Suicide Data Dashboard. 2017.

https://cohealthviz.dphe.state.co.us/t/HSEBPublic/views/CoVDRS_12_1_17/Story1?:embed=y&
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