Quality of Lethal Means Counseling Documentation in the Veterans Health Administration

This study examined the characteristics and quality of lethal means counseling (LMC) action plans documented as part of the Safety Planning Intervention (SPI) carried out in U.S. Department of Veterans Affairs Medical Centers (VAMCs), as well as differences in documentation quality based on patient and clinical characteristics.

Three authors rated 910 LMC action plans abstracted from six VAMCs selected for geographic and facility-level diversity. Ratings, based on the SPI scoring algorithm, range from 0 (no text pertaining to lethal means access reduction) to 3 (highly specific).

LMC action plans received low quality scores (mean±SD=1.29±0.86). Documentation was often vague or reviewed past actions instead of formulating a specific plan for lethal means access reduction. Steps to reduce firearm access were documented in plans for 74% of veterans reporting firearm access (54% of all veterans). Steps to reduce access to medications (20%) and other lethal means (13%) were less frequently documented. Plan text was in veterans' own words, as intended, only 27% of the time. Quality of LMC action plans was rated higher for male versus female veterans, for veterans with versus without documented access to firearms, and for outpatient versus residential and emergency settings.

In this study examining documentation quality of a sample of LMC action plans across a health care system, the average score for quality was low. Findings indicate clinician awareness of firearm risks but less discussion about other lethal means. Future work should develop training and implementation strategies to improve LMC action plan documentation.