This project was initiated by the Country SA PHN (CSA PHN) under the National Suicide Prevention Trial.

The CSA PHN worked with the Black Dog Institute on a series of community forums in the Port Augusta area as it had a relatively high Indigenous suicide rate and its population – 14,000 people from 27 language groups – meant there was ‘critical mass’ to evaluate a new approach.

Community consultations in 2017 indicated people were keen for follow-up services for people leaving hospital after a suicide crisis, identifying this as a gap in local services.¹

An Aboriginal working group was established in collaboration with the local community, including people with lived experience and representatives from the local health network and Aboriginal Community Controlled Health Organisation (ACCHO). The group spent eight months documenting the co-design process and developing a model, followed by four months of stakeholder consultation.

CSA PHN commissioned the Pika Wiya Health Service Aboriginal Corporation to deliver the Aboriginal Aftercare Service in Port Augusta. Pika Wiya Health Service Corporation recruited an aftercare team comprising the clinical team leader, who is a social worker, and two Aboriginal health workers. The aftercare team sits within the social and emotional wellbeing team (SEWB) and has internal supports from a psychologist and visiting psychiatrist.

Research shows that a previous suicide attempt is one of the strongest predictors of a further attempt. In order to reduce the likelihood of a further attempt, a coordinated plan is required for those survivors of that initial attempt. This requires immediate intervention and individualised care and referral after discharge and throughout the next 3 months.

The consultation process² revealed that the aftercare service needs to include:

• a recognition of the importance of community
• appropriate service funding, delivery availability and resourcing
• implementation in a culturally safe manner including an evaluation of the design
• recruitment of support staff who have trauma experience and lived experience
• Ability to extend client care past 3 months to 6 months, to provide a culturally safe service where there is increased complexity in presentation.
• traditional healers, social and emotional wellbeing support and Aboriginal leadership
• recognition by Western medical practitioners and providers of the existing cultural expertise, mentoring and leadership within the Aboriginal community and,
• the integration of medical, mental health and other services.

Additionally, the Aboriginal working group recommended² that the design should include:

• face to face contact while in the hospital emergency department
• culturally respectful communication
• the importance of cultural and spiritual factors when considering treatment options
• involving family for background information and assistance in the assessment, care planning and treatment processes and,
• providing social and emotional well-being support to family and community, inclusive of children.

The program has drawn upon the Black Dog Institute’s Guidelines for Integrated suicide-related crisis and follow-up care in Emergency Departments and other acute settings as a guide for developing the Aboriginal Aftercare Service Design.² The working group  recommend that these guidelines be reviewed after 12 months of service delivery, and adapted or changed to reflect new learnings. The Aftercare Service comprises seven non-hierarchical interventions. These are:

1. Brief contact interventions

This is a non-clinical intervention which uses minimal intrusion activities such as telephone calls, text messages to encourage help-seeking behaviours which are helpful in reducing the frequency of suicide attempts.

2. Coordinated assertive aftercare:

This intervention contains five distinct processes. These are:

• face to face contact – during the stay in the emergency department, the person is met by the service provider
• assertive follow-up – the person is met again by a service provider within 24 hours of discharge
• ongoing risk assessment and planning – a safety plan is developed with the individual’s goals and encourages safety in daily life
• encouragement and motivation to adhere to treatment – this is to reduce the barriers to further care where follow-up appointments are managed to ensure that the person connects with appropriate health and other social support services and,
• problem solving and solution focussed counselling – this includes intensive contacts through face-to-face or electronic communications

3. Brief therapy combined with brief contact interventions

A more structured intervention consisting of narrative therapies to help the individual better understand the factors that have led to the attempt. This may be one to ten brief contacts with an appropriate person such as a counsellor or psychologist using a person-centred narrative therapy.

4. Combined clinical and non-clinical models of care

Using the individual’s family or other care givers, including friends, the brief contacts are to help the individual gain a sense of belonging in the community and with his or her family. This would include appropriate activities to help the person connect to culture, community and country.

5. Post-discharge plans and primary health care

Intensive follow-up plans are established along with a safety plan for the individual in conjunction with the person’s family and care givers. Established medical practitioners are also included in this intervention.

6. Coordinated support to utilise available services

A case manager ensures that the individual is able to access and attend culturally appropriate post-care services for health management as well as reconnect with friends, family and the community.

7. Providing support for caregivers and recognising their role

Friends and family of the individual benefit from ongoing support for chronic mental health issues. These people who are supporting the person receive culturally appropriate education, upskilling and capacity building.

Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.

A complementary document for the admitting hospital’s emergency department are the Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.⁴ These guidelines consist of six steps for urgent care, clinical assessment and discharge. Briefly, these are:

1. Triage and notification to the Suicide Response Team or Mental Health Team

This involves stabilising the patient and offering to notifying friends, family or carer.

2. Comprehensive Psychosocial Assessment

The Comprehensive Psychosocial Assessment (CPA) is a broad assessment of a person’s mental, physical and emotional health, as well as their ability to function in the community. It covers assessment of suicidality, medical/ mental health assessment and history, coping resources and support and the ability to recover in the community. Importantly, the CPA is an opportunity to build rapport and show compassion and understanding.

3. Treatment care plan – inpatient and/or outpatient

Draft of treatment plan prepared and the individual is informed of various options for care.

4. Arrange referral and follow-up services

Aftercare providers finalise the plan and gain consent from the individual for personal information to be shared with service providers. Referrals and appointments are then arranged for 24 to 72 hours after discharge.

5. Discharge Care Plan

This plan includes an explanation of the plan as well as recommendations for treatment and support, relapse prevention and emergency contact details. The patient is discharged with medications and service provider contacts. Aftercare staff arrange for client transport a referral to supporting services by telephone.

6. Follow-up care and case management

This step is described in the Aboriginal Aftercare Service Design which is briefly described above.

The project has produced two sets of guidelines – for use in the emergency department at Port Augusta Hospital and for the community mental health team. These are the Aboriginal Aftercare Service Design² and the Guidelines for Integrated Suicide-Related Crisis and Follow-Up Care.⁴ Each offers a comprehensive staged approach to maintaining contact through admission and after discharge with a mix of psychosocial, clinical and healing approaches with a strong focus on family and community.

An unanticipated positive outcome has been greater collaboration between clinical and cultural workers across the spectrum of mental health services. Mental health plans and referrals overseen by the visiting psychiatrist now frequently include a recommendation for healing alongside other supports. Aftercare workers have been invited to participate in traditional healing on country with ngangkari. The Pitjantjatjara word ngangkari is defined as an Indigenous practitioner of bush medicine (see Further Reading). Hospital mental health staff similarly are reported to be more comfortable referring people post-discharge to social and emotional wellbeing services and GP services knowing that these services can draw on the expertise of the aftercare team. Ongoing clinical management including medication support now sits with the Pika Wiya Health Service and not the hospital which continues to build the capacity within the health service.

From December 2018 to June 2019, around 120 people have been supported with 13 to 20 referrals a month to the end of 2019. Three-quarters of referrals are from the emergency department while the remainder come directly from the ACCHO which demonstrates that the Aftercare Service is appropriately supporting the most acute needs. The Aftercare Service is also working with established postvention services that includes the National Indigenous Critical Response Service  and Beyond Blue’s service, The Way Back.

The Aboriginal Aftercare Service is consciously based on ATSISPEP’s three levels of intervention⁵ that are:

1. Universal Interventions which attend to those factors that create dysfunction as well as creating an environment in which individuals and the community are able to seek help before suicide attempts.
2. Selective Interventions which focus on youth who are at higher risk of suicide.
3. Indicated Interventions which ensure that those who are a risk to themselves or have attempted suicide are assisted in their recovery.

The program has been managed by the Pika Wiya Health Service Aboriginal Corporation and the ACCHO which meets the recognised need for strengthening Indigenous governance. The use of the lived experience of Aboriginal and Torres Strait Islander people in Port Augusta through the workshops during the development of the design has established a community and cultural focus in the design. The design includes a broad, closely-integrated use of public health services and other services such as culturally-safe healing and reconnection to culture and country.

While the program managers are collecting data which will be used to improve services, no formal evaluation of the program has taken place. CBPATSISP recognises that this program is still developing however this program is demonstrating a commitment to recognised principles and therefore is recognised as a promising program.

1. National Suicide Prevention Trial: Survey Data Report April 2018. Not available online. Country SA PHN, Nuriootpa South Australia.
2. Aboriginal Aftercare Service Design November 2019. Country SA PHN, Nuriootpa South Australia.
3. LifeSpan strategies and components. Black Dog Institute.
4. Guidelines for integrated suicide-related crisis and follow-up care for Aboriginal and Torres Strait Islander people in the Emergency Department in Port Augusta, South Australia November 2019. Country SA PHN, Nuriootpa South Australia. N/A
5. Dudgeon, P., Milroy, J., Calma, T., Luxford, Y., Ring, I., Walker, R., Cox, A., Georgatos, G., & Holland, C. (2016). Solutions That Work: What the Evidence and Our People Tell Us. Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project Report. Perth, WA: University of Western Australia.

Further reading:

Ngangkari – Traditional Healers. Ngaanyatjarra Pitjantatjara Yankunytjatjara Women’s Council

Institute’s Guidelines for Integrated suicide-related crisis and follow-up care in Emergency Departments and other acute settings. Black Dog Institute.