Syndromic Surveillance (SyS) Data Sharing for School-Based Prevention Initiative

Tri-County Health Department (TCHD), Colorado's largest local health department, is located in the Denver metro area. It is the health department for Adams and Arapahoe counties serving over 1.2 million people and provides public health services to Douglas County's over 357,000 residents¹. In Adams County, with a population of 511,469, 49.4% of the population is white (non-Hispanic), 3.1% is Black or African-American, 3.6% is Asian, and 40.4% is Hispanic². In Arapahoe County, with a population of 651,345, 59.6% of the population is white (non-Hispanic), 10.5% is Black or African-American, 5.9% is Asian, and 19.5% is Hispanic³. The agency's jurisdiction includes 15 school districts with more than 360 public schools¹. There is not currently a standard process between school districts and hospital systems to share timely emergency department (ED) data related to suicide for youth suicide prevention. Due to a multitude of reasons including stigma related to mental health and health-seeking behaviors, school districts currently rely upon delayed aggregate reports or parent or student self-report information which is largely incomplete. The collaboration of the TCHD Maternal Child Health (MCH) and Child Fatality Review Teams (CFRT) suicide-related community level engagement and the data-to-action strategies provided by the TCHD Syndromic Surveillance program have the unique ability to help fill this gap.

Syndromic Surveillance (SyS) is a timely system for near real-time monitoring of hospital visits and prompt detection of data anomalies. TCHD SyS staff serve as the site administrators for Colorado's locally managed SyS network for monitoring data, communicating with partners, and sharing information⁴. In 2019, the program was awarded a Suicide and Violence Prevention (SVP) grant from the US Centers for Disease Control and Prevention (CDC) to support statewide suicide prevention efforts to reduce suicide in Colorado. 

Addressing suicide is a priority at TCHD, especially among youth in Colorado, and a focal point of the agency's mental health and suicide prevention frameworks⁵. In our three counties, about one in six high-school-aged youth reported seriously considering suicide in 2019 and one in three reported mental health distress: feeling so sad or hopeless every day for two or more consecutive weeks that they stopped doing usual activities. Mental health distress and suicidality are more commonly reported among gay, lesbian, bisexual, and transgender youth - compared to their heterosexual or cisgender peers - and among females⁶.  TCHD's frameworks define the optimal public health role in mental health promotion and suicide prevention across the life course. The creation of mental health and suicide prevention frameworks was informed by a regional assessment of assets and gaps and is a guide to meaningful public health efforts related to mental health and suicide. The frameworks serve as a clarifying catalyst for implementation of shared strategies and provide effective language to convey the unique public health role in improving mental health and reducing rates of suicide. Additionally, TCHD's 2019-2024 Public Health Improvement Plan (PHIP) prioritizes mental health and access to mental health care. TCHD's MCH work takes a risk and protective factors approach which recognizes that different types of violence are interconnected and often share the same root causes. Internally, the TCHD MCH team built upon existing partnerships from the CFRT to brainstorm how TCHD SyS could share information across disconnected systems, such as our school district and hospital partners, and developed the SyS Data Sharing for School-Based Suicide Prevention Initiative.

The SyS Data Sharing for School-Based Suicide Prevention Initiative shares how TCHD and our cross-sector partners work to alleviate the gap between mental health and crisis response school district staff and hospital ED data. Our efforts provide access to aggregate timely emergency data related to non-fatal suicide behavior to support proactive prevention efforts. Historically, public health data shared with school districts related to suicide prevention is delayed, as data collection and reporting takes time. School districts often rely upon Healthy Kids Colorado Survey data, which is conducted every other year with results released mid-way through the following year, and CFRT data, which is typically delayed at least one year. School districts do not have access to timely data on non-fatal suicide-related outcomes, including self-directed violence, suicide attempts, overdose, and suicidal ideation, as they are not directly connected with hospital systems. Outside of Colorado's local SyS system, SyS data is most typically shared with public health partners. TCHD's work with school mental health and crisis response staff was previously exclusive to the work of CFRT and not utilized for other prevention-related or data sharing work within TCHD. The SyS Data Sharing for School-Based Suicide Prevention Initiative is innovative in its ability to bridge data sharing between hospitals and school districts and provide access to this timely data source to support prevention efforts.

The goal of the SyS Data Sharing for School-Based Suicide Prevention Initiative is to connect hospital ED data, TCHD work related to youth suicide prevention (by CFRT, MCH, and SyS staff), and mental health and crisis response school district partners for the purpose of sharing timely SyS data to support suicide prevention efforts among youth residents of participating school districts. To accomplish this, TCHD CFRT, MCH, and SyS staff met with mental health and crisis response school district staff to educate them about the usefulness of timely SyS data and engage in a dialogue regarding how this data could be helpful to inform their prevention-related strategies. TCHD began monitoring suicide-related ED visit trends among youth residents of the participating school districts and piloted alert notifications when data anomalies (spikes) were detected in the SyS system. The SyS team continues to monitor and provide timely data to these school district partners with intentions to expand to additional school districts across the TCHD jurisdiction in the future. The participating school district partners now have improved situational awareness regarding suicide-related ED trends among their students to inform prevention efforts and TCHD staff have greater understanding of prevention activities and capacity of school district staff.   

Sources:

1. https://www.tchd.org/236/About

2. https://data.tchd.org/reports/Adams_Countyfactsheet_JAN2020_Final.pdf

3. https://data.tchd.org/reports/Arapahoe_countyfactsheet_JAN2020_Final.pdf

4. https://www.tchd.org/264/Syndromic-SurveillanceMeaningful-Use-Dec

5. https://www.tchd.org/870/Mental-Health-and-Suicide-Prevention

6. https://cdphe.colorado.gov/healthy-kids-colorado-survey-data-tables-and-reports

The Colorado Child Fatality Prevention System reports increases in the rates and counts of suicide completions among youth (17 years and below) over the past ten years, with significant annual peaks found in the number of suicide completions in 2017 among residents of Adams and Arapahoe counties (10 deaths in each county respectively) and in 2018 in Douglas county (7 deaths)¹. Suicide death rates among youth aged 10-18 years in our three counties have increased steadily over the last decade and we anticipate this upward trend to persist into 2021 as youth and families navigate the COVID-19 pandemic, economic downturn, and racial injustice^2,3. School-age youth are particularly vulnerable and school districts are working to provide mental health resources and suicide prevention with limited data regarding non-fatal emergency department visits or hospitalizations related to suicide beyond self or parent-report. 

In SyS data, TCHD specifically monitors non-fatal ED visits related to suicide in order to enhance our situational awareness and to ultimately prevent suicide completion. Among youth (18 years and below) residents of the three counties served by TCHD, the annual percent of non-fatal ED visits related to suicidal ideation rose from 2019 to 2020 (2.6 to 3.4 percent, p < 0.001) and stabilized at 3.4 percent in 2021. Among the same population, the annual percent of non-fatal ED visits related to suicide attempt also increased from 2019 to 2020 (0.7 to 1.0 percent, p < 0.001) but fell from 1.0 percent in 2020 to 0.8 percent in 2021 (p < 0.001). The majority of ED visits related to suicide are those who are in the ED for suicidal ideation and much fewer related to suicide attempts. Thus, because suicide-related SyS data specifically monitors non-fatal cases, it may be of particular interest to those working in suicide prevention to use this data for timely situational awareness and proactive prevention efforts within their capacity. These trends and the magnitude of the percent of ED visits related to suicide indicators among youth are not apparent when observing the same trends for the total population in the three counties, indicating a particular need to focus on youth in this area. For this reason, the target population for the SyS Data Sharing for School-Based Suicide Prevention Initiative is school-age youth, especially students in middle and high school, who are residents of the school districts' corresponding zip codes. The program was piloted in two school districts: Adams 12 Five Star Schools and Cherry Creek School District. Adams 12 Five Star Schools includes 52 schools within its district, serving 38,707 students. Cherry Creek School District includes 65 schools and serves 56,172 students⁴. Partnering with these two school districts provided an opportunity to pilot the SyS Data Sharing for School-Based Suicide Prevention Initiative with a large portion of the target population.

We are mindful of the continued progress in the research community related to understanding how race and ethnicity, economic status, sexual orientation and gender identity correlate with health.  With our SyS data work, we seek to collaborate with the community and share data to help us to understand the life-long inequities that persist across groups in order to support eradication of these injustices. Tragically, Colorado continues to see an increase in youth suicide and poor mental health outcomes. The COVID-19 pandemic has highlighted the issues impacting school-age youth, especially students in middle and high school who have had their in person learning disrupted. The SyS Data Sharing for School-Based Suicide Prevention Initiative specifically works to address health equities by targeting youth and providing further detailed information based on the needs of the individual school district. This includes important stratification such as that by sex, as males are more likely to complete suicide but females make more suicide attempts⁵, to allow for more targeted efforts in the school districts. Every aspect of the information provided in the alert reports are informed by the feedback and direction from the school district partners to meet the unique needs of their districts and student bodies.

TCHD staff spurred innovation with the power of asking questions of the mental health and crisis response staff within the schools to identify opportunities for shared learning and the exchange of ideas to fuel ongoing innovation. TCHD staff viewed the school districts staff as partners in the work, as they provide the best feedback for why and how TCHD should be developing SyS data alerts for the school districts. As TCHD has continued to work pursuing the sharing and use of SyS data to better inform school districts suicide prevention efforts, TCHD has found that by continuing to ask questions, in the long term we can find better answers with data to shape prevention related efforts at the community level.   

This work is innovative as it is working to share real time data with school districts, it is a completely new data source for school district partners, and it is a non-traditional method of data sharing for syndromic surveillance. While school district partners have access to retrospective data sources, SyS provides timely, near-real time ED data allowing partners an opportunity to address suicide prevention in a more proactive way. This is an innovative strategy in regards to our ability to share timely SyS data with school districts to inform and support their mental health and youth suicide prevention efforts. School districts may utilize this data to enhance their training for teachers and staff regarding mental health and suicide prevention, to inform their superintendant and other key leadership making decisions for their districts, prioritization and resource allocation, or to form task forces to address consistently pressing issues as evidenced by this data, as one such school district has begun since the beginning of our partnership. SyS data is most valuable when it can be translated and communicated with an audience able to use it, such as inducing decision makers and key mental health and crisis response staff within school districts to make actionable use of this data.

There are few examples of SyS data sharing with school districts and across multiple sectors. In 2014, a Missouri County School Syndromic Surveillance program presented a model in which school staff members were trained to utilize, monitor, and report data using syndromic surveillance⁶. While this model provided school personnel with direct access to this timely data source, the program required staff time and resources which are not always available. Regular monitoring and notification of statistically significant data anomalies of interest at the zip code-to-school district level requires little additional weekly monitoring for SyS epidemiologists and templates of data alert notification and analysis code for graphic creation allow for an efficient streamline of communication. In other programs, SyS data has been used cross-jurisdictionally with success. One such example includes data sharing across multiple health departments in different counties in California to mitigate the effects of wildfires⁷. Currently, the TCHD SyS team provides weekly COVID-19 notification reports, which include additional indicators of interest such as those related to youth behavioral health and influenza, to SyS, hospital, and other community partners in order to provide timely situational awareness. These examples provide the foundation for SyS Data Sharing for School-Based Suicide Prevention of sharing SyS data across sectors. Sharing information between two unique sectors, public health and education, for suicide prevention is new and contributes to a growing body of knowledge demonstrating data to action.

Sources:

1. https://cohealthviz.dphe.state.co.us/t/PSDVIP-MHPPUBLIC/views/CFPSDashboardFinalLocal/Suicide?iframeSizedToWindow=true&%3Aembed=y&%3AshowAppBanner=false&%3Adisplay_count=no&%3AshowVizHome=no

2. https://cdphe.colorado.gov/center-for-health-and-environmental-data/registries-and-vital-statistics/vital-statistics-program

3. https://www.coloradohealthinstitute.org/research/suicide-colorado

4. https://www.cde.state.co.us/schoolview/frameworks/official/0020

5. https://afsp.org/suicide-statistics/

6. https://application.naccho.org/Public/Applications/View?id=1296

7. https://www.cdc.gov/nssp/success-stories/CA-WIldfires.html

The overarching goal of the SyS Data Sharing for School-Based Suicide Prevention Initiative is to better inform suicide prevention efforts using timely data and bi-directional communication with our school district partners for the purpose of reducing suicide in Colorado. The long term goal of this work is to bridge the gap of disconnected systems to support enhanced data sharing, between public health, hospital systems and school districts. In doing so, TCHD serves as the convener to engage health systems, hospitals and school districts to engage and collaborate on efforts to help prevent youth suicide.  A short-term goal includes sharing SyS data to create compelling alert reports, along with incorporating other risk and protective factors data to inform community level conversations, mental health promotion, and engagement with diverse audiences to prevent youth suicide. The objectives of the SyS Data Sharing for School-Based Suicide Prevention Initiative include: 1) establishing bi-directional communication with school district partners, 2) weekly monitoring of suicide-related emergency department trends among school-age youth in participating partner school districts, and 3) provide timely notifications or reports when alerts (data anomalies) are present. This is an ongoing practice that has been successful due to continued collaboration between the TCHD MCH, SyS, and CRFT teams and our participating school partners. In the future, we plan to develop a more direct connection between school district partners and hospital partners, in coordination with public health, for timely information sharing and collaboration on youth suicide prevention initiatives.

The accomplishments of the goals and objectives of the SyS Data Sharing for School-Based Suicide Prevention Initiative are numerous and growing. TCHD teams successfully leveraged partnerships established by the CFRT to implement a more upstream approach to suicide prevention. The SyS Data Sharing for School-Based Suicide Prevention Initiative provided educational opportunities for school district partners to learn more about syndromic surveillance as a timely data source and connection to real-time hospital information. By doing so, it has empowered school district partners to understand and utilize this data within their own day-to-day prevention work. It established ongoing monitoring for our school partners which will allow for ongoing timely action during periods where we see increased emergency department visits related to suicide among their student bodies such as enhanced and targeted student outreach, dissemination of prevention materials, and convening of task forces. Finally, it established more robust bi-directional communication between TCHD staff and school districts for better cross-sector information sharing to help put data into action. School district partners now have better data-driven situational awareness while TCHD staff have a better understanding of what current preventive actions take place at the school-district level. This enhanced effort can be used in the future to support broader prevention efforts across additional school districts as this work continues to expand.

This collaborative work initially began when the TCHD Syndromic Surveillance Program was awarded a CDC sole source grant for Suicide and Violence Prevention in 2019. TCHD SyS and MCH teams began communicating about their shared goals and brainstorming ways to advance suicide prevention efforts. Collaboration between the TCHD SyS, MCH, and the Child Fatality Review (CFRT) teams illuminated a lack of real-time hospital data available to school districts and their suicide prevention teams. The MCH team was instrumental in bridging relationships between CFRT school district members with the SyS team, allowing for new partnership building with known stakeholders with vested interest in preventing suicide in their school districts. From May to July of 2021, TCHD SyS, MCH, and CFRT teams virtually met with school district partners representing four different school districts to introduce syndromic surveillance and to learn more about the activities and capacity of school district partners and how to enhance these cross-disciplinary partnerships. In August 2021, after confirming school district zip codes within two districts, the TCHD SyS team began monitoring suicide-related data for youth residents of the school district's corresponding zip codes. Upon receiving data alerts for both districts in September 2021, the TCHD SyS and MCH teams met with participating partners again to share pilot alert notifications and collect feedback. As of October 2021, the TCHD SyS team developed updated alert notification report templates for both school districts as requested and continues to monitor these suicide-related trends. Going forward, the TCHD teams hope to share timely data alert notifications with these school district partners as they arise, continuously welcome feedback in order to improve this data sharing communication, and expand monitoring to more school districts. We will continue to meet with school district partners when subsequent alert notifications arise to review the alert, gather their feedback, and request updates on how this data has been utilized to continue refining information sharing. Lessons learned from these two pilot districts will inform the expansion of this program to additional school districts.

TCHD staff seized the opportunity to utilize SyS data to inform, educate and empower people about the issues of suicidal ideation and suicide attempts of young people in the ED and to mobilize school partnerships with the long term goal of better using real time local level data to identify actions and solve health problems. TCHD recognizes the importance of continued relationship building for ongoing access to and improvement of SyS data sharing with school districts and other key partners. Future work for TCHD includes continuing to share data, including for the purpose of encouraging cross-system partnerships, and building additional partnerships among youth-serving organizations and health systems engaged in suicide prevention. 

TCHD staff came together to serve as a change agent to leverage existing partnerships and expertise and to identify innovative strategies to enhance current suicide prevention efforts.  This work was built off of internal collaboration of staff across different divisions and programs who recognized the need for innovation related to protective factors related work with the goal of youth suicide prevention. TCHD staff approached meetings with curiosity and a desire to learn more about the needs of external partners (school districts staff supporting mental health, suicide prevention and crisis response), how partners already collect data, and where TCHD could fill in gaps. Our engagement strategy with school districts was successful as we reached out to identified mental health and crisis response staff with whom we already had an established relationship via the TCHD CFRT.

This work was strengthened by a recognition of TCHD staff that to make an impact on the issues related to youth suicide and youth suicide prevention, illuminating the need to broaden our approaches and use a spectrum of strategies to implement data sharing that impacts youth and adolescents and build community capacity to address and promote youth suicide prevention. Communication of data and alert notification reports includes narrowing in on the most affected populations and sharing that information with partners while maintaining patient privacy standards. This practice upholds these values via an innovative and sustainable means of cross-sector information sharing.

The labor costs for this project were supported by three different grants: the Title V MCH block grant and the CDC Suicide and Violence Prevention (SVP) sole source grant, which established a syndromic surveillance epidemiologist. The MCH Action Plan included work to support internal collaboration for youth suicide prevention.  MCH grant funding also supported 10% of the CFRT Coordinator position to strengthen strategic partnerships and utilize local level data to determine potential upstream prevention deliverables for suicide prevention. The SVP grant requires outreach and data sharing of suicide-related SyS data to community partners to support and inform suicide prevention efforts. The costs associated with participation from the school districts were provided in-kind.

The evaluation of SyS Data Sharing for School-Based Suicide Prevention Initiative is driven by the qualitative information gathered via these innovative public health and school district partnerships. By meeting our first objective, to establish communication channels with school district partners, we learned that our school partners largely rely upon self-report (from student or parent) to gather and track suicidality in their districts. Access to non-fatal hospital level data was one missing piece of the overall picture of youth suicide which the SyS Data Sharing for School-Based Suicide Prevention Initiative fills to provide a more comprehensive understanding of youth suicide in school districts. By approaching these partners with more questions than answers, we allowed for a creative collaborative process resulting in an information sharing practice which will be most useful and sustainable going forward for all stakeholders.

We were able to meet, present, and gather initial feedback with eight school district partners representing four unique school districts. Staff from these school districts included the Chief Health Officer, Director of Community Partnerships for Crisis Intervention, Director of Social, Emotional and Behavioral Services, and the Prevention and Crisis Recovery Coordinator. In the three initial meetings we held over the summer break, we provided education about SyS data and how the data can be utilized, and we empowered our school district partners to understand, explain, and request this data. We emphasized the ability of our system to provide both timely data alerts to enhance situational awareness as well as historical trends of non-fatal suicide-related ED data in the SyS system to provide an overview for the district. For example, TCHD SyS provides weekly notification reports for regional updates on health indicators of interest¹, including COVID-19, suicidal ideation, and suicide attempts.

Of those four initial school district contacts, we confirmed corresponding school district zip codes with two of those districts, which allowed us to begin monitoring and sharing data for those two confirmed districts within the National Syndromic Surveillance Program's (NSSP) Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE). We set up two queries for each school district to monitor ED visits related to suicidal ideation and suicide attempt. These CDC-validated case definitions for suicidal ideation and suicide attempt search ED records using their chief complaint (free text) and discharge diagnosis fields (ICD-10 codes) for terms and codes which meet the case definition criteria. TCHD validated these definitions in 2020 (CDC Suicide Attempt v1) and 2021 (CDC Suicidal Ideation v1) to enhance accurate monitoring of suicide-related trends in our surveillance system. By using exponentially-weighted regressions based on the most recent four weeks of data, the ESSENCE system calculates an expected number of visits related to suicidal ideation or suicide attempt and compares that value to the actual observed number of visits related to the specified suicide indicators that week or time period. When the observed value exceeds the expected value with statistical significance, calculated within the ESSENCE system, the system provides a notification via email so that the alert and its associated cases can be reviewed. This alert is what is used to develop an alert notification report to summarise the aggregated cases in a meaningful and actionable way for our school district partners.

We developed the alert notification report coding in RStudio to run descriptive statistics and visualization and finished the report template in Microsoft Publisher. We developed three report examples using TCHD local aggregated information to share with partners during the initial meetings. The alert notification reports were organized into two sections: a background section and results section. The background section included information regarding the population of interest and the definition information used to identify cases (e.g. CDC Suicidal Ideation v1). The results section included a written summary of the alert - how many cases were identified or what percent of ED visits were related to the specified suicide indicator which triggered the alert and over which time period (weekly data). For visualization, the report included a trendline for the most recent eight weeks of data, displaying percent of ED visits related to the suicide indicator among youth residents of zip codes corresponding to the specified school district and a mark to identify the week during which the alert took place. Additionally, in the results section, we provided a data table which provided stratification by sex and by age group (0-9 years, 10-14 years, and 15-18 years). At the discretion of the epidemiologist, a histogram displaying the total ED visits over the same time period was also provided if there were notable changes which may have impacted the overall percent of the ED visits related to suicide indicators. Finally, the results section concluded with a recommendation regarding whether the data indicated a need for immediate action to assist partners with decision-making for suicide prevention.

The eight school district partners with whom we met during our initial partnership meetings indicated that the use of these alert reports would be impactful to their prevention efforts due to their lack of real-time data. School district partners mentioned the use of the timely reports to initiate mental health promotion to students such as providing materials and messaging related to suicide help lines and other resources to encourage health-seeking behavior. This message campaign would include proactive communication to parents with additional resources for mental health promotion and suicide prevention. They indicated the usefulness of the stratification of the aggregate data to inform more targeted outreach based on geography, age group, sex, and race or ethnicity. This targeted approach would help them better identify which schools and what age group or other specific populations to direct mental health resources and crisis response support in their school districts. School district partners in these meetings also mentioned the ability to use these reports to enhance their youth suicide prevention curriculum and increase gatekeeper training for all school staff. Overall, all partners with whom we were able to connect provided feedback that they would have useful potential applications of these data alert reports.

Since the inception of this initiative, one partner at a participating school district developed a task force to specifically address mental health and suicide prevention in their district and expressed their interest in utilizing these data alerts to inform their prioritization of mental health resources, including staff time and outreach efforts. Additionally, one partner (from a district not yet participating in pilot reports) reached out to request suicide-related data for students in the specific county to present to their school board. Over a few short months, this data has been put into action by supporting the development of the task force and informing school board meetings and decision-making in our counties.

While the SyS Data Sharing for School-Based Suicide Prevention Initiative did not lend itself to outcome measures in the given timeframe, we were able to gather feedback on the pilot alert reports. In the pilot reporting period, we received two alerts, one for each district, and created two reports for these alerts to be shared as pilot reports with three mental health and crisis response team members of the two school districts. We met virtually to review the pilot reports for alerts detected in September in both partner school districts, resulting in two individual sessions for qualitative information-gathering. All three school district partners (representing two districts) communicated that the reports were helpful in providing situational awareness and simple to comprehend, even for lay folks. In addition to the stratification we provided by age and sex, all three partners from the two school districts requested further stratification by race and ethnicity and by geography, which were added to an updated alert report template. The race and ethnicity stratification table includes the percent of ED visits related to the suicide indicator among youth residents of the zip codes corresponding to the specified school district by race and ethnicity groups, with race and ethnicity categories separated as patients may identify as multiple race or ethnic groups. To provide more specified information by geography, choropleth maps were built in ESRI ArcMap (Version 10.8) to stratify the percent of ED visits related to the suicide indicator among youth residents of the zip codes corresponding to the specified school district by zip code. This will continue to be an iterative process and is a benefit of the SyS Data Sharing for School-Based Suicide Prevention Initiative that it can be tailored to meet the needs of each school district partner.

The long-term goals of the SyS SVP grant and the MCH and CFRT teams include reducing the number of suicides in Colorado. As part of the SyS SVP grant, we are tasked with weekly monitoring of suicide-related hospital trends regularly for the purpose of early detection and prevention of suicide. The SyS Data Sharing for School-Based Suicide Prevention Initiative is an important piece in ensuring that this long term goal is achieved. As we continue the SyS Data Sharing for School-Based Suicide Prevention Initiative, we will continue to monitor the long-term suicide-related hospital trends in these school districts as well as the timely alerts. We plan to capture the utilization, helpfulness, and additional qualitative feedback from our partners on a regular basis via a brief survey. We also plan to meet regularly with our school district partners, individually and in group settings, to collect information regarding the usefulness of this data, adjust our data communications as needed, and provide an opportunity for knowledge exchange. The sustainability of the SyS Data Sharing for School-Based Suicide Prevention Initiative relies upon the care and investment of these stakeholders and maintaining engagement with partners to ensure that these data products are helping them work towards these overarching shared long-term goals is pivotal.

Sources:

1. https://www.tchd.org/637/Syndromic-Surveillance-Newsletters-Repor

Through the SyS Data Sharing for School-Based Suicide Prevention Initiative, we learned many lessons. On many levels, partnership and collaboration were pivotal to the success of this practice. Collaboration between TCHD internal departments - MCH, SyS, and CRFT - was the key to finding common goals and leveraging partnerships to identify key external stakeholders who may have the most interest in partnering in this work. We learned the importance of building partnership first in order to better understand our partners and to meet them where they are. Through this connection, we were able to gain insight into the data our school partners already had available and the information for which they lacked, allowing us to understand how we could fill the information gap. We also learned about their capacity and what prevention activities they already enact to better understand what information may be helpful to them. By going in with an intent to learn and explore, we were able to create a better collaborative approach to information sharing. We remained flexible to adjustments and avoided a one-size-fits-all mentality in order to best support our partners and their unique needs. 

The sustainability of the SyS Data Sharing for School-Based Suicide Prevention Initiative fits well within TCHD's newly developed Suicide Prevention framework for our agency, data is specifically called out as an important tool and the use of data for suicide prevention.  As a local public health agency, we recognize we play an important role in convening and educating partners on the use of data for suicide prevention. We want to enhance our collaboration with our school district partners to collect, analyze, interpret and report data; and to use data to identify, monitor and advance partnership goals for suicide prevention. Together with our partners, we want to continually use data to inform where and among whom problems exist and the nature of those problems so we can use our data for action. Suicide prevention aims to reduce the incidence, prevalence and recurrence of suicidal ideation and behavior by mitigating risk factors and increasing protective factors associated with suicide prevention.

In terms of community engagement, the SyS Data Sharing for School-Based Suicide Prevention Initiative relied upon outreach and bi-directional coordination with stakeholders outside of public health to ensure successful collaboration. With the help of the TCHD CFRT, we went to school districts with questions instead of answers, knowing we had data to share but not knowing how or when best to provide the information and in what format. We recognized a need to provide an educational opportunity in order to collaborate and empower partners to use this timely data. This process required community feedback and support in order to put the data into action and share knowledge across sectors. 

A benefit of the SyS Data Sharing for School-Based Suicide Prevention Initiative is its transferability to other school districts and key stakeholders across the TCHD jurisdiction as well as other SyS jurisdictions who participate in the Colorado local syndromic surveillance efforts across Colorado. The CDC SVP grant expanded the Colorado Local SyS Program to the Colorado National Collaborative (CNC) counties, which were counties identified with high rates of suicide in the state. Sustainability will involve sharing the SyS Data Sharing for School-Based Suicide Prevention Initiative not only within the TCHD jurisdiction, but also with these CNC counties, the state health department, ED physicians, and other vested stakeholders dedicated to reducing suicide rates through multi-pronged prevention strategies in the state of Colorado. This model acts as a blueprint to be shared with counties across the country as they continue or begin to use SyS for their own suicide prevention work going forward.

School districts in Colorado, especially their mental health and crisis response staff members, have a vested interest in and commitment to suicide prevention and mental health promotion. They have expressed their need for this hospital data connection in order to inform their work in a proactive and timely way. Because the SyS Data Sharing for School-Based Suicide Prevention Initiative identified specific key partnerships with school district staff members already actively engaged in suicide prevention work, we are confident that the SyS Data Sharing for School-Based Suicide Prevention Initiative has the necessary stakeholder commitment needed for sustainability and expansion. By employing a multi-team and cross-sector approach, we have ensured that communication and partnerships will continue to last and grow even as organizational or staff changes occur. Through the SyS Data Sharing for School-Based Suicide Prevention Initiative, we will connect this work to larger county and state-wide efforts for suicide prevention across the life course.

Thus, this work demonstrates the importance of both internal and external collaboration. TCHD and its school partners are continuously working on using real time data to increase the relevance and effectiveness of strategies and programming to promote mental health and the prevention of youth suicide. The internal collaboration resulted in the ability to leverage multiple funding streams that might have not traditionally been considered together to enhance community prevention efforts. We were creative and innovative in internal strategic planning and in brainstorming to whom we could reach out to leverage existing partnerships and establish new ones. External collaboration with intentionally selected partners provided a strong foundation from which to develop shared goals and processes to help address youth suicide in our counties. The enhanced partnerships across our different sectors allow for strength-based collaboration, and bridging together timely information with the ability to reach large populations of youth for direct prevention efforts. The use of real-time hospital data at the school district level provides insights and innovation to how best we can employ data-to-action strategies to impact school-age youth population at greatest risk for suicide.