Tuolumne County Suicide Prevention Strategic Plan

Introduction
When any health condition occurs at significantly higher rates in one
population than another it becomes a matter for study and possible
community concern. Whether lung cancer in smokers or immune
deficiency in intravenous drug users, a presumption exists that there is an
unrecognized reason for the anomaly. The goal of subjecting such a
phenomenon to study is to institute measures to prevent suffering.

In 2006, the incidence of suicide in Tuolumne County nearly doubled.

Tuolumne County has rated among California counties with the highest
rates of suicide in recent years. In fact, virtually all counties in California
with a population under 60,000 register the highest suicide rates.
Recognizing the scope of this tragedy, multiple local agencies, coalitions,
government entities and private citizens formed a Suicide Prevention Task
Force in 2007 to analyze the factors that increase the risk of suicide and
to identify protective factors that might mitigate that increased risk so
that tangible steps might be taken to reverse the trend. This Suicide
Prevention Strategic Plan is the product of that effort.

Suicide prevention campaigns have been guided by the plans of national

and state experts. In 2001, the National Academy of Sciences published
the Institute of Medicine’s report, Reducing Suicide: A National
Imperative. In 2008, the California State Department of Mental Health
released its draft California Strategic Plan on Suicide Prevention.
However, these excellent documents provide only a framework for
activating local resources. The job of implementing the recommendations
of such research falls upon the local jurisdictions and is dependent upon
the cooperation of agencies and, more importantly, the community itself.

The Tuolumne County Strategic Plan for Suicide Prevention follows the
Strategic Directions of the California plan. Specifically addressed are
Training, Prevention/Intervention, Community Education and Monitoring
and Surveillance to assure accountability. The Appendices list information
about various evidence-based programs and community education
proposals which will be implemented to seek to prevent suicide during the
three year planning period and beyond.

While this Strategic Plan takes into consideration the financial cost and
demonstrated benefit of each suicide prevention program proposed herein,
Tuolumne County acknowledges that there is an unmeasurable cost to a
community when a member contemplates suicide, and a community-wide
wound inflicted by the completion of suicide. It is therefore the hope of

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the Suicide Task Force that the steps outlined in this plan will not only
accomplish the goal of reducing suicide in our community, but also
address those issues which underlie the social and psychological causes of
suicidal ideation and shed light on the reasons why suicide is so prevalent
in rural communities, so that benefits can be universally shared.

Overview
Tuolumne County has consistently registered some of the highest rates of
suicide in California. In 2006, an analysis of multiple factors correlating
with higher suicide rates in counties throughout California was
undertaken. This study confirmed relationships between social, mental
health, and demographic risk factors for suicide and highlighted the
problem facing rural counties. With funding from a local community
foundation and encouraged by the mobilization of multiple local agencies,
organizations and community members, a Tuolumne County Suicide
Prevention Task Force (SPTF) was launched in January, 2007, to
coordinate local suicide prevention activities. In August, 2008, the SPTF
convened to further consolidate a strategic plan for suicide prevention.
This Strategic Plan is the product of that effort.

Suicide Rates and Trends

The overall rate of suicide in California between 1999 and 2005 averaged
9.3 suicides per year per 100,000 persons. The average rate for the
United States during this period was 10.7 with an overall slight trend
upwards.1 Suicide rates for states considered rural, based upon
percentage of population living in metropolitan areas,2 average 50%
higher than urban states. The rate of increase in suicide rates between
1999 and 2005 for rural states has been three times that of urban states.3

Suicide death rates are thought to be underestimated from death

certificate data because of the extensive criteria that must be met in order
to convincingly certify that a death was intentional. The test for suicidal
intent is often not met in such cases as overdose deaths or suspicious
motor vehicle accidents, particularly when a note is not left by the victim.
A “suicide note” from the victim is found in fewer than 50% of suicides.4

Tuolumne County experienced a suicide rate in 2006 that was nearly

double the county average (See Figure 1). This upward trend
1
Surveillance for Violent Deaths – National Violent Death Reporting System, 2005; MMWR, Department of
Health and Human Services, CDC, Vol.57, No. SS-03, April 2008
2
Bowers, D.E and Reeder, R.. Rural Conditions and Trends, United States Department of Agriculture, Economic
Research Service, Vol. 9, No. 1, 1998.
3
CDC. Web-based Injury Statistics Query and Reporting System (WISQARS™). Atlanta GA: US Department of
Health and Human Services, CDC 2008. Available at http://www.cdc.gov/ncipc/wisqars/default.htm
4
Goldsmith, S.K. et al., Reducing Suicide: A National Imperative, Institute of Medicine, The National
Acadamies Press, Washington D.C., 2002.
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January 29, 2009
simultaneously raised concern from various local agencies, coalitions and
government entities, resulting in individual and formal meetings on the
subject of suicide prevention. State and regional resources were
consulted to assist with evaluating the scope of the trend for Tuolumne
County and for other rural counties throughout the state. Resulting from
this preliminary research, funding was procured in January, 2007, from
the Sonora Area Foundation, a local community foundation, and a
community wide task force was convened to share local data and begin
planning to address suicide prevention.

Figure 1
Suicide Rate per 100,000
40.0

35.0

30.0

25.0
Death Rate

20.0 Tuolumne
County
15.0
California
10.0

5.0

0.0
*
19 0
19 1
19 2
19 3
19 4
19 5

20 0
20 1
20 2
20 3
20 4
20 5
20 6
19 6
19 8
20 9

20 7
08
9
9
9
9

0
0
0
0
9
9

9
9
9
0
0
0

0
19

Year
*2008 data is for January to November

Task Force attendees included individuals from Public Health, Law

Enforcement, Behavioral Health, Board of Supervisors, schools, the Office
of Education, local hospital, medical practitioners, non-profit agencies,
emergency medical response, service clubs, senior support agency, faith-
based organizations, probation, Human Services, child development,
recreation and community members, some with personal experience with
suicide in their families.

Mission Statement
The mission statement of the Suicide Prevention Task Force is:
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January 29, 2009
“to coordinate the planning, implementation and monitoring of projects
throughout Tuolumne County that prevent and reduce the risk of suicide
incorporating the core values of integrity, accountability, compassion,
collaboration and professionalism.”

The No Wrong Door philosophy represents the coordination of efforts by

local county agencies, community based organizations, educational
institutions, businesses and community members to ensure that anyone
exhibiting suicidal behavior is helped immediately, regardless of where
they initially present. This goal will be met through a variety of
community-wide trainings, some focused on specific populations, some for
the general public, in order to open dialogue and raise awareness about
risk factors, protective factors and warning signs of suicide.

The Tuolumne County Suicide Prevention Task Force

Quarterly meetings were conducted between August, 2007, and
September, 2008. Projects throughout the community that targeted
suicide prevention were presented, cataloged, and included in a resource
directory so that participants could network with similar assets.
Community presentations were conducted to raise awareness through
multiple venues, including radio, newspaper and slide presentations.
Mental health crisis resource cards were printed and distributed, and the
local crisis response telephone line supervised by the Behavioral Health
Department was reinforced. Screening programs for depression were
launched at the local college and at the annual Health Fair. In early 2008,
the Prevention and Early Intervention Coordinator from the Behavioral
Health Department was made available to the Task Force to assist with
further program development.

In September, 2008, an annual meeting of the Task Force was conducted

for the purpose of preparing a county-wide Strategic Plan for Suicide
Prevention. The four strategic directions recommended by the California
Strategic Plan on Suicide Prevention were used as a framework: 1)
Development of a Suicide Prevention system, 2) Training and Workforce
Enhancements 3) Community Education, and 4) Monitoring and
Surveillance for Effectiveness. A format was recommended in which age-
specific groups would consider evidence-based programs and practices for
each of these strategies that could address the needs of four different age
group populations: 1) Youth (18 years and under), 2) Young Adult (16-24
years), 3) Adult (25-60 years), and 4) Older Adult (over 60 years).

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After age-specific concerns were addressed by these age-group
subcommittees, the groups were rearranged to coincide with the model for
the strategic plan that had been proposed. Five subcommittees
contributed materials for inclusion into the strategic plan through the
subcommittee chairpersons, in the realms of training, prevention,
intervention, community education, and monitoring/surveillance. These
submissions were compiled into this Strategic Plan for the community.

Suicide Prevention Task Force Subcommittees

The SPTF was divided into subcommittees in order to address different
components of the plan.

Training: The purpose of the Training Subcommittee was to identify

suicide prevention trainings that impact all sectors of Tuolumne County.
The committee’s task was then to identify the target audiences and the
community groups/agencies/service organizations/churches from which
individuals could be selected to train as trainers for the range of suicide
prevention training programs.

Prevention Subcommittee: The Prevention Subcommittee was asked to

comprehensively assess existing county suicide prevention services and
identify gaps. The committee would then develop a local suicide
prevention action plan based on the assessment. The goal of this
committee long term was to coordinate efforts by local county
agencies, community based organizations, educational institutions,
businesses and community members (using a “No Wrong Door”
philosophy) to ensure that anyone exhibiting suicidal behavior is helped
immediately, regardless of where or when they initially present.

Intervention Subcommittee: The Intervention Subcommittee’s

purpose was to assess existing county suicide intervention services and
identify major gaps, then develop local suicide intervention strategies
based on this assessment.

Community Education Subcommittee: Broad goals for the Community

Education Subcommittee included the development of a plan to
increase awareness of suicide, educate the community about suicide,
encourage and invigorate the community to act to address suicide, and
de-stigmatize depression and suicide. Desired outcomes for this
committee included: to identify target audiences to educate by age
group, identify means, strategies and venues to educate, determine the
cost of strategies, and to determine timing and frequency of education
strategies

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January 29, 2009
 Monitoring and Surveillance Subcommittee: The purpose of this
committee was to assure community-wide system accountability
through monitoring and surveillance of the incidence of suicide. By
identifying data sources for potential gaps in the community system
the Monitoring and Surveillance Committee ultimately seeks to
maximize system effectiveness.

Regional and Local Risk Analysis

Identifying specific causal relationships between factors that either impart
an increased risk of suicide or provide protection from suicide has been an
elusive goal. The 2002 Institute of Medicine report points out that “lack of
longitudinal and prospective studies are a critical barrier to understanding
and preventing suicide.5” Nevertheless, designing a strategic plan for
suicide prevention demands that specific goals be considered, and that
these goals be specific to the target population.

Figure 2
Tuolumne County and National Suicide Death Rates by Age

40
35 National Suicide
Death Rates
30 2002

Annual Rate per 25

100,000 20 Average
Tuolumne County
15 Suicide Death
Rates, 1990-
10 2006
5
0
<20 20-24 25-34 35-44 45-54 55-64 65-74 75-84 >85
Age in Years

Data collection regarding the incidence of suicide in rural California was

initiated by the Tuolumne County Health Department in early 2006. This
data was presented to the California Rural Health Policy Council in
September, 2006. Subsequently, a research project was launched under
funding by the Tuolumne County YES Partnership and the Sonora Area
5
S.K. Goldsmith et al., Reducing Suicide: A National Imperative, Institute of Medicine, 2002, The National
Acadamies Press, Washington D.C.
6
January 29, 2009
Foundation to analyze risk factors for rural counties in California that
correlated with suicide, with a particular focus on factors that might
respond to local suicide prevention interventions.

In this cross-sectional observational study,6 suicide rates in California

counties for the period 2002-2004 were compiled. Explanatory variables
previously recognized as correlating with higher suicide rates were
identified from prior research and collected for each California county.
These data were used to estimate a series of ordinary least squares (OLS)
regression models of suicide rate as a function of measures of Violence,
Macroeconomic Conditions, Firearm Availability, Mental Health Status,
Substance Abuse, Poverty, Ethnic Composition, and Rural-Urban
Characteristics.

The strongest explanators of suicide rate related to the Violence, Mental

Health, and Substance Abuse models. Rural-Urban Characteristics and
Ethnic Composition were strong predictors of suicide rate, while rural
proximity to an urban setting attenuated the effect of rurality on
increasing suicides. Firearm Availability also directly correlated with
suicide rate, albeit weakly.7 The Macroeconomic and Poverty models
evidenced no meaningful explanatory power relating to suicide rates.
Television viewing, as a measure of social isolation, was found to lack
correlation with suicide rates, although viewing data was only available for
county clusters and conclusions about correlations with television viewing
rates only speculative.

The second source for data regarding local suicide risk is gained from the
conduction of psychological autopsies. Confidential Law Enforcement and
Behavioral Health agency reviews of cases provide valuable insights into
individual risk factors. While such data remains strictly confidential,
recognizing such factors provided critical insight into potential system
improvements and confirmed that the suicide indicators identified in the
earlier research were locally relevant.

Risk Factors and Protective Processes

Prevention programs are designed specifically to promote the reduction of
risk factors and processes, and to enhance protective factors and
processes.8 Both risk and protective factors operate in multiple life

6
Stolp, S.T. and Stolp, CW. Social Variables and Suicide Risk in Rural California Counties, pre-publication
copy, 2009
7
It should be noted, however, that 85% of completed suicides for Tuolumne County in 2006 involved firearms.
8
Hawkins J D, Catalano R F, Miller J Y (1992). Risk and Protective Factors for Alcohol and Other Drug
Problems in Adolescence and Early Adulthood: Implications for Substance Abuse Prevention. Psychological
Bulletin, 112(1), 64-105.
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January 29, 2009
domains. These include individual, family, school, peer, and community, as
well as workplace and society. Further, risk and protective factors vary
with the age and developmental stage of the individual9. The California
Strategic Plan on Suicide Prevention specifically emphasizes the
importance of age-appropriate suicide prevention planning in Core
Principle 6: “Employ a life span approach to suicide prevention.”10 Each
developmental phase brings new tasks to be accomplished; just as each
individual is continually changing and evolving, risk and protective factors
emerge and disappear over time or, if present for a long time, may
express themselves differently11. Thus, prevention programs must be
matched to the appropriate developmental stage of the individuals for
which they are designed.

Protective factors proposed by Surgeon General David Satcher in 1999

that afford protection against suicide include effective and appropriate
clinical care for mental, physical, and substance abuse disorders; easy
access to a variety of clinical interventions and support for help seeking;
restricted access to highly lethal methods of suicide; family and
community support; support from ongoing medical and mental health care
relationships; learned skills in problem solving, conflict resolution, and
nonviolent handling of disputes; and cultural and religious beliefs that
discourage suicide and support self-preservation instincts.12

Risk factors that correlate with high suicide rates include, previous suicide
attempt; mental disorders—particularly mood disorders such as
depression and bipolar disorder; co-occurring mental and alcohol and
substance abuse disorders; family history of suicide; hopelessness;
impulsive and/or aggressive tendencies; barriers to accessing mental
health treatment; relational, social, work, or financial loss; physical
illness; easy access to lethal methods, especially guns; unwillingness to
seek help because of stigma attached to mental and substance abuse
disorders and/or suicidal thoughts; influence of significant people—family
members, celebrities, peers who have died by suicide—both through direct
personal contact or inappropriate media representations; cultural and
religious beliefs—for instance, the belief that suicide is a noble resolution

9
Report To Congress On The Prevention And Treatment Of Co-occurring Substance Abuse Disorders And
Mental Disorders, Substance Abuse and Mental Health Services Administration, U.S. Depart. Of Health and
Human Services 2002
10
California Strategic Plan on Suicide Prevention, California Suicide Prevention Plan Advisory Committee,
California Department of Mental Health, April, 2008
11
Mrazek PJ and Haggerty RJ 1994, Reducing Risks for Mental Disorders: Frontiers for Preventive
Intervention Research, National Academy Press, Washington DC
12
The Surgeon General’s Call To Action for Suicide Prevention, U.S. Department of Health and Human Services,
1999, Washington D.C.
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January 29, 2009
 of a personal dilemma; local epidemics of suicide that have a contagious
influence; isolation, a feeling of being cut off from other people.13

Age Specific Goals

Sociological factors that influence the occurrence of suicide are different
for different age groups. The factors listed in Figure 3 are recognized as
valuable considerations for evaluating suicide prevention activities in
specific age groups.141516

Figure 3
Age Group Goals and Objectives

5 – 11 years Institute protective factors through skill building in listening, coping, self
esteem, problem solving, conflict resolution. Begin dialogue regarding mental
health issues, substance abuse.

12 – 18 years Increase protective factors through open dialogue with trained personnel
describing the risks and signs of suicidal behavior; increase skills in problem
solving, conflict resolution, self esteem, resiliency; reduce isolation,
alienation, oppression; address issues specific to culture, gender, sexual
orientation, gender identity; increase safety by providing crisis and ongoing
assistance and support.

Age 18 – 60 Enhance protective factors by reducing isolation, strengthening community

involvement, educate regarding substance abuse and mental/physical
health; increase safety by providing crisis and ongoing assistance and
support; address specific needs of transitional age youth.

Age 60+ Increase protective factors through identifying isolated individuals and
reducing isolation; educate regarding aging and mental/physical health
issues; increase safety by providing crisis and ongoing assistance and
support; address age-specific challenges of depression, substance abuse and
alienation, strengthen connections back to the community and/or faith-based
groups.

Strategic Plan Structure and Coordination with Other Plans

The overall structure of the Tuolumne County Suicide Prevention Strategic
Plan follows the four Strategic Directions of the California Strategic Plan
13
The Surgeon General’s Call To Action for Suicide Prevention, U.S. Department of Health and Human Services,
1999, Washington D.C.
14
The Surgeon General’s Call To Action for Suicide Prevention, U.S. Department of Health and Human Services,
1999, Washington D.C.
15
The Effectiveness of Universal School-Based Programs for the Prevention of Violent and Aggressive Behavior,
MMWR, Department of Health and Human Services, CDC, Vol.56 No. RR-7, August 2007
16
Kushner, H.I. and Sterk, C.E., The Limits of Social Capital: Durkheim, Suicide and Social Cohesion, American
Journal of Public Health, American Public Health Association, Vol. 95, No. 7, July 2007
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for Suicide Prevention, except that Strategic Direction 1, “establishing a
system of suicide prevention,” is divided into Prevention activities and
Intervention activities. There are therefore five strategic directions in this
plan, one correlating with each of the subcommittees earlier described.
For the purposes of this plan, “intervention” activities are defined as
responses to people in acute suicidal crisis, including the process of
evaluating individuals suspected of actively seeking to end their lives.

Bringing specific attention to the intervention component of the strategic

plan will highlight these crisis services. Public review of the basic plan will
thereby identify universal entryways available to those requiring
emergency suicide prevention services.

The 2001 National Strategy for Suicide Prevention17 provides guidance for
evidence based practices that have been successful in other settings. The
goals recommended by the national plan have been incorporated into
components of our local program and are cited when they are specifically
addressed.

Planning Period
This Strategic Plan is to be implemented over a three year period, as
follows:

Year One……………April, 1 2009 to June 30, 2010

Year Two……………July 1, 2010 to June 30, 2011
Year Three…………July 1, 2011 to June 30, 2012

It is recommended that the SPTF begin to renew this planning effort 30

months following the date of implementation of this plan.

Through the deliberations of the coordinating agency, the committees and

subcommittees described below, modifications of this plan may be made.
Keeping the community-wide suicide prevention effort a dynamic process
will allow each segment of the program to adapt to the needs of the
community. It is also important that adequate support and time be
dedicated to projects in accordance with the project-specific scientific
evidence to allow the benefits to be captured.

Definitions
For uniformity of interpretation, the following definitions are used for the
terminology in this Strategic Plan.
17
National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Dept of
Health and Human Services, Public Health Service, 2001
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 Community Education: General education, awareness and stigma
reduction campaigns for the general population regarding behavioral
health care and suicide prevention. This is consistent with the
concept of “universal prevention.”18

Core Programs: Programs for which funding and implementation will

be sought in year one of the three year strategic plan.

Expanded Programs: Programs which are expected to be

implemented in years two or three of the three year strategic plan.
Expanded programs may be moved up to year one through the
actions of the Core Committee if funding is procured earlier and a
need is identified.

Evidence-based Programs: Programs for which studies have been

performed and reviewed that statistically demonstrate or strongly
suggest effectiveness in diminishing the risks and/or incidence of
suicide when they are implemented in a population.

Fidelity of Implementation: Indication that resources are locally

available and appropriate to allow the implementation of a program
in the manner in which the program was originally designed. As an
example, a plan designed for urban populations may not be
appropriate for implementation in a rural setting like Tuolumne
County.

Gatekeeper: A person trained to assist an individual who presents as

a suicide risk to enter the local system of care where further help
can be received.

Intervention: Recognizing the multiple areas of overlap between

Prevention and Intervention, “intervention” was defined as the
following: the immediate steps/activities taken to prevent suicide by
intervening at the time of crisis; the imminent act of preventing a
suicide- including a mental health evaluation for danger to self
(5150 evaluation) transport and hold; the point when someone is
recognized as immediately at risk; the 5150 evaluation is generally
the cut off point when actions move from prevention to intervention;
the initial assessment is the “grey zone” between prevention and
intervention.

18
Gordon, R. (1987), ‘An operational classification of disease prevention’, in Steinberg, J. A. and Silverman, M.
M. (eds.), Preventing Mental Disorders, Rockville, MD: U.S. Department of Health and Human Services, 1987.
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 Prevention: Any action or program designed to prevent suicide by
modifying risk factors and protective factors.

Train-the-Trainer Instruction: Programs designed to train

individuals to become proficient in training other people, using a
particular curriculum.

Programs and Proposals

This portion of the strategic plan is divided into three sections: 1) Current
Programs for Training, Prevention, Intervention and Community Education
in suicide prevention which are already in place, 2) Newly proposed
Training, Prevention and Intervention Programs, and 3) Newly proposed
Community Education projects. The newly proposed programs are listed
in charts in the Appendices. Core Programs are those which are planned
for implementation in year one, and the Expanded Programs are those
which are planned for implementation in years 2 or 3. Appendix A lists
the Core Programs and Appendix B the Expanded Programs for the
Training, Prevention and Intervention section, and Appendix C shows both
Core and Expanded programs for Community Education.

1) Current Programs for Training, Prevention, Intervention and

Community Education
In preparing the Three Year Strategic plan it was decided to first assess
and identify (as well as acknowledge) the current ongoing suicide
prevention programs being accomplished locally. These programs are
currently being funded by county departments, local agencies, law
enforcement, faith-based organizations, the local hospital, local media,
schools and service clubs. The Suicide Prevention Task Force convened
over a 12 months period to share local data, compile as list of current
programs, and monitor the cross-agency efforts identified below.
Ongoing funding and operation of these programs by the current
funding sources is encouraged.

Amador-Tuolumne Community Action Agency: Friday Night Live

activities and programs offered throughout the year at schools and
local venues, addressing issues such as suicide, substance abuse,
family involvement and general health.

Behavioral Health Department: Operates the county behavioral

health services program, which includes the Crisis, Assessment and
Intervention Program (which includes a 23-hour bed patient
assessment program), Outpatient Behavioral Health Services, and a

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 Crisis Assessment Team that evaluates patients in the local hospital
emergency department.

Columbia College: Provides depression screening and licensed

counseling services through the student health program on campus.

Dawn’s Light Center for Children and Adults in Grief: This local non-
profit agency provides Suicide Loss Support Groups, several
Children’s Grief Groups, and offers the Yellow Ribbon Suicide
Prevention Program and Yellow Ribbon Cards. This agency also
provides grief management and suicide prevention presentations to
various local groups, including some schools.

Law Enforcement, including the Tuolumne County Sheriff’s Office

(TCSO), the Sonora Police Department and the California Highway
Patrol: Many calls from the public require assessment by Law
Enforcement, particularly coming in to the TCSO dispatching center,
to determine the risk of suicidality. The TCSO averages one to two
calls per day requiring an assessment of suicide risk.

Mountain Women’s Resource Center: Provides teen violence and

bullying prevention training in local schools and for community
groups.

Tuolumne County Office of Education (TCOE) and YES Partnership

“Understanding And Preventing Suicide” Brochure: A three-fold
brochure developed as a student senior project and sponsored by
the Office of Education and the YES Partnership, describing signs of
suicidal risk and providing education about effective interventions to
prevent suicide. This has been distributed at schools and health
fairs.

TCOE and Local Schools: Provides the Jason Foundation Suicide

Prevention Program at two local high schools. An ongoing Challenge
Day program is underway at local high schools to improve social
skills and prevent bullying behavior. Other selected promotional
programs for mental health are offered at various local schools,
kindergarten through 12th grade.

Rotary Club Crisis Resource Cards: Over 10,000 resource cards

have been printed and distributed to local county agencies,
businesses, churches and schools providing numbers and websites
to access suicidal or other mental health crisis services.

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 Rotary Club Safe Place Projects: Projects that are currently
underway include the Community Dog Park, Columbia Elementary
Sports Park, Sonora High Track lights, and the Sonora library new
childrens' reading room. Rotary is also supporting Dawn's Light
Sonora High Grief Group, and coordinating community projects with
the Tuolumne County Recreation Department.

Recreation Department Crisis Resource Cards: This “accordion card”

directory is an updated edition, entitled “HELP Make the Call.” It is
an extensive resource for youth and includes emergency numbers
for various health crises, including suicidal ideation. These cards
have been widely distributed.

Recreation Department Youth Services Directory for Community

The “Youth Services Directory” booklet was published by the
Tuolumne County Youth Services Directory Committee with a large
number of local resources to enhance the quality of life for local
youth. The “Youth Services Directory” is available and has been
distributed.

Senior Outreach Activities, including the Senior Center, Area 12

Agency on Aging, Social Security offices, Veterans Services, Senior
Ombudsman, “Golden Age Partners,” Senior Peer Program, Catholic
Charities and Meals on Wheels: Each of these programs offers
preventive health services with varying amounts of training in
suicide prevention throughout the county.

Visiting Nurses Association/Hospice Program: Provides an annual

“Coping With the Holidays” program, teen grief support at local high
schools, and ongoing grief support groups in Tuolumne and
Calaveras Counties.

2. Training, Prevention and Intervention Programs

Core Programs
The Core Programs for Training, Prevention and Intervention
represent programs recommended for funding in year one of the
Strategic Plan and are listed in Appendix A.

The Suicide Prevention Task Force identified critical core programs

and proposals for inclusion in the Suicide Prevention Strategic Plan
in the realms of training, prevention and intervention that could be
implemented in the first year of the three year Strategic Plan if
funds were made available. Note that a brief description for each

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 identified core proposal is included in the following chart, as well as
target audience, age groups to benefit from proposal, outcomes,
annual costs, an agency that could provide oversight of the
proposal, identified in-kind contribution or cash available from a
sponsoring agency and what level of priority the proposal would
have in the first year. Please refer to the “Training, Prevention and
Intervention Core Proposals” chart for Year One, Appendix A.

Expanded Programs
The Expanded Programs for Training, Prevention and Intervention
represent programs recommended for funding in years two or three
of the Strategic Plan, and are listed in Appendix B.

These represent programs and strategies that were important and

yet not feasible to implement until years two and three – either due
to costs for the program, level of priority and/or ability to implement
if funds were to become available. Note that in this chart a brief
description was included, as well as target audience, age groups to
benefit from proposal, outcomes, annual costs, a possible agency
that could provide oversight of proposal, and any identified in-kind
contribution or cash available from a sponsoring agency. Please
refer to the “Training, Prevention and Intervention Expanded
Proposals” chart for Years Two and Three, Appendix B.

3. Community Education Programs

A Community Education Committee was formed in order to determine
how best to communicate, build awareness and encourage groups,
organizations, companies, and individuals to act and engage in suicide
prevention, training and intervention A list of strategies was
developed for the universal dissemination of education, awareness and
stigma reduction campaigns for the general population relating to
suicide prevention. Please refer to the “Community Education Core and
Expanded Proposals” chart, Appendix C.

Prioritizing Programs
The Suicide Prevention Task Force chairpersons from the five
subcommittees (Training, Prevention, Intervention, Community Education,
and Monitoring and Surveillance) decided upon a set of criteria for
prioritizing programs identified as being Core Proposals. Programs were
then prioritized in accordance with these criteria, with #1 assigned for top
priority, #2 for second and #3 for third, so that the Task Force could
prioritize which proposals to implement first based upon the availability of
funds in year one.

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Criteria for Inclusion Into The Strategic Plan
Programs were prioritized according to the following criteria:
• No Wrong Door: Each program was evaluated on its potential to
support and achieve the community goal of “No Wrong Door.”
• Age-Specific Goals: See Figure 3
• Evidence-based Documentation: Whether specific programs
designed to promote protective factors and diminish risk factors for
suicide can actually diminish the occurrence of suicide in rural
California counties is a question that largely remains unanswered.
Programs that focus on improving general coping skills and
resiliency show promise for suicide prevention. However it is
difficult to demonstrate efficacy in experimental models for suicide
prevention, in part because of the low base rate of completed
suicide, the short duration of implementation and assessment in
most studies, and the insufficient power generated by the
complexities of county-based data.19 The Tuolumne County
Strategic Plan for Suicide Prevention can serve as part of the
rigorous analysis that is required in order to establish the
generalized effectiveness of various suicide prevention programs.
• Relevant to Local Risk Analysis: The risk analysis conducted for
California counties in 2006 and 2007 suggests that substance abuse,
firearm availability, racial demographics (higher suicide rates for
Native American and White residents) and rural location are
significant predictors of high suicide rates in rural counties like
Tuolumne County.20 Psychological autopsy data confirmed local
relevancy of these risk factors. Mental health care for low income
populations was also a fairly strong predictor, but otherwise, mental
health factors weakly correlated with suicide rates. The rate of
completed suicide was highest for males and for those over 70 years
of age and those 35 to 44 years of age, similar to the bimodal
occurrence of suicide nationally (See Figure 2). Firearms were used
in 85% of suicides in Tuolumne County in 2006.
• Fidelity of Implementation: Whether specific suicide prevention
programs can be broadly applied to regions like Tuolumne County is
an important consideration. Considering local resources and
capacities may render it difficult to reproduce experimental
conditions in Tuolumne County, or programs may have been
designed for urban settings inapplicable to the needs of Tuolumne
County.

19
S.K. Goldsmith et al., Reducing Suicide: A National Imperative, Institute of Medicine, 2002, The National
Acadamies Press, Washington D.C.
20
Stolp, S.T. and Stolp, CW. Social Variables and Suicide Risk in Rural California Counties, pre-publication
copy, 2009
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 • Cost/Benefit Assessment: Ultimately, a cost-benefit analysis of each
program is a necessary consideration.

Monitoring and Surveillance

For the purposes of monitoring the community for suicidal incidents and
system utilization, a monitoring and surveillance plan was developed. Six
different data sources will provide a Monitoring and Surveillance
committee with statistical information regarding incidents of intentional
self-injury or suicidal events. The Monitoring and Surveillance committee
will meet quarterly. In all cases, strict patient confidentiality is observed
and data reviewed only in an anonymous fashion to identify potential
trends over time. Trends to be monitored may include gender, age, race,
residence and method. Data sources include the following.
1) Law Enforcement Child Death Review Team: As required by Section
11166.7 of the Penal Code, the Tuolumne County Sheriff’s Office
(TCSO) provides oversight for the local Child Death Review Team. An
annual report is prepared of the review of all deaths in the county of
people under 25 years of age. This team meets in an ad hoc fashion
and tracks suicide deaths in the county. Members include the
Sheriff/Coroner's Office, Probation, Public Health, Behavioral Health,
District Attorney's Office, Victim/Witness, Child Welfare Services,
California Highway Patrol, and the Sonora Police Department. Data is
shared with the Monitoring and Surveillance committee only as trend
data and not specific to any one case.
2) Public Health Death Certificate Review: The Health Officer reviews
all local death certificates each month and provides consultations for
deaths that occur with suspicious medical circumstances. Specific
attention is paid to identify cases of so called “passive suicide,” in which
a death may have been due to intentional overdose with prescription
medications or noncompliance with medical recommendations.
Ongoing surveillance for suicidal deaths is conducted and overall rates
shared with the Monitoring and Surveillance Committee.
3) Hospital-based E-Code monitoring: The International Classification
of Diseases maintains a series of Supplemental Codes, called “E-codes,”
to modify a diagnostic code for patients seen. E-codes 950 through
959 identify “suicide and self inflicted injury,” including poisoning.
Sonora Regional Medical Center will provide monthly rates of E-codes
950-959 for patients seen in both outpatient and inpatient sites,
allowing a way to monitor for suicidal attempts without fatal outcomes.
The data is entirely anonymous.
4) Behavioral Health Psychological Autopsies: Patients followed by the
Behavioral Health Department undergo case review under a Quality
Improvement Program. Part of case reviews include psychological
autopsies of cases with unfavorable outcomes, including suicide or

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 suicidal attempts. While specific case information is strictly
confidential, trends as they relate to suicide prevention are shared in
the setting of the Monitoring and Surveillance committee.
5) Statewide Statistical Section: Statewide data is gathered from the
Department of Public Health Statistical Section to monitor for regional
suicide trends.
6) Data specific to Screening Campaigns: Periodic screening for
depression may be conducted at the annual Health Fair or Columbia
College. The results of such screening may be shared to provide
insight into local trends for depressive illness or suicidal ideation.

Structure of Strategic Plan Oversight

This Strategic Plan will be implemented under the following organizational
structure.
Strategic Plan Coordinating Agency
Given the large number of recommended strategies and projects, a
monitoring/coordinating entity, the Coordinating Agency, will be sought
to assume responsibility for implementation, coordination, project
management and overall supervision. A Request For Qualifications
(RFQ) will be drafted to solicit bids and the successful organization be
awarded a contract in the range of $50,000 to $80,000. The successful
bidder will have primary responsibility to:
1. Monitor the projects to ensure identified outcomes are achieved.
Project status reports from the project contractees will be received
by this agency.
2. Organize materials to present to a Core Oversight Committee
(COC described below) composed of volunteers from the Suicide
Prevention Task Force (SPTF).
3. Prepare an annual report for submission to the entire SPTF.
4. Oversee and implement the Community Education component
of the Strategic Plan. Money will be set aside from the $50,000 to
$80,000 funding pool to pay for brochures, posters, calendars, etc.

Core Oversight Committee

The Suicide Prevention Committee will reform in early 2009 as the Core Oversight
Committee (COC) with 6 to 8 members to provide overall responsibility for
implementation of the Strategic Plan strategies and projects. This committee will
include key individuals involved in each of the five Strategic Plan components –
suicide prevention, intervention, training, community education and monitoring.
The COC will have the primary responsibility for overseeing the contractor who
will be charged with implementation and monitoring of the strategies and projects.
The COC will meet with the contractor on a quarterly basis. It is the intention that
the Community Education and Monitoring and Surveillance committees will
continue to meet between 2-4 times annually to be a resource to the Core

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 Oversight Committee and contracted Coordinating Agency. The COC will also be
responsible for ensuring the ongoing development of the Strategic Plan over time.

Community Education Committee

The Community Education Committee will meet 2 to 4 annually to
provide support to the Core Committee and Coordinating Agency.

Monitoring and Surveillance Committee

Consisting of members from the TCSO, Public Health, Behavioral
Health, and the SPTF, for a total of no more than six members, the
Monitoring and Surveillance Committee will meet quarterly to review
data from the sources noted earlier in this plan. A report will be
prepared and provided to the Core Committee annually.

Fundraising Committee
A small development/fundraising committee is being formed to begin
work to seek grants from a range of funders in Tuolumne County and
California in particular. It should be noted that $10,000 of the contract
amount ($50,000 -- $80,000) will be set aside to cover fundraising
costs in year one of the Community Education projects and strategies.

Funding and estimated Costs

The estimated costs to implementing all programs listed in the core
proposal chart for year one are estimated at $245,400 total, not including
the costs of coordination and fundraising.

Proposals given a #1 priority are estimated to cost $36,000, #2 priority

proposals are estimated to cost $199,400, and #3 priority proposals are
estimated at $10,000.

The Tuolumne County Behavioral Health Mental Health Services Act

(MHSA) Prevention and Early Intervention(PEI) funds of $40,000 will be
available to use for training costs each year for a four year period.

Funds totaling approximately $205,400 will be sought to support the

additional programs for the first year of the Strategic Plan. In Year Two
and Three, the expanded proposals are estimated to cost up to $301,055
(ongoing costs).

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