Implementation Strategies to Improve Outpatient Mental Health Treatment Initiation for Primary Care Patients With Suicidal Thoughts and Behaviours: A Scoping Review.

Implementation Strategies to Improve Outpatient Mental Health Treatment Initiation for Primary Care Patients with Suicidal Thoughts and Behaviors: A Scoping Review: Initiating Outpatient Mental Health Care - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Published in final edited form as: J Eval Clin Pract. 2026 Feb;32(1):e70362. doi: 10.1111/jep.70362 Search in PMC Search in PubMed View in NLM Catalog Add to search Implementation Strategies to Improve Outpatient Mental Health Treatment Initiation for Primary Care Patients with Suicidal Thoughts and Behaviors: A Scoping Review Initiating Outpatient Mental Health Care Eric S Crosby Eric S Crosby 1 Department of Psychiatry, University of Pennsylvania Find articles by Eric S Crosby 1 , Eleanor Turi Eleanor Turi 1 Department of Psychiatry, University of Pennsylvania 2 National Clinician Scholars Program, University of Pennsylvania 5 Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania 6 Leonard Davis Institute of Health Economics, University of Pennsylvania Find articles by Eleanor Turi 1, 2, 5, 6 , Danielle Eisenman Danielle Eisenman 1 Department of Psychiatry, University of Pennsylvania Find articles by Danielle Eisenman 1 , Emilie Famiglio Emilie Famiglio 1 Department of Psychiatry, University of Pennsylvania Find articles by Emilie Famiglio 1 , Gabriela Khazanov Gabriela Khazanov 1 Department of Psychiatry, University of Pennsylvania 3 Center of Excellence for Substance Addiction Treatment & Education, Crescenz Veterans Affairs Medical Center Find articles by Gabriela Khazanov 1, 3 , Shari Jager-Hyman Shari Jager-Hyman 1 Department of Psychiatry, University of Pennsylvania Find articles by Shari Jager-Hyman 1 , Courtney Benjamin Wolk Courtney Benjamin Wolk 1 Department of Psychiatry, University of Pennsylvania 4 Penn Center for Implementation Science, University of Pennsylvania Find articles by Courtney Benjamin Wolk 1, 4 Author information Copyright and License information 1 Department of Psychiatry, University of Pennsylvania 2 National Clinician Scholars Program, University of Pennsylvania 3 Center of Excellence for Substance Addiction Treatment & Education, Crescenz Veterans Affairs Medical Center 4 Penn Center for Implementation Science, University of Pennsylvania 5 Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania 6 Leonard Davis Institute of Health Economics, University of Pennsylvania ✉ Corresponding Author: Eric Crosby; 3535 Market St, 3 rd Floor, Philadelphia, PA, USA 19104; [email protected] PMC Copyright notice PMCID: PMC13087918  NIHMSID: NIHMS2146060  PMID: 41569904 The publisher's version of this article is available at J Eval Clin Pract Abstract Primary care is a common healthcare contact before suicide. When suicide risk is identified in primary care, patients are often referred to specialty outpatient mental health care. However, many do not initiate care. Strategies to improve the initiation of specialty outpatient mental health care among adults in primary care settings with suicidal thoughts and/or behaviors remain unclear. This scoping review operationalized implementation strategies used in primary care to facilitate the initiation of specialty mental health care. We used established methodology and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE, CINAHL, Embase, PsycInfo, and Google Scholar were searched for peer-reviewed articles in English that contained implementation strategies to improve the initiation of specialty outpatient mental health care among adults in primary care settings with suicidal thoughts and/or behaviors. We excluded abstracts, editorials, grey literature, and studies focused on intensive outpatient or partial hospitalization programs. At least two independent reviewers screened, completed a full-text review, and extracted study data. Implementation strategies were labeled and defined using the Expert Recommendations for Implementing Change (ERIC) strategies and operationalized using recommended reporting guidelines. Of the 606 citations screened, five studies were retained. An average of 8.6 unique strategies per study were identified. No study used an established taxonomy of strategies to label and define strategies nor stated all recommended reporting details. Common strategies aligned with ERIC strategies to ‘promote adaptability’, ‘develop and implement tools for quality monitoring’, ‘remind clinicians’, ‘facilitate relay of clinical data to providers’, and ‘centralize technical assistance’. Studies generally reported strategies’ actions, targets, timing, and outcomes, but inconsistently reported strategy actors, dose, and justification. Greater specification of implementation strategies to improve the initiation of specialty outpatient mental health care among adults in primary care settings with suicidal thoughts and/or behavior is needed. Keywords: primary care, time-to-treatment, implementation science, community mental health services, suicide prevention Suicide is a leading cause of death worldwide and suicide rates in the United States (U.S.) have increased over recent decades ( World Health Organization [WHO], 2025 ). This is in part due to primary care setting’s limited procedures to support the identification, assessment, and/or referral of patients with suicidal thoughts and/or behaviors to specialty outpatient mental health care settings. Primary care settings are ambulatory health services provided to individuals in community environments as their first point of contact for general medical and mental health needs ( WHO & United Nations Children’s Fund [UNICEF], 2018 ). Approximately 64–98% of suicide decedents have contact with primary care in the year before death ( Ahmedani et al., 2014 ; Saini et al., 2014 ). Because primary care settings are often visited by suicide decedents before death, primary care providers in many countries are tasked with using evidence-based practices to identify, assess, and refer patients experiencing suicidal thoughts and/or behaviors to specialty mental health settings in order to receive a higher level of care (WHO, 2003, 2018 ). However, only one in four primary care clinics have written policies and procedures for the management of suicidality ( Saini et al., 2014 ). As a result, less than one-third of suicide decedents have contact with specialty outpatient mental health services in the year before death ( Stene-Larsen & Reneflot, 2019 ). Identification of implementation strategies used in primary care settings to improve the identification, assessment, and transition to specialty outpatient mental health care for individuals with suicidal thoughts and behaviors is a promising method to decrease suicide risk. Implementation strategies represent the systematic processes to integrate evidence-based healthcare innovations into usual care ( Powell et al., 2012 ). Identifying the range of implementation strategies used in primary care to identify, assess, and transition patients to specialty outpatient mental health care will help researchers determine which strategies are feasible across settings, evaluate their impact on patient engagement, and inform primary care settings’ continuity of care practice guidelines. Effective continuity of care across healthcare settings reduces suicide risk by up to 20% ( Che et al., 2023 ). Therefore, the purpose of this study is to identify and operationalize implementation strategies used in primary care settings to improve the identification, assessment, and transition to specialty outpatient mental health care for individuals with a history of suicidal thoughts and/or behaviors. Clinical Pathway from Primary Care to Specialty Mental Health The clinical pathway from primary care to specialty mental health settings for individuals with suicidality is a sequence in which primary care providers identify and assess patients for recent suicidal thoughts and/or behaviors, provide immediate psychosocial support (e.g., advice on restricting access to means for suicide), seek consultation with or refer to a mental health specialist, and ensure follow-up until the patient is stable ( WHO, 2016 ). Although the overall pathway is consistent across countries, the specific assessment tools, available resources, and systems differ ( National Institute for Health and Care Excellence, 2022 ; Perlman et al., 2011 ; Sarkhel et al., 2023 ). In the U.S., best practices recommendations are for primary care providers to screen patients using self-report measures to identify suicide risk (e.g., Patient Health Questionnaire-9; PHQ-9), conduct a suicide risk assessment interview to determine severity of suicide risk (e.g., Columbia-Suicide Severity Rating Scale; C-SSRS), and deliver a brief intervention to manage suicide risk ( Ayer et al., 2022 ). This brief intervention may include a referral to specialty outpatient mental health treatment for those at non-imminent suicide risk ( Ayer et al., 2022 ). The referral process optimally includes (a) a referral when patient needs are outside primary care’s scope, (b) tracking the referral until completion, (c) an appointment with a mental health provider, (d) transfer of patient information to the mental health provider, (e) transfer of mental health consult results and treatment recommendations to primary care provider, and (f) a mutual care management plan between primary care and mental health providers ( Mehrotra et al., 2011 ). However, these steps are often partially completed or omitted ( Allwood et al., 2019 ). Barriers in the Primary Care to Specialty Mental Health Pathway The barriers to transitioning individuals at risk for suicide from primary to specialty mental health care occur throughout the clinical pathway and arise from provider competency limitations, cultural factors, systemic issues, and logistical constraints ( Trude & Stoddard, 2003 ). Primary care providers often struggle to manage suicide risk because they feel uncertain about when and how to ask about suicidality due to insufficient training and knowledge ( Mayer et al., 2025 ). Patients are reluctant to disclose suicidal thoughts and/or behaviors due to the stigma associated with mental health care or concerns about the implications of suicide disclosure ( Mayer et al., 2025 ; Wolk et al., 2024 ). Systemic healthcare challenges such as insufficient time in primary care for suicide risk discussions, long mental health clinic waitlists, and inadequate insurance coverage further limit access to specialty care ( Mayer et al., 2025 ; Perlman et al., 2011 ; Wolk et al., 2024 ). Communication barriers further complicate transitions as patients often do not respond to calls or messages due to competing life demands and limited resources, and healthcare staff have limited availability for outreach ( Wolk et al., 2024 ). Even when outreach successfully leads to scheduled mental health appointments, patients face logistical barriers such as limited access to public transportation, long travel distances, and high transportation costs that reduce appointment attendance ( Wolk et al., 2024 ). When a standardized patient endorsed both physical and mental health symptoms during a primary care appointment, less than half of providers provided a mental health referral ( Kravitz et al., 2006 ). Among patients offered a referral, approximately half were provided limited or no assistance from primary care staff in attaining services ( Kravitz et al., 2006 ). Ultimately, less than half of individuals referred from primary care to outpatient mental health settings scheduled and attended a follow-up appointment ( Pace et al., 2018 ; Vechiu et al., 2024 ). Cross-System Implementation Strategies Cross-system implementation strategies aim to increase care coordination between systems by aligning operations across systems ( Bunger et al., 2024 ). Cross-system implementation strategies have been identified related to staffing programs (e.g., co-located staff), promoting service access (e.g., establishing referral protocols), and aligning treatment plans across providers (e.g., shared decision-making; Bunger et al., 2024 ). For primary care clinics to effectively implement strategies that improve the transition to outpatient mental health care, they must understand how the strategy is operationalized. According to best practice guidelines for specifying and reporting implementation strategies, there are nine dimensions of strategy operationalization. These dimensions include defining the strategy’s name and conceptual definition, the person(s) completing the strategy, the action(s) to be completed, including the actions’ targets, temporality, and dose, the implementation outcome(s) affected by the action, and the justification of why the strategy actions would impact the implementation outcomes ( Proctor et al., 2013 ). The Expert Recommendations for Implementing Change (ERIC) compilation provides the names and definitions of 73 implementation strategies ( Powell et al., 2015 ). However, it remains unclear which strategies have been used in primary care settings to transition individuals at risk for suicide to specialty outpatient mental health care and how these strategies have been operationalized in each setting. A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis confirmed that no reviews have been completed or were in progress on strategies used to improve the initiation of outpatient mental health services for individuals with suicidal thoughts and/or behaviors in primary care. Review Objective The objective of this scoping review was to identify, label, define, and operationalize implementation strategies used in primary care settings for adults with a history of suicidal thoughts and/or behaviors to improve the initiation of outpatient mental health treatment. Methods This scoping review protocol was registered with Open Science Framework, followed the JBI methodology for scoping reviews, and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) in accordance with a priori protocol ( Crosby et al., 2024 ; Tricco et al., 2018 ; Peters et al., 2020 ). Inclusion and Exclusion Criteria We used the “PCC” mnemonic (population, concept, and context) to develop inclusion criteria ( Peters et al., 2020 ). The population was adults (18 years of age or older) with any history of suicidal thoughts and/or behaviors. The concept was an Expert Recommendations for Implementing Change (ERIC) implementation strategy ( Powell et al., 2015 ) that aimed to improve the clinical pathway from primary to specialty mental health care (i.e., the identification, assessment, referral, or connection of patients with suicidality in primary care to specialty outpatient mental health care). The primary care context was defined by the United States Institute of Medicine as “integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” ( Donaldson et al., 1996 , p. 31). Although this is a U.S. based definition, it aligns with the WHO’s (2018) international conceptualization of primary care settings. This definition was chosen because a previous scoping review on the management of suicide in primary care identified a substantial proportion of relevant studies conducted in the U.S. ( Saini et al., 2024 ). However, since scoping reviews determine the full coverage of a body of literature on a topic, global studies were also included to capture diverse primary care contexts ( Munn et al., 2018 ). The diverse contexts may limit the generalizability of results, as distinct nations and even constituent countries within the same sovereign state, can differ in their extent of service integration ( Campbell, 2007 ; Spicer, 2015 ). Evidence Sources We included all empirical studies published in peer-reviewed journals in the English language from any year and country up to January 2025. Studies were excluded if they were conference abstracts, editorials, commentaries, study protocol papers, unpublished studies, grey literature, or focused on partial hospitalization and intensive outpatient treatment programs. Search Strategy A three-step search strategy was used. First, a limited search of MEDLINE (PubMed), CINAHL (EBSCO), Embase (OVID), PsycInfo (APA PsycNET), and Google Scholar was completed to identify preliminary articles. We examined index terms and keywords in titles and abstracts to develop a complete search strategy and adapt the strategy to all databases (see Supplemental Materials ). Next, a comprehensive search of the aforementioned databases was conducted in order to locate all potential articles related to the study topic. Due to the wide-ranging search results produced by Google Scholar, we only examined the first 125 articles for relevancy. Finally, after title and abstract screening and full-text review (see Study Selection below), the reference list of selected full-text articles was screened for additional studies ( Peters et al., 2020 ). Study Selection After the complete search, all identified citations were uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia), which automatically removed duplicates. We completed title and abstract screening, then full-text articles that met this study’s inclusion and exclusion criteria were uploaded into Covidence to undergo full-text review. We piloted title and abstract screening and full-text review to ensure consistent use of inclusion and exclusion criteria, then independently completed screening and full-text review with at least two reviewers. Disagreements between reviewers were resolved through consensus discussion with a third reviewer with expertise in both suicide prevention and implementation science ( Peters et al., 2020 ). Data Extraction We piloted and refined the full-text article data extraction template based on article information to ensure reliability of data extraction across at least two independent reviewers. We extracted study title, author(s), corresponding author email, journal of publication, year of publication, and country of origin. We also extracted the study rationale, aim(s), study design, participant inclusion/exclusion criteria, total sample size, and type of primary care model and provider setting. Finally, we extracted implementation strategy dimensions, including the strategy’s name and definition; actor(s); action(s); action(s) targets, temporality, and dose (i.e., frequency, duration, and intensity); implementation outcome(s); and the justification for why the strategy would produce the implementation outcome ( Proctor et al., 2013 ). Primary care models were defined by SAMHSA’s Levels of Integration: Coordinated (i.e., separate systems and facilities with minimal or basic collaboration), Co-located (i.e., separate or shared systems in same facilities with regular communication), and Integrated (i.e., shared systems and facilities with in-depth, routine communication; Center for Integrated Health Solutions, 2020 ). The updated Consolidated Framework for Implementation Research (CFIR) defined the socioecological levels of the implementation strategy actions targets ( Damschroder et al., 2022 ): Outer Setting, Inner Setting, Innovation, Individuals, and Implementation Process. Implementation outcomes were categorized according to Proctor and colleagues’ specifications: Acceptability, Adoption, Appropriateness, Costs, Feasibility, Fidelity, Penetration, and Sustainability ( Proctor et al., 2011 ). Discrepancies between reviewers were resolved through consensus discussion with a third reviewer with expertise in suicide prevention and implementation science. Data Synthesis and Interpretation Implementation strategies were labeled and defined according to the Expert Recommendations for Implementing Change (ERIC) and were grouped into established implementation strategy categories: evaluative and iterative strategies, provide interactive assistance, adapt and tailor to context, develop partner and consumer interrelationships, train and educate partners and consumers, support clinicians, engage consumers, utilize financial strategies, and change infrastructure ( Powell et al., 2015 ; Waltz et al., 2015 ). We operationalized strategies according to recommendations for specifying and reporting implementation strategies ( Proctor et al., 2013 ). At least two independent reviewers assessed the specificity of the strategies until consensus was reached, with disagreements resolved by an additional reviewer. A critical appraisal and risk of bias assessment was not included because scoping reviews map available evidence, rather than provide a clinically meaningful synthesis of evidence ( Peters et al., 2020 ). Results Study Characteristics As seen in Figure 1 , titles and abstracts were screened for 606 unique citations, 44 full-text articles were reviewed, and five articles were retained. Most studies were conducted in the U.S. ( n = 4/5). Studies examined strategies via a type III randomized trial design ( n = 2/5), cross-sectional design ( n = 2/5), and a prospective observational cohort design ( n = 1/5). Sample sizes ranged from 1,216 to 155,917 with mean or median participant age ranging from 39.7 to 73.5. Figure 1. PRISMA Flow Diagram. Open in a new tab Note . STBs = Suicidal thoughts and/or behaviors; OPMH = Outpatient mental health services. Definitions of suicidal thoughts and/or behaviors varied across studies. They included endorsement of any positive response ( Denneson et al., 2014 ; Maulik et al., 2017 ) or a ‘nearly every day’ response ( Lawrence et al., 2010 ) to ‘thoughts of being better off dead or of hurting yourself’ on the PHQ-9 (item 9); a suicidal method, intent, plan, or recent suicidal behavior (items 3–5 or 6b) on the C-SSRS screen ( Bahraini et al., 2022 ); suicidal ideation questions from the Primary Care Evaluation of Mental Disorders (PRIME-MD) interview form ( Bartels et al., 2004 ); and ‘thoughts of taking your life’ from The VA “Pocket Card” Risk Assessment ( Denneson et al., 2014 ). Between 4 and 36 percent of participants reported a history of suicidal thoughts and/or behaviors. Strategies were implemented in integrated Department of Veterans Affairs medical centers ( Bahraini et al., 2022 ; Bartels et al., 2004 ; Denneson et al., 2014 ), as well as coordinated rural primary care centers ( Maulik et al., 2017 ), community health centers and outpatient hospital networks ( Bartels et al., 2004 ), and HIV-focused primary care clinics ( Lawrence et al., 2010 ). Intervention Characteristics Two studies investigated implementation strategies for multiple components of the clinical pathway from primary to specialty mental health care. These studies focused on screening and/or assessment for suicide risk and a brief intervention for suicide risk ( Maulik et al., 2017 ; Lawrence et al., 2010 ). Three studies focused on a singular component of the clinical pathway from primary to specialty mental health care. Two of these studies standardized suicide risk screening alone ( Bahraini et al., 2022 ; Denneson et al., 2014 ) and one improved referral to specialty outpatient mental health treatment alone ( Bartels et al., 2004 ). The referral process in the U.S. studies followed established clinical pathways from primary to specialty mental health care. In the study conducted outside the U.S., trained female community health lay workers, who were residents of the communities they served, conducted household visits to screen for suicide risk ( Maulik et al., 2017 ). Patients with a positive screen were referred to a primary care physician at a local health center. The physician assessed and provided treatment as appropriate, referring patients to specialty outpatient mental health when suicide risk was beyond their capacity ( Maulik et al., 2017 ). Implementation Strategies As seen in Table 1 , the total number of unique implementation strategies per study ranged from 6 to 14. There was a mean of 8.6 unique implementation strategies across studies. Among the 73 ERIC implementation strategies, 24 (33%) were used at least once and 49 strategies were never used ( Powell et al., 2015 ). Table 1. Retained Studies on Implementation Strategies for Suicide Risk Clinical Pathway from Primary Care to Specialty Mental Health (N = 5) Title Study Country Study Purpose Study Design and Sample Primary care and mental health model Intervention Number of unique strategies a Mental health follow-up and treatment engagement following suicide risk screening in the Veterans Health Administration Bahraini et al., 2022 USA To evaluate mental health follow-up and treatment engagement in the VHA following administration of the screen, a component of the VHA’s universal suicide risk screening program. Cross-sectional Veterans ( N =155,917; M age = 50.73; 18% with STBs) who completed the C-SSRS screen after a positive suicide risk screening between 2018–2020 at 140 veteran medical centers. Integrated VA medical centers Standardized suicide risk screening 7 Improving Access to Geriatric Mental Health Services: A Randomized Trial Comparing Treatment Engagement with Integrated Versus Enhanced Referral Care for Depression, Anxiety, and At-Risk Bartels et al., 2004 USA Test whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in behavioral health services by older primary care patients. Type III hybrid implementation-effectiveness randomized trial Older adults ( N = 2,022, M age = 73.5; 36% with STBs; n = 1,023 referral to outpatient care condition, 36% with STBs) with a positive screening for psychological distress, suicidal ideation, or substance use from primary care clinics. Integrated VA medical centers, as well as coordinated community health centers and outpatient hospital networks Referral and follow-up contact model 9 Mental health utilization of new-to-care Iraq and Afghanistan Veterans following suicidal ideation assessment Denneson et al., 2014 USA Evaluate impact of brief structured suicidal ideation assessments on mental health care among new-to-care veterans. Cross-sectional New-to-care veterans ( N = 465; 56% between 25–35 years of age; 32% with STBs) screened for depression in a metropolitan or rural-based primary care, or a mental health outpatient setting between 2008–2009 at three VA medical centers. Integrated VA medical centers Standardized suicide risk screening 7 Increasing use of mental health services in remote areas using mobile technology: a pre–post evaluation of the SMART Mental Health project in rural India Maulik et al., 2017 India Develop and evaluate the feasibility and acceptability of multifaceted intervention using training, task shifting, and mobile–based decision support to increase the screening and referral of individuals with common mental health disorders. Type III hybrid implementation-effectiveness randomized trial Adults ( N = 5,167; M age = 39.7; 4.34% with STBs) located in rural villages served by a primary care clinic in Andhra Pradesh, India. Coordinated rural primary care centers with mental health providers Identification and management of common mental disorders 14 Routine, Self-Administered, Touch-Screen, Computer Based Suicidal Ideation Assessment Linked to Automated Response Team Notification in an HIV Primary Care Setting Lawrence et al., 2010 USA Test implementation of routine screening of suicidal ideation and associated conditions using computerized patient-reported outcome assessments. Prospective observational cohort design Adults with HIV ( N = 1,216; M age = 44; 14% with suicidal ideation) from two distinct HIV primary care clinics. Coordinated HIV-focused primary care with mental health providers Efficient and patient acceptable suicide risk screening 6 Open in a new tab Note . VHA = Veterans Health Administration; C-SSRS = Columbia-Suicide Severity Rating Scale; Department of Veterans Affairs = VA; STBs = Suicidal thoughts and/or behaviors. a Implementation strategies were defined according to Powell et al., (2015) . Implementation Strategies’ Names and Conceptual Definitions No study labeled and defined implementation strategies consistent with ERIC or another taxonomy of strategies ( Powell et al., 2015 ). As seen in Figure 2 , the most frequently reported strategies aligned with the ERIC strategies to ‘promote adaptability’ ( n = 4/5 studies), ‘develop and implement tools for quality monitoring’( n = 4/5), ‘remind clinicians’ ( n = 3/5 studies), ‘facilitate relay of clinical data to providers’ ( n = 3/5 studies), and ‘centralize technical assistance’ ( n = 3/5 studies; Powell et al., 2015 ). Figure 2. Frequency of Unique ERIC Implementation Strategies Across Retained Studies by Implementation Category (N = 5). Open in a new tab Note . Implementation strategies were defined according to Powell et al., (2015) and categorized according to Waltz et al., (2015) . These five ERIC strategies covered four implementation strategy categories ( Waltz et al., 2015 ). In the ‘adapt and tailor to context’ category, ‘promote adaptability’ refers to identifying ways a clinical innovation can be tailored to meet local needs while preserving fidelity. For the ‘evaluative and iterative’ category, ‘develop and implement tools for quality monitoring’ involves developing, testing, and introducing the correct inputs into quality-monitoring systems. Concerning the ‘support clinicians’ category, ‘remind clinicians’ involves developing reminder systems to help clinicians to recall information or prompt innovation use and ‘facilitate relay of clinical data to providers’ includes providing as close to real-time data as possible about process and outcome measures using integrated communication methods. In the ‘interactive assistance’ category, ‘centralize technical assistance’ involves developing and using a centralized technical assistance system for implementation issues ( Powell et al., 2015 ; Waltz et al., 2015 ). Actors As seen in Table 2 , there was poor reporting of actors who delivered strategies. Three studies did not label the actors for the majority of actions, but described activities that are typically completed by implementation teams ( Bahraini et al., 2022 ; Bartels et al., 2004 ) or high-level leaders and innovation deliverers ( Denneson et al., 2014 ). Two studies described that most actions were completed by the research team or were prescribed to innovation deliverers ( Maulik et al., 2017 ; Lawrence et al., 2010 ). Table 2. Operationalization of Implementation Strategies for Suicide Risk Clinical Pathway from Primary Care to Specialty Mental Health (N = 5) Study ERIC Strategy Name ERIC Strategy Definition Actions Temporality Actor Action Frequency Action Duration Action Intensity Action Target a Justification Bahraini et al., 2022 Change service sites Change the location of clinical service sites to increase access Expanded suicide risk screening to primary care Before implementation - - - - Inner Setting - Revise professional roles Shift and revise roles among professionals who provide care, and redesign job characteristics Mandate change Have leadership declare innovation priority and determine to have it implemented Mandated suicide risk screening in primary care - - - Annually - Change record systems Change records systems to allow better assessment of implementation or clinical outcomes Added PHQ-9 item nine to depression and PTSD screens - - - - - - Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Administered C-SSRS screen to those with positive PHQ-9 After patient has a positive (some level of suicidal ideation) on item 9 on the PHQ-9 - - - - Innovation - Develop and implement tools for quality monitoring Develop, test, and introduce into quality-monitoring systems the right input (e.g., the appropriate innovation-specific algorithms) Defined positive C-SSRS screen as “yes” to items 3, 4, 5, or 6b - - - - - - Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Required a comprehensive suicide risk evaluation Same day as positive C-SSRS screen Any licensed independent practitioner - - - - Stage implementation scale-up Phase implementation efforts by starting with small pilots or demonstration projects and gradually move to a system wide rollout Examined feasibility of suicide risk protocol After one implementation year Researcher - - - Implementation Process - Bartels et al., 2004 Obtain formal commitments Obtain written commitments from key partners that state what they will do to implement the innovation Obtained agreements from mental health clinics to comply with primary care referral requirements - - - - - Outer Setting - Model and simulate change Model or simulate the change that will be implemented prior to implementation Required model to be in place and functioning Before implementation - - At least six months - Implementation Process - Develop and organize quality monitoring systems Develop and organize systems and procedures that monitor clinical processes and/or outcomes for quality assurance Confirmed model fidelity and satisfaction, and systematically monitored through a process evaluation during site visits - - - Each site - Develop and implement tools for quality monitoring Develop, test, and introduce into quality-monitoring systems the right input (e.g., the appropriate innovation-specific protocols) Purposely reexamine implementation Monitor progress and adjust clinical practices and implementation strategies to continuously improve care quality Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Referred patients to outpatient care in a separate location with licensed behavioral health professionals Within two to four weeks of appointment that identified suicide risk Primary care physician - - - Innovation Minimizing time from referral to specialty mental health improves patient treatment Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Offered assistance with transportation After referral - - - - Inner Setting Providing transportation to specialty mental health improves patient treatment Make billing easier Make it easier to bill for the clinical innovation Facilitated direct or third-party coverage for costs of specialty behavioral health visits - - - - Payment coverage for specialty mental health improves patient treatment engagement Remind clinicians Develop reminder systems to help clinicians to recall information and/or prompt clinical innovation use Informed primary care physician of appointment with behavioral health provider - - - - - Promote network weaving Identify and build on existing high-quality working relationships and networks within and outside the organization to promote information sharing and innovation implementation Coordinated follow-up contacts if the patient did not attend first scheduled appointment - - - - - Denneson et al., 2014 Mandate change Have leadership declare innovation priority and determine to have it implemented Designated suicidal ideation assessment for those with positive depression or PTSD screens Before implementation VA high-level leaders - - Nationally Inner Setting - Change record systems Change records systems to allow better assessment of implementation or clinical outcomes Embedded assessment tools and clinical reminder system in electronic medical records - - - Nationally - Centralize technical assistance Develop and use a centralized system to deliver technical assistance focused on implementation issues Develop and implement tools for quality monitoring Develop, test, and introduce into quality-monitoring systems the right input (e.g., appropriate innovation-specific patient outcome measures) Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Conducted depression screening using PHQ-9, or PHQ-2 with item nine of the PHQ-9, and/or the VA “Pocket Card” Risk Assessment - - Annually - - Innovation - Facilitate relay of clinical data to providers Provide as close to real-time data about key outcomes using integrated channels of communication for innovation use Listed screening results in progress notes - - - - - - Remind clinicians Develop reminder systems designed to help clinicians to recall information and/or prompt clinical innovation use Positive screening results generated new clinician follow-up reminders - - - - - - Maulik et al., 2017 Developed educational materials Develop and format supporting materials to make it learning about innovation easier Conducted a community stigma reduction campaign with printed and video materials and live performances Before implementation - Eight weeks - - Individuals’ Characteristics Community-based mental health stigma reduction campaign increased patient initiation of care Distributed educational materials Distribute educational materials Use mass media Use media to reach large numbers of people to spread the word about the clinical innovation Increase demand Attempt to influence the market for the clinical innovation to increase the maturity of the market for the clinical innovation Revised professional roles Shift and revise roles among professionals who provide care and redesign job characteristics Shifted suicide screening from primary care professionals to community lay workers Before implementation - - - - Inner Setting - Centralize technical assistance Develop and use a centralized system to deliver technical assistance focused on implementation issues Developed electronic decision and reminder systems from lay workers and PCPs on a mobile platform Before implementation Researchers - - - - Conduct cyclical small tests of change Implement changes in a cyclical fashion using small tests of change before system-wide changes Validated decision and reminder system against a psychiatrist’s diagnosis, finalized iteratively using simulated data, and tested in village Before implementation - - Tested system in one village Implementation Process - Developed educational materials Develop and format supporting materials to make it easier for stakeholders to learn the innovation Provided classroom training and supervised field training to lay workers with feedback; trained doctors individually using educational modules Before implementation - - - Inner Setting - Distributed educational materials Distribute educational materials Provide clinical supervision Provide clinicians with ongoing innovation supervision Conduct ongoing training Plan and conduct training in the clinical innovation in an ongoing way Monitored work of lay workers and PCPs, and provided clinical and technical support - Ongoing - - - Change service sites Change the location of clinical service sites to increase access Screened patients in their homes and referred them to primary care clinics or organized health camps so that patients could visit PCP closer to home - Lay workers - - Select villages Innovation - Intervene with patients to enhance uptake and adherence Develop strategies with patients to encourage and problem solve around adherence Informed patients with positive screens about the time/location of health camps - Lay workers - - - Innovation - Referred patients with suicide risk beyond PCP’s capacity to outpatient mental health - PCPs - - - - Remind clinicians Develop reminder systems designed to help clinicians to recall information and/or prompt clinical innovation use Electronic systems sent out reminders to lay workers and PCPs to conduct suicide risk screenings and follow-up with patients on positive screens - - - - - Inner Setting - Facilitate relay of clinical data to providers Provide as close to real-time data about key outcomes using integrated channels of communication for innovation use Allowed clinical data from systems to be shared between the lay workers and primary care physicians using cloud computing - Researchers - Ongoing - - Assess for readiness and identify barriers and facilitators Assess aspects of an organization to determine its readiness, barriers, and strengths that can be used in implementation Conducted process evaluation using questionnaires, focus groups, interviews with community members, lay workers, PCPs, and research staff After implementation - - - Implementation Process - Lawrence et al., 2010 Centralize technical assistance Develop and use a centralized system to deliver technical assistance focused on implementation issues Developed an open-source, web-based software application with patient assessments Before implementation - - - Inner Setting - Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Included normalcy statements or phrasing of questions in assessments to decrease perception of judgment in several of the standardized instruments - - Several scales Develop and implement tools for quality monitoring Develop, test, and introduce into quality-monitoring systems the right input (e.g., appropriate innovation-specific processes measures) Conducted testing of web-based patient-reported outcome software to determine the mean time for completion - - - Implementation Process - Change physical structure and equipment Evaluate current configurations and adapt, physical structure and/or equipment accommodate innovation Integrated touchscreen devices with web-based software into waiting rooms - - - - - Inner Setting - Facilitate relay of clinical data to providers Provide as close to real-time data about key outcomes using integrated channels of communication for innovation use Categorized those who responded “nearly every day” to the suicidal ideation question to receive a comprehensive suicide risk assessment - Licensed mental health professional - - - Innovation - Intervene with patients to enhance uptake and adherence Develop strategies with patients to encourage and problem solve around adherence Discussed results of suicide risk assessment and recommended course of action with both the patient and PCP - - - - Open discussion with problem-solving increases attendance Promote adaptability Identify ways a clinical innovation can be tailored to meet local needs and clarify innovation elements that must be maintained for fidelity Recommended specialty outpatient mental health appointment, family or friend for support or supervision, or emergency department referral - - - Mental health visit one week of screening - Open in a new tab Note . Dash (−) indicates data were not reported; All studies examined penetration as an implementation outcome, which was defined according to Proctor et al. (2011) ; ERIC = Expert Recommendations for Implementing Change; PHQ-9 = Patient Health Questionnaire-9; C-SSRS = Columbia-Suicide Severity Rating Scale; PCP = Primary Care Physicians. a Implementation targets were defined according to Consolidated Framework for Implementation Research Damschroder et al. (2022) . Targets All studies identified targets related to improve the clinical pathway from primary to specialty outpatient mental health care. These targets ranged from accurately identifying individuals at risk for suicide in primary care to enhancing care coordination between primary care and specialty mental health providers after referral. Four studies aimed to better identify individuals at risk for suicide in order to refer them to appropriate levels of care. One study targeted community mental health symptom and service awareness and the number of trained mental health workers to encourage screening and referrals to outpatient mental health ( Maulik et al., 2017 ). Two studies targeted the lack of a structured protocol for suicide screening and assessment to increase the number of referrals ( Bahraini et al., 2022 ; Denneson et al., 2014 ). Another study targeted patient acceptability and efficiency of disclosures of suicidal thoughts and behaviors to increase the number of referrals ( Lawrence et al., 2010 ). The fifth study only provided an enhanced referral model to specialty outpatient behavioral health services to increase care coordination after the referral ( Bartels et al., 2004 ). Actions Strategies involved multiple actions across all CFIR domains ( Damschroder et al., 2022 ; see Table 2 ). Outer Setting. To develop relationships across primary care and specialty mental health settings, outpatient behavioral health agencies agreed to comply with a coordinated primary care referral model ( Bartels et al., 2004 ). Innovation. To create a structured clinical pathway for individuals with suicide risk, participants underwent suicide risk screening with the PHQ-9 ( Bahraini et al., 2022 ; Denneson et al., 2014 ; Lawrence et al., 2010 ; Maulik et al., 2017 ), or the VA “Pocket Card” Risk Assessment ( Denneson et al., 2014 ). Those endorsing suicidal thoughts and/or behaviors directly received a comprehensive suicide risk assessment by a licensed provider ( Lawrence et al., 2010 ), or received a C-SSRS screen and a positive C-SSRS triggered a comprehensive suicide risk assessment by a licensed provider ( Bahraini et al., 2022 ). Results of the suicide risk evaluation were documented in progress notes and positive results generated follow-up reminders for subsequent screenings ( Bahraini et al., 2022 ; Denneson et al., 2014 ). Screening results and follow-up reminders were shared between providers ( Lawrence et al., 2010 ; Maulik et al., 2017 ). Treatment plans were discussed with patients ( Lawrence et al., 2010 ). Primary care physicians were notified of scheduled mental health appointments and coordinated patient follow-up with mental health providers if the first appointment was missed ( Bartels et al., 2004 ). Inner Setting. To support the clinical pathway from primary care to specialty mental health for those with suicide risk, suicide risk screening shifted from primary care providers in clinics to community lay workers in patient homes ( Maulik et al., 2017 ). An integrated web-based patient self-report assessment tool was developed with statements that aimed to decrease patients’ perceptions of judgment and placed in waiting rooms ( Lawrence et al., 2010 ). Suicide risk screening was expanded to and mandated in primary care settings, the PHQ-9 was integrated into annual mental health assessments, and/or clinical reminders were embedded in electronic medical records ( Bahraini et al., 2022 ; Denneson et al., 2014 ). Electronic decision-support and reminder systems were developed to guide community lay workers in suicide risk screening and primary care physicians in care recommendations ( Maulik et al., 2017 ). Providers received training and monitoring with electronic systems ( Maulik et al., 2017 ). Participants were offered transportation assistance and financial support for mental health visits ( Bartels et al., 2004 ). Individuals (Roles and Characteristics). To increase innovation recipients’ need and capability to engage in a suicide risk evaluation and referral, a mental health awareness and stigma reduction door-to-door, poster and brochure, video, and live performance campaign was conducted ( Maulik et al., 2017 ). Implementation Process. Key components or full clinical pathways were piloted before implementation ( Bartels et al., 2004 ; Lawrence et al., 2010 ; Maulik et al., 2017 ). A process evaluation was completed after initial or complete implementation ( Bahraini et al., 2022 ; Maulik et al., 2017 ). Temporality Strategies occurred throughout the primary to specialty mental health clinical pathway, but often did not extend past the referral decision (see Table 2 ). All studies reported a strategy in preparation for improving clinical pathway implementation. These included evaluative and iterative strategies (e.g., ‘conduct cyclical small tests of change’ and ‘develop and implement tools for quality monitoring’; Bartels et al., 2004 ; Maulik et al., 2017 ; Lawrence et al., 2010 ), interactive assistance (i.e., ‘centralize technical assistance’; Denneson et al., 2014 ), infrastructure changes (e.g., ‘mandate change’ and ‘change record systems’; Bahraini et al., 2022 ), and clinician training and education (e.g., ‘developed and distributed educational materials’; Maulik et al., 2017 ). Most studies ( n = 4/5) reported strategy actions during suicide risk screening and/or assessment to better identify individuals in need of referral. These strategies focused on adapting and tailoring practices to the context (e.g., ‘promote adaptability’; Bahraini et al., 2022 ), supporting clinicians (e.g., ‘remind clinicians’; Denneson et al., 2014 ), engaging consumers (e.g., ‘intervene with patients to enhance uptake and adherence’; Lawrence et al., 2010 ), and training and education (e.g., ‘provide ongoing consultation’; Maulik et al., 2017 ). Some studies ( n = 3/5) reported strategy actions after a referral to outpatient mental health ( Bahraini et al., 2022 ; Bartels et al., 2004 ; Maulik et al., 2017 ). These studies focused on tailoring practices to the context (e.g., ‘promote adaptability’; Bartels et al., 2004 ), supporting clinicians actions (e.g., ‘remind clinicians’; Maulik et al., 2017 ), high-quality provider relationships (e.g., ‘promote network weaving’ and ‘facilitate relay of clinical data to providers’; Bartels et al., 2004 ; Maulik et al., 2017 ), and finances (e.g., ‘make billing easier’; Bartels et al., 2004 ). Two studies reported ‘assessing readiness, barriers, and facilitators’ and ‘staging implementation scale-up’ after strategy implementation ( Bahraini et al., 2022 ; Maulik et al., 2017 ). Dose All studies provided incomplete information about the frequency, duration, or intensity of strategies (see Table 2 ). To better identify participants at risk of suicide, an eight-week stigma reduction campaign was completed ( Maulik et al., 2017 ), the phrasing of several screening measures were modified ( Lawrence et al., 2010 ), and annual suicide risk screenings were administered ( Bahraini et al., 2022 ; Denneson et al., 2014 ). However, the number of activities completed during the stigma reduction campaign, the extent of modifications for screening measures, and the duration of suicide risk screening were not reported. To enhance care coordination after referral, a fully functioning referral model was required for six months, referral to outpatient mental health care occurred within two to four weeks of the primary care appointment that identified suicide risk, and coordinated contact between providers occurred if the participant did not attend the initial mental health appointment ( Bartels et al., 2004 ). However, the frequency of referrals in the fully functional model, the degree of care coordination to schedule mental health appointments, and the number of coordinated contacts after a missed mental health appointment were not reported ( Bartels et al., 2004 ). Ongoing implementation support was also reported without a specific frequency, duration, or intensity ( Maulik et al., 2017 ). Outcomes and Justifications All studies examined how the strategies affected patient penetration or reach, which assessed the number of participants that attended specialty outpatient mental health services. No other implementation outcomes were reported. Justifications for patient penetration were largely absent. Two studies did not mention justifications for the selected strategies ( Bahraini et al., 2022 ; Denneson et al., 2014 ). Among the three other studies, one study described empirical evidence that a community-based mental health stigma reduction campaign increased patient initiation of mental health care ( Maulik et al., 2017 ). The second study cited empirical evidence that open discussion of suicide risk with a problem-solving approach increased specialty outpatient mental health appointment attendance ( Lawrence et al., 2010 ). The final study cited clinical practice guidelines that suggested providing transportation, payment coverage, and minimizing time from referral to specialty mental health appointments improved patient engagement in mental health treatment ( Bartels et al., 2004 ). However, none described the underlying mechanism of their strategies and why the outcome would occur. No study proposed a theoretical justification. Discussion We identified, labeled, defined, and operationalized implementation strategies used to improve the initiation of outpatient mental health treatment for adults with a history of suicidal thoughts and/or behaviors identified in primary care settings. We screened 606 citations and retained five studies that implemented an average of 8.6 strategies per study across a range of primary and specialty mental health care settings. Although no study used a formal taxonomy to label and define strategies, common strategies used aligned with ERIC strategies to ‘promote adaptability’ (i.e., tailor innovations to local needs while maintaining fidelity), ‘develop and implement tools for quality monitoring’ (i.e., developing and introducing inputs into quality-monitoring systems), ‘remind clinicians’ (i.e., developing clinician reminder systems), ‘facilitate relay of clinical data to providers’ (i.e., provide real-time data using integrated communication methods), and ‘centralize technical assistance’ (i.e., develop and use centralized technical support systems; Powell et al., 2015 ). No study reported all dimensions of strategy operationalization. Studies generally reported the strategies’ actions, targets, temporality, and outcomes. However, there was inconsistent reporting of strategies’ actors, dose, and justifications. Findings highlight the need for greater specification in reporting of implementation strategies to better allow researchers and primary care clinics to accurately test and adopt strategies to improve access to specialty outpatient mental health care for individuals with suicidal thoughts and/or behaviors. The diversity in healthcare settings and levels of integration likely reflects cultural, skill-based, and financial differences among providers and services–such as varying attitudes toward mental health, differences in professional training, and unequal funding for care ( Wakida et al., 2018 ). These disparities highlight the need for implementation strategies that foster community-wide collaboration to address institutional cultures, establish complementary measures of healthcare quality, and develop joint funding streams across medical and mental health services ( Eaves et al., 2020 ). The average number of implementation strategies per study is consistent with previous review of suicide prevention implementation strategies ( Chen et al., 2024 ). Multi-faceted implementation strategies may be common because organizational change often occurs at multiple socioecological levels and requires different strategies tailored to each levels’ needs ( Harvey & Kitson, 2015 ). This suggests future research should clearly delineate and report each discrete implementation strategy and its targeted socioecological level to improve the transition from primary care to specialty outpatient mental health. This can be accomplished through using an established taxonomy of implementation strategies and a framework for determinants of organizational change (e.g., ERIC and CFIR; Damschroder et al., 2022 ; Powell et al., 2015 ; Waltz et al., 2015 ). This will ensure that future researchers and quality improvement teams can systematically identify which strategies have been used to promote the initiation of specialty outpatient mental health care among individuals referred from primary care due to suicidal thoughts and/or behaviors. Frequently reported ERIC implementation strategies aligned with best practices for suicide prevention in primary care. Best practice recommendations are to significantly redesign suicide prevention practices to fit within the primary care service delivery model and for behavioral health providers to provide ongoing consultation to support primary care physicians ( Bryan & Rudd, 2010 ). These strategies promote systematic suicide screening, assessment, and referral, ensuring that individuals at risk are effectively transitioned from primary care to specialty mental health services. Primary care providers report both limited behavioral health knowledge to effectively screen and assess suicide risk, as well as poor communication with other care settings that compromises continuity of care ( Rotoli et al., 2019 ). If strategies focused solely on either pre- or post-referral processes, they might improve outpatient mental health attendance but fail to ensure the appropriate individuals are referred to care, or vice versa. Contrary to implementation strategy reporting recommendations, no study used a formal taxonomy to label and define implementation strategies. This may be because only a small proportion of clinical researchers explicitly identify themselves as using implementation science methods, despite almost all reporting incorporating implementation science methods at least sometimes ( Stevens et al., 2020 ). This misspecification of method use diminishes implementation science research and primary care clinics’ ability to adopt appropriate strategies. Existing taxonomies of implementation strategies that provide names and definitions of strategies can help improve the consistency of terms and concepts. Greater consistency will allow primary care staff to efficiently explore research literature, compare findings across studies, and replicate effective strategies across settings ( Powell et al., 2015 ). Our findings suggest that the use of standardized implementation strategy names and definitions in future research would enhance the clarity and reproducibility of strategies. Consistent with a previous review of implementation strategies, no study reported all dimensions of strategy operationalization ( Hooley et al., 2020 ). Of note, all studies focused on participant reach–a later stage implementation outcome–while earlier-stage outcomes such as feasibility or fidelity were not examined. Limited reporting of implementation strategies and their justifications may be due to journal word limits, an emphasis on results supporting conclusions, or context-specific adaptations ( Duff et al., 2010 ; Hoffmann et al., 2013 ). Later-stage implementation outcomes may have been prioritized to support real-world decision making (Proctor et al., 2023). However, presenting results with a theoretical foundation and utilizing online appendices for detailed strategy reporting can strengthen empirical conclusions ( Nilsen & Birken, 2020 ). In addition, examination of a range of outcomes across the implementation process is critical. If strategy fidelity increases over time and precedes participant reach, increased fidelity may be a strong predictor of reach, which may be useful to promote strategy generalizability across contexts ( Proctor et al., 2011 ). Future research should take advantage of available resources to detail all dimensions of strategy operationalization and assess multiple implementation outcomes across the implementation process. Limitations This review was limited to published, peer-reviewed literature in English with adult patients, which may have excluded some relevant implementation strategies. Only English-language studies were included to maintain accuracy in data extraction and interpretation, and to minimize the risk of translation-related misinterpretations. This review focused on adults because service delivery models from primary to specialty mental health care differ between adolescent and adult populations ( Schlesinger et al., 2023 ). Restricting inclusion to adults enhanced conceptual coherence and comparability across strategies. Our definition of primary care settings was based in the U.S. model. However, the U.S. model aligns with the international conceptualization of primary care that recommends a first-contact, comprehensive approach to healthcare ( WHO, 2018 ). This review also only examined how implementation strategies were labeled, defined, and operationalized, and did not examine the strategies’ effects on implementation or clinical outcomes. Last, despite using at least two independent reviewers, the potential for subjectivity in operationalizing implementation strategies remained. However, this was mitigated through consensus discussions with an expert in suicide prevention and implementation science. Conclusions We identified, labeled, defined, and operationalized strategies that aimed to improve the initiation of outpatient mental health treatment among adults identified in primary care settings with a history of suicidal thoughts and/or behaviors. The most common strategies aligned with ERIC strategies to ‘promote adaptability’, ‘develop and implement tools for quality monitoring’, ‘remind clinicians’, ‘facilitate relay of clinical data to providers’, and ‘centralize technical assistance’ ( Powell et al., 2015 ). No study labeled, defined, and operationalized all strategy dimensions. Greater specification in reporting of implementation strategies would allow researchers to accurately identify and test strategies, and primary care clinics to effectively deliver strategies that improve the transition from primary care to specialty mental health for adults with suicidal thoughts and/or behaviors. Supplementary Material Table S1 and Table S2 NIHMS2146060-supplement-Table_S1_and_Table_S2.docx (29.2KB, docx) Funding: This work was supported by National Institute of Mental Health [T32 MH109433; R21 MH123851; P50 MH127511] and the National Clinician Scholars Program at Perelman School of Medicine in the Department of Psychiatry at the University of Pennsylvania. Footnotes Ethical considerations: This article does not contain human participants. Consent to participate and for publication: Informed consent for this article was not obtained because it does not contain human participants. Conflicts of Interest: Dr. Wolk receives royalties from Oxford University Press. Data availability: Data available from corresponding author upon request. References Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, Lynch F, Owen-Smith A, Hunkeler EM, Whiteside U, Operskalski BH, Coffey MJ, & Solberg LI (2014). Health Care Contacts in the Year Before Suicide Death. Journal of General Internal Medicine, 29(6), 870–877. 10.1007/s11606-014-2767-3 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Allwood C, O’Brien A, & Glue P (2019). Referrals from primary care to community mental health teams: What’s missing? Journal of Primary Health Care, 11(4), 334. 10.1071/HC19053 [ DOI ] [ Google Scholar ] Ayer L, Horowitz LM, Colpe L, Lowry NJ, Ryan PC, Boudreaux E, Little V, Erban S, Ramirez-Estrada S, & Schoenbaum M (2022). Clinical Pathway for Suicide Risk Screening in Adult Primary Care Settings: Special Recommendations. Journal of the Academy of Consultation-Liaison Psychiatry, 63(5), 497–510. 10.1016/j.jaclp.2022.05.003 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Bahraini N, Reis DJ, Matarazzo BB, Hostetter T, Wade C, & Brenner LA (2022). Mental health follow-up and treatment engagement following suicide risk screening in the Veterans Health Administration. PLOS ONE, 17(3), e0265474. 10.1371/journal.pone.0265474 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Bartels SJ, Coakley EH, Zubritsky C, Ware JH, Miles KM, Areán PA, Chen H, Oslin DW, Llorente MD, Costantino G, Quijano L, McIntyre JS, Linkins KW, Oxman TE, Maxwell J, Levkoff SE, & PRISM-E Investigators. (2004). Improving Access to Geriatric Mental Health Services: A Randomized Trial Comparing Treatment Engagement With Integrated Versus Enhanced Referral Care for Depression, Anxiety, and At-Risk Alcohol Use. American Journal of Psychiatry, 161(8), 1455–1462. 10.1176/appi.ajp.161.8.1455 [ DOI ] [ PubMed ] [ Google Scholar ] Bryan CJ, & Rudd MD (2010). Managing suicide risk in primary care. New York, NY: Springer Publishing Company. [ Google Scholar ] Bunger AC, Chuang E, Girth AM, Lancaster KE, Smith R, Phillips RJ, Martin J, Gadel F, Willauer T, Himmeger MJ, Millisor J, McClellan J, Powell BJ, Saldana L, & Aarons GA (2024). Specifying cross-system collaboration strategies for implementation: A multi-site qualitative study with child welfare and behavioral health organizations. Implementation Science, 19(1), 13. 10.1186/s13012-024-01335-1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Campbell JL (2007). Provision of primary care in different countries. Bmj, 334(7606), 1230–1231. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Center for Integrated Health Solutions. (2020). Standard framework for levels of integrated health care. Substance Abuse and Mental Health Services Administration & Health Resources and Services Administration. https://www.thenationalcouncil.org/wp-content/uploads/2020/01/CIHS_Framework_Final_charts.pdf [ Google Scholar ] Che SE, Gwon YG, & Kim K-H (2023). Follow-up timing after discharge and suicide risk among patients hospitalized with psychiatric illness. JAMA Network Open, 6(10), e2336767. 10.1001/jamanetworkopen.2023.36767 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Chen JI, Roth B, Dobscha SK, & Lowery JC (2024). Implementation strategies in suicide prevention: A scoping review. Implementation Science, 19(1), 20. 10.1186/s13012-024-01350-2 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Crosby E, Turi E, Eisenman D, Famiglio E, Khazanov G, Jager-Hyman S, & Wolk CB (2024). Implementation strategies to improve primary care patients’ initiation of specialty outpatient mental health treatment: A scoping review protocol. https://osf.io/hezx9/ [ DOI ] [ PMC free article ] [ PubMed ] Damschroder LJ, Reardon CM, Widerquist MAO, & Lowery J (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science: IS, 17(1), 75. 10.1186/s13012-022-01245-0 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Denneson LM, Corson K, Helmer DA, Bair MJ, & Dobscha SK (2014). Mental health utilization of new-to-care Iraq and Afghanistan Veterans following suicidal ideation assessment. Psychiatry Research, 217(3), 147–153. 10.1016/j.psychres.2014.03.017 [ DOI ] [ PubMed ] [ Google Scholar ] Duff JM, Leather H, Walden EO, LaPlant KD, & George TJ (2010). Adequacy of Published Oncology Randomized Controlled Trials to Provide Therapeutic Details Needed for Clinical Application. JNCI: Journal of the National Cancer Institute, 102(10), 702–705. 10.1093/jnci/djq117 [ DOI ] [ PubMed ] [ Google Scholar ] Eaves ER, Williamson HJ, Sanderson KC, Elwell K, Trotter RT, & Baldwin JA (2020). Integrating Behavioral and Primary Health Care in Rural Clinics: What Does Culture Have to Do with It? Journal of Health Care for the Poor and Underserved, 31(1), 201–217. 10.1353/hpu.2020.0018 [ DOI ] [ PubMed ] [ Google Scholar ] Harvey G, & Kitson A (2015). Translating evidence into healthcare policy and practice: Single versus multi-faceted implementation strategies – is there a simple answer to a complex question? International Journal of Health Policy and Management, 4(3), 123–126. 10.15171/ijhpm.2015.54 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Hoffmann TC, Erueti C, & Glasziou PP (2013). Poor description of non-pharmacological interventions: Analysis of consecutive sample of randomised trials. BMJ, 347(sep10 1), f3755–f3755. 10.1136/bmj.f3755 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Hooley C, Amano T, Markovitz L, Yaeger L, & Proctor E (2020). Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review. Administration and Policy in Mental Health and Mental Health Services Research, 47(1), 19–35. 10.1007/s10488-019-00965-8 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Institute of Medicine (US) Committee on the Future of Primary Care, Donaldson MS, Yordy KD, Lohr KN, & Vanselow NA (1996). Defining Primary Care. In Primary Care: America’s Health in a New Era. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK232631/ [ PubMed ] [ Google Scholar ] Kravitz RL, Franks P, Feldman M, Meredith LS, Hinton L, Franz C, Duberstein P, & Epstein RM (2006). What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms. Journal of General Internal Medicine, 21(6), 584–589. 10.1111/j.1525-1497.2006.00411.x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Lawrence ST, Willig JH, Crane HM, Ye J, Aban I, Lober W, Nevin CR, Batey DS, Mugavero MJ, McCullumsmith C, Wright C, Kitahata M, Raper JL, Saag MS, & Schumacher JE (2010). Routine, Self-Administered, Touch-Screen, Computer-Based Suicidal Ideation Assessment Linked to Automated Response Team Notification in an HIV Primary Care Setting. Clinical Infectious Diseases, 50(8), 1165–1173. 10.1086/651420 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Maulik PK, Kallakuri S, Devarapalli S, Vadlamani VK, Jha V, & Patel A (2017). Increasing use of mental health services in remote areas using mobile technology: A pre–post evaluation of the SMART Mental Health project in rural India. Journal of Global Health, 7(1), 010408. 10.7189/jogh.07.010408 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Mayer L, Barzel A, Clemens V, Fegert J, Grau K, Gündel H, Haun M, Lamp N, Rassenhofer M, Rothermund E, & Oexle N (2025). Barriers to suicide prevention in primary care: A qualitative study among general practitioners in Germany. Mental Health & Prevention, 37, 200381. 10.1016/j.mhp.2024.200381 [ DOI ] [ Google Scholar ] Mehrotra A, Forrest CB, & Lin CY (2011). Dropping the Baton: Specialty Referrals in the United States. The Milbank Quarterly, 89(1), 39–68. 10.1111/j.1468-0009.2011.00619.x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, & Aromataris E (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 18(1), 143. 10.1186/s12874-018-0611-x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] National Institute for Health and Care Excellence. (2022). Self-harm: Assessment, management and preventing recurrence. [ PubMed ] Nilsen P, & Birken S (2020). Overview of theories, models and frameworks in implementation science. Handbook on Implementation Science, 10(9781788975995.00008). [ Google Scholar ] Pace CA, Gergen-Barnett K, Veidis A, D’Afflitti J, Worcester J, Fernandez P, & Lasser KE (2018). Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments. The Annals of Family Medicine, 16(4), 346–348. 10.1370/afm.2263 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Perlman C, Neufeld E, Martin L, Goy M, & Hirdes J (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Ontario Hospital Association and Canadian Patient Safety Institute. [ Google Scholar ] Peters MD, Marnie C, Tricco AC, Pollock D, Munn Z, Alexander L, McInerney P, Godfrey CM, & Khalil H (2020). Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synthesis, 18(10), 2119–2126. 10.1097/XEB.0000000000000277 [ DOI ] [ PubMed ] [ Google Scholar ] Powell BJ, McMillen JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, Glass JE, & York JL (2012). A Compilation of Strategies for Implementing Clinical Innovations in Health and Mental Health. Medical Care Research and Review, 69(2), 123–157. 10.1177/1077558711430690 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, & Kirchner JE (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), 21. 10.1186/s13012-015-0209-1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Proctor EK, Powell BJ, & McMillen JC (2013). Implementation strategies: Recommendations for specifying and reporting. Implementation Science, 8(1), 139. 10.1186/1748-5908-8-139 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, & Hensley M (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 38(2), 65–76. 10.1007/s10488-010-0319-7 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Rotoli A, da Silva MRS, dos Santos AM, de Oliveira AMN, & Gomes GC (2019). Mental health in Primary Care: Challenges for the resoluteness of actions. Escola Anna Nery, 23(2), e20180303. 10.1590/2177-9465-EAN-2018-0303 [ DOI ] [ Google Scholar ] Saini P, Hunt A, Blaney P, & Murray A (2024). Recognising and Responding to Suicide-Risk Factors in Primary Care: A Scoping Review. Journal of Prevention, 45(5), 727–750. 10.1007/s10935-024-00783-1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Saini P, While D, Chantler K, Windfuhr K, & Kapur N (2014). Assessment and management of suicide risk in primary care. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35(6), 415–425. 10.1027/0227-5910/a000277 [ DOI ] [ PubMed ] [ Google Scholar ] Sarkhel S, Vijayakumar V, & Vijayakumar L (2023). Clinical Practice Guidelines for Management of Suicidal Behaviour. Indian Journal of Psychiatry, 65(2), 124. 10.4103/indianjpsychiatry.indianjpsychiatry_497_22 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Schlesinger A, Sengupta S, Marx L, Hilt R, Martini DR, DeMaso DR, Beheshti N, Borcherding B, Butler A, & Fallucco E (2023). Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. Journal of the American Academy of Child & Adolescent Psychiatry, 62(2), 91–119. [ DOI ] [ PubMed ] [ Google Scholar ] Spicer J (2015). Integrated care in the UK: Variations on a theme? London Journal of Primary Care, 7(3), 41–43. 10.1080/17571472.2015.11494375 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Stene-Larsen K, & Reneflot A (2019). Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scandinavian Journal of Public Health, 47(1), 9–17. 10.1177/1403494817746274 [ DOI ] [ PubMed ] [ Google Scholar ] Stevens ER, Shelley D, & Boden-Albala B (2020). Unrecognized implementation science engagement among health researchers in the USA: A national survey. Implementation Science Communications, 1(1), 39. 10.1186/s43058-020-00027-3 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, … Straus SE (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine, 169(7), 467–473. 10.7326/M18-0850 [ DOI ] [ PubMed ] [ Google Scholar ] Trude S, & Stoddard JJ (2003). Referral gridlock: Primary care physicians and mental health services. Journal of General Internal Medicine, 18(6), 442–449. 10.1046/j.1525-1497.2003.30216.x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Vechiu C, Zimmermann M, Zepeda M, O’Donohue WT, & Broten L (2024). Referral Patterns and Sociodemographic Predictors of Adult and Pediatric Behavioral Health Referrals in a Federally Qualified Health Center. The Journal of Behavioral Health Services & Research, 51(1), 101–113. 10.1007/s11414-023-09855-2 [ DOI ] [ PubMed ] [ Google Scholar ] Wakida EK, Talib ZM, Akena D, Okello ES, Kinengyere A, Mindra A, & Obua C (2018). Barriers and facilitators to the integration of mental health services into primary health care: A systematic review. Systematic Reviews, 7(1), 211. 10.1186/s13643-018-0882-7 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, Proctor EK, & Kirchner JE (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science, 10(1), 109. 10.1186/s13012-015-0295-0 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Wolk CB, Pieri M, Weiss SE, Harrison J, Khazanov GK, Candon M, Oslin DW, Press MJ, Anderson E, & Famiglio E (2024). Engaging primary care patients at risk for suicide in mental health treatment: User insights to inform implementation strategy design. BMC Primary Care, 25(1), 371. 10.1186/s12875-024-02616-w [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] World Health Organization & United Nations Children’s Fund. (2018). A vision for primary health care in the 21st century:towards universal health coverage and the Sustainable Development Goals. World Health Organization. (2016). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Mental health Gap Action Programme (mhGAP) (version 2.0). World Health Organization. https://iris.who.int/handle/10665/250239 [ PubMed ] [ Google Scholar ] World Health Organization. (2018). National suicide prevention strategies: Progress, examples and indicators. World Health Organization. https://iris.who.int/handle/10665/279765 [ Google Scholar ] World Health Organization. (2025). Suicide worldwide in 2021: Global health estimates. Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Table S1 and Table S2 NIHMS2146060-supplement-Table_S1_and_Table_S2.docx (29.2KB, docx) Data Availability Statement Data available from corresponding author upon request. 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