Developing and Piloting an Implementation Strategy for a Brief, Motivational Interviewing-based Lethal Means Safety Counseling Intervention in Primary Care Settings

and Abstract Significance to VA: The Veterans Health Administration (VHA) and Veterans Affairs (VA) Health Systems Research have identified suicide prevention as a leading clinical and research priority, and firearm injury accounts for 72% of Veteran suicides. Lethal means safety, or limiting access to means for suicide, is an evidence-based suicide prevention strategy and is recommended by the 2024 VA/Department of Defense Clinical Practice Guidelines. VHA identified Primary Care (PC) as a critical setting in which to offer LMS counseling. While PC Mental Health Integration (PCMHI) clinicians are uniquely positioned to offer LMS counseling for firearms within PC settings, , no LMS intervention has been tested specifically among the Veteran population or implemented to guide clinicians in facilitating LMS counseling in VHA settings. To bridge this gap, I received mentored funding to develop a clinician-informed, brief, motivational interviewing (MI)-based LMS counseling protocol, called RAMP (Raise the subject, Assess current storage, Motivate change, and Plan next steps), to guide PCMHI clinicians in LMS counseling for Veteran firearm owners with elevated suicide risk. While the intervention was well-received among PCMHI clinicians, given the importance and sensitivity of these conversations, Veteran and leadership input is needed to optimize RAMP’s feasibility and acceptability. Innovation and Impact: The proposed research will fill a critical gap in VHA suicide prevention efforts by tailoring and piloting a brief, MI-based LMS intervention for firearm storage, called RAMP, with Veteran firearm owners with elevated suicide risk who receive care in VHA PCMHI. RAMP is the first MI-based LMS protocol developed for PCMHI clinicians. RAMP incorporates evidence-based strategies: 1) MI strategies, 2) a novel visual tool to guide LMS counseling, 3) distribution of firearm lockboxes, and 4) cultural competency training for clinicians. The proposed randomized controlled pilot of the tailored LMS counseling intervention will inform the future effectiveness testing of an LMS intervention for firearm storage for PC settings. Specific Aims: 1) Tailor RAMP intervention elements using an iterative, Veteran-centered participatory research approach. 2) Evaluate the feasibility and acceptability of the tailored RAMP in a randomized controlled pilot at the West Haven PCMHI clinic with Veteran firearm owners with elevated suicide risk. 3) Assess perceived barriers and facilitators of providing LMS counseling for firearm storage through a mixed methods formative evaluation with a national sample of VHA PCMHI and mental health leaders. Methodology: 1) Twelve Veteran consultants on a Veteran Advisory Board will provide iterative, group- and individual-based feedback to improve RAMP’s acceptability among Veterans. 2) To evaluate the feasibility and acceptability of RAMP in the randomized controlled pilot, we will use study tracking data as well as mixed methods assessments of both Veteran firearm owners seeking care in PCMHI (n=50) and PCMHI clinicians (n=6). 3) We will conduct brief mixed methods interviews with a national sample of VHA PCMHI leaders (n=20) and mental health leaders (n=20) to understand barriers and facilitators of LMS counseling. Path to Translation/Implementation: This proposed T3 research and training will support two applications for IIR funding, including a fully powered, multi-site, randomized controlled effectiveness trial of RAMP for Veteran firearm owners with elevated suicide risk. Project Number: 1IK2RD000503-01A2 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Frances Aunon | Institution: VA CONNECTICUT HEALTHCARE SYSTEM, WEST HAVEN, CT | Activity Code: IK2 | Study Section: HSR-4 Mental and Behavioral Health[HSR4] View on NIH RePORTER: https://reporter.nih.gov/project-details/11243696