After 988’s Launch, Experts Emphasize More Work Needed

Abstract

Back to table of contents Previous article Next article Government & LegalFull AccessAfter 988’s Launch, Experts Emphasize More Work NeededKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:23 Dec 2022https://doi.org/10.1176/appi.pn.2023.01.1.4AbstractThousands of people have received help through the 988 Suicide & Crisis Lifeline since its launch last July. Yet there is still a great deal of work to do to ensure callers can rely on a comprehensive in-person crisis system and get connected to the best and most appropriate resources in their areas.Michael H. Allen, M.D., explains the impact that 988 has had on the mental health crisis system with the mathematics term “asymptotic.” It refers to situations in which development occurs rapidly in the beginning, but gains occur more slowly as the goal gets closer.“You might get to 75% of the way pretty quickly, but you get to 90% more slowly, and the last 10% can take a long time,” explained Allen, a member of the National Suicide Prevention Lifeline Steering Committee; a professor of psychiatry and emergency medicine at the University of Colorado School of Medicine; and medical director of Rocky Mountain Crisis Partners, Colorado’s 988 hotline. “988 could be the catalyst, and places that are ready for a comprehensive crisis services system could get where they need to go pretty fast.”While 911 was established in the late 1960s, it took decades for the system in operation today to become widely available. Even by the end of 1976, it was serving only about 17% of the population, according to NENA: the 9-1-1 Association. By 1987, only half the population had access to 911.Similarly, it will take time for the vast majority of the country to have access to a comprehensive crisis services system through 988. When 911 was implemented, Allen explained, it connected the country to services that were largely already available: fire, police, and emergency medical services. “988 is really going to work only to the extent that it has a crisis system to interact with,” he said.In contrast to 911, most people who call 988 can have their crises resolved over the phone without the need to connect them with crisis services personnel, according to Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness (NAMI).“If we look at the increase in contacts in August and September, that equates to hundreds of thousands more people who reached out for help, felt they had someone to turn to, and [felt] they had someone to listen to them,” Wesolowski said. “That in and of itself is remarkable. But we also know that we don’t have the systems in place to meet a range of crisis needs. 988 needs to be looked at as a first step. We have a lot more work to do on the system and on 988 itself.”More People Called 988 in August, SeptemberThe Federal Communications Commission (FCC) first proposed 988 in a report to Congress in 2019. When it launched last July, 988 immediately connected the entire country to the 988 Suicide & Crisis Lifeline, previously known as the National Suicide Prevention Lifeline, which was accessed with a 10-digit number. The 988 Lifeline consists of a network of more than 200 call centers funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and administered by Vibrant Emotional Health.Data show that 988 has already made a difference. According to a Kaiser Family Foundation analysis of 988 data from August 2022 compared with August 2021, more people contacted 988 following its launch in July. Further, callers waited on hold for less time, and they connected with crisis counselors at higher rates. Between August 2021 and August 2022, the rate of total calls, chats, and texts to the Suicide & Crisis Lifeline rose by 45%, from 248,252 to 361,140. In September, the number of calls continued to increase but at a slower pace, according to data from SAMHSA.‘A Chance to Fundamentally Transform Our Crisis System’While data are available on how often calls are made to and answered by the network of call centers, how effective 988 is in connecting people in crisis with reliable, in-person care and/or following up with them is not entirely clear.Ensuring Commercial Insurers Pay Their Fair ShareLauren Finke, policy director with The Kennedy Forum, explained that, in California, the first step to developing a strong mental health crisis system was passing SB 855, a significant mental health parity bill. The law, enacted in 2020, requires insurers in the state to make coverage determinations consistent with generally accepted standards of care for mental and substance use disorders using criteria developed by nonprofit, clinical specialty associations.“SB 855 is a good road map for what medically necessary mental health and substance use disorder coverage looks like,” Finke said. “It mandates what services enrollees in commercial plans are entitled to in the state, and we view the 988 legislation as an important second step to ensure [that] coverage of the behavioral health crisis continuum established under SB 855 is working.”Very often, public plans such as Medicaid take on the burden of paying for crisis services, but commercial insurers must also pay for those services at parity with physical health emergencies, Finke said. Key to 988’s success is ensuring that commercial insurers are paying their fair share.A brief created by the Kennedy Forum emphasized that 988 presents an opportunity to standardize and increase access to the entire continuum of mental health care, including preventive outreach and engagement with people at risk, as well as crisis call centers, mobile crisis teams, and crisis stabilization options. “Today, much of this continuum remains underfunded, understaffed, or altogether nonexistent,” the brief stated.“To build out a robust behavioral health crisis continuum of care centered around 988, states need to take action to require commercial insurers to cover behavioral health emergency services—particularly ensuring coverage of mobile crisis response—for their plan members in the same manner insurers would cover physical health emergency services,” the brief continued.“988 represents a huge opportunity for the states,” Finke said. “The federal government is bringing in money to start an increased federal match for mobile crisis teams, SAMHSA has been providing mobile planning grant dollars, and there are even more new funding sources all related to 988. It feels unfair to let commercial insurers off the hook. They should be part of these conversations about how this care will be implemented and how they’re meeting their obligations to provide that care under federal parity laws.”Even before 988, Allen explained, there was a lot of variation in the mental health crisis call centers that now feed into 988. Some were small and operated almost exclusively by volunteers, while others were large, professional call centers with more resources to follow up with callers. The same is true now that 988 has launched. Services can differ vastly and especially depend on what kind of crisis services were available before 988’s launch.Only five states have enacted comprehensive 988 legislation, according to NAMI: California, Colorado, Nevada, Virginia, and Washington. Among other provisions, these laws fund 988 through a monthly charge on phone bills, which ensures 988 funding is sustainable. Many states are appropriating funds to 988, but appropriated funding is always at risk, Wesolowski argued, while monthly fees to phone lines is a more reliable form of funding.There is also room for improvement to the 988 system itself, she continued. Data collection has been a struggle because call centers are not necessarily on a unified data platform, and data about what happens after a person contacts 988 may not be available. It is difficult to hold the system accountable when detailed data on how calls are being answered and what kind of additional crisis services callers are getting are unavailable, she said.Training is also an area that needs more attention, Wesolowski said. “We’ve leveraged the existing National Suicide Prevention Lifeline, which has been a lifesaving service for almost 20 years, but that is traditionally more focused on suicide prevention,” she said. “Now we want people to call for a range of mental health and substance use crises. We need to ensure that all crisis counselors have the training to meet those needs and provide culturally competent care.”Ensuring Callers Are Connected to Local CounselorsThere is still much work to do to ensure callers get access to local resources that can help them in a crisis. Calls that local crisis centers cannot answer are automatically routed to a national backup crisis center, but the ideal goal is for calls to be answered as locally as possible. Many states had higher in-state answer rates in August 2022 compared with August 2021, according to SAMHSA’s data, with most answering more than 80% of calls in state. “We don’t want calls to ring over to an out-of-state backup center, because they don’t know our crisis system or our local resources,” Allen said. “We feel very motivated to hang onto Colorado callers.”The way 988 calls are routed can also prevent callers from getting connected to local call centers. According to the FCC, over 80% of calls made to the Lifeline are made from cell phones. Cell phone carriers route 911 calls based on the location of the cell tower nearest to the caller. While this can still be imprecise (the caller may be some distance from the closest cell tower), it at least provides a general idea of where the individual is located. However, when individuals move outside that region, they usually do not get a new cell number. That means callers who move from one part of the country to another and call 988 on their cell phones will get counselors in their previous location who are unlikely to immediately know callers’ best local resources.In 2020, the FCC submitted a 988 Geolocation Report to Congress that examined the feasibility and cost of using geolocation in 988 calls. The FCC concluded that there are numerous benefits to using geolocation. “However, … the various systems used to gather and transmit dispatchable location information for 911 calls are rapidly evolving, which may complicate efforts to establish similar capabilities for callers to 988.” There are also important legal issues to consider, including privacy of caller information. The FCC recommended the establishment of a multi-stakeholder advisory committee to continue examining the issue. It then held a 988 Geolocation Forum in May 2022. According to the FCC’s website, the commission “is actively analyzing the information gathered during the forum.”Using geolocation in 988 calls is essentially a “trust exercise,” Allen said. “Even when there is an active rescue and we need to dispatch 911 services, it is usually done with the individual’s cooperation and agreement,” he said. “We really do not want to send the police if we don’t have to. We’re aware that the police response is often going to be heavy handed, and that’s more likely to be the case when there are people of color involved, and we are very mindful of that.”“I want to emphasize that we are closer to the starting line than the finish line,” Wesolowski said. “988 gives us a tremendous opportunity, and it would be a tragedy to lose that opportunity and miss the chance to fundamentally transform part of our mental health system. We have to stay committed to this for the long term and build out crisis services everywhere.” ■“Taking a Look at 988 Suicide & Crisis Lifeline Data, One Month After Launch”“988 Geolocation Report” ISSUES NewArchived