Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Since the launch of 988 in July 2022, the 988 Suicide and Crisis Lifeline — a network of crisis contact centers funded by the Substance Abuse and Mental Health Services Administration and run by Vibrant Emotional Health — has answered over 14.5 million calls, texts and chats.
Prior to 988’s launch, experts hoped the number would lessen demand on 911 systems and connect people with behavioral health responses instead of thrusting them into the criminal legal system. How and to what degree this has translated is unclear because there’s no comprehensive, centralized national database tracking 911 calls.
The Vera Institute estimated in April 2022, before 988 launched, that around 20% of 911 calls involve behavioral health. Some communities, like Baltimore, had percentages over 35%.
If 911 receives around 240 million calls per year — a figure reported by the National Emergency Number Association, a member-based organization focused on 911 policy and technology — then roughly 48 million calls could potentially be diverted from 911 and receive a behavioral health response.
Cities across the U.S. are developing crisis call diversion programs to improve collaboration and divert mental health calls from a traditional 911 response. Austin, Des Moines, Houston and Tucson have mental health professionals co-located at their 911 contact centers. In these locations, mental health is the fourth crisis responder, with call takers asking callers whether they need a police, fire, EMS or mental health response.
Some communities are also increasing 911 call transparency through public data portals and using identifiable call tags for mental health and substance use-related calls. Austin, Minneapolis, Portland, San Francisco and Seattle databases use tags like suicide/attempt, person in crisis, welfare check, overdose and intoxicated person.
Austin and Seattle’s data tracking systems are especially accessible. A quick analysis shows identified behavioral health calls, compared to overall 911 calls, comprised roughly 1.25% (2023) in Seattle and 3.8% (2024) in Austin.
Even so, without nationwide call tag standardization, it’s difficult to know more broadly what calls could have been diverted.
Crisis call diversion program managers share that demand on 911 diversion programs hasn’t lessened since the launch of 988. However, Chiara Jaranilla, Houston’s crisis call diversion program manager, said this doesn’t reflect 988’s capabilities but instead the workforce challenges diversion programs face.
“Our numbers are dependent on our staffing,” she said. “We’ve definitely seen ups and downs in staffing, so it wouldn’t be accurate to say there were more or less calls as a result of 988, but there are still tons of calls for our small team to take.”
In Utah, diversion staff turnover and 911 dispatch attrition have presented challenges in maintaining consistent workflow. The program has diverted roughly 1% of 911 calls.
Many communities don’t yet have crisis call diversion programs but do partner with mobile crisis services. Utilization depends on service availability and on whether 911 first responders trust these services to provide a timely response.
Skepticism from 911 emergency responders has been, in part, because 988 has long used a caller’s area code while 911’s approach of geolocation is far more precise.
In October, the Federal Communications Commission adopted rules requiring 988 georouting for all wireless carriers. Verizon and T-Mobile were the first major carriers to implement the new regulations, followed by AT&T last month.
Unlike geolocation, georouting doesn’t provide the person’s precise location but instead ensures access to nearby crisis resources.
“We won’t be able to track people like 911 does,” Dr. Tia Dole, chief 988 Lifeline officer at Vibrant, told CrisisTalk in July 2023. “The sole purpose of georouting is to connect people to their local call center.”
Mobile crisis expert Preston Looper told CrisisTalk in July that law enforcement is especially risk-averse. With georouting, he believes 911 contact centers will be less hesitant to rely on 988.
Another challenge is the general population and even healthcare providers’ lack of awareness of 988 and when to reach out to 988 versus 911.
Two complementary documents, one by the Substance Abuse and Mental Health Services Administration and the other from the National Emergency Number Association, aim to improve awareness, usage and interoperability.
In December, the Substance Abuse and Mental Health Services Administration released educational guidance for healthcare providers that gives an overview of the differences between 988 and 911, along with real-world examples, de-escalation techniques and what to expect from each system to help providers make an informed decision on how to connect people to the best response.
The guide walks providers through in-person and telehealth crisis scenarios, highlighting when and how to use 988 and 911, and links to a safety planning guide.
Case examples include those where people are in emotional distress or suicidal, with or without a plan, or experiencing problematic nonemergency substance use or overdose.
The National Emergency Number Association released complementary standards on 911-988 interoperability in January. The document outlines operational and technical considerations for 911 Emergency Communication Centers, also called Public Safety Answering Points, on diverting people in need of mental health and substance use support services.
“It’s an excellent document that has been in the works for a couple of years,” Richard McKeon, public health advisor at the Substance Abuse and Mental Health Services Administration, told the 988 Jam on March 5.
Guidance includes safety questions to help 911 call centers determine when to transfer calls to 988 and bidirectional transfer protocols and procedures.
Sample agreements provide templates for memoranda of understanding, sharing information, 911 call center standard operating procedures and a decision tree for 911 call center operations.
The sample decision tree recommends diversion of those who want to speak with a mobile crisis team, as long as they are not a threat to themselves or others. A risk-level matrix provides guidance on what response or responses to dispatch, whether alone or in tandem.
The sample matrix has four risk levels: level 1 (routine), level 2 (moderate), level 3 (urgent), and level 4 (emergent). Levels 1 through 3 can divert to 988, with levels 2 and 3 either going to 988 or the 911 call center dispatching a mobile crisis team. Level 4 emergencies result in traditional first responder dispatch or a tandem response that also includes a mobile crisis team.
Communities can tailor these sample documents to align with local policy. For example, Los Angeles County’s call matrix diverts calls to Didi Hirsch Mental Health Services if someone has a weapon but is alone. In Houston, Jaranilla told CrisisTalk if the weapon “isn’t being wielded or can be put away,” it’s not considered part of the crisis situation.
The document also provides example scenarios for 911 and 988 partners to work out together — like when a caller who has taken a potentially lethal dose of prescription drugs hangs up on 988. Who calls back? Who responds when there are competing needs — a teen in crisis supervising two young children?
These sample discussion scenarios help 911 and 988 determine which agency is responsible for what and when.
The protocols and procedures provide 911 call centers a template for diverting behavioral health calls and improving collaboration with 988. However, until there’s centralized 911 data tracking, the feedback loop between 911 and 988 contact centers on what calls can divert will be hindered.
A federal framework for 911 contacts (including texts, voice calls and video) — in conjunction with the rollout of Next Generation 911, which has expanded tracking capabilities — could improve standardization and help identify calls and texts eligible for diversion.
There is no such framework at present and Next Generation 911 deployment has been slow.
In March, the Federal Communications Commission adopted rulemaking aimed at enhancing Next Generation 911 reliability and interstate interoperability. This could be utilized to help standardize data collection as well as improve data sharing, diversion and deployment of mental health mobile crisis services.
