Connect with:
Monday / November 28.

911 Must Be Part of the 988 Conversation

911 Must Be Part of the 988 Conversation

In October, the Pew Charitable Trusts released an issue brief highlighting that most 911 call centers lack the resources to address mental health and substance use (“behavioral health”) crises. Then, several months ago, the public charity released a follow-up report looking into 911 call centers affiliated with the Safety and Justice Challenge, a John D. and Catherine T. MacArthur Foundation initiative. The initiative aims to reengineer and rebuild local criminal justice systems to increase equity and reduce jail incarceration. “The report explains how these sites differ from other 911 call centers in how they collect, manage, and share mental health call data,” says Tiffany M. Russell, former project director of Mental Health and Justice Partnerships at the Pew Charitable Trusts. 

She points out that the 16 Safety and Justice Challenge sites they interviewed diverge from most 911 call centers in their data collection, feedback loops, and collaboration with behavioral health partners. “There was significantly more interaction and data sharing between 911 and behavioral health among the challenge sites,” she says. 

While 911 public safety answering points and behavioral health services commonly collect data, the information each gathers often stays within its own silo. According to Russell, collaboration between the two allows partners to discuss and analyze data and protocols to more effectively and efficiently divert 911 mental health and substance use calls. “We found that 911 call centers that partner with behavioral health were more likely to report their data to internal leadership and their external partners,” she says. The challenge sites also generally had more data on mental health and substance use crisis calls and other frequent system utilizers, and both 911 call centers and their behavioral health partners could easily access the data.

With “988” going live on July 16, Russell points out that the development and implementation of state and county 988 plans must include 911 call centers. “They have to be part of the 988 conversation,” she says. But, unfortunately, while interviewing leaders at PSAPs nationwide, she discovered that many don’t even know about the three-digit number for mental health, substance use, and suicide crises. “We started interviewing leadership at 911 PSAPs in March 2021 and found that behavioral health leaders were having conversations with each other about 988 but not with leadership at 911 call centers,” says Russell. 

When those at 911 PSAPs did hear about 988, it was through the lens of behavioral health leaders and agencies. “Call center leaders were told behavioral health was managing the implementation,” she says. “They weren’t part of the conversation.” Since then, Russell notes there has been increased first responder engagement in 988 dialogue, but partnerships with 911 call centers remain insufficient. “For the most part, across the United States,” she says, “there’s been little consideration of what seat 911 should have at the table.” “Yet, that’s where most behavioral health calls currently go.”

While estimates typically range between 10% and 20%, it’s unclear what percentage of behavioral health calls go to 911. In part, this is because of insufficient call code standardization, and calls often aren’t coded as mental health or substance use crisis calls but as “suspicious person,” “criminal trespass,” “public indecency,” or “other.” Russell shares that there’s a call code she finds particularly frightening—“proceed with caution.” “I just imagine officers showing up to that call already on high alert,” she points out. 

Even if a call is identified as behavioral health, Russell says many call centers don’t have call codes that relate to these crises. However, other call takers and dispatchers don’t code calls as mental health or substance use emergencies because it doesn’t change who they will dispatch, which is typically law enforcement. This is especially true in communities with insufficient linkages between 911 and behavioral health services. “They don’t understand why they should code it as something different if there’s no separate response,” she notes. “We want to encourage communities to develop those codes and to start collecting data, even if they don’t have another response.” She says that gathering accurate call data will help communities assess their current behavioral health call volume more accurately. 

Also, while law enforcement may later identify a call as having a mental health or substance use component, there’s often not a feedback loop that goes back into the 911 system and amends the original call code, which makes tracking behavioral health calls immensely challenging. That’s not true for 911 Emergency Medical Services, which have a feedback loop and a nationwide standardized system and database—NEMSIS—for tracking calls. In November, Dia Gainor, executive director of the National Association of State EMS Officials, told #CrisisTalk that if there’s a disconnect between “reason for dispatch” and “clinical findings,” a local ambulance service’s quality improvement program can use the NEMSIS database to run comparisons. Code standardization and call tracking, said Gainor, have also allowed EMS to identify crisis trends, like suspected fatal and non-fatal overdoses. “If communities use the database, it will allow them to track their populations’ behavioral health needs,” she said. “The potential—not only for understanding crisis volume but also the implications for prevention—is huge.”

Unlike EMS, law enforcement hasn’t yet adopted a standardized database. A similar approach—along with a feedback loop and quality improvement program to sift through disparities and system challenges—could help communities collect and analyze 911 data more effectively. One respondent to the second PEW report, a Safety and Justice Challenge site, said 911 telecommunicators couldn’t also be expected to do data management. When asked by a Pew researcher what advice they’d give other 911 call centers, the respondent said, “For the love of Pete, please hire an analyst.” 

Russell points out that building out a standardized call coding system and database as well as adding 911 call center analysts will require braided federal, state, and local funding. However, earlier identification of calls with a behavioral health nexus—along with 911 and 988 partnership and connectivity—helps to ensure 911 call centers can divert most 988 calls. Both collaboration and linkages between the parallel but intersecting systems are essential. “Law enforcement is risk-averse,” she says, “so law enforcement won’t trust that behavioral health crisis services can handle emergency calls without a partnership.” Additionally, 911-988 connectivity must work both ways, allowing 911 calls to rapidly link to 988 and the reverse. “If 911 transfers to 988, but the call drops, or it’s difficult for 988 to connect back to 911, public safety answering point leadership fears those calls could end tragically,” says Russell. 

Some communities like Harris County, Austin, Tucson, and Charleston have turned to 911 call center co-location of behavioral health clinicians, physical or virtual, to foster partnership and inter-system connectivity. The benefits have been surprising. For example, Marisa Aguilar, practice manager of Integral Care’s Expanded Mobile Crisis Outreach Team, told #CrisisTalk that co-locating at Austin’s 911 call center and integrating into the PSAP’s computer-aided dispatch system, commonly called CAD, has been “a game-changer.” “We no longer have dropped calls,” she said. Furthermore, the diversion program’s clinicians can view incoming 911 calls to help identify and divert those where someone might need behavioral health support. The partnership has also resulted in a continuous and robust feedback loop with law enforcement and EMS, where they review data to identify missed opportunities. 

In an email, Aguilar shared that her team does monthly reviews with the Austin Police Department on call code accuracy—calls that should have been coded as mental health but weren’t. The team also submits regular weekly reports to EMS so that their quality assurance team can review calls. Since co-location, the Austin program has diverted roughly 85.4% of behavioral health calls from law enforcement and transferred them to their EMCOT clinicians. 

Russell highlights that some 911 call centers are expanding their data collection. For example, a data analyst at Charleston’s 911 call center, Alanna-Jean Keith, told a Pew researcher, “We basically capture the ‘who, what, when, [and] where’ in our dispatch system.” The data collection and sharing and behavioral health clinician co-location have helped produce a shift in call response, resulting in data-backed evidence that supports why dispatching behavioral health responders is a far better response than taking people to jail. “To rally around some real numbers and some excitement about what we could do different[ly] and better, I think really gave us the energy and the synergy to move forward.”

According to Russell, communities that have incorporated data analysts are getting a clearer picture of behavioral health 911 call volume and behavioral health data from the local hospital system and jails. “Having this information helps create support for crisis system redesign and system linkages from all the key players,” she says. 

Russell hopes state leaders invite 911 to their 988 conversations. “Not enough of our state leaders are thinking about how they’re working together with 911 around 988,” she says, “and again, it’s this very siloed approach to behavioral health.” “They’re thinking of these systems as separate and apart versus different access points of entry into the behavioral health crisis system.”