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OPINION | 988, Shared Accountability, and Equity in Behavioral Health Crisis Services

988, Shared Accountability, and Equity in Behavioral Health Crisis Services

There’s a fundamental change underway, where accessible, therapeutic, and community-based response to behavioral health crises is gaining recognition as a distinct and essential community service. No longer satisfied with choosing between criminalization and medicalization, nationwide, there’s momentum to define behavioral health crisis response on its own terms. On July 16, 2020, the FCC adopted rules establishing 988 as the nationwide number for mental health, substance use, and suicide crises. Broad goals include meeting people’s needs in environments where they already seek support, providing care in the least restrictive environment, and optimizing taxpayer dollars by investing in crisis prevention and crisis early intervention of mental health problems and crises. Earlier this year, Virginia’s Gov., Ralph Northam, signed legislation designating a 988 call center and providing a monthly telecom tax, which will go into the Crisis Call Center Fund and be spent on the crisis system along the entire continuum of care.

Yet, the wave of recent interest in bolstering behavioral health crisis response can’t be decoupled from the current behavioral healthcare landscape or social context. Moreover, accountability issues in our system are significant, as shown in the escalating costs of behavioral healthcare alongside rising rates of behavioral health problems, jail populations, and homelessness. Last year, there was a nationwide call for reckoning with systemic racism in the United States, bringing national attention to racial disparities compounded with disability status in lethal law enforcement encounters. In Virginia, the 988 legislation was named in honor of Marcus-David Peters—a young Black biology teacher fatally shot by law enforcement in 2018 amid a behavioral health crisis.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has explicitly highlighted the relevance of a systems approach to crisis services implementation in its national guidelines for behavioral health crisis care—calling effective crisis care “the first line of defense in preventing tragedies of public and patient safety, civil rights, extraordinary and unacceptable loss of lives, and the waste of resources.” However, details of how financing and accountability should work under such a dramatic paradigm shift in the broader emergency response landscape have not been fully articulated or tested. From a systems perspective, state-by-state analysis of accountable entities, Medicaid structures, and county-state relations are the very infrastructures for the incentives and disincentives for systems change. We need to bring local, regional, state, and national conversations to the forefront as a first step in building accountability, equity, and access into the fabric of system development.

No matter the state, there are many public, private, and third sector entities at different levels of complexity and governance that would describe themselves as fully dedicated to the health and wellbeing of individuals within a particular population or geographic area. But how many of these entities would feel comfortable being held accountable for the outcomes of the crisis system without large-scale increases in their authority, scope, or budget? As leaders navigate preparing for 988, they need to understand the relevant accountability structures clearly and, if needed, build additional capacity to work collaboratively across complex, interdependent systems. That includes local governments, counties, health planning districts, statewide governance structures, independent regulatory authorities, and call center-Public-Safety Answering Point catchment areas. For example, in Virginia, we have more PSAPs than counties, with significant differences in operation between those who operate independently versus those within local law enforcement. Consequently, we will probably use multiple approaches to process integration and call transfer.

Virginia also retains its public behavioral health infrastructure throughout the state with 40 community services boards (CSBs) who’ve long been accountable for providing emergency services 24/7 to those in their catchment area, intersecting with a relatively recent expansion and behavioral health carve into the Medicaid plan administered by 6 MCOs. Since 2016, the state hospital system has been legislatively required to provide a “bed of last resort,” creating high levels of risk, strain, and accountability in the public behavioral health sector. As the state moves toward building out its 988 crisis system, an accountability framework is essential—where the benefits and risks inherent in operating crisis services are distributed fairly across system partners.

In most communities, building out a crisis system will bolster certain functions, partnerships, or entities but will not include large-scale structural changes. Understanding the circumstances under which the governance of shared resources works sustainably within the context of layered, complex, and often messy governmental arrangements can help develop the processes of accountability. A polycentric approach, where authority and responsibility among entities overlap, makes it so they must work together. Under this framework, leaders need to consider the “fit” between different centers of authority and the complexities in intricate and often tricky relationships between the public sector, private sector, and third sector entities at the federal, state, regional, and local levels.

Leaders should also build consensus with stakeholders to extend flexibility to the most local level possible. Sometimes, that’s the state or federal level. Other times, local structures provide a more tailored service. In Virginia, the 988 crisis system infrastructure is starting to settle into a statewide call center data platform with regional call centers and mobile crisis hubs that can rapidly dispatch public and private teams. At every step, there’s an emphasis on developing functional processes and reimbursement structures with peer-led and BIPOC-led agencies. At the local level, cross-agency policies and collaborations must coordinate between pre-screening for state hospital admissions, law enforcement, magistrates, and PSAPs. These multi-sector partnerships require resources, supports, and ongoing attention.

Successfully implementing crisis services requires large-scale cooperation, cultivation of shared purpose, and psychological flexibility across various stakeholders, all with different needs, authorities, and histories of discrimination and distrust in the behavioral health system. Attending to the complicated systems factors at play provides an opportunity to more fully realize the promise of deinstitutionalization and Olmstead with accountability structures that reinvest savings from higher levels of care into robust, preventative community supports. Further still, today’s crisis system leaders have an opportunity to be part of the broader social movement to shift the public behavioral health safety net out of jails and prisons and into community care through the careful structuring of incentives and shared accountability at each level of complexity. Decisions made by leaders across many sectors and at many levels of authority during the build-out of a comprehensive crisis system will have lasting implications for access, sustainability, and equity.

Authors Lisa Jobe-Shields and Katharine Hawkes explore how local, regional, state, and national conversations must be brought to the forefront as a first step in building accountability, equity, and access into the fabric of system development.

The analysis here represents the authors’ perceptions as individuals playing a role in implementing crisis services and does not necessarily represent an official viewpoint of the Commonwealth of Virginia. Learn more about science-based approaches to collaboration and polycentric governance in complex systems at