Matthew L. Goldman, M.D., M.S., medical director of Comprehensive Crisis Services at the San Francisco Department of Public Health, says communities need to buckle down now to ensure that 988, the three-digit number the FCC designated to mirror 911 for mental health and suicide crises, fulfills its potential when it launches nationwide in July 2022.
What can transform 988 into a robust tool for advancing crisis systems, says Dr. Goldman, is implementation, funding, coordination, clinical best practices, and research and evaluation. “Otherwise,” says Dr. Goldman, “988 will be only a rebranding of 1-800-273-TALK, the number to the SAMHSA-funded National Suicide Prevention Lifeline.”
Dr. Goldman and Michael F. Hogan, Ph.D., former New York mental health commissioner, dive into 988 and other opportunities to improve mental health crisis systems in September’s Psychiatric Services issue. They make clear that while the three-digit number and corresponding marketing will have an impact, without adequate infrastructure and funding, volume increases will overwhelm Lifeline call centers, hindering the intent of creating 988 in the first place: helping more people in psychiatric crisis.
The 170-plus Lifeline accredited crisis centers across the United States have played a vital role in de-escalating callers’ suicidality and improving outcomes, notes Dr. Goldman, diverting people from police interaction, the emergency room, inpatient hospitalization, and jail.
Since launching in 2005, Lifeline call volume has increased by roughly 15% each year. In its first year, Lifeline call centers answered over 46,000 calls. In 2019, they answered over 2.2 million. But for people who desperately need Lifeline’s resources, says Dr. Goldman, a couple of million callers are a drop in the bucket. “The vast majority of mental health calls still go to 911 instead of to 1-800-273-TALK.”
Why the number of calls to crisis lines versus 911 are so disparate is complex. In part, notes Dr. Goldman, it’s because people most apt to reach out to the Lifeline and other crisis services are doing so about themselves, while bystanders typically call 911 when they notice someone—a family member, friend, or stranger—in psychiatric distress. “The problem,” he says, “is that a person in a mental health crisis needs a person-centered mental health, non-police response.” Yet, when you dial 911, you’re more likely to get police.
“For the most part, these specialty services are not yet in the public consciousness,” he says.
No one knows exactly how much 988 will affect Lifeline call volume, but experts estimate that calls will at least double in the first year, likely resulting in no less than 4.4 to 5 million callers. Dr. Goldman says it could be far more, depending on the corresponding marketing push. “988 is also far easier to remember than 1-800-273-TALK.” Consequently, people who might not have historically called the Lifeline will call 988.
“This is the exciting opportunity of 988,” says Dr. Goldman. “There’s going to be a broad public understanding of a number to call that can more appropriately help someone in a mental health crisis than police.”
An Opportunity to Build a Foundation Where Police Are Not the Default Mental Health Provider
Matching people to a mental health instead of a law enforcement response is vital for people with mental health challenges generally, says Dr. Goldman, but particularly for communities of color where “people are loath to call 911 because of longstanding challenges with local police.” He points to the family of Walter Wallace Jr., who called 911 on Monday, October 26. According to Shaka Johnson, the family’s attorney, the family asked for an ambulance, not police, to mitigate Wallace’s psychiatric crisis.
The Philadelphia Inquirer reported that local police were no stranger to Wallace’s issues and, in fact, responded twice that fateful Monday to reports of disturbances at his home before answering a third call and shooting Wallace as he allegedly approached them with a knife. When officers arrived, Johnson says Wallace’s pregnant wife told them he was in a psychiatric crisis and had Bipolar disorder.
Dr. Goldman says widespread awareness among Americans to call 988 rather than 911—a number that’s part of health departments instead of police departments—may decrease similar tragedies. That’s not to say mental health crisis services and stakeholders like police need not foster relationships with one another. Quite the opposite. Implementing 988, he says, will take partnerships between all players, including the community, mental health crisis lines, mobile crisis, police, fire department, emergency medical services, and the rest of the health and crisis care system at large. As it exists now, the multi-dimensional system has changed little since 1967, when the FCC established 911.
“Reworking these pathways will be a challenge and needs collaboration,” he says, “to make 988 part of the workflow to divert 911 calls, when appropriate.”
Where to Start
The place to start preparing for 988, says Dr. Goldman, is with the community. Having a community-oriented process that engages people of color and other marginalized populations is implementation 101, but he notes it’s the most often forgotten element. “People in the community who are marginalized need to be a part of building the foundation of this new system,” he says, “so they don’t continue to be sidelined and harmed by the very systems that are supposed to help them.”
Each community will need to do an environmental scan, looking nationally at crisis models that are thriving, conducting local needs assessments, and determining what components they already have in place or are a priority to develop. They also need a snapshot of their clinical needs—for example, whether people in the community are most affected by psychosis, opioids, or methamphetamines—and that there are corresponding resources to address these needs.
“From the onset, and with 988 in mind, the community has to identify its crisis system priorities and what’s feasible in the near and long term.”
Dr. Goldman points to Maricopa and Pima Counties in Arizona as the Camelot of psychiatric crisis services. “They’ve got it all,” he laughs. At the center is a crisis call center—often called “care traffic control” because it’s analogous to air traffic control, which uses computers, radar, and visual references to monitor and direct aircraft in the sky and on the ground. Air traffic controllers have to make quick decisions to ensure the safety of planes and their passengers. Similarly, notes Dr. Goldman, that’s what Maricopa County’s crisis line does for psychiatric crises. It takes Lifeline calls and coordinates with 911 dispatch to triage mental health crisis calls through the call center, making it the single point of access repository for all variety of mental health crisis calls.
“The value of a single access point is twofold: the right people are triaging calls on the phone, and they’re able to have centrally coordinated dispatch of mobile crisis teams.”
Behavioral health facilities have also developed a “no wrong door” approach with police, allowing officers to do rapid drop-offs and return to their patrol duties, diverting people in crisis from jail and emergency departments.
None of Arizona’s robust crisis care continuum, notes Dr. Goldman, could have happened without adequate partnership, workflow review, and funding.
Currently, Lifeline centers are often under-resourced and under-funded, with 58% of member call centers stating they answer calls without designated funds. Funding is made up of temporary grants and small annual stipends. This isn’t sufficient, notes Dr. Goldman, to get 988 off the ground, let alone sustain it.
Under 988, with adequate infrastructure and funding, Lifeline call centers can transform into coordinating centers that triage and de-escalate calls and connect people to resources like mobile crisis, if needed. Dr. Goldman says there needs to be legislation—federal, state, and local—to authorize these pathways and fund them. “It can be done regulatorily or within each agency.” Legislation can also require 911 systems to review their current workflow process of mental health crisis calls and partner with 988 crisis call centers to develop a protocol for transferring psychiatric calls.
Additional 988-specific grants and braided funding are vital to its development, but Dr. Goldman says what will create long-term sustainability is reimbursement for call center functions. He says the COVID-19 pandemic resulted in rapid regulatory and policy changes temporarily expanding telehealth, allowing clinicians to bill for audio and video sessions with clients. “Is a call with a crisis counselor so different from a telehealth evaluation?” Dr. Goldman asks. “Rather than think of a mental health intake for someone in crisis as a call center function, they could bill it as a telehealth encounter.” He says it’s time to engage Medicaid, Medicare, and private insurers to find sustainable reimbursement solutions for psychiatric crisis services.
Crisis Research and Evaluation
One impediment to reimbursement, says Dr. Goldman, is insufficient research and evaluation to illustrate the efficacy of the full array of crisis services, with most research focused on suicidality and the Lifeline call centers. Madelyn S. Gould, Ph.D., M.P.H., at Columbia University, has evaluated the Lifeline, revealing its hotline services reduce suicidality of callers and improve outcomes. Dr. Gould and her colleagues studied 240 counselors at eight crisis hotline services across the United States—seven were Lifeline call centers. In 2007, the researchers reported that callers’ suicidality lessened, and so too did their psychological pain and hopelessness. Callers said in a follow-up call with the researchers that the latter two continued to diminish even after the crisis call ended. Among non-suicidal callers, Dr. Gould and her colleagues found that their distress also declined during the call and continued to decrease between when the call ended and when the researchers called them.
In 2018, Dr. Gould and her colleagues reported that Lifeline follow-up calls to suicidal callers are a vital intervention, stopping them from dying of suicide (79.6%) and keeping them safe (90.6%). Yet, notes Dr. Goldman, there’s not enough research about the call centers and non-suicidal psychiatric crisis. “Are the call centers also resolving these crises and improving outcomes longer term?”
There’s also been far less research on mobile crisis teams, notes Dr. Goldman, and most studies have been quasi-experimental and retrospective, looking at the impact on inpatient utilization among people who receive mobile crisis services. “There’s not enough about how people are faring after a mobile crisis visit,” he says. “Inevitably, there will be a subset of the population who accesses mobile crisis and still needs additional crisis services.” The benchmark of reutilization remains unknown, and without it, Dr. Goldman says there’s no quality measure for programs to compare themselves to and no accountability metrics.
Dr. Goldman wonders if telehealth could play a mitigating role for people who mobile crisis teams typically take to the emergency department instead of a crisis facility. Some mobile crisis services are doing just that. For example, EMPACT Suicide Prevention Center at La Frontera Arizona launched a pilot early this year, where mobile crisis teams can use an on-call psychiatrist through telehealth to help keep people in the community instead of going to the ED. Erica Chestnut-Ramirez, EMPACT’s vice-president, told #CrisisTalk in February that she’s interested to see how the pilot will affect stabilization numbers.
Often, data exists in electronic health records and in claims, if reimbursement is happening, and most mobile crisis providers conduct internal tracking. “There’s a difference,” says Dr. Goldman, “between quality assurance/quality improvement and research.” The latter is a more scientific approach to answer whether a mobile crisis team reduces reutilization of acute services, connects people to outpatient care, lessens interaction with the police, or diverts people from jail and the emergency department.
“These questions need to be examined more rigorously,” he says. “So when we look back in five years and tell the 988 story and justify its continued existence, we can say exactly how it made a difference.”
As communities begin self-evaluations to prepare for 988, Dr. Goldman recommends they partner with academics to ensure evidence-based practices, high standards of care, accountability, and secure financing. “Medicare, Medicaid, and private insurers,” says Dr. Goldman, “may not be convinced to fund crisis services unless they have clear evidence that supports the investment in them.”
Fortunately, mental health services research and implementation science are trending topics right now in academic departments. Dr. Goldman says researchers want to be part of implementing the mental health crisis system of the future. “That’s an appealing ask,” he says. “We want to find alternatives to policing just as much as everyone else.”
Dr. Goldman says it’s also dire that the United States simultaneously creates a national consortium for crisis research and evaluation to develop a cohesive national strategy, identify gaps, and develop robust evidence for 988 and other psychiatric crisis care initiatives.
People often perceive research as taking years before outcomes are determined, but Dr. Goldman says, with 988, communities will be building and testing the plane while it’s in the sky. From the start, they will need to pull from existing data infrastructures to answer the questions they need to ask. In San Francisco, for example, that means tapping into the Coordinated Care Management System (CCMS), which is a model for linking general medical and mental health records to data systems from housing, public assistance, and criminal justice.
“Having these data streams connected and speaking to one another,” he says, “allows for better partnership and for communities to answer the intricate and important questions needed to support 988.”