In Los Angeles County, calls that come into 911 or even its non-emergency business lines are, by default, considered higher risk. Historically, these level four calls have resulted in law enforcement dispatch or a co-responder team. (Co-responder models are typically two-person teams that comprise a police officer or emergency medical technician partnered with a behavioral health professional.) Captain John Gannon, LA County Sheriff’s Department, says that while 911 call takers would ask the caller questions to determine the type of emergency the person was likely experiencing, what they could do next was limited. “Even if the person’s crisis was a level three or two, there was no other agency for us to contact, so law enforcement would keep the call,” he says.
Today, the county has developed a call assessment matrix and amended 911 call taker procedures to help triage the vast majority of 911 behavioral health calls to Didi Hirsch Mental Health Services. (The term behavioral health includes both mental health and substance use disorders.) “The system is running as a pilot in the city of Los Angeles,” says Captain Gannon, “but the county plans to make it countywide before 988 goes live.” Telecom carriers must direct the three-digit nationwide number for mental health, substance use, and suicide crises to the Lifeline by July 16. Until that happens, county 911 calls that dispatchers and call takers consider a level 3—moderate risk—and lower are transferred to the LA County Department of Mental Health.
There’s a growing movement across the United States to find alternatives to justice system involvement for people experiencing behavioral health or quality of life challenges. That’s no less true in LA, where the killing of David Ordaz, Jr. and the critical injury of Isaias Cervantes, a deaf and autistic man, by law enforcement made headlines in 2021. Both men were experiencing a mental health crisis. Both are also Latino. According to February 2022 data from the Washington Post’s police shooting database, of people killed in the United States by a police officer in the line of duty since January 1, 2015, 22% were Black, 15% were Hispanic, and 22% were identified as having a mental illness. A similar database conducted by The Los Angeles Times reveals that, since 2001, nearly 80% of people killed by law enforcement were Black or Latino.
Unlike many communities, LA County does have ample crisis response resources. In fact, there are at least 10 different types of crisis teams. “However, coordination,” says Captain Gannon, “has been highly lacking.” A diagram of the crisis system in the director of mental health’s July 21, 2021 report reveals limited and pilot connections between 911 and the behavioral health continuum, with a longstanding pathway going directly from 911 to law enforcement.
In September, Dr. John Franklin Sierra, a health systems engineer and senior staff analyst at the LA County Department of Mental Health, shared with #CrisisTalk that the diagram illustrates not only the limited connectivities between 911 and behavioral health but also insufficient linkages between behavioral health services. For example, in LA, 988 calls will be answered by Didi Hirsch Mental Health Services, a 988-Lifeline accredited call center. Yet, the call center isn’t connected to the LA County Department of Mental Health, which runs the county’s largest mobile crisis response. “Didi Hirsch provides crisis counseling over the phone, and we dispatch mobile crisis services,” he said. “Our services complement one another, and while we are partners, there’s been a disconnect in the design of the pathways between our organizations that we’ve had to address.”
The diagram helped inform a countywide crisis system redesign, including preferred diversion pathways for behavioral health emergencies. The call assessment matrix, along with amended call procedures, says Captain Gannon, is vital to ensure standardization among the county’s 78 primary public safety answering points, including 911 call centers. The matrix has four levels, with level 4 calls designated the highest risk to level 1, where there is no crisis or the crisis was resolved. Captain Gannon says, under the reengineered system, 911 call takers will immediately divert level 1-3 calls to Didi Hirsch Mental Health Services, the 988 call center. “If it’s not a level four emergency, we will automatically reclassify it as a two, and the call will go to DD Hirsch to resolve,” he says. “The goal is to minimize co-response when possible and maximize the efficiency of teams out in the field.” However, if a person needs an in-person response, the 988 call center will connect with the LA County Department of Mental Health to deploy a mobile crisis team for a level 3 call or co-dispatch one for a level 4 call.Callers to 911, reporting what later turns out to be a behavioral health or quality of life emergency, are often third-party callers reporting “strange behavior.” In fact, after gathering information from the caller, 911 call takers frequently code behavioral and quality of life calls as “suspicious person,” “directed patrol,” “criminal trespass,” “street/sidewalk hazard,” “person injured/down,” “demented person,” or “public indecency.”
Navigating a person’s perceptions of what another person is experiencing comes with inherent pitfalls, which is why call takers and dispatchers at LA County public safety answering points must take an eight-hour crisis stabilization course. The call procedures and training were developed by the LA County Sheriff’s Department Mental Evaluation Team and their policy unit, Field Operations Support Services, alongside the LA County Department of Mental Health and 911 subject matter experts. The training integrates recorded behavioral health calls—where students maneuver through multiple scenarios with a series of questions to help them determine what classification in the call assessment matrix is the best fit—and addresses prevention and alternatives to incarceration. The instructors also teach call takers and dispatchers how to identify suicide and other mental health risk factors and train them on grounding techniques such as sensory grounding, cognitive grounding, and active listening.
The county’s call procedures and the training delineate the difference between a crisis and an emergency. According to the procedures, the best response to a mental health crisis is not law enforcement but a mental health crisis or community team. Examples of a person experiencing a mental health crisis are someone bedridden from depression or fearful of leaving their home because of paranoia or anxiety. “A mental health crisis is contained, doesn’t express itself outwardly, and isn’t dangerous,” says Captain Gannon.
On the other hand, a mental health “emergency,” as defined by the procedures, is when there’s a perceived safety concern. Calls to 911 remain level four—the highest level—if the caller believes the person they’re calling about exhibits behavior that suggests physical violence or has a weapon or an object that can potentially be used as a weapon like a baseball bat. (However, calls do divert to Didi Hirsch when the caller has a weapon but is alone.) What makes this murky is that the information is often dependent on a third party’s perceptions. For example, when a 911 caller in Miami saw Arnaldo Rios Soto, a man with severe autism, and his behavioral therapist, Charles Kinsey, she created an entire narrative, telling the 911 call taker she’d seen a man holding a gun to his head (it was a toy truck) while another man was “trying to talk him out of it.” To mitigate the challenges of navigating a third-party’s perceptions, the matrix includes mobile crisis services co-dispatch for a level 4 call, ensuring that people, no matter the perceived level of danger determined by the caller, will receive a mental health service response.
Another challenge, notes Captain Gannon, is funding. Similar to Washington State, California’s 988 bill has received a lot of pushback from telecom companies on service fees, trying to limit what fees can cover. “These groups have a lot of power,” he says. However, the National Suicide Hotline Designation Act is not ambiguous—states can implement a monthly telecom customer service fee to pay for 988-related services. The fee can cover costs attributed to (a) ensure efficient and effective 988 call routing to an appropriate crisis center and (b) personnel and providing acute mental health, crisis outreach, and stabilization services by directly responding to the 988 hotline. Washington State was able to push through a service fee that began at 24 cents per service line in October and will shift to 40 cents per line in January 2023.
Last summer, Senators Jeffrey A. Merkley, Christopher S. Murphy, and Ron Wyden sent a letter to Meredith Attwell Baker, president and CEO of CTIA, a trade association representing the United States wireless communications industry. The senators said the reported efforts by CTIA and its member companies to stop or limit states’ adoption of funding mechanisms to support 988 implementation could threaten 988 implementation. They went on to state that “every American should be doing everything they can to get those in crisis help when and where they need it, and not working to tie the hands of those who can provide it.”
Since the LA City pilot launched in February 2021, Captain Gannon says more people from traditionally underserved populations have reached out. “We believe this correlates with people learning that we will properly screen the calls and won’t send law enforcement unless it’s absolutely necessary,” he notes. “I think that made it possible for people who might be otherwise afraid to call us—you know, you don’t want us to hurt you or your family member.”
Captain Gannon highlights that system connections and procedural changes must happen in synchrony for communities to effectively respond to behavioral health crises. “The technology must be in place to link 911 and 988,” he says. Currently, in LA County, calls are forwarded or transferred, which makes them vulnerable to dropped calls and hangups. “Also, people don’t want to tell their story three times,” he points out. “Each time you have to convey what’s happening, you lose something, and you assume you told the latest operator everything, but you start forgetting what you told who.”
LA County is working with the state, specifically, the Governor’s Office of Emergency Services, to integrate linking 911 and 988 call centers through the 911 architecture. “By doing so,” says Captain Gannon, “911 call takers and dispatchers will be able to bring 988 online and both entities will be able to hear the caller.” The 988 call center would similarly be able to link to 911. “However, until the technology is in place, linkages between 911 and 988 won’t be a seamless process.”