988: How We Got Here and What Comes Next

After what seems like a flash of time, the official launch of the nation’s mental health hotline, 988, was July 16th. What does this mean for the everyday American? How did we get here? How are states organizing themselves to introduce, launch, and sustain this new public service program? In this article, we will be answering these questions to highlight the importance of having localized mental health services, and how the diversity in how these services is implemented, creates the opportunity for advancing the entirety of the crisis care continuum.

How does 988 work?

When an individual calls 988, their call will automatically be rerouted to the geographically closest National Suicide Prevention Lifeline call center where they will be connected to a trained counselor who can address their immediate needs and organize ongoing care. 988 calls will be covered equally for cell phones and landline-based calls. The call centers were established and will be maintained by one or multiple state agencies.

Why is 988 so important?

According to the National Association of Mental Illness (NAMI), 1 in 5 U.S. adults will experience a mental illness, with 1 in 20 experiencing a serious mental illness. Encompassing this staggering statistic is the nation’s major issues with producing and implementing a comprehensive mental health crisis care system. Standardization of these efforts is critical in taking a major step towards comprehensive care. 988 is a major step forward to implement better quality, standard crisis care. Echoing NAMI’s sentiment: mental healthcare is healthcare. Just as 911 was intended to be a form of healthcare for physical injuries, 988 is intending itself to be the form of the healthcare needed to begin treatment of a mental health crisis.

Where did 988 come from?

Up until the July 16th launch, individuals and families experiencing a mental health crisis were referred to calling the National Suicide Prevention Lifeline, Veterans Crisis Line, or various local support systems. But more needed to be done. Mental health experts and service organizations called for a singular 3-digit code, like 911, that could be better advertised and utilized for the public, and bolster the essential service with the governmental support that is needed. However, momentum was made when Congress passed the “National Suicide Hotline Improvement Act,” which mandated the FCC to complete an investigative report on the state of the mental health crisis lines and their recommendations on if 988 was the best route to improve those services. This strong report collaborated by the FCC, U.S. Department of Health and Human Services, Department of Veteran Affairs, and the North American Numbering Council, was published in 2019. Just a couple of months later, a worldwide pandemic unearthed and intensified an existing mental health crisis. Legislators had to act quickly.

In the summer of 2020, Congress passed sweeping mental health legislation to begin to address the impacts of the pandemic on American’s mental and behavioral health crisis during the initial waves of COVID-19 pandemic. Called the “National Suicide Hotline Designation Act of 2020,” this bill mandated the designation of dial code 988 as the national suicide prevention and mental health crisis hotline. Federal funding mechanisms were also implemented to disburse money to states to create the infrastructure for 988 centers and service providers.

How did states adapt to this mandate?

Some states were ahead of the curve in implementing a call line dedicated to mental health crises, but many other states were essentially starting from scratch. Associations like NAMI and the National Association State Mental Health Program Directors (NASMHPD), as well as the Substance Abuse and Mental Health Service Agency (SAMHSA), all published playbooks on their steps and recommendations for implementing the best organization for 988 centers and polices.

Over the last two years, states have tackled preparedness for 988 in varying ways. States like Colorado, Nevada, Virginia, and Washington took immediate legislative action to implement centers, policies, evaluation tools, and a funding stream. But other states like Alaska, Arizona, Florida, and Texas, took longer to implement legislation and still have not established a long-term source of funding for the centers.

Overall, there is still a lot of work to be done to ensure 988 centers have the best chance of serving the public.

What potential issues may arise after 988 goes live?

Outside of the fundamental issues listed above, mental health and 911 stakeholders have expressed through the legislative process of implementing the basics of 988, there is a bigger question regarding 988: how 988 fit into the emergency management life cycle as a whole? This question encompasses one of the largest concerns Ravers have heard in 988 conversations across the country: interoperability and awareness. How are calls transferred between 988 and 911? How do we direct the pubic on when to call either helpline? How do first responders coordinate in an emergency where there is a mental health and physical safety issue? How do these responders coordinate in simultaneous incidents occurring in multiple locations?

What are the proposed solutions?

Since policy has only scratched the surface of 988’s structure and potential, stakeholders have been looking for creative and innovative solutions to address the above listed questions. Here are the 3 points of solutions that states have been considering:

1. Capabilities to share critical information on the caller’s status and necessary accommodations. As 988 is a service that provides help and support for people in crisis, having any and all information on an individual’s medical, mental and behavioral health, and additional critical information for responders and intervention teams to accelerate response time with actionable information to better customize their response to a person in crisis. The City of Chicago introduced their critical information tool last year as a community safety, but is used in all aspects of public safety to assist dispatchers and responders with providing crucial details and assist the city in providing resources to those who need them.
2. Capabilities to allow real time information sharing between first responders and mental health crisis intervention teams. Just with 911 calls, 988 calls may need to call in intervention without the consent of the caller when an immediate risk is detected. As both first responders and crisis intervention teams are needed, both need to communicate as they will typically not be traveling together. Having this information across sectors of public safety allow better quality response and to learn more about ones community needs and working with neighboring communities to address larger issues and services. Charleston, North Carolina currently has a program to begin addressing these issues in homeless populations and those with mental health symptoms and being able to identify individuals who need specialized assistance.
3. Capabilities to ensure calls can be warm transferred between 988 and 911, including past interactions and notes. In the beginning days of the 988 launch, there is going to be a massive campaign to ensure individuals know when to utilize the helpline. Therefore, there is an expected issue of people calling one line when they need to be in the hands of the other. This is where “warm transfers” come into play. A “warm transfer” is when a 911 or 988 dispatcher is able to get a caller to the other service line and get the information that dispatcher has already received from the caller to the other dispatch center. Many centers do not have this capability at this time, but many jurisdictions are looking into those investments. Seconds count when an individual is in distress and in need of assistance. Being able to easily float information between each center will reduce response time, promote coordination across the board, give all public safety authorities the ability to better review incident response, and, most importantly, make the services provided more effective. One of the most well-known examples of this type of system being implemented is the Denver STAR Program, who have an amazing success rate of helping those with a mental health crisis. Here, Denver was able to successfully incorporate the STAR program with mainstream public safety response service with technology that allows the STAR team to receive real time information from dispatchers.

In conclusion, we know that 988 is essential to the welfare of the mental health crisis care continuum, to public safety, and public health at large. Rave Mobile Safety is here to help communities with 911 and 988 services. Our team has been consistently engaged with stakeholders and continues to work across the country to help make these services as effective and efficient as possible. We look forward to continuing this important work.