Behavioral Health Crisis Services.
Crisis mental health services are intended to stabilize a person in crisis to prevent further deterioration, provide immediate treatment and intervention, and provide treatment services in the least restrictive environment available. Substance use disorder detoxification services are provided to persons to assist with the safe and effective withdrawal from substances. Behavioral health crisis services include: crisis telephone support, crisis outreach services, crisis stabilization services, crisis peer support services, withdrawal management services, and emergency involuntary detention services.
Behavioral health administrative services organizations (BHASOs) are entities contracted with the Health Care Authority to administer certain behavioral health services and programs for all individuals within a regional service area, including behavioral health crisis services and the administration of the Involuntary Treatment Act. In addition, each BHASO must maintain a behavioral health crisis hotline for its region.
National Suicide Prevention Hotline.
The Substance Abuse and Mental Health Services Administration (SAMHSA) partially funds the National Suicide Prevention Lifeline (Lifeline). Lifeline is a national network of about 180 crisis centers that are linked by a single toll-free number. Lifeline is available to people in suicidal crisis or emotional distress. When a person calls the number, the call is routed to a local crisis center based upon the caller's area code. Counselors at the local crisis center assess callers for suicidal risk, provide crisis counseling services and crisis intervention, engage emergency services when necessary, and offer referrals to behavioral health services. In addition, the SAMHSA and the Department of Veterans Affairs have established the Veterans Crisis Line which links veterans with suicide prevention coordinators. In Washington, there are currently three local crisis centers participating in Lifeline.
In October 2020 Congress passed the National Suicide Hotline Designation Act of 2020 (Act). The Act designates the number 988 as the universal telephone number within the United States for the purpose of accessing the National Suicide Prevention and Mental Health Crisis Hotline system that is maintained by Lifeline and the Veterans Crisis Line. In addition, the Act expressly authorizes states to collect a fee on commercial mobile services or Internet protocol-enabled voice services for: (1) ensuring the efficient and effective routing of calls made to the 988 National Suicide Prevention and Mental Health Crisis Hotline to an appropriate crisis center; and (2) personnel and the provision of acute mental health crisis outreach and stabilization services by directly responding to calls to the crisis centers.
Crisis Hotline Centers.
The Department of Health (Department) must designate one or more crisis hotline centers to provide crisis intervention services and crisis care coordination to persons who access the 988 Crisis Hotline within Washington. Prior to becoming recognized as a crisis hotline center, an entity must be designated as a crisis hotline center by the Department. Once a crisis hotline center is designated, it must contract with the Department to receive reimbursement for providing crisis hotline services.
To provide crisis intervention services and crisis coordination, a crisis hotline center must meet several standards. The crisis hotline center must participate in the National Suicide Prevention Lifeline network and meet operational, clinical, reporting, and quality improvement standards established by the Department. Crisis hotline centers must be able to deploy both crisis and ongoing services, including mobile crisis teams and co-responder teams. Crisis hotline centers must collaborate with managed care organizations, behavioral health administrative services organizations, and other health care payers to coordinate linkages for persons who contact the 988 Crisis Hotline with ongoing care needs. Crisis hotline centers must communicate across crisis and emergency response systems to coordinate access to crisis receiving and stabilization services for persons who access the 988 Crisis Hotline. Crisis hotline centers must also meet Department standards for serving high-risk and special populations with the goal of promoting behavioral health equity for all populations. Lastly, crisis hotline centers must use technology that is interoperable between the state's crisis and emergency response systems, such as 911 systems, emergency medical services systems, other nonbehavioral health crisis services, and the National Suicide Prevention Lifeline.
Crisis hotline centers must operate a technologically advanced behavioral health crisis call center system with the capacity to: (1) receive crisis assistance requests through phone calls and other methods of communication; (2) access real-time information from behavioral health payers for the coordination of behavioral health crisis services; (3) assign and track local responses to behavioral health crisis calls; (4) arrange appropriate same-day, next-day, and follow-up appointments for persons contacting the crisis hotline center; (5) track and provide real-time bed availability information to crisis responders and persons in crisis; and (6) assure follow-up services to individuals accessing the 988 Crisis Hotline.
Crisis Response Services.
Each behavioral health administrative services organization (BHASO) must have community-based rapid crisis response services for persons who contact the 988 Crisis Hotline in need of stabilization services. The crisis response services must be provided by enhancing and expanding mobile rapid response crisis teams. Mobile rapid response crisis teams are teams that include peers and provide professional, on-site, community-based interventions such as outreach, de-escalation, stabilization, resource connection, and follow-up support for persons experiencing a behavioral health crisis. Mobile rapid response crisis teams may either be jurisdiction-based or embedded in emergency medical services and must collaborate with local law enforcement and include police as co-responders when public safety is an issue and law enforcement assistance is necessary. In addition, specialized mobile rapid response crisis teams must be created to respond to the unique needs of youth and geriatric populations. The Health Care Authority (Authority) must consult with tribes to create tribal mobile rapid response crisis teams.
Medicaid managed care organizations, the BHASOs, and health plans must assign a care coordinator to, and provide same-day and next-day appointments for, their enrollees or clients who seek services from the behavioral health crisis system.
Before July 16, 2022, the Authority must develop a plan for the equal statewide distribution of crisis stabilization services and beds, peer respite services, and behavioral health urgent care. Crisis services administered by the BHASOs must include adult, youth, and geriatric mobile rapid response crisis teams; crisis stabilization services; and peer respite services. Crisis receiving and stabilization services, short-term residential facilities, and peer-operated respite services must meet minimum expectations and best practices adopted by the Authority. By July 1, 2026, the BHASOs must provide for the availability of an adequate network of secure withdrawal management and stabilization services to ensure access to treatment, investigation, transportation, court-related and other services under the Involuntary Treatment Act.
The responsibility for payment of crisis services is established for managed care organizations, the BHASOs, the Authority, and private health care plans. Every fiscal biennium the Legislature must appropriate funds to managed care organizations, the BHASOs, and the Authority to reimburse providers of crisis services. In addition, the Department must provide adequate funding for the expected increase in call volume to the state's crisis hotline centers.
Administrative Coordination.
The Governor must appoint a 988 Crisis Hotline System Director (Director) to provide direction and oversight in the implementation and administration of the 988 Crisis Hotline and behavioral health crisis system components. The Director must assure coordination between the 988 Crisis Hotline, the crisis hotline centers, and the 911 emergency communications system; assure proper communication between crisis hotline centers and behavioral health crisis services; review the adequacy of training for crisis hotline personnel and 911 operators, with respect to their interactions with the crisis hotline center; oversee the coordination and adequacy of behavioral health crisis services; assure that Authority contracts with managed care organizations and the BHASOs support the behavioral health crisis system; and oversee the collaboration between the Department and the Authority with respect to their roles in the behavioral health crisis system.
The State Enhanced 911 Coordination Office must collaborate with the Department to assure consistency and equity of care for individuals in crisis whether they call 911 or 988.
The Department and the Authority must provide an annual report of the 988 Crisis Hotline's usage and call outcomes, as well as information about crisis services, including mobile rapid response crisis teams and crisis stabilization services. The report must also include information about fund deposits to and expenditures from the Statewide 988 Behavioral Health Crisis Response Line Account (988 Account). Beginning in 2023, the report must be submitted each November to the Governor and the appropriate committees of the Legislature.
Implementation Coalition.
The Governor is directed to establish an implementation coalition to enhance and expand behavioral health and suicide prevention crisis services in Washington. The William D. Ruckelshaus Center or another neutral party is responsible for providing staff support and facilitation services to the implementation coalition.
The membership of the implementation coalition includes at least 50 members. Members represent interests including the Legislature, executive branch agencies, local government, health carriers, behavioral health providers and facilities, recipients of and family members of recipients of crisis response services, family members of persons killed by law enforcement during a behavioral health crisis, peer support service providers, behavioral health crisis stabilization experts, crisis hotline centers, the BHASOs, community mental health and substance use disorder agencies, behavioral health advocates, law enforcement, police accountability groups, local health jurisdictions, physicians, and hospitals. In addition, the Governor must request the participation of a person representing the interests of tribal governments. All members may vote, except those representing the executive branch.
The implementation coalition must make recommendations on: (1) the implementation and monitoring of the progress of the 988 Crisis Hotline in Washington; and (2) statewide improvement of behavioral health crisis response services. Specifically, the implementation coalition must report on:
The implementation coalition must report to the Governor and the appropriate committees of the Legislature by December 1, 2021, with a preliminary report, and by November 1, 2022, with a final report.
Statewide 988 Behavioral Health Crisis Response Line Tax.
The Statewide 988 Behavioral Health Crisis Response Line Tax (988 Tax) is imposed on all radio access lines and interconnected voice over internet protocol (VoIP) service lines. A radio access line is a telephone number assigned to or used by a subscriber for two-way local wireless voice service from a radio communications company, including cellular telephone service, personal communications services, and network radio access lines. A VoIP service line is a service that enables real-time, two way voice communications using a broadband connection. The 988 Tax amount for each of these lines is gradually increased so that the 988 Tax is 30 cents per line per month between October 1, 2021, and December 31, 2022; 50 cents per line per month between January 1, 2023, and June 30, 2024; and 75 cents per line per month beginning July 1, 2024.
Proceeds from the 988 Tax must be deposited into the 988 Account. The 988 Account is an appropriated account in the State Treasury. Money from the 988 Account may only be used for the routing of calls from the 988 Crisis Hotline to an appropriate crisis hotline center and for personnel and the provision of acute behavioral health, crisis outreach, stabilization services and follow-up case management.
(In support—from testimony on HB 1182, which is identical to HB 1477 except for the title, on January 28, 2021) Much happens in behavioral health care at the point of crisis and this bill provides an opportunity to take a closer look at the system. The 988 number is an opportunity to make the behavioral health crisis system stronger. There will be a significant increase in call volume once the change to the 988 number occurs because of the easier access, and there must be increased funding to support the necessary staff and technology to accommodate this. The current crisis system does not work for everyone and is inefficient and overly complex, inadequately funded, and has too few workers. When people have the courage to call for help, they must be helped. Thoughts of taking one's life can be impulsive and fleeting moments where rapid and supported interventions are urgently needed. This bill's vision of the 988 system and these call centers is to support people in crisis from the point of first contact and make sure that they receive a call, triage, a warm handoff, a rapid response, and following up to make sure they received services. This bill assures there will be quick access to openings for continuum-of-care options. Instead of giving out a phone number and hoping that the next call is made, the call center will discern the most promising service package for the caller with current knowledge about resources, such as bed availability. There is a need to create technologically advanced care systems. This bill would be a game changer by getting peer supports for people in crisis and their families to connect them with the services they need. This bill will help the new 988 service reach its full potential by linking people experiencing behavioral health crises with appropriate community-based supports before they end up in an emergency department, a prison, or possibly putting themselves or others at risk.
Over the past decade, deaths by suicide have increased by over 36 percent in Washington with 5,000 lives lost in the past five years. Suicide is the leading cause of death for Washingtonians under the age of 25. Suicide rates are higher among veterans; American Indians and Alaska Natives; lesbian, gay, bisexual, transgender, and queer youth; and people in rural areas.
Some people may be concerned about calling 911 in a mental health crisis and a tool like 988 is a component of dismantling structural and systemic racism. The holes in the safety net leave people in standoffs with law enforcement, when they should be in the care of a counselor. This is a great compromise between communities of color, mental health professionals, and police departments. There needs to be coordination and training of all parties, including the 911 system and law enforcement.
(Opposed—from testimony on HB 1182, which is identical to HB 1477 except for the title, on January 28, 2021) None.
(Other—from testimony on HB 1182, which is identical to HB 1477 except for the title, on January 28, 2021) This bill sets up a crisis hotline that is separate from the current system, which is not practical. Counties already have existing behavioral health crisis hotlines that are governed by the Health Care Authority (Authority) and have processes and relationships with existing providers. The Authority should oversee the system so there is not an additional layer of cost and administrative burden from multiple state agencies. There are concerns about moving oversight of the crisis lines to a statewide official and an agency that is different than the one that oversees all of the other behavioral health services in the state.
The overhaul of the crisis delivery system is not beholden to the same time frame as the implementation of the 988 number, so there should be further discussions and planning. There is no planning stage for the centralized platform that is the basis of the mandate on hospitals, primary care, and other behavioral health providers to provide real-time bed and service availability. It is important to step back and inventory what is already in place and working in order to thoughtfully build capacity and ensure that when people call 988 there will be help at the other end. The timing of the bill's requirements must be realistic and achievable with respect to system changes, hiring, training, and cost. There should be more representation by behavioral health administrative services organizations in the implementation coalition. Even after 988 is implemented, there will still be suicide calls coming to the 911 system and, conversely, calls to 988 that belong with 911, so it is essential to assure that the two programs are connected and coordinated from the very beginning to ensure consistency.
The bill needs to be scaled so that it can be successful. This could create too broad of a system that cannot meet the regional needs of individuals, especially in rural areas. The underlying issues of behavioral health funding, workforce supply, and housing solutions also need to be addressed. Crisis services need to be funded on a capacity basis, rather than a fee-for-service basis. It is not clear how the state will provide the funding for the workforce, technology, and infrastructure needed to implement the bill. This would be very difficult to comply with because providers do not hold appointments open for same-day services. This bill shifts some of the systemic shortfalls on to health plans. There should be a more targeted approach of working at the regional crisis hotline level to bolster their capacity at the regional level and meet the needs that the 988 requirements will demand, as well as building up the emergency department and jail diversion efforts.
The substitute bill clarifies that the 988 tax applies to prepaid wireless lines and synchronizes the effective dates for the tax to October 1, 2021. In addition, landlines are added to the tax base.
(In support) People considering suicide are terrified and isolated. Suicides in Washington are up 36 percent. Five thousand Washingtonians are lost to suicide each year and about two to three young adults per week. The pandemic has only exacerbated the mental health crisis. Calls to crisis lines and 911 have increased. Washington's behavioral health system is currently broken and historically underfunded. Loved ones' only option is calling 911, going to an emergency department, or trying one of the many crisis lines. There are long waits in some counties for behavioral health services and thousands die due to this underfunded, uncoordinated and outdated system.
Moreover, the Black, Indigenous, and People of Color (BIPOC) community members with suicidal ideation and suffering from racial trauma also experience disparity in access to treatment. The cost is one cent per day to save a BIPOC member and to address the mental health impacts from structural racism.
The federal government has created a simple 988 number to ensure the efficient and effective routing of calls related to mental health crisis. The legislation also includes the authorization of a tax to provide the investment in new technology, the personnel to respond to the calls, allow for the partnership with law enforcement and 911, and the personnel to provide triage, support and hand-offs to the proper care. Currently, 911 performs an essential role in handling calls with behavioral health components, this bill recognizes that most of these calls go beyond 911 training and resources, and 988 will provide a higher level of service. There are already other states taking the lead on this. In the long run, this investment will save Washington money by diverting the appropriate cases to services instead of the emergency department or an interaction with law enforcement.
Those who have experienced the current crisis response for suicidal ideation or acute behavioral health crisis attest to the heartbreak that failures of the system cause. Lack of understanding and proper crisis response is critical to success. Diverting persons in crisis away from emergency departments and law enforcement and into supportive crisis services saves lives.
(Opposed) None.
(Other) Although, the designation of 988 as a crisis hotline is a great idea, there are concerns about the use of funding. The proceeds of the tax should be restricted to funding the equipment and personnel necessary to the implementation and maintenance of the 988 crisis line.
There is concern about the fiscal viability of the policy contained in the bill. The policy advocates investment in all areas of behavioral health, not just the 988 crisis line. Technology, facilities, staffing of beds, personnel for the crisis lines, and the crisis response teams will be expensive and it does not appear that the current 988 tax as proposed will be sufficient to fund all the bill's requirements.
There is not a line per county for the crisis hotlines. There are currently nine regional crisis hotlines. The focus should be on working with existing system and using 988 proceeds to build up and bolster the current system. It would be counterproductive to invest in the technology and cost of building a parallel system. Also, the Health Care Authority should have a bigger role in the 988 crisis hotline as it already contracts out for crisis services.
In addition, the 988 tax should be imposed on landlines in addition to cellular phone lines and voice over Internet protocol service lines.