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.
Behavioral Health Crisis Response and Suicide Prevention System.
Crisis Hotline Centers and Crisis Call Center Hubs.
The Department of Health (Department) must provide adequate funding for an expected increase in the use of the state's crisis lifeline call centers once the 988 hotline number is established. The funding must be established at a level anticipated to achieve an in-state call response rate of at least 90 percent by July 22, 2022. The level of funding must be determined by considering call volume predictions, cost per call predictions provided by the National Suicide Prevention Lifeline (Lifeline), guidance on call center performance metrics, and necessary call center upgrades.
By July 1, 2023, the Department must adopt rules with standards that crisis call centers must meet to become designated as a crisis call center hubs. A "crisis call center hub" is defined as a state-designated center participating in the Lifeline network to respond to statewide or regional 988 calls. The Department must collaborate with other agencies in developing the rules and must consider recommendations from the Crisis Response Improvement Strategy Committee (Strategy Committee) and guidelines from national organizations.
By July 1, 2024, the Department must designate crisis call center hubs to provide persons who access the 988 Crisis Hotline within Washington with crisis intervention services, triage, care coordination, referrals, and connections. To be designated as a crisis call center hub, an entity must contract to provide crisis call center hub services. The contracts must require the crisis call center hubs to participate in the Lifeline network; meet operational, clinical, and reporting standards established by the Department; and collaborate with the Health Care Authority (Authority), the Lifeline, and the Veterans Crisis Line to assure consistent messaging. In addition, the contracts must require crisis call center hubs to employ highly qualified, skilled, and trained clinical staff to provide empathy to callers, de-escalate crises, assess behavioral health disorders and suicide risk, triage to system partners, and provide case management and documentation.
Behavioral Health Crisis Response System and Suicide Prevention Technologies.
The Department and the Authority must coordinate to develop the technology and platforms needed to manage and operate the behavioral health crisis response and suicide prevention system. The technologies must include: (1) a new technologically advanced behavioral health and suicide prevention crisis call center system platform for use in crisis call center hubs that has technology that is interoperable with other crisis and emergency response systems statewide; and (2) a behavioral health integrated client referral system that coordinates system information with the crisis call center hubs and behavioral health entities. The agencies must designate a primary technology system to provide:
In developing and implementing the technology and platforms, the Department and the Authority must create a technical and operational plan for the development of technology and platforms for the call center hub system. Prior to beginning a new information technology development following the initial planning phase, the agencies must submit the technical and operational plan to the Governor, the Office of Financial Management, the steering committee of the Strategy Committee, and the appropriate committees of the Legislature. The technology and operational plan must be approved by the Office of the Chief Information Officer, the Office of Financial Management, and the steering committee of the Strategy Committee before the expenditure of funds beyond the initial planning phase. A draft technology and operational plan is due by January 1, 2022, and a final plan by August 31, 2022. The plan must address data management, data security, data flow, data access and permissions, protocols for health information privacy procedures, cybersecurity requirements, service level agreements by vendor, maintenance and operations costs, identification of applicable software as a service product, integration limitations by system, data analytic and performance metrics, liability, identification of the agency to host the electronic health record software, identification of the regulatory agency, the timeline from initiation to implementation of the solutions, efficient use of state resources and maximization of federal financial participation, and a comprehensive business plan analysis.
State Agency Responsibilities.
The Department is assigned the primary responsibility for establishing and designating the crisis call center hubs and the Authority is assigned the primary responsibility for developing and implementing the crisis response system and services to support the work of the crisis call center hubs. It is the stated expectation that the agencies will collaborate to ensure seamless, continuous, and effective service delivery with the statewide crisis system. In addition, the Department must collaborate with the State Enhanced 911 Coordination Office, Emergency Management Division, and Military Department to use technology that is interoperable between the 988 Crisis Hotline system and crisis and emergency response systems used throughout the state, to assure cohesive interoperability, to develop training programs and operations for both 911 public safety telecommunicators and crisis line workers, to develop suicide and behavioral health crisis assessments and intervention strategies, and to establish efficient and equitable access to resources via crisis hotlines.
The Authority is assigned specific duties related to collaborating with counties and behavioral health administrative services organizations (BHASOs) to develop dispatch procedures; establishing agreements with managed care organization and BHASOs to provide services and coordination regarding crisis services, including arranging next-day appointments; creating best practice guidelines to deploy crisis response services to 988 hotline callers; developing procedures regarding information sharing and communication between and across crisis and emergency response systems; and establishing guidelines to serve high-risk populations.
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 and Suicide Prevention Line Account (988 Account). Beginning in 2023, the report must be submitted each November to the Governor and the appropriate committees of the Legislature. The Joint Legislative Audit and Review Committee must conduct an audit once the act has been fully implemented to focus on the use of funds from the Account. The report is due by November 1, 2027.
The Governor must appoint a 988 Hotline and Behavioral Health Crisis System Coordinator to provide project coordination and oversight for the implementation and administration of the 988 Crisis Hotline. The coordinator must oversee the collaboration between the Department and the Authority, coordinate and facilitate communication between stakeholders, review the development of training for crisis call center personnel, and coordinate the implementation of other behavioral health initiatives.
When acting in their statutory capacities, the state, the Department, the Authority, the State Enhanced 911 Coordination Office, the Emergency Management Division, the Military Department, and other state agencies and their employees are deemed to be carrying out duties owed to the public and not any individual person or class of persons. Crisis call center hubs are deemed to be independent contractors, separate and apart from the state.
Crisis Response Improvement Strategy Committee.
The Strategy Committee is established to develop an integrated behavioral health crisis response and suicide prevention system. The Office of Financial Management must contract with the Behavioral Health Institute at Harborview Medical Center to facilitate and provide staff support to the the Strategy Committee.
The Strategy Committee includes the Director of the Authority, or the Director's designee; the Secretary of the Department, or the Secretary's designee; a representative of the Office of the Governor; the Insurance Commissioner, or the Commissioner's designee; up to two members representing federally recognized tribes, one from Eastern Washington and one from Western Washington; two members of the House of Representatives; two members from the Senate; the Director to the Department of Veterans Affairs, or the Director's designee; the State Enhanced 911 Coordinator, or the Coordinator's designee; a member with lived experience of a suicide attempt; a member with lived experience of a suicide loss; a member with experience of participation in the crisis system related to a mental health disorder; a member with experience of participation in the crisis system related to a substance use disorder; a member from each crisis call center in Washington that is contracted with the Lifeline; up to two members representing BHASOs, one from an urban region and one from a rural region; a member from the Washington Council for Behavioral Health; a member from the Association of Alcoholism and Addiction Programs of Washington State; a member from the Washington State Hospital Association; a member from the National Alliance on Mental Illness of Washington; two members representing the behavioral health interests of persons of color, one recommended by Sea Mar Community Health Centers and one recommended by Asian Counseling and Referral Service; a member representing law enforcement; a member representing a university-based suicide prevention center of excellence; a member representing an emergency medical services department with a CARES program; a member representing Medicaid managed care organizations; a member representing commercial health insurance; a member from the Washington Association of Designated Crisis Responders; a member from the Children and Youth Behavioral Health Work Group; a member from a social justice organization addressing police accountability and the use of deadly force; and a member from an organization specializing in facilitating behavioral health services for LGBTQ populations.
The Strategy Committee must submit its work to a steering committee of the full Strategy Committee. The steering committee consists of the Director of the Authority, or the Director's designee, the Secretary of the Department, or the Secretary's designee, a representative of the Office of the Governor, one of the members from the House of Representatives, and one of the members from the Senate. The steering committee must convene the Strategy Committee, select three co-chairs, form subcommittees, schedule meetings, and establish agendas. In addition, the steering committee must monitor and make recommendations related to funding crisis response services from the Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Account (Account), including analysis of projected expenditures, the cost of providing statewide coverage of mobile rapid response crisis teams, options to reduce the tax, and the viability of funding mobile rapid response crisis services from the Account. The steering committee must submit a preliminary report to the Governor and the Legislature on the analysis of the account by January 1, 2022, and a final report by January 1, 2023.
By January 1, 2022, the Strategy Committee must develop a comprehensive assessment of the behavioral health crisis response and suicide prevention system, including an inventory of existing services and resources. The comprehensive assessment must identify statewide and regional insufficiencies in necessary services and resources, goals for the provision of statewide and regional behavioral health crisis services and resources, a process for establishing outcome measures and improvement targets for the crisis response system, and potential funding sources.
The steering committee must provide progress reports by January 1, 2022, and January 1, 2023, and a final report to the Governor and the appropriate committees of the Legislature by January 1, 2024. In developing the report, the steering committee must consider the comprehensive assessment and discussions with the Strategy Committee and reports from subcommittees. The report must include:
The steering committee must form several specified subcommittees and may form others. The required subcommittees pertain to tribal issues, credentialing and training, technology, cross-system crisis response collaboration, and confidential information and coordination. Participants on the subcommittees are not required to be Strategy Committee members and each subcommittee must have at least one member representing rural interests, urban interests, and the interests of youth.
The Strategy Committee must report to the Governor and the appropriate committees of the Legislature by January 1, 2023.
Health Insurance Coverage.
Health plans must make next-day appointments available to enrollees with urgent, symptomatic behavioral health conditions by January 1, 2023. The appointment does not need to be with a behavioral health professional as long as it is with a licensed provider acting within their scope of practice. The appointment may be provided through telemedicine.
Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Tax.
The Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Tax (988 Tax) is imposed on all radio access lines, interconnected voice over Internet protocol (VoIP) service lines, and switched access 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. "Switched access line" means the telephone service line which connects a subscriber's main telephone or equivalent main telephone to the local exchange company's switching office. The 988 Tax amount for each of these lines is phased in so that the 988 Tax is 24 cents per line per month between October 1, 2021, and December 31, 2022, and is increased to 40 cents per line per month beginning January 1, 2023.
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.
Cities and counties are prohibited from imposing a tax on radio access lines, interconnected voice over Internet protocol service lines, or switched access lines for the purpose of routing calls made to the 988 Crisis Hotline to a crisis hotline center or crisis call center hub or for responding to 988 Crisis Hotline calls.
Appropriations.
For the 2021-23 fiscal biennium, the Department is appropriated:
For the 2021-23 fiscal biennium, the Authority is appropriated:
For the 2021-23 fiscal biennium, the Office of Financial Management is appropriated $200,000 from the 988 Account to provide staff and contracted services support to the Strategy Committee and the steering committee.
(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.
(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.
(In support) The existing crisis response system does not work. Currently, the only option for individuals and family members seeking services is calling 911, with response provided by law enforcement officers who are put in unfair circumstances having to deal with these types of cases. Individuals are treated in emergency rooms and there is not the appropriate follow up to ensure they receive the treatment they need. The entities in charge have not delivered an effective system and something new needs to be put into place.
This bill proposes to build on the things that work in the system. The state does not have a choice to implement the 988 number as the federal legislation has passed which will result in increased call volumes.
Crisis call centers answer thousands of calls per month, yet suicide rates continue to rise. The provisions of the bill will allow people in crisis to receive access to the help they need. This will require adequate funding to ensure there is adequate staffing and technical support.
(Opposed) None.
(Other) While there is a need for a workable 988 funding framework, the functions proposed to be funded in this bill are too broad. The fees should be limited to funding equipment and crisis center personnel for call taking and routing, including training costs.
The original bill required hospitals to provide real-time information about bed and service availability, which is premature and not designed and feasible at present. It is also not required to stand up the 988 hotline by the deadline required in the federal act. The original version also called for setting up a secondary crisis system rather than building on the current system.