Behavioral Health Crisis Services.
Crisis mental health services are intended to stabilize a person in mental health 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.
In October 2020 Congress passed the National Suicide Hotline Designation Act of 2020 (Act) which 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 the National Suicide Prevention 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 costs attributed to: (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.
In 2021 House Bill 1477 was enacted which established several changes to the behavioral health crisis system in response to the adoption of 988 as the new phone number for the National Suicide Prevention and Mental Health Crisis Hotline. The bill established crisis call center hubs to provide crisis intervention services, case management, referrals, and connection to crisis system participants beginning July 1, 2024. The bill also charged the state with developing a new technology platform for managing communications with the 988 hotline and a tax was imposed upon phone lines to support the activities. In addition, the Crisis Response Improvement Strategy Committee was established to review and report on several items related to the behavioral health crisis system.
Designated 988 Contact Hubs.
Crisis call center hubs are renamed "designated 988 contact hubs" (988 hubs) and further defined as a contact center that streamlines clinical interventions and access to resources for people experiencing a behavioral health crisis. The date by which the Department of Health (Department) must adopt rules for designating 988 hubs is extended from July 1, 2023, to January 1, 2025, and the date for designating the 988 hubs is extended from July 1, 2024, to January 1, 2026.
The 988 hubs must display 988 crisis hotline information on their websites, including a description of what a caller should expect when contacting the 988 hub and a description of the options available to the caller such as specialized call lines for veterans, American Indian and Alaska Native persons, Spanish-speaking persons, LGBTQ populations, and persons connected with the agricultural community.
The 988 hubs must develop and submit protocols regarding interactions between the 988 hub and the 911 call centers within the region to the Department and receive approval of those protocols. The 988 hubs, in collaboration with the region's behavioral health administrative services organization (BHASO), must also develop and submit protocols related to the dispatching of endorsed mobile rapid response crisis teams and community-based crisis teams (crisis teams) to the Health Care Authority (Authority) and receive approval of those protocols. The 988 hubs must train employees to screen persons contacting the 988 crisis hotline to determine if they are connected to the agricultural community and if they would prefer to be connected with an agricultural hotline. Data and reports submitted by 988 hubs must include deidentified information related to the number of contacts connected to the agricultural community and the nature of those contacts. The Department and the Authority must require 988 crisis call centers and 988 hubs to enter into data sharing agreements with the Department, the Authority, and BHASOs to provide reports and data regarding 988 crisis hotline calls, including dispatch time, arrival time, and disposition of the outreach for those calls referred for outreach. The Authority must monitor trends in 988 crisis hotline caller data and submit an annual report to the Governor and the Legislature summarizing the data and trends in the information.
The Department may fund partnerships between 988 call centers and 988 hubs with public safety answering points to increase the coordination and transfer of behavioral health calls received by certified public safety telecommunicators that are better addressed by the 988 system.
The behavioral health and suicide prevention crisis call center system platform must be fully funded by July 1, 2024, rather than July 1, 2023. The Department and the Authority must include the 988 hubs in the decision-making process for selecting the technology platform. The requirement that the technology platform be able to deploy all crisis response services, including 988 teams, designated crisis responders, and fire department mobile integrated health teams is removed.
988 Crisis Hotline Awareness.
The Department must develop informational materials and a social media campaign to promote the 988 crisis hotline and crisis hotlines for veterans, American Indians and Alaska Native persons, and other populations. The Department must make the informational materials available to medical clinics, behavioral health clinics, media, kindergarten through grade 12 schools, higher education institutions, and health care professionals attending suicide prevention training.
Outpatient behavioral health agencies must display the 988 crisis hotline number in common areas and on after-hours phone messages. Inpatient and residential behavioral health agencies must include the 988 crisis hotline number in the discharge summary provided to persons being discharged.
Endorsed 988 Rapid Response Crisis Teams.
By April 1, 2024, the Authority must establish standards for issuing an endorsement to mobile rapid response crisis teams and community-based crisis teams. While the definition of "mobile rapid response crisis teams" is unchanged, a "community-based crisis team" is defined as a team that is part of an emergency medical services agency, a fire service agency, a public health agency, a medical facility, or a city or county government, other than a law enforcement agency, that provides the same community-based interventions as a mobile rapid response team. An endorsement signifies that the crisis team maintains the capacity to respond to persons who are experiencing a significant behavioral health emergency that requires an urgent in-person response. The decision for a crisis team to become endorsed is voluntary, however, it is a requirement to become eligible for performance payments. The decision of a crisis team not to become endorsed does not prohibit it from participating in the crisis response system and does not affect its responsibilities and reimbursement for services under contracts with managed care organizations and BHASOs.
The standards for an endorsement relate to staffing, training, and transportation. With respect to staffing, the crisis teams must meet staffing requirements to be able to effectively respond in person to a person experiencing a significant behavioral health emergency. The crisis teams must have credentialed and supervised staff employed by a behavioral health agency and include certified peer counselors as a best practice, to the extent practicable based on workforce availability. The crisis teams may include personnel from other participating entities such as fire departments, emergency medical services, public health, medical facilities, nonprofit organizations, and city and county governments. Law enforcement personnel may not participate on a crisis team. With respect to transportation, the standards must address capabilities for transporting a person experiencing a significant behavioral health emergency to appropriate crisis stabilization services according to regional transportation procedures.
Until January 1, 2030, alternative endorsement standards apply to a community-based crisis team that is comprised solely of an emergency medical services organization that is located in a county in Eastern Washington with a population of less than 60,000 residents. Under the alternative endorsement, the community-based crisis team is exempt from meeting the standard personnel requirements if the team's personnel have met training requirements applicable to emergency medical service and fire service personnel, the team operates under a memorandum of understanding with a behavioral health agency to provide direct, real-time consultation from a behavioral health provider while the team is responding to a call, and the team does not include law enforcement personnel. The Authority must conduct a review of the ability of community-based crisis teams endorsed under the alternative standards to provide timely and appropriate responses to persons experiencing a behavioral health crisis. The Authority must report to the Governor and the health policy committees of the Legislature on its findings with any recommendations by December 1, 2028.
Subject to funding, the Authority must establish an endorsed crisis team performance program (performance program) using funds from the Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Account (Account). The performance program must issue: (1) establishment grants to support crisis teams in meeting endorsement standards; (2) performance payments in the form of an enhanced case rate for crisis teams that have received an endorsement; and (3) supplemental performance payments in the form of an enhanced case rate for endorsed crisis teams that meet specific response times and in-route times. The response times and in-route times are established in two phases so that:
The Authority must administer the performance program in a way that maximizes the ability to receive federal matching funds. The Authority must contract with the Medicaid managed care rate actuary to conduct an analysis and develop options for payment mechanisms and levels for the rate enhancements in a way that allows for maximum leverage of federal Medicaid matching funds. The Authority must submit a report to the Governor and the appropriate committees of the Legislature by December 1, 2023, with a summary of the actuarial analysis, payment mechanism options, payment rate level options, and related cost estimates.
Ten percent of the annual receipts for the Account must be dedicated to the performance program and the endorsement activities. Up to 30 percent of these funds for the performance program and endorsement activities must be dedicated to 988 teams affiliated with a tribe in Washington.
Training.
The University of Washington (UW) School of Social Work, in consultation with the Washington Council for Behavioral Health and BHASOs, must plan for regional collaboration among behavioral health providers and first responders working within the 988 crisis response system. In addition, they must standardize practices and protocols and develop a needs assessment for trainings. The UW must convene a stakeholder group of representatives of BHASOs, crisis service providers, 988 crisis call centers, persons with lived experience, and a statewide organization of field experts. By June 30, 2024, the UW, with the assistance of the stakeholder group must develop an assessment of training needs, a mapping of current and future funded crisis response providers, and a comprehensive review of all required behavioral health training.
The UW School of Social Work, in collaboration with the stakeholder group, must develop recommendations for the creation of crisis workforce and resilience training collaboratives to offer voluntary regional trainings for personnel in the behavioral health crisis system. The recommendations must consider: integrating 988-specific training into existing behavioral health training; identifying trainings on behavioral health crisis system topics; identifying best practice approaches to working with specific populations; identifying ways to provide training specific to the agricultural community; identifying ways to increase public access to and participation in trainings on topics related to the behavioral health crisis system; and establishing ways to sustain and fund the crisis workforce and resilience training collaboratives, as well as a timeline for implementation. The UW School of Social Work must submit a report to the Governor and the appropriate committees of the Legislature by December 31, 2024.
By July 1, 2024, suicide prevention training for health care providers must include content on the availability of and services offered by the 988 crisis hotline and the behavioral health crisis response and suicide prevention system and best practices for assisting persons to access them.
Liability Protection.
Acts or omissions related to the dispatching decisions of 988 crisis call center staff or 988 hub staff with dispatching responsibilities do not impose liability upon a 988 crisis call center or 988 hub and their staff, members of a crisis team, or public safety answering points and their staff. The liability protection applies to acts or omissions occurring in good faith, within the scope of the staff person's responsibilities, and in accordance with approved dispatching procedures.
Acts or omissions related to the transfer of calls from the 911 line to the 988 crisis hotline or from the 988 crisis hotline to the 911 line by certified public safety telecommunicators, 988 crisis call center staff, or 988 hub staff do not impose liability upon public safety answering points and their staff, a 988 crisis call center or 988 hub and their staff, or members of a crisis team. The liability protection applies to acts or omissions occurring in good faith, within the scope of the staff person's responsibilities, and in accordance with approved call system transfer protocols.
Crisis Response Improvement Strategy Committee.
The Office of Financial Management is removed as the agency to contract with the Behavioral Health Institute to support the Crisis Response Improvement Strategy Committee (Strategy Committee) and is replaced with the authorization of the Behavioral Health Institute to contract for those support services. A member of the Strategy Committee with lived experience is added to the Steering Committee of the Strategy Committee.
The 988 Geolocation Subcommittee is created to examine privacy issues related to federal planning efforts to route 988 crisis hotline calls based on a person's location. The 988 Geolocation Subcommittee must examine ways to implement federal recommendations in a manner that maintains public and clinical confidence in the 988 crisis hotline.
The Strategy Committee is extended by one year until June 30, 2025. The Strategy Committee must submit an additional progress report by January 1, 2024, and the final report is delayed until January 1, 2025.
The Senate amendments assign the lead responsibilities for regional collaboration and development of a training needs assessment to the Health Care Authority (Authority) and the behavioral health administrative services organizations (BHASOs), in collaboration with the University of Washington, the Harborview Behavioral Health Institute, the Washington Council for Behavioral Health, and the Statewide 988 Coordinator, rather than to the University of Washington School of Social Work, in consultation with the Washington Behavioral Health Council and the BHASOs. The University of Washington, through the Harborview Behavioral Health Institute and in consultation with specified stakeholders, is assigned the primary responsibilities for assessing training needs, mapping crisis providers, and reviewing training requirements by June 30, 2024. The Authority and the BHASOs, in collaboration with specified stakeholders, must develop recommendations for crisis workforce and resilience training collaboratives.
The Senate amendments require contracts with the designated 988 contact hubs to include training employees on agricultural community cultural competencies for suicide prevention and sharing relevant resources, rather than screening callers for an association with the agricultural community and preference for connection with a hotline for the agricultural community. Employees may make warm transfers and referrals to crisis hotlines that specialize in working with members of the agricultural community, unless the person is currently in crisis. The requirement that training prepare staff to work with callers from the agricultural community in a way that maintains anonymity is removed. The designated 988 contact hubs’ websites may include resources for programs and services related to suicide prevention for the agricultural community, rather than agricultural community options being required to be displayed on the their websites. The requirement that the designated 988 hubs’ reporting include deidentified information regarding contacts connected to the agricultural community is removed.
The Senate amendments require BHASOs, in partnership with the Authority, to convene an annual crisis continuum of care forum to identify and develop collaborative regional-based solutions which may include capital infrastructure requests, local capacity building, or community investments. The BHASOs and the Authority must jointly submit recommendations supporting the efforts to the Joint Legislative Executive Committee on Behavioral Health.
The Senate amendments clarify that data sharing agreements between the designated 988 contact hubs and other entities must comply with laws related to protected health information. The Department of Health, rather than the Authority, must monitor trends in 988 hotline caller data.
The Senate amendments add nonprofit crisis response providers to the definition of a “community-based crisis team.” The expiration of the 988 hotline and behavioral health crisis system coordinator position is extended from June 30, 2024, until June 30, 2028.
(In support) This bill creates a template for the rapid response teams which are a critical component of meeting people experiencing a behavioral health crisis where they are and getting them to the services that they need as quickly as possible. This bill lays the groundwork for mobile rapid response units specifically trained to deal with behavioral health crisis de-escalation and care which mitigates police response and frees up law enforcement to attend to other needs. All Washingtonians should feel comfortable calling 988 knowing that the response they receive will be from trained behavioral health care workers and that law enforcement is only sent out in rare and appropriate circumstances.
It will be good to have training in the 988 system and crisis response for providers so they are familiar with what is available and how to use the system. Communities from across Washington should be stakeholders in the training so that it is truly culturally competent for all. Training is a critical component of the bill and ensuring that the training happens in conjunction with the BHASOs at the regional level will be important. This bill helps provide training to rapid response team personnel which is designed to be regional. The secondary trauma training is important because this is difficult work. The bill ensures that behavioral health care workers receive the training they need for crisis services.
The development of informational materials, a social media campaign, and display of the 988 information will ensure that more people become aware of the service. There is support for creating the informational materials and the social media campaign for 988. The informational materials and social media campaign are important because the general public will not know when to call 911 or 988.
As more entities build out their capacity to respond, the issue of liability will be a critical concern for growing the system in order to get people the services that they need safely and efficiently. The bill ensures that 988 call center employees are afforded the same liability protections as 911 workers.
It is good to see the extension of some of the dates to allow more time to implement some of the bill's goals. This bill creates a much needed framework for developing standards and practices for organizations to become a part of the 988 crisis response system. This bill shows that the contributions of stakeholders with lived experience will be a top priority by having them on the steering committee. There is support for establishing the Geolocation Subcommittee, including the 988 call centers in the decision making process for the technology platform, and adding the liability protections.
(Opposed) None.
(Other) The social media campaign aligns with the work of the Department of Health (Department) to make sure that people know the service is available. The extension of the rulemaking deadline for crisis contact center hubs is helpful to allow for equitable input from tribal nations and other community partners. There needs to be continued work on the implementation of the geolocation information. There needs to be clarification on the definition and roles of what an existing mobile crisis response team is to differentiate between it and the co-responder teams and the rapid response teams. The endorsement of the mobile rapid response crisis teams should remain at the Health Care Authority, rather than the Department. The response timelines should not be in contract, not statute, since there is no data to inform what a timely response is. There needs to be more work on the financing conversation.
(In support) As the state continues to reimagine the behavioral health system, 988 is an important and critical piece, particularly in respect to the crisis care continuum. Funding that is going to support the 988 crisis lines needs to be leveraged and maximized to get the best outcomes for the system and the individuals using it. The crisis centers are going to be culturally competent from east to west and make sure that individuals who respond understand the plight of the callers from many different communities. This is an investment in Washington's most vulnerable populations.
Currently, there is a gap in crisis resources for individuals with autism and those with co-occurring intellectual and behavioral health disorders, which will be addressed by this bill. Important provisions include development of a plan for training first responders and behavioral health providers. This should help build regional relationships and preserve the well-being of the workforce.
Dedicating 988 account funds for the 988 rapid response teams is helpful but it is only one part of the braided funding streams and should be done in a way that does not supplant current state or federal Medicaid funding. There is a need for increased funding to support the workforce for the entire behavioral health system so people can be treated before they are in crisis.
(Opposed) None.
(Other) The vision of the bill is for simplified affordable care for those in a behavioral health crisis. Changes are needed to ensure that 988 revenues can maximize federal Medicaid funds and build on existing state and local investments. This includes further strengthening the data-sharing language in section 5 of the bill, and alignment of mobile crisis teams standards in section 8 with existing teams that are already funded.