Background:

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 (BH-ASOs) 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.  Each BH-ASO 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 linked by a single toll-free number, 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.  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 accessing the National Suicide Prevention and Mental Health Crisis Hotline system maintained by Lifeline and the Veterans Crisis Line.  The act expressly authorizes states to collect a fee on commercial mobile services or Internet protocol-enabled voice services for 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 personnel and the provision of acute mental health crisis outreach and stabilization services by directly responding to calls to the crisis centers.

Summary of Amended Bill:

The Health Care Authority (HCA) must collaborate with the Department of Health (DOH) to establish state crisis call center hubs and an enhanced crisis response system.  DOH must take primary responsibility for designating crisis call center hubs.  HCA must take primary responsibility to develop the crisis system and support the work of the crisis call center hubs.

 

DOH must:

• provide adequate funding to achieve a 90 percent in-state call response rate for Lifeline calls by July 16, 2022, anticipating an expected increase in call volume based on the implementation of the 988 crisis hotline, and to achieve an in-state call response rate of at least 95 percent by July 1, 2023;
• adopt rules for designation of crisis call center hubs by July 1, 2023, allowing for designation of hubs by July 1, 2024;

• establish training requirements for crisis response workers at crisis call center hubs that require at least a bachelors or masters level of education or an approved apprenticeship program with specified competencies and training requirements, require call center staff to coordinate with certified peer counselors as available, and include a path for continued employment and skill advancement for experienced crisis call center employees; and
• collaborate with HCA, the Lifeline, and veteran's crisis line networks to assure consistency of public messaging about the 988 crisis hotline.

 

DOH and HCA must coordinate to develop the technology and platforms necessary to manage and operate the behavioral health crisis response and suicide prevention system, including:

• a new technologically advanced behavioral health crisis call center system developed by DOH which can receive assistance requests through calls, texts, chats, and other similar methods of communication and uses technology which is interoperable across crisis and emergency response systems such as 911 and 988; and
• a behavioral health integrated client referral system developed by HCA capable of providing system coordination information to crisis call center hubs and other entities involved in behavioral health care, including:
  1. real-time bed availability for all behavioral health bed types, and
  2. real-time information relevant to the coordination of behavioral health crisis response services, including information about less restrictive alternative treatment orders and mental health advanced directives, and information necessary to collaborate with emergency departments, providers, and payers within the system to establish a safety plan for the person and facilitate their transition to follow-up noncrisis care.

 

The technology platforms must include:

• access to real-time information related to the coordination of behavioral health crisis response services;
• capability to request deployment of appropriate crisis response services, including mobile rapid response crisis teams, corresponder teams, designated crisis responders, mobile integrated health teams, or fire department CARES programs and track them through global positioning technology;
• means to track the outcome of the 988 call to enable appropriate follow-up, cross-system coordination, and accountability, including the means to document immediate services dispatched, reports generated, and whether the caller was successful in making the transition to the next level of care;
• the means to provide geographically, culturally, and linguistically appropriate services to persons who are part of high-risk populations or need specialized services or accommodations; and
• consultation with tribal governments to ensure coordinated care in a government-to-government relationship, with access to dedicated services for tribal members.

 

DOH and HCA must collaborate with the State Enhanced 911 Coordination Office, Emergency Management Division, and Military Department to assure cohesive interoperability and develop common training programs, operations strategies, and establish efficient, equitable access to resources via crisis hotlines.

 

HCA must:

• collaborate with county authorities and BH-ASOs to develop procedures to dispatch behavioral health crisis services in coordination with crisis call center hubs;
• establish formal agreements with managed care organizations and BH-ASOs to arrange next-day appointments for persons contacting 988 experiencing urgent, symptomatic behavioral health care needs;
• create best practice guidelines by July 1, 2023, for deployment of appropriate and available crisis response services by crisis call center hubs that minimize nonessential reliance on emergency room services and the use of law enforcement;
• develop procedures to allow appropriate information sharing and communication across crisis and emergency response systems; and
• establish guidelines to appropriately serve high-risk populations for crisis response. These guidelines must be designed to promote behavioral health equity with regard to race, ethnicity, gender, socioeconomic status, sexual orientation, and geographic location, including training requirements and procedures to provide linguistically and culturally competent care.  HCA must establish guidelines that minimize nonessential reliance on emergency room services and use of law enforcement, considering input from relevant stakeholders and the interim committee.

 

Crisis call center hubs must:

• contract with DOH to meet specified requirements;
• have an active agreement with Lifeline;
• meet Lifeline best practices guidelines for operational and clinical standards; and
• connect persons who contact the 988 crisis hotline with geographically, culturally, and linguistically appropriate services.

 

When acting in their statutory capacities, the state, DOH, HCA, State Enhanced 911 Coordination Office, Emergency Management Division, Military Department, other state agencies, and their officers, employees, and agents are deemed to be carrying out duties to the public in general and not to any individual person or class of persons.  Crisis call centers are deemed to be independent contractors, separate and apart from DOH and the state.

 

Crisis Response Improvement Strategy Committee.  The Office of Financial Management must contract with the Behavioral Health Institute at Harborview Medical Center to staff and facilitate a Crisis Response Improvement Strategy Committee (CRIS) for the purpose of developing an integrated behavioral health crisis response system.  CRIS must have 36 members appointed or requested by HCA representing specified groups, including four legislative members appointed by their respective caucuses.  CRIS must have a steering committee consisting of five specified members, which shall convene meetings, set agendas, form subcommittees, including five subcommittees specified by statute, and choose three co-chairs for CRIS from among their members.  CRIS must be open to public testimony, develop a comprehensive assessment of the behavioral health system including identification of goals and outcome measures, and develop recommendations to be reported to the Governor and Legislature by January 1, 2022, January 1, 2023, and January 1, 2024, in many areas, including:

• strategies, funding sources, and cost estimates to provide for equitable distribution of statewide behavioral health crisis services;
• a vision for an integrated crisis network addressing the needs of distinct communities, including youth, geriatric populations, American Indians and Alaska Natives, LGBTQ youth, persons in the agricultural community; 
• recommendations for ensuring equity;
• quantifiable goals for provision of statewide behavioral health crisis services, including a  plan for establishing outcome measures and improvement targets;
• a work plan with implementation timelines for the bill requirements;
• a study of the components required to implement the specifications for the behavioral health crisis call center platform;
• requirements for health plans, managed care organizations, and BH-ASOs;
• allocation of funding responsibilities between public and private insurers; and 
• the composition of a statewide behavioral health crisis response oversight board.

 

Annual Report.  DOH and HCA must provide an annual report of the 988 crisis hotline usage, call outcomes, and crisis services staring in November 2023.

 

Project Coordinator.  The Governor must appoint a 988 Hotline and Behavioral Health Crisis System Coordinator to provide project coordination and oversight for the implementation of this act and other projects supporting the behavioral health crisis system, with the position to expire on June 30, 2024.

 

Technical and Operational Plan.  DOH and HCA must create a sophisticated technical and operational plan describing features related to the development of technology platforms and protocols for the protection of client information.  A draft plan must be submitted to the Governor and specified Legislative committees by January 1, 2022, and a final plan by August 1, 2022.  An appropriation of $500,000 to HCA from the General Fund is provided for a consultant to critically analyze the development and implementation technology and platforms and operational challenges to best position the technology solutions for success.

 

988 Behavioral Health Crisis Response and Suicide Prevention Line Tax.  A tax is imposed on radio access lines, voice over Internet protocol service lines, and switched access lines purchased or subscribed to by state residents of $0.24 per line per month beginning October 1, 2021, and increasing to $0.40 on January 1, 2023.  Collection and penalty provisions are provided.  Proceeds must be deposited in a Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Account.  Expenditures from the account must be used to ensure the effective routing of 988 crisis hotline calls and for personnel and services provided directly in response to 988 calls.  Moneys from the account may not be used to supplant general fund appropriations for behavioral health services or for Medicaid-covered services provided to Medicaid enrollees.  A preemption clause prevents any city or county from imposing an additional line tax for purposes similar to this act.

 

Monitoring Crisis System Funding.  The steering committee of the CRIS Committee must monitor and make recommendations related to the use of funds in the account, and identify potential options to reduce the tax if feasible, or use the proceeds to fund mobile rapid response crisis teams or other behavioral health first responder services recommended by the CRIS Committee.  The steering committee must submit recommendations to the Governor and the Legislature by January 1, 2022, and January 1, 2023.

 

The Joint Legislative Audit and Review Committee must schedule an audit following full implementation of this act to provide transparency how funds from the account have been expended, and determine whether funds were used to supplement, rather than supplant baseline services.  The audit report must be provided by November 1, 2027, and include recommendations.

Appropriation: $500,000 is appropriated to HCA from the General Fund.

Fiscal Note: Available.

Creates Committee/Commission/Task Force that includes Legislative members: Yes.

Effective Date: The bill contains several effective dates. Please refer to the bill.

Staff Summary of Public Testimony on Engrossed Second Substitute Bill (Behavioral Health Subcommittee to Health & Long Term Care):

The committee recommended a different version of the bill than what was heard.  PRO:  One in four police shootings involve people with behavioral health disorders.  Our state has a higher rate of suicide than the national average, with a 36 percent increase in suicides over the last decade.  Suicides are higher for veterans, American Indians and Alaska Natives, LGBTQ youth, and for people living in rural areas.  With 988 we can create a responsive, robust, caring system that will save lives.  We are trying to right size between the skills needed, costs, and demands.  We live in a great innovation state and we need to invest in the technology.  My husband died because of stigma.  It is very important to pay crisis system workers a living wage, and embed peers deeply in the system.  Crisis centers are pivotal.  This will help develop smarts in the community about access to care.  Our system is broken and it does not work.  My wife never got the critical care she needed.  She was evaluated as high risk, and still discharged with no plan, outreach, or follow up.  Fixing this requires money and requires effort.  The tax is necessary to sustain the system.  Taxes should prioritize the needs of citizens.  Folks with substance use disorders have greater needs than ever.  Alcohol sales are up; addictions are increasing.  This will save dollars downstream by getting people the help they need in advance.  We can not talk about behavioral health without talking about racism, discrimination, and inequity.  What is the value of a human life?  My experience with the crisis system created layers of trauma on top of post-traumatic stress disorder.  CAHOOTS is a crisis intervention that puts crisis workers in the driver's seat of crisis response.  We cannot stand still.  The fragmented, confusing crisis system did not serve my son, who died by suicide two years ago.  The system requires profound levels of illness and yet response is slow and people are under served.  We must charge forward so the 988 hotline serves as a foundation for a more functional system.  There is a role for private insurance in responding to behavioral health needs.  We must ensure private health insurers meet their obligations with respect to linkages to follow-up care, care coordination, and system funding.  We need to work on compliance with behavioral health parity laws.  Calling 911 puts a caregiver of a person with psychosis into an explosive situation.  These encounters are deeply traumatic.  We must stop the criminalization of mental illness and put treatment first.  Emergency departments consistently fail to admit patients who should be admitted, and the result is suicide.  Our crisis center works hard but people often do note get the help they need.  Inadequate crisis center funding contributes to barriers accessing the crisis system.  This bill has continued to improve throughout the legislative process.  Behavioral health providers must be on the CRIS.  We are concerned about the lack of references in the bill to designated crisis responders.  We need to recruit and retain a community behavioral health workforce.  A behavioral health-specific crisis response service will help everyone in our state.  The difficulty of finding an outpatient behavioral health provider is really overwhelming.  Making that search easier would bring enormous benefits, but will take dedicated work.  The 211 system wants to be technologically interconnected with these systems.  We need dedicated funding for the services, as well as the call lines.  It does no good to have a 988 system that refers to nowhere.  

 

OTHER:  Thank you for the hard work and the improvements in this bill.  This bill requires close collaboration, new technology, and fiscal support.  This bill supports the goals in our suicide prevention plan, and will save lives.  Washington has been an leader in 988.  We have a planning grant and are engaging in early collaboration to lay the groundwork.  We feel the urgency of this moment because the crisis system is failing so many of us.  We need clear direction, vision, and funding.  How will this work?  We must think through the necessary components and capabilities.  Single bed certifications are not real behavioral health beds.  Hospitals need a seat at the table.  Emergency department are the front door to crisis care.  This will take all of us working together.  Some requirements are so broad that they will undermine the central goal of getting 988 up and running by the required date.  Health information interoperability is complex and the timeline for implementing health information exchange technology is too aggressive.  The functions proposed to be funded by the 988 fee are too broad.  The fee should support equipment and direct costs of taking and routing calls, including training of call center personnel.  Washington wireless consumers pay 29 percent of their bills in government taxes and fees, the third highest government tax and fee burden in this country.  This legislative session has been brutal on taxes—billions and billions of dollars.  There are other places to get this money.

Persons Testifying (Behavioral Health Subcommittee to Health & Long Term Care): PRO: Representative Tina Orwall, Prime Sponsor; Abraham Dairi, citizen; Laura Van Tosh, citizen; Reagan Dunn, King County Council; Justine McClure, American Foundation for Suicide Prevention; Jennifer Stuber, Forefront Suicide Prevention, University of Washington; Nick Federici, Pioneer Human Services & Washington 211; Jane Beyer, Office of the Insurance Commissioner; Levi Van Dyke, Volunteers of America Western Washington; Melanie Smith, NAMI Washington; Dr. Donald Ross, King County Medical Society; Joan Miller, Washington Council for Behavioral Health; Jerri Clark, MOMI—Mothers of the Mentally Ill; Brad Banks, Behavioral Health Administrative Services Organizations; Paula Sardinas, Washington Build Back Black Alliance.

Persons Signed In To Testify But Not Testifying (Behavioral Health Subcommittee to Health & Long Term Care): No one.

Staff Summary of Public Testimony on Bill as Amended by Behavioral Health Subcommittee to Health & Long Term Care (Ways & Means):

The committee recommended a different version of the bill than what was heard.  PRO: There is a complete breakdown in the continuum of care for emergency response to suicide. My wife committed suicide six months ago. This tax would actually help constituents. This bill will provide help for Washingtonians. Response teams are unarmed and trained in deescalation techniques. This proposed system will help chip away at devastating suicide numbers. Mental health needs to be a priority in our communities across the nation.  We currently are sending people to the most expensive service, the emergency room. We have an opportunity to divert that and revolutionize the delivery of crisis services. Washington has the opportunity to be a leader in the mental health space. Crisis calls save lives. We would like to handle our own call center technology for responding to calls. We are concerned the workforce does not currently exist to support this effort. Some timelines are too specific and aggressive. We recommend that the Health Care Authority have a stronger role in planning and implementation. I had a friend commit suicide because I was unable to pick up her call. There are not enough resources out there. Having a unified number will help. This will simplify access to the system. We request full funding to build upon efforts through the Health Care Authority, managed care organizations, and behavioral health administrative service organizations. We request this bill recognize the geographic and cultural needs in all towns and communities across the state. We recommend this be funded through the Health Care Authority. Currently, the costs for suicide are borne by families, communities, and local governments. Think of those costs to be saved in relation to the costs to create this system.

 

OTHER: We have concerns with the scope of funding provided in this legislation, but we support the 988 designation. The 988 fee should be limited to call costs and personnel for call centers only. Consumers in Washington already face the third highest fee burden in the country. We request the fee be lowered to fund required services only. We support the vision, but have concerns with the subcommittee. We prefer the Health Care Authority be put in charge of most aspects of the bill.

Persons Testifying (Ways & Means): PRO: Abraham Dairi; Laura Van Tosh; Justine McClure, American Foundation for Suicide Prevention; Jennifer Stuber, University of Washington; Paula Sardinas, WA Build Back Black Alliance; Pat Morris, Volunteers of America Western Washington; Kristin Sisley, American Foundation for Suicide Prevention; Vicki Lowe, American Indian Health Commission for WA State.

Persons Signed In To Testify But Not Testifying (Ways & Means): No one.