WSR 24-20-090
PROPOSED RULES
DEPARTMENT OF HEALTH
[Filed September 29, 2024, 6:09 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 22-15-084.
Title of Rule and Other Identifying Information: Standards for designation of 988 contact hubs, chapter 246-350 WAC. The department of health (department) is proposing a new chapter of rules to implement E2SHB 1477 (chapter 302, Laws of 2021). The rules establish standards for designation of crisis call centers as crisis hubs within the 988 national suicide prevention and mental health crisis hotline system.
Hearing Location(s): On November 5, 2024, at 9:00 a.m., at the Department of Health, Town Center 2, Rooms 166/167, 111 Israel Road S.E., Tumwater, WA 98501; or virtual. Register in advance for this webinar https://us02web.zoom.us/webinar/register/WN_Hk3jXkFkSdGXyjG7a_H8Dg. After registering, you will receive a confirmation email containing information about joining the webinar. The department will be offering a hybrid public hearing. Participants may attend virtually or in person at the physical location. You may also submit comments in writing.
For individuals that would like to request American Sign Language or other services, please contact Me'Kyel Bailey by October 22, 2024.
Date of Intended Adoption: November 12, 2024.
Submit Written Comments to: Me'Kyel Bailey, P.O. Box 47830, Olympia, WA 98504-7830, email mekyel.bailey@doh.wa.gov, beginning date and time of filing, by November 5, 2024, at 11:59 p.m.
Assistance for Persons with Disabilities: Contact Me'Kyel Bailey, phone 360-764-9161, TTY 711, email mekyel.bailey@doh.wa.gov, by October 22, 2024.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rule establishes standards that crisis centers must meet to be designated by the department as 988 contact hubs. No existing rules would be changed.
Reasons Supporting Proposal: E2SHB 1477 and E2SHB 1134 (chapter 454, Laws of 2023) establish 988 contact hubs as a means to streamline crisis care services and referrals. E2SHB 1134, codified in RCW 71.24.890(3), requires the department to develop rules setting standards which crisis centers must meet in order for the department to designate them as hubs. The rules will help ensure that crisis response has consistency across hubs and is able to meet minimum service standards.
Statutory Authority for Adoption: E2SHB 1477 (chapter 302, Laws of 2021), E2SHB 1143; RCW 43.70.040(1) and 71.24.890(3).
Statute Being Implemented: RCW 71.24.890(3).
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Governmental.
Name of Agency Personnel Responsible for Drafting: Me'Kyel Bailey, 111 Israel Road S.E., Tumwater, WA 98501, 360-764-9161; Implementation and Enforcement: Lonnie Peterson, 111 Israel Road S.E., Tumwater, WA 98501, 360-819-7397.
A school district fiscal impact statement is not required under RCW 28A.305.135.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Me'Kyel Bailey, P.O. Box 47830, Olympia, WA 98504-7830, phone 360-764-9161, TTY 711, email mekyel.bailey@doh.wa.gov.
This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:
Is exempt under RCW 19.85.025(3) as the rules are adopting or incorporating by reference without material change federal statutes or regulations, Washington state statutes, rules of other Washington state agencies, shoreline master programs other than those programs governing shorelines of statewide significance, or, as referenced by Washington state law, national consensus codes that generally establish industry standards, if the material adopted or incorporated regulates the same subject matter and conduct as the adopting or incorporating rule; rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect; rule content is explicitly and specifically dictated by statute; and rules adopt, amend, or repeal a procedure, practice, or requirement relating to agency hearings; or a filing or related process requirement for applying to an agency for a license or permit.
Explanation of exemptions: RCW 34.05.310 (4)(c) applies to portions of WAC 246-350-020; RCW 3[4].05.310 (4)(d) applies to all of WAC 246-350-001, WAC 246-350-010 and portions of WAC 246-350-020; RCW 34.05.310 (4)(e) applies to portions of WAC 246-350-020; and RCW 34.05.310 (4)(g) applies to all of WAC 246-350-030.
Scope of exemption for rule proposal:
Is partially exempt.
The proposed rule does impose more-than-minor costs on businesses.
Small Business Economic Impact Statement (SBEIS)
The proposed rules establish standards for designation of crisis centers as designated 988 contact hubs.
SBEIS Table 1 below identifies and summarizes which businesses are required to comply with the proposed rule using the North American Industry Classification System (NAICS).
SBEIS Table 1. Summary of Businesses Required to comply to the Proposed Rule:
NAICS Code
(4, 5, or 6 digit)
NAICS Business Description
Number of Businesses in Washington state
Cost Threshold
624190
Other Individual and Family Services
2,952
$7,219.80
While WAC 246-350-001, 246-350-010, and 246-350-030 are exempt as identified above, portions of the proposed requirements in WAC 246-350-020 include probable costs that businesses in the industry must comply with to comply with the proposed rule.
The following is an analysis of the probable costs to comply the proposed rules in WAC 246-350-020.
Description: Subsection (6) requires employment of sufficient staff to respond to 90 percent of initial incoming contacts within 30 seconds without placing those contacts on hold. This requirement is lower than the federal recommendations, expressed as follows:
Applicable to 988 crisis contact centers: Lifeline centers should work to achieve and maintain at least the following monthly target key performance indicators for all services the center provides for 988:
•Ninety-five percent of 988 lifeline contacts answered are answered within 20 seconds or less;
•Ninety percent of contacts answered are answered within 15 seconds or less;
•Less than 5 percent of contacts abandoned; and
•Less than 10 percent of contacts rolling over to the national backup system.
The department developed the 90 percent/30 seconds requirement based on generally recognized best practices available at the time the rule was drafted and informed by feedback regarding feasibility from crisis centers. Substance Abuse and Mental Health Services Administration's (SAMHSA) 988 quality and services plan, which contains the recommendations immediately above, was released many months after the rule had been drafted. While the department recognizes the importance of the federal aspirations, it opted not to change the rule because the federal guidelines in this instance are recommendations rather than requirements.
Cost(s): Indeterminate due to the variability of call volume.
Description: Subsection (7) requires designated 988 contact hub staff to be provided with initial and ongoing trauma-informed training in skills including, but not limited to, best practices in risk assessment; effective triage to system partners when additional clinical intervention is needed; cultural humility; providing developmentally appropriate, culturally appropriate services to support members of communities at higher risk for suicide, including members of the agricultural community; crisis deescalation; information security; and collecting basic safety information.
These training requirements were designed to incorporate interested party feedback on the training desired and help 988 contact hubs to comply with contractual requirements established in RCW 71.24.890 (4)(b)(iii)-(iv). The department declined to specify required hours or provenance of trainings because training requirements are specified in the network agreements that centers must enter into to become 988 lifeline centers. The network administrator (Vibrant Emotional Health (Vibrant)) requires completion of three Vibrant-developed core self-paced online trainings for crisis counselors. Vibrant also provides guidance on training during the clinical review phase of the application process for joining the 988 network. Because the network agreements are subject to change at Vibrant's discretion, the department sought in this subsection to bring together the various subject matter training requirements while retaining the flexibility to accommodate changes in the network agreement by setting specific training standards in its contracts with 988 contact hubs rather than in rules.
The department included the term "trauma informed" to clarify the kind of training approach that is recognized as a best practice for providing empathy to callers in acute distress. The requirement of a self-care component to address secondary trauma was added at the request of crisis contact centers.
The initial and ongoing trauma-informed training as required in the proposed rule is exempt pursuant to RCW 34.05.310 (4)(d) as it clarifies the requirements in statute without changing its effect.
The proposed rule also requires training to include a self-care component designed to address secondary trauma. This is an added training.
Cost(s): There are no probable costs. Training on self-care for secondary trauma is available online without charge, though 988 contact hubs would be permitted to use other sources if desired.
Description: Subsection (15) requires messaging about the 988 and the suicide and crisis lifeline is consistent with messaging released by the authority, the department, the National 988 Administrator, SAMHSA, and the veterans crisis line networks.
RCW 71.24.890 (4)(b)(vi) requires 988 contact hubs to collaborate with the authority, the veterans crisis line, and the "national suicide prevention lifeline." The proposed rule clarifies what is meant by collaborating with the lifeline, a term that refers to the 988 network of call centers rather than an entity that can be collaborated with. Messaging about the lifeline is conducted by SAMHSA and the National Administrator; to avoid confusion, the proposed rule identifies those entities in the rule. This portion of the proposed rule is exempt pursuant to RCW 34.05.310 (4)(d) as the proposed rule clarifies the statutory requirement without changing its effect.
The requirement for consistent messaging released by the department is not exempt from analysis.
Cost(s): There are no probable costs for 988 contact hubs to provide consistent messages with the department, as the department's messaging is required to be consistent with that of the national suicide prevention lifeline and the veterans crisis line, with which 988 contact hubs are statutorily required to ensure consistency of messaging.
Why the proposed rule may impose more-than-minor costs for businesses in the industry.
Based on the analysis of the proposed rule and because of the of indeterminate cost assumptions the department assumes that the proposed rule may impose more-than-minor costs, calculated to be $7,219.80, for businesses in the industry. Because of the variability of call volume, the department is unable to determine specific costs.
Based on the indeterminate cost assumptions the department has determined that the rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule.
The department is unable to mitigate costs because it must establish the same standard for all 988 contact hubs regardless of size because timely access to resources is important.
The department held four listening sessions (two for tribes and two for the community in which businesses of all sizes were invited) in spring 2023 prior to drafting the rule and four workshops (two for tribes and two for the community again in which businesses of all sizes were invited) in autumn 2023 to gather feedback on the draft rule. The department also circulated the rule for review and feedback among the Tribal 988 Subcommittee of the Crisis Response Improvement Strategy Committee, the three existing 988 suicide and crisis lifeline centers in the state, and behavioral health administrative services organizations in spring 2024.
The department is unable to determine the variability of call volume and therefore is unable to determine what if any additional staff will need to be hired.
A copy of the statement may be obtained by contacting Me'Kyel Bailey, P.O. Box 47830, Olympia, WA 98504-7830, phone 360-764-9161, TTY 711, email mekyel.bailey@doh.wa.gov.
September 27, 2024
Kristin Peterson, JD
Chief of Policy
for Umair A. Shah, MD, MPH
Secretary
OTS-5558.1
Chapter 246-350 WAC
STANDARDS FOR DESIGNATION OF 988 CONTACT HUBS
NEW SECTION
WAC 246-350-001Purpose.
The purpose of this rule is to establish consistent standards and a process for the department to designate crisis centers as 988 contact hubs. To qualify for designation as a 988 contact hub, a crisis center must comply with this chapter and any other state or federal requirements.
NEW SECTION
WAC 246-350-010Definitions.
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "988 contact hub" means a state-designated contact center that streamlines clinical interventions and access to resources for people experiencing a behavioral health crisis, participates in the 988 Suicide and Crisis Lifeline network to respond to statewide or regional 988 contacts, and meets the requirements of RCW 71.24.890.
(2) "988 Suicide and Crisis Lifeline" means the national network of local crisis centers, reachable by dialing or texting "988," providing free and confidential emotional support to people in crisis or emotional distress 24 hours a day, seven days a week.
(3) "Authority" means the Washington state health care authority.
(4) "Behavioral health services" means either mental health services as described in chapters 71.24 and 71.36 RCW, substance use disorder treatment services as described in chapter 71.24 RCW, or both, which, depending on the type of service, are provided by licensed or certified behavioral health agencies, or behavioral health providers, or are integrated into services offered by other health care providers.
(5) "Care coordination" means the coordination of an individual's health care needs with the assistance of a primary point of contact.
(6) "Certified peer counselor" means a person who has met the requirements of WAC 182-115-0200 and has been recognized by the Washington state health care authority as a certified peer counselor.
(7) "Community-based crisis team" means a team that is part of an emergency medical services agency, a fire service agency, a public health agency, a medical facility, a nonprofit crisis response provider, or a city or county government entity other than a law enforcement agency, that provides the on-site community-based interventions of a mobile rapid response crisis team for individuals who are experiencing a behavioral health crisis.
(8) "Crisis center" means a resource for people in behavioral health crisis that responds to crisis contacts via phone, text, or chat capabilities.
(9) "Culturally appropriate services" means effective, equitable, understandable, respectful, western and indigenous quality care and treatment services that are responsive to a community's cultural health beliefs, practices, and preferences.
(10) "Cultural humility" means the ability to remain open to another person's identity, including their cultural background, beliefs, values, and traditions, and its effects on behavioral health care decision-making.  
(11) "Department" means the Washington state department of health.
(12) "Help seeker" means an individual in crisis, as defined by that individual, who contacts 988 via any of the available modalities.
(13) "Indian health care provider" means a health care program operated by the Indian health service or by an Indian tribe, tribal organization, or urban Indian organization as those terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603).
(14) "Mobile rapid response crisis team (MRRCT)" means a team that provides professional on-site community-based intervention such as outreach, de-escalation, stabilization, resource connection, and follow-up support for individuals who are experiencing a behavioral health crisis, that shall include certified peer counselors as a best practice to the extent practicable based on workforce availability, and that meets standards for response times established by the authority.
(15) "Mobile response and stabilization services (MRSS) teams" are mobile rapid response crisis teams that provide developmentally appropriate crisis intervention and a separate but connected in-home stabilization phase for youth and families.
(16) "Primary point of contact" means the person who provides information to the individual and their caregivers and works with the individual to ensure they receive the most appropriate treatment without duplication of care.
(17) "Secretary" means the secretary of the Washington state department of health.
(18) "Tribe" means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (43 U.S.C. § 1601 et seq.), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
NEW SECTION
WAC 246-350-020Standards for designation as a 988 contact hub.
A crisis center must meet the requirements of this section in order to be designated as a 988 contact hub. At a minimum, a crisis center must:
(1) Obtain and maintain an active agreement with the administrator of the 988 Suicide and Crisis Lifeline and remain in substantial compliance with that agreement to the satisfaction of the administrator.
(2) Participate in the 988 Suicide and Crisis Lifeline network.
(3) Adopt and use a technology platform approved by the department and maintain the necessary infrastructure, including equipment and software, maintenance, upgrades, and technical support, to operate all required 988 services and respond to help seekers via phone calls, text, chat, and other similar methods of communication that may be developed in the future.
(4) Ensure interpretation services are available in the help seeker's preferred language.
(5) Ensure services are accessible to those who are deaf or hard of hearing.
(6) Employ sufficient staff to respond to 90 percent of initial incoming contacts within 30 seconds without placing those contacts on hold.
(7) Provide designated 988 contact hub staff with initial and ongoing trauma-informed training in skills including, but not limited to, best practices in risk assessment; effective triage to system partners when additional clinical intervention is needed; cultural humility; providing developmentally appropriate, culturally appropriate services to support members of communities at higher risk for suicide, including members of the agricultural community; crisis de-escalation; information security; and collecting basic safety information. Training shall also include a self-care component designed to address secondary trauma.
(8) Provide crisis line counseling, intervention services, triage, care coordination, referrals, and connections to incoming contacts from any jurisdiction within Washington 24 hours a day, seven days a week, every day of the year.
(9) Provide referrals in the help seeker's geographical region to developmentally and needs-appropriate services including, but not limited to:
(a) Emergency medical care;
(b) Behavioral health crisis services;
(c) Tribal behavioral health services and, where needed, tribal first responders.
(10) Coordinate with certified peer counselors as available to respond to follow-up calls with the help seeker's consent.
(11) Maintain sufficient resources to provide follow-up communications with help seekers as appropriate.
(12) Provide services to help seekers regardless of the ability or willingness of the help seeker to disclose all information requested by crisis center staff and regardless of whether the help seeker is communicating through a third party.
(13) Collect and maintain current information on local resources that could be used as alternate interventions to 911, and ensure that staff are guided on how to access such services so that emergency services (911, police, sheriff) are contacted for assistance only in cases where risk of harm to self or others is imminent or in progress, and when a less invasive plan for the help seeker's safety cannot be collaborated on with the individual.
(14) Adopt and implement policies and procedures for connecting self-identified tribal members in crisis to appropriate tribal services when the help seeker wishes to use tribal services; follow the tribe's established tribal crisis coordination protocols; and coordinate responses whenever possible with tribes, including tribal behavioral health agencies, Indian health care providers, and, where necessary, tribal police.
(15) Ensure messaging about the 988 and the Suicide and Crisis Lifeline is consistent with messaging released by the authority, the department, the National 988 Administrator, the Substance Abuse and Mental Health Services Administration, and the Veterans Crisis Line networks.
(16) Comply with all reporting requirements established by the department.
(17) Enter into and comply with an agreement with the department.
NEW SECTION
WAC 246-350-030Designation process.
(1) The department may issue a 988 contact hub designation to a crisis center that demonstrates to the satisfaction of the department that it meets the standards under this chapter.
(2) To apply for designation, a crisis center shall submit to the department an application on forms provided by the department.
(3) To recommend a crisis center for designation as a 988 contact hub, behavioral health administrative services organizations shall comply with the recommendation process established by the department.
(4) 988 contact hub designations are valid for five years and may be renewed by the department upon application by the crisis center to the department.
(5) The department may deny, suspend, or revoke the designation of any 988 contact hub at any time for failure to meet minimum standards under this chapter or for failure to substantially comply with the contract specified in subsection (6) of this section.
(a) If an application is suspended, revoked, or denied, the department shall provide the designated 988 contact hub or hub applicant a letter of denial, suspension, or revocation, including a statement of the reasons for the action. Letters of suspension and revocation shall be effective 28 days after the designated 988 contact hub receives the notice.
(b) A designated 988 contact hub or hub applicant that is aggrieved by the decision to suspend, revoke, or deny designation has the right to an adjudicative proceeding. The proceeding is governed by the Administrative Procedure Act, chapter 34.05 RCW. The application for adjudicative proceeding must be in writing, state the basis for contesting the adverse action, include a copy of the adverse notice, and be served on or received by the department within 28 days of the effective date of the decision.
(6) Upon designation, a 988 contact hub shall enter into a contract and data sharing agreement with the department.