988 Suicide and Crisis Lifeline. In July 2022 the National 988 Crisis Line was implemented in Washington, providing an easy-to-remember three digit number in every state which allows callers to reach the suicide prevention counseling service formerly known as the National Suicide Prevention Lifeline. 988 crisis call centers interact with individuals who reach out by cell phone, land line, text, chat, and voice-over-Internet devices.  The 988 crisis call centers offer live interaction in Spanish and interpretation services in over 240 languages and dialects. Specialty services offered targeted at the needs of discrete communities include the Veteran's Crisis Line, LGBTQI+ Youth Subnetwork Line, the Native and Strong Lifeline serving American Indians and Alaska Natives, and an American Sign Language service.

988 Lifeline Crisis Centers. The Department of Health (DOH) has oversight of contracting and certification with 988 call centers. DOH holds statutory responsibility to designate 988 contact hubs by January 1, 2026, which must meet statutory requirements for technological capabilities and training. DOH currently contracts with three 988 call centers: Volunteers of America Western Washington, Frontier Behavioral Health, and Crisis Connections. These call centers resolve a large percentage of calls in house but have the ability to refer callers to 911, regional crisis lines, and to request the dispatch of mobile crisis teams.

Regional Crisis Lines. Every county in Washington is served by a regional crisis line, which are call lines administered or contracted at the regional service area level by behavioral health administrative services organizations (BH-ASOs). Regional crisis lines provide behavioral health crisis response services 24 hours a day, seven days a week, 365 days a year to callers, which include but are not limited to dispatch of mobile crisis teams, community-based crisis teams, and designated crisis responders. While regional service lines resolve most calls in the community by providing remote or in-person stabilization services, regional crisis lines provide the portal to the involuntary commitment system through their interface with designated crisis responder agencies.

Regional Service Areas. Regional service areas are the purchasing regions in Washington for publicly-funded health care, both under the state Medicaid program and for BH-ASO services. There are ten regional service areas, organized at the county level, which range from single-county regional services areas such as the King and Pierce BH-ASOs, to groupings of up to nine counties, as found in the Greater Columbia BH-ASO, serving Central and Southeast Washington.

Behavioral Health Administrative Services Organizations. A BH-ASO is an entity contracted with the Health Care Authority (HCA) to administer behavioral health services using state funds within a regional service area, emphasizing services which are not eligible for federal financial participation under the state Medicaid program, and also services included within the state Medicaid program for individuals who do not qualify for Medicaid enrollment. BH-ASOs oversee regional crisis lines and designated crisis responders, which jointly provide the portals to the involuntary commitment system. BH-ASOs descend from regional support networks and behavioral health organizations which were local behavioral health networks operated by county authorities, and operate within the ten regional service areas. The county authorities within each of the regional service areas have the right of first refusal to administer the BH-ASO. County authorities administer the BH-ASO, either directly or through a joint operating agreement in multi-county regions, in seven of the ten BH-ASOs. HCA has contracted with a private company, Carelon Behavioral Health, to administer the BH-ASOs in the remaining three regions.

Efforts at Crisis System Coordination. Legislation enacted in 2021 gives HCA and DOH responsibility for enhancing the Washington State crisis response system, each working collaboratively in respective roles, according to many particulars specified in the legislation. A group called the Crisis Response Improvement Strategy Committee (CRIS Committee) was formed to advise HCA and DOH in these efforts. The CRIS Committee has up to 32 designated or appointed members who report to a six-member steering committee. The CRIS Committee in turn has seven subcommittees. The CRIS Committtee, steering committee, and seven subcommittees have met extensively since late 2021. The CRIS Committee has provided three progress reports so far to the Governor and Legislature, and has a final report due January 1, 2025, after which the CRIS Committee and its subdivisions expire in law on June 30, 2025.

A BH-ASO must have the responsibility to coordinate the behavioral health crisis response and suicide prevention system within each regional service area. The BH-ASO must take the lead role regionally in establishing a comprehensive plan for dispatching mobile rapid response crisis teams and community-based crisis teams.

The BH-ASO must be the primary system coordinator within each regional service area and have the authority to convene partners and stakeholders in the behavioral health crisis response and suicide prevention system for the purpose of establishing clear regional protocols. The protocols must memorialize expectations, understandings, lines of communication, and strategies for optimizing crisis response. The protocols must describe how partners and stakeholders will share information. 988 contact hubs most share real-time information with regional crisis lines. 

DOH and HCA must facilitate the BH-ASOs' role as primary system coordinators at the regional level, including by supporting the development of the protocols as requested by each BH-ASO. The protocols must be in writing, with copies of the final document provided to DOH, HCA, and the State 911 Coordination Office. Each protocol must be updated as needed and at intervals of not less than three years. A nonexclusive list of regional partners and stakeholders is provided for the BH-ASO to invite to participate in protocol development.

A BH-ASO, instead of DOH, may designate the 988 contact hub or hubs within a regional service area among candidates which meet necessary state and federal certification requirements. The designated hub or hubs must be able to collectively provide the full panoply of culturally appropriate services to meet legal requirements within the regional service area. A BH-ASO should only designate a new hub or hubs when designation is needed to fulfill an articulated need identified in the regional crisis system protocol. DOH must certify new hubs which are able to meet state and federal certification requirements at the request of a BH-ASO.

PRO: The bill is broader than initially intended. We have toured the state to see crisis response programs in different regions. Many didn't know what else was happening around them. There is a lack of information. There are great crisis response programs and we don't know enough about what is happening at the local level. This bill attempts to ensure we have regional accountability and knowledge. We want each region to develop a clear crisis plan, and discover what their needs are. This is not an attempt to bring back regional support networks. The goal is to get individuals the right care, at the right place, at the right time. People access the system in multiple ways, so the crisis system must be dynamic and diverse. We need collaboration and accountability. This bill provides the tools, and lets us choose the right 988 contact hubs within each region. This is a step in the right direction. DOH has done a great job of making sure the call centers come online and can meet requirements. I feel this work has been done in a vacuum and it has been difficult to develop plans that respond to local needs. I have mapped all the crisis response teams and they all report virtually no efforts at coordination. What needs to happen is really complicated and this is a start. State agencies aren't on the ground doing the work. The BH-ASOs can potentially take a broad role in coordination, accountability, and transparency. In 1995 the communities in our region came together because we had a high youth suicide rate. That taught us about the need to have culturally and geographically learned clinicians, who know our rural area.

OTHER: We welcome regional collaborations and accountability, but we strongly believe the critical work of 988 designation requires statewide coordination and oversight. DOH's role in the 988 system is to oversee call center contracts. We ensure all federal grant requirements are met and oversee tax expenditures from the 988 account. DOH is in the best position to make unbaised decisions in designating 988 contact hubs. We coordinate with other stateside lines including the Attorney General's Safety and Wellbeing Tip Line, 211, poison control, and domestic violence hotlines. We have a government-to-government relationship with tribes which BH-ASOs lack. This bill would unravel work done over several years to establish 988 contact center infrastructure, including scaling up call center staff, promotional campaigns for 988, and community outreach. The call answer rate is increasing and there are plans to improve service and increase promotion of 988. We are ready to take a collaborative approach in designating call center hubs.

PRO: Senator Manka Dhingra, Prime Sponsor; Brad Banks, Behavioral Health Administrative Services Organizations; Jennifer Stuber, University of Washington School of Social Work; Drew McDaniel, Columbia Wellness.