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.
Crisis Hotline Centers and Crisis Call Center Hubs.
By July 16, 2022, the Department of Health (Department) must provide adequate funding for an expected increase in the use of the state's crisis lifeline call centers. The funding must be established at a level anticipated to achieve an in-state call response rate of at least 90 percent. 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.
The Department must designate one or more crisis hotline centers to provide crisis intervention, triage, referrals, and connections to persons who access the 988 Crisis Hotline within Washington. Prior to becoming recognized as a crisis call center hub, an entity must be designated by the Department. Once a crisis call center hub is designated, it must contract with the Department to receive reimbursement for providing crisis call center hub services.
To provide crisis intervention services and crisis care coordination, a crisis call center hub must meet several standards. The crisis call center hubs must participate in the Lifeline network and meet operational, clinical, reporting, and quality improvement standards established by the Department. Crisis call center hubs must be able to deploy both crisis and ongoing services, including mobile crisis teams and co-responder teams. Crisis call center hubs must collaborate with managed care organizations, behavioral health administrative services organizations (BHASOs), and other health care payers to coordinate linkages for persons who contact the 988 Crisis Hotline with ongoing care needs. Crisis call center hubs must communicate across crisis and emergency response systems to coordinate access to crisis receiving and stabilization services for persons who access the 988 Crisis Hotline. Crisis call center hubs must also meet Department standards for serving high-risk and special populations with the goal of promoting behavioral health equity for all populations. Lastly, crisis call center hubs must use technology that is interoperable between the state's crisis and emergency response systems, such as 911 systems, emergency medical services systems, other nonbehavioral health crisis services, and the Lifeline.
Crisis call center hubs must operate a technologically advanced behavioral health crisis call center system developed by the Health Care Authority (Authority). The Authority must develop the call center system with the capacity to: (1) receive crisis assistance requests through phone calls and other methods of communication; (2) access real-time information from behavioral health payers for the coordination of behavioral health crisis services; (3) assign and track local responses to behavioral health crisis calls; (4) arrange appropriate next-day, and follow-up appointments for persons contacting the crisis call center hub; (5) track and provide real-time bed availability information for all behavioral health bed types to crisis responders and persons in crisis; and (6) assure follow-up services to individuals accessing the 988 Crisis Hotline.
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 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 assessment and intervention strategies, and to establish efficient and equitable access to resources via crisis hotlines.
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 Line Account (988 Account). Beginning in 2023, the report must be submitted each November to the Governor and the appropriate committees of the Legislature.
988 Implementation Team.
The Department, in consultation with the Authority must convene the 988 Implementation Team to prepare for the successful transition of the state's call centers that are contracted with the Lifeline to the 988 crisis hotline. The 988 Implementation Team consists of:
The 988 Implementation Team must provide guidance and consultation to the Department for its responsibilities related to funding the expected increase in the use of the state's crisis lifeline call centers. The 988 Implementation Team must also assist in determining the activities and resources necessary to achieve a 90 percent in-state call response rate. In addition, the 988 Implementation Team must review the adequacy of training for crisis hotline center personnel, as well as the training for 911 public safety telecommunicators with respect to their interactions with the crisis hotline center. The 988 Implementation Team must report its findings and recommendations to the Governor and the appropriate committees of the Legislature by January 1, 2022.
Crisis Response Improvement Strategy Committee.
The Crisis Response Improvement Strategy Committee (Strategy Committee) is established to develop an integrated behavioral health crisis response system. The Office of Financial Management must select a private entity to facilitate the Strategy Committee's activities and serve as a liaison between agencies, the Strategy Committee, and the Governor's Blue Ribbon Commission on the Intersection of the Criminal Justice and Behavioral Health Crisis Systems.
The Strategy Committee includes all of the members of the 988 Implementation Team, as well as four legislators, a representative of the Office of the Insurance Commissioner, a representative of the American Indian Health Commission for Washington State, a representative of BHASOs, and a representative of health plans. The representative from the Authority is the chair of the Strategy Committee.
The Strategy Committee must identify barriers and make recommendations: (1) to implement and monitor the progress of the 988 Crisis Hotline in Washington; and (2) for the statewide improvement of behavioral health crisis response services. Specifically, the Strategy Committee must report on:
The Strategy Committee may form subcommittees with additional participants to review specific topics. The Strategy Committee must seek input regarding the current crisis response system and ways to improve it from tribes, veterans, the LGBTQ community, and communities of color.
The Strategy Committee must report to the Governor and the appropriate committees of the Legislature by January 1, 2023.
Statewide 988 Behavioral Health Crisis Response Line Tax.
The Statewide 988 Behavioral Health Crisis Response 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 30 cents per line per month between October 1, 2021, and December 31, 2022, and is increased to 50 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.
(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.