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 (BH-ASOs) are entities contracted with the Health Care Authority(HCA) 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. 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 accessing the National Suicide Prevention and Mental Health Crisis Hotline system maintained by the National Suicide Prevention 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 costs attributed toensuring 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.
 
In 2021, E2SHB 1477 was enacted which established several changes to the behavioral health crisis system in response to the adoption of 988. 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 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.  The Crisis Response Improvement Strategy Committee (CRIS Committee) was established to review and report on several items related to the behavioral health crisis system.

Publicizing and Promoting the 988 Hotline. Behavioral health agencies must display the 988 crisis hotline number in common areas and include the number as a calling option on any phone message for persons calling the agency after business hours. Inpatient or residential behavioral health agencies must include the 988 number in the discharge summary provided to the individual after discharge.

The Department of Health (DOH) must develop informational materials and a social media campaign related to the 988 crisis hotline. The informational materials must include information for persons seeking services at behavioral health clinics and medical clinics. DOH must make the materials available to clinics, media, K-12 schools, higher education institutions, and other relevant settings. DOH must consult with tribes, the Washington State Department of Veteran Affairs, representatives of agricultural communities, persons with lived experience, and other stakeholders when developing the educational materials and social media campaign.

Minimum standards for suicide assessment, treatment, and management training programs for licensed and certified professionals in Washington must be updated by July 1, 2024, to include content specific to the 988 crisis hotline and behavioral health response and suicide prevention system, with mandatory incorporation by September 1, 2024.

Extension of Dates. The time for DOH to adopt rules for designation of designated 988 contact hubs and to designate the 988 contact hubs are each extended by 18 months, until January 1, 2025, and January 1, 2026, respectively. The date by which the technological platform for the 988 system must be fully funded is extended by one year to July 1, 2024. The date of the final report of the CRIS Committee is extended one year until January 1, 2025, and its expiration is extended to June 30, 2025.

Requirements for Crisis Call Centers and Designated 988 Contact Hubs. Crisis call center hubs are renamed designated 988 contact hubs. DOH may provide funding to support crisis call centers and designated 988 contact hubs to enter into limited on-site partnerships with 911 systems to increase the coordination and transfer of behavioral health calls received by 911 to the 988 system. Tax revenue may be used to support on-site partnerships.

DOH must require crisis call centers to enter into data-sharing agreements with DOH, HCA, and applicable BH-ASOs to provide reports and client level data regarding 988 crisis hotline calls, including dispatch time, arrival time, and disposition of the outreach for each call referred for outreach. Crisis call centers must report this data to BH-ASOs to maximize Medicaid reimbursement and for other purposes including coordinating care for individuals with a history of frequent crisis system utilization. HCA must monitor trends in 988 caller data and submit an annual report to the Governor and appropriate committees of the Legislature beginning December 1, 2027.

Requirements to contract as a designated 988 contact hub are increased. A 988 contact hub must:

• train employees to screen persons to determine if they are associated with an agricultural community for connection to a specialized crisis hotline;
• display 988 crisis hotline information prominently on their websites and social media;
• include a description of what the caller should expect with contacting the crisis call center and the options available to the caller;
• provide options including transfer to specialized call lines for veterans, American Indian and Alaska Natives, Spanish-speakers, LGBTQ persons, and persons connected to the agricultural community;
• develop and submit protocols with 911 call centers within the region;
• develop and submit protocols with BH-ASOs for dispatching mobile rapid response crisis teams and community-based crisis teams;
• report information regarding the number of contacts connected to the agricultural community; and
• enter into data-sharing agreements to provide reports and client-level data to DOH and HCA regarding 988 hotline calls, including dispatch and disposition information for outreaches.

Technology Platform Decision. DOH and HCA must include crisis call centers and designated 988 contact hubs in the decision process for selecting any technology platforms used to operate the 988 system. DOH and HCA must not make decisions that would interfere with the routing of 988 calls, texts, or chats with the National Suicide Prevention Lifeline or national 988 administrator. The technology is no longer required to be interoperable across crisis and emergency response systems or to be able to request deployment of crisis teams and track their local response through global positioning technology. 

The Crisis Response Improvement Strategy Committee. The steering committee of the CRIS Committee is increased by a sixth member who must be a person with lived experience of a suicide attempt or loss, or participation in the crisis system. A 988 geolocation subcommittee is established to examine privacy issues related to federal planning efforts to route 988 calls based on the person's location rather than area code.

Mobile Rapid Response Crisis Team and Community-Based Crisis Team Endorsements. HCA must establish standards for a voluntary endorsement credential for mobile rapid response crisis teams and community-based crisis teams by April 1, 2024. This endorsement must make the team eligible for performance payments. To attain an endorsement, a crisis team must meet the following benchmarks defined by the HCA standards:

• achieve minimum staffing requirements to effectively respond to persons experiencing a significant behavioral health emergency, which must include licensed staff of a behavioral health agency and may include certified peer counselors, fire departments, emergency medical services, public health, medical facilities, nonprofit organizations, and city and county governments, but not law enforcement personnel;
• maintain capability to transport an individual experiencing a significant behavioral health emergency to a location providing crisis stabilization services and meet minimum vehicle, equipment, and communication requirements; and
• meet standards for initial and ongoing training of personnel and for providing clinical supervision to personnel.

An exception to minimum staffing requirements, valid until January 1, 2030, allows a team comprised solely of an emergency services agency in an Eastern Washington county with fewer than 60,000 residents to not include a licensed provider employed by a behavioral health agency provided that the team receives real time consultation from a behavioral health provider by telephone or other remote technologies.

HCA must conduct an on-site survey of the crisis team's operation to award an endorsement, which must be renewed every three years. The endorsement must be subject to denial, suspension, or revocation. A crisis team without an endorsement may respond to an individual experiencing a significant behavioral health emergency when there is no endorsed team available.

The costs of endorsement activities must be designed to maximize the state's ability to receive federal matching funds based on options for payment mechanisms provided by contracted actuaries. The endorsement-related activities must further be supported with funding from the 988 Line Tax. HCA must:

• issue establishment grants to support mobile rapid response crisis teams and community-based crisis teams seeking to meet the elements necessary for endorsement;
• issue performance payments in the form of an enhanced case rate to crisis teams that have received an endorsement;
• issue supplemental performance payments at a higher rate to crisis teams that have received an endorsement and demonstrate that for the previous three months they have met response time and in-route time standards:
  1. to arrive at the individual's location within 30 minutes at least 80 percent of the time in urban areas, increasing to within 20 minutes by January 1, 2027;
  2. to arrive at the individual's location within 40 minutes at least 80 percent of the time within suburban areas, increasing to 30 minutes by January 1, 2027; or
  3. to be in route within 15 minutes of being dispatched by the designated 988 contact hub at least 80 percent of the time, increasing to 10 minutes by January 1, 2027;
• submit a report by December 1, 2023, to the Office of Financial Management and the Legislature summarizing its analysis of payment mechanism options and related cost estimates; and
• submit a report by December 1, 2028, to the Governor and health policy committees of the Legislature reviewing the endorsed mobile rapid response crisis teams and their ability to provide timely and appropriate response to persons experiencing a behavioral health crisis.

Modifications to the Line Tax. Proceeds of the 988 Line Tax may be used to enhance mobile crisis service standards by endorsed mobile rapid response crisis teams. Ten percent of the proceeds must be dedicated to endorsed teams and endorsement activities, up to 30 percent of which may be dedicated to mobile rapid response crisis teams affiliated with a tribe.

Training. HCA and BH-ASOs, in collaboration with the University of Washington (UW), the Washington Council for Behavioral Health, and the Statewide 988 Coordinator must plan for regional collaboration among behavioral health providers and first responders to standardize practices and protocols and develop a needs assessment for trainings. The training needs assessment must be developed by the UW and completed by June 30, 2024, and shall include a mapping of current and future funded crisis response providers and a comprehensive review of all behavioral health training required in statute and rule. UW must convene, at a minimum, the following stakeholders for the assessment:

• at least two BH-ASO representatives, one from Eastern and one from Western Washington;
• at least three crisis services providers identified by the Washington Council on Behavioral Health, one from Eastern and one from Western Washington and one dedicated to serving communities of color;
• a crisis call center representative;
• HCA and DOH;
• at least two individuals with lived experience related to behavioral health issues, a suicide attempt, or suicide loss; and
• a representative of the Co-Responder Outreach Alliance.

The UW School of Social Work must solicit public comment from advocates from persons with developmental disabilities, veterans, American Indians and Alaska Natives, LGBTQ populations, and persons connected with the agricultural community when making recommendations on future crisis provider training needs.

Crisis Workforce Training Collaboratives. HCA and BH-ASOs must develop recommendations by December 31, 2024, for establishing crisis workforce and resilience training collaboratives to offer voluntary regional trainings for behavioral health providers, peers, first responders, co-responders, 988 and 911 call center personnel, and interested members of the public, in collaboration with UW, the Washington Council for Behavioral Health, and the State 988 Coordinator. The collaborative must encourage the development of foundational and advanced skills and practices in crisis response and foster regional collaboration.

Crisis Continuum of Care Forum. BH-ASOs must convene an annual crisis continuum of care forum in partnership with HCA, with participation from partners serving regional service areas to identify and develop collaborative regional-based solutions. These may include capital requests, capacity-building, or community investments. HCA must fund the forum and must jointly submit recommendations with BH-ASOs to the Joint Legislative-Executive Committee on Behavioral Health.

Liability Protection. Liability protection is provided to crisis call center and designated 988 contact hub staff, members of mobile crisis rapid response teams, the certified public safety telecommunicator, and the public safety answering point for any acts or omissions related to dispatching decisions of any crisis call center or designated 988 contact hub staff, and for the transfer of calls from the 911 line to the 988 line or vice versa.

• Requires BH-ASOs to convene an annual crisis continuum of care forum with participation from regional crisis system partners, funded by HCA.
• Transfers convening and final report responsibility for the planning for regional collaboration, standardizing practices and protocols, developing a needs assessment for training, and developing recommendations for establishing crisis workforce and resilience training collaboratives to HCA and BH-ASOs in collaboration with the UW, the Washington Council on Behavioral Health, and the Statewide 988 Coordinator.
• Requires future contracts between DOH and designated 988 contract hubs to require the hubs to prominently display 988 crisis hotline information on their social media.
• Expands the definition of "community-based crisis team" to include teams which are part of a nonprofit crisis response provider.

The committee recommended a different version of the bill than what was heard. PRO: Washington is leading the country with its 988 work. The heart of this bill is the rapid response teams. It is important to have a clinical response instead of law enforcement whenever possible. The endorsement standards are voluntary but may lead to regional partnerships. Every region is different. 30 percent of the funding for crisis teams will go to tribes. You should consider more focus on youth and youth crisis training. We know a strong crisis response is critical to the health of our residents. Mobile crisis response produces culturally responsive care. Giving people what they need when they need it makes us healthier. This is the next step to build a more robust crisis response system. A social media campaign is critical to raise awareness. Crisis teams also help the families and friends of people with mental illness. Available of mobile rapid response frees up police response and is welcomed by BIPOC communities. Persons with developmental disabilities need resources for crisis though 988 centers. Veterans die by suicide at two and a half times the rate of the general population and support this bill. We must leverage Medicaid funding to the maximum extent possible. It is so important to have provider and regional voices lead this effort. A crisis line saved my life when I was suicidal.
 
CON: Data shows implemented behavioral health teams are not effective and do not improve outcomes. Three full-time DCRs only detained six people and there is no positive outcome data. 20 percent of 988 users account for 80 percent of call volume, and frequently refuse intervention.
 
OTHER: Putting performance time metrics in statute before we know they are possible is premature; we should wait until we have data from the teams. Thank you for the focus on working with those with lived experience. Please amend language around the agricultural work to adjust the word screening. Please make HCA the lead agency for training.