Hello and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director of SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Reimagining Crisis Response, 988 and a Crisis Standard of Care. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, and credit for participating in today's webinar will be available until October 2nd, 2021. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. And please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now, I'd like to introduce you to the faculty for today's webinar, Angela Kimball and Hannah Wieselowski. Angela Kimball brings extensive expertise in grassroots advocacy campaigns and mental health policy to NAMI. Her work aims to fight inequities and champion better care for people with mental health conditions and their families. Hannah Wieselowski directs NAMI's advocacy strategy, working with NAMI state organizations and affiliates to identify and cultivate advocacy leaders and provide resources to help advocates promote NAMI policy priorities. Hannah and Angela together lead NAMI's efforts on the implementation of the 9-8-8 crisis services. Thank you both for leading today's webinar. Hello, everyone, and welcome. I'm Angela Kimball, and Hannah and I have no conflicts of interest or relationships to disclose for this presentation. And our learning objections for all of you today are for you to be able to evaluate how 9-8-8 will operate in communities, how it fits with existing services, and what will and will not happen without additional action. Our second learning objective is to compare and understand the relationship between the three components of a crisis standard of care, including 24-7 crisis call centers, mobile crisis teams, and crisis stabilization programs. And thirdly, to determine opportunities at the local, state, and federal level to better build a crisis response system. So we're excited you're joining us today. Hannah and I are going to share a brief overview of 9-8-8, what it is, how it's part of a larger crisis standard of care, how it will work, and what's needed for it to be effective, including discussing opportunities at all levels. First, I'd like to begin by sharing some reminders of the trauma and the tragedy of inadequate crisis care. Today, people experiencing a mental health crisis frequently encounter law enforcement. Unlike other health care crises, like a heart attack, mental health crises are often criminalized. And as a result, people with mental illness are experiencing trauma and tragedy every day. And between 2015 and 2020, according to a Washington Post database, one in four fatal shootings by police were of people with mental illness, and of those, one in three were people of color. In just the three weeks after the trial over the death of George Floyd concluded, 12 people with mental illness died in encounters with police. And over 2 million times each year, people with serious mental illness are booked into our nation's jails, and the rates that people are dying by suicide and overdose deaths are simply unacceptable. There's been a jump in overdose rates in the last year from roughly 80,000 to over 93,000. We believe very firmly that people deserve help, not handcuffs. We all see headlines like these all too often. At NAMI, many in our organization actually live in fear of these tragedies happening to ourselves or someone we love. Last year, we heard about Daniel Prude, a man who was experiencing a mental health crisis, and instead of help, a hood was put over his head by police, and he later died. Walter Wallace Jr., whose family called for help with a mental health crisis, and as his mother watched and pleaded, police shot her son. A nine-year-old girl in Rochester, New York, who was in distress earlier this year, her family called for help, and she was handcuffed and pepper sprayed. A nine-year-old girl. And a boy in Utah with autism, whose mother warned he was in crisis and that he was afraid of law enforcement. She hoped to get help de-escalating the situation. Instead, her son was shot multiple times. And just this week, we're learning more about a Black Army veteran in crisis whose wife called for help after he was triggered by 4th of July fireworks. He was shot by police and later died. We live with headlines like this, but it doesn't have to be this way. Fortunately, we have an incredibly unique opportunity to reimagine our nation's approach to crisis response with the upcoming launch of 988, a nationwide number for mental health and suicidal crises that will go live by July of 2022. We're using this opportunity to promote a new standard of care for crisis response that fundamentally consists of three core components. 988 will be a simpler entry point, but it's critical that a 988 call results in a robust response, and here's what that should look like. Communities need crisis call center hubs. These call center hubs should be available 24-7 with calls to 988 answered by local call takers who are well-trained to counsel people in crisis. They should be able to take not only calls, but text and chats and connect people to additional care and needed services, including dispatching mobile crisis teams. We also need those mobile crisis teams for people for whom talking on the phone is not going to be enough. Mobile crisis teams should be staffed by trained behavioral health professionals, including peers, that can de-escalate, engage people, and connect them to services. And for those who need more support, the third component, crisis stabilization, provides recovery-oriented observation and stabilization, often for 23 hours in a living room-like setting. This should lead to a warm handoff to either more intensive or community-based care. So how would this look like in a real-life situation? I'll share a version of this. When my son experienced a psychotic episode a few years ago, a friend was able to call a behavioral health crisis line for me, but with 988, it'd be much easier to remember and dial. My son was delusional and threatening, and so this was not a situation that could be resolved over the phone. The crisis line dispatched a mobile crisis team that includes CIT-trained police officers, but they took a backseat to clinicians. The lead clinician established a rapport with my son, and after spending time putting together the pieces and seeing the state he was living in, said, I'm hearing, Alex, you haven't slept for days, and things are getting kind of intense. Do I have that right? And he said, yeah, my head hurts, and I just want to sleep, but I can't. And she said, I know the doctor at the hospital will definitely be able to help you get to sleep and help your head stop hurting. Does that sound okay to you? Are you willing to go with me? And remarkably, he said, yeah, I'll go. I just want my head to stop hurting. The next step in his journey was a crisis stabilization unit, which after 23 hours, moved him into a psychiatric inpatient unit because he was still delusional and paranoid. And I can't say the hospitalization and the rest of his journey went well, but the crisis response piece did. And so this is what we want all across the country, because under different circumstances, my son or anyone we know who is dealing with severe mental health or substance use symptoms could easily have ended up in jail or worse. We'll talk about each of the three components of the crisis standard of care a bit more shortly, but let me first share why now. As I mentioned, this effort has its roots in the creation of a nationwide three-digit number for mental health and suicidal crises, 988. After a bill requiring the Federal Communications Commission, or FCC, to look into the feasibility of a three-digit number for suicidal mental health crises, the FCC recommended to Congress that they adopt 988. They explored other numbers like 211 and 611, but ultimately the FCC recommended 988 as the most viable option and that it should route to the existing National Suicide Prevention Lifeline. In 2020, Congress, with absolutely rare unanimous action in both chambers, passed the National Suicide Hotline Designation Act, which established 988 in law. Essentially, Congress said that 988 calls will go to the lifeline and that the lifeline scope will extend beyond suicide prevention to also include responding to mental health crises. The FCC also acted to say this number must be available nationwide by July 2022, requiring telecommunications providers to direct all calls to 988 to the lifeline by that date. But while Congress acted on 988 specifically, their language went further. It showed clear intent that we need more than a number. The legislation allowed states to collect monthly fees on phone bills to fund a crisis system, similar to fees charged on phone bills for 911. The legislation said states could act to implement these fees and use it for the efficient and effective routing of calls made to 988 and, I quote, personnel in the provision of acute mental health crisis outreach and stabilization services by directly responding to the 988 National Suicide Prevention and Mental Health Crisis Hotline. Grammatical challenges aside, with this language, Congress set the expectation that more than a number should be available and provided a mechanism for states to fund services. Now, NAMI, joined by our partners in the mental health community, are taking this opportunity to ensure improved crisis response systems in states across the country. And with that, I'd like to turn it over to Hannah to explain where we are today. Thanks, Angela. Hi, everyone. I'm Hannah Wieselowski, and I'm pleased to be with you today. Thank you for joining us. While congressional and FCC action to create this three-digit number is a landmark action, it's important that we are clear on what it actually accomplished and what it didn't do. First, it created this new number to be routed through the existing National Suicide Prevention Lifeline. While the Lifeline's full name isn't changing, the scope of the Lifeline is expanded to now include mental health in addition to suicidal crises. The FCC started the clock requiring 988 to be available everywhere by July 16, 2022, which is only 10 and a half months away from right now. It allowed states to take additional action to implement a fee on telecommunications, bills to support call centers and related crisis services, which Angela just mentioned. And it also required a report to Congress on resources needed for 988. We anticipate that that report will be delivered shortly and will help inform Congress of additional appropriations that are needed. But what did it not do? It did not require states to act to build up crisis services. So while we know there's going to be much greater demand for this crisis line as people become aware of this alternative to 9-1-1, it does not ensure that there are appropriate services in place on the ground to respond to the calls coming in. As of right now, only a portion of calls to the Lifeline are answered by call centers in their state. Demand increases will need more capacity for call centers, but also resources to make sure that the additional response options, like mobile crisis teams and crisis stabilization programs, are in place when they're needed for certain calls. But while the federal legislation didn't require states to act, it also didn't provide for any additional federal funding for crisis infrastructure. Fortunately, we're seeing some movement now, but there is no guarantee of that being available for perpetuity. We'll talk more about that in a minute. The legislation did not create a centralized office within the federal government to coordinate all agency activity on 988 and crisis services. Currently, SAMHSA administers the Lifeline, the 988 portion of this, but the additional mechanisms at CMS and elsewhere in HHS and other agencies do not have a single coordinating office. Additionally, without insurance coverage, sustainability becomes a challenge for any type of treatment or intervention. The legislation did not mandate coverage by Medicare or commercial health plans for crisis services. Currently, only some services are covered by some type of plans. However, with what action was taken, we see this as an opportunity to truly reimagine crisis response and do more. We're going to talk about what is happening now and what needs to happen in just a minute. Dialing 911 in a mental health crisis can result in unimaginable heartbreak and lasting trauma. Having an alternative is truly a game changer if we take this opportunity. 988 will be the option for anyone who is experiencing suicidal thoughts or other signs of a mental health emergency, like delusions, mania, or paranoia. This will be a number that individuals in crisis or those around them can call for help. We're hoping, too, that 988 will serve people experiencing substance use crises. While phone companies are not required to direct calls made to the number 988 to the Lifeline until July 2022, many have already flipped the switch, so to speak, to connect any calls to 988 to the Lifeline today. However, in the interim, until all telecommunications providers are required to do so, we encourage people to continue to share local crisis numbers or the National Suicide Prevention Lifeline's full number, which is 1-800-273-TALK or 8255. However, if 988 were live and promoted today, what could we expect? Unfortunately, we'd face vastly different and largely inadequate crisis systems in different communities. First, the next year is going to be critical to training up existing Lifeline centers to address a broader scope of crises, moving from mainly a suicide prevention focus to also include mental health crises. While many of these call centers already address mental health and substance use crises, not all do. All call takers need to be trained and equipped to do so. Second, no two communities look alike in what crisis services they have available right now. It's a patchwork system that is largely insufficient to provide what people in crisis truly need, which results in law enforcement too often being called to address a crisis. If your house was on fire and you called 911, you would expect the fire department to respond. For 988, there is no shared understanding yet of what services, including mobile crisis teams and crisis stabilization programs, will be available in every community. If we operate with a status quo, call centers will still only be able to dispatch law enforcement when a situation requires an in-person response, or people will still call 911 for help. That is unacceptable. Again, the implementation of 988 gives us a chance to address our crisis standards of care, but we have to act fast. So I just want to give you a little bit more of an idea of how 988 is going to operate. So I'll walk you through how calls to the National Suicide Prevention Lifeline, which 988 will be routed through, are directed. So a call to 988 will go to the main number, and then a person will have an option to hit a few buttons. But first, a little bit of background on the National Suicide Prevention Lifeline. The Lifeline is administered by the Substance Abuse and Mental Health Services Administration, or SAMHSA, our co-host today. Vibrant Emotional Health is the entity that runs the Lifeline network under a contract with SAMHSA. The Lifeline is available 24 hours a day, seven days a week. And when a person dials 988, they have the option to press 1 to go to the Veterans Crisis Line, or press 2 to be routed to a Spanish Assistance Line. Any other calls are routed to their local call centers, if available. Currently, calls are routed based on area code, although the mental health community is working closely with the FCC and others to address that, as many people, including myself, don't live in the same place that the area code on my phone has. Right now, there are about 180 local call centers in the Lifeline's network across the country. Some states are able to answer most of their calls within their state, but others have more limited capacity to do so, or may operate under limited hours. If the local call center doesn't pick up quickly, the call then goes to one of the network's backup call centers. So, no call to 988 will go unanswered. The goal is to get as many calls as possible answered locally, because local call centers will be able to connect to local services. And if mobile crisis teams are in place in that community, to dispatch those teams when needed. In 2018, the Lifeline network answered 2.2 million calls, and we expect that that number is going to increase significantly once 988 goes live and once it's promoted. For one, without the concern of a law enforcement response, more people may be willing to call for help. Additionally, mental health crisis calls that once went to 911 are going to be diverted to 988. And part of this effort is to really coordinate at a state level the interoperability of those emergency response systems. So, there are protocols in place for 911 calls that really should be going to 988. Finally, as more people become aware that this resource exists, there will be more people calling for help. Many people are simply unaware that there is the National Suicide Prevention Lifeline, as well as local crisis lines that are out there, or they may not remember the number in the heat of the moment when they really need that help. This is going to make that much easier. I'm going to turn it back to Angela to share a bit more detail on how we're working to make call centers answering 988 calls well-positioned to address this increase in demand. Angela? Thanks, Hannah. So call centers should provide someone to talk to. They should have well-trained staff, as I mentioned before, and be available through phone, text, and chat 24-7, 365 days of the year. And they should serve as hubs that have really strong connections with not only other emergency systems, but also with their local mental health and substance use provider networks. They should be able to dispatch mobile crisis teams and ensure those connections, including to crisis stabilization and more intensive services. While the majority of calls are resolved with call center staff, there is a need for those staff to be able to make same-day and next-day appointments with local mental health providers and conduct follow-up calls, as well as connect to other resources in the local community. Unfortunately, very little funding goes to local call centers from the federal government. Local call centers may receive state funding. They get small, very small, grants from the Lifeline. Sometimes they get grants for offering other services and philanthropic donations. But this kind of funding structure is not sustainable currently, and certainly not with the expanded scope and expected increase in demand once 988 goes live. So we need increased federal investments. And what we're asking for from Congress is $240 million for the Lifeline network to scale up new technology, train on the expanded scope that includes mental health crises and more. But we're also asking for $400 million to help provide resources to fund those local call centers so they aren't cobbling together funding to keep their doors open. With adequate federal funding, there can be more guidelines and consistency across the country. But just like with the entire crisis standard of care, there are state and local components to this as well. For crisis call centers, we're actually urging states to act quickly to create protocols that help ensure collaboration, which we need between 988 and 911 and other emergency response systems. We're also advocating for states to implement the monthly fees on phone calls as allowed by federal law to fund not only call center operations, but also other parts of the crisis response system that aren't covered by federal funding. And states also need to look closely at their current call center capacity and plan for how they'll address the increase. That may mean bringing some existing crisis call lines into the Lifeline network or adding call centers. More than 40 states took a planning grant from Vibrant Emotional Health, which runs the National Lifeline, to help plan for the implementation of 988 to help address some of these needs. And now, Hannah is going to share a little bit more about mobile crisis teams. Thanks, Angela. So, mobile crisis teams are really someone to respond. And as Angela mentioned, the majority of calls can be answered over the phone. But estimates from existing communities where there are robust crisis call centers, as well as the National Suicide Prevention Lifeline, are that about 5 to 10 percent of the calls are going to need additional response. So, they need more than is offered over the phone. When needed, these teams travel to the individual experiencing a crisis, de-escalating the situation in a non-threatening way, and providing assessment and stabilization, or they may help the individual into a higher level of care, if appropriate. There are many different models of in-person crisis response. There are co-responder models, for example, that include both mental health staff and law enforcement officers. And Angela mentioned that earlier in her own personal story. Many mobile crisis teams, though, are staffed entirely by behavioral health professionals, including peers, and only rely on law enforcement in very limited situations, typically less than 5 percent of all mobile crisis team dispatches. However, law enforcement trained in de-escalation are critical for when backup is needed. And NAMI is a big supporter of de-escalation training for law enforcement. In the American Rescue Plan Act, which was signed into law earlier this year, back in March, there was an important provision that increased the federal matching rate in Medicaid for mobile crisis teams for a period of three years, and increased it to 85 percent. And what this means is that the federal government will pay a higher share of the cost for Medicaid coverage of mobile crisis teams. And that's really important to open up state funding to help these mobile crisis teams get started. Of course, we would like to see that made permanent so that that is an increase that's available to states for more than three years into the future. There are some costs that can't be billed to Medicaid or other insurers, like the time it takes to reach an individual in crisis, especially in rural and frontier areas, or purchasing vehicles. Additionally, there are some people who don't have insurance, so there should be federal funding and coverage by all health plans to help provide sustainable funding. At the state level, we're urging for legislation that is passed on 988 to require statewide availability of mobile crisis teams. Again, setting that expectation that when somebody calls and needs that help, it will be available in every community. We want every state to pass this legislation. And this can be accomplished by having mobile crisis teams locally or in some rural or frontier areas, it may be necessary to have these mobile crisis teams available regionally. But many times we see standards for how long it takes to get a response written into legislation or operating plans. We're also asking that the monthly fees on phone bills, so again, these user fees on telecommunications bills, it's similar to how 911 is funded, that they be able to be used for mobile crisis team costs that aren't covered otherwise by federal or state funding or bill to insurance. So now I'm going to pass it back to Angela to talk about the third critical component of a crisis response system. Thanks, Hannah. So the last major component is crisis stabilization or somewhere to go. In a subset of those mobile crisis team calls, crisis stabilization may be needed. So this is the part of the crisis continuum that's needed for the smallest number of people, but provides the most intensive care. And because of that, it's also the most expensive part of the continuum to fund. But its availability is really critical to stabilize some people in crisis and to connect them to appropriate care. Now crisis stabilization is a term that can refer to multiple options. An increasingly common option is a crisis stabilization unit that's in a living room-like setting, and it provides observation and stabilization help for under 24 hours. For some people, obviously, there'll be a need for a short-term crisis facility stay, crisis residential care, inpatient hospitalization, or other intensive services. And I want to note that strong crisis stabilization programs have peer supports. They include detox facilities. They don't require medical clearance, and they help people get the right follow-up care, including those more intensive or specialized services. Finally, that they accept all police referrals with zero rejections and provide dedicated areas for first responders to drop off an individual and turn around within five or ten minutes. That may sound impossible, but I can tell you there are communities that are implementing this across this country, and Arizona is one of those places we like to highlight. But to make this more widespread, we really need a few things to happen. For one, not all insurers, in fact most insurers, do not cover crisis stabilization. So we're working to remove barriers to coverage, as well as hurdles that make it hard for these programs to bill insurance. We're also advocating for more resources to states that help them build the bricks and mortar to support centers, as those infrastructure costs are often very hard to cover. And at the state level, again, monthly fees on phone bills should be able to be applied to unbillable costs of crisis stabilization. And state action should also mandate that these programs are available statewide. For some states, this might be regionally, or it might be co-located with other local services. So now I'm going to move on and talk to you about some federal investments, because while federal 988 legislation didn't provide federal funding for a crisis system, there's been, since that time, some significant investments at the federal level. I'd like to highlight in December of 2020, Congress passed the fiscal year 2021 funding bill and a COVID package, and in that bill, Congress included $1.65 billion in COVID-focused mental health relief, and many states have chosen to use that for crisis services. They also increased the lifelines appropriations by $5 million to $24 million. And here's an important piece. They set aside 5% of the mental health block grant, which equated to $35 million of the total $757.5 million in the block grant, specifically for crisis services. Then in March of this year, in the American Rescue Plan Act, Congress provided $1.5 billion in additional funds for that block grant. And while states were not required to use any portion of those funds for crisis services, SAMHSA encouraged states to do so. And that's particularly useful because those block grant funds that state mental health divisions have received are much more flexible than other kinds of funding. Additionally, as we mentioned earlier, a short-term increase in the federal Medicaid matching rate for mobile crisis team services was included in ARPA, as well as $15 million for mobile crisis team planning grants to help states prepare for this increase. So these investments were significant, but we could see even more in the year to come. The House has approved a fiscal year 2022 spending bill that would double the block grant to an unprecedented $1.58 billion and create a 10% set aside for crisis services. And that would provide about $158 million a year to be distributed among the states just for crisis services. This could be used by states for a variety of crisis service needs, and it's a really important funding stream for states to fill in the gaps in their crisis system. Additionally, the Appropriations Committee Chair, Rosa DeLauro from Connecticut, included a $100 million mobile crisis team grant program, which is a brand new federal resource. And finally, addressing the gap of a federal coordinating office, the bill provides $10 million to create that office within health and human services. But I need to caution, the Senate has not yet acted on this bill. However, we're still very hopeful that these will remain in any final fiscal year 2022 budget bill. There's an opportunity here also to establish consistent standards for crisis continuum of care and require insurers to cover it. So one of my favorite bills in front of Congress right now is Senate Bill 1902, the Behavioral Health Crisis Services Expansion Act. It was introduced in a bipartisan fashion by Senators Cortez Masto from Nevada and Senator John Cornyn from Texas. This is an amazing bill because it would require HHS to set standards for crisis care nationally, and require federally regulated health plans to cover mobile crisis teams in crisis stabilization services. And just to give you a hint, federally regulated health plans includes Medicare, Medicaid, individual and small group plans that are within the Affordable Care Act on the marketplace, large groups that are self-funded, TRICARE, and the federal employee health benefits plans. Doing all this would level the playing field for both public and private insurers and the people they cover and create much more uniformity and stability of financing. And now I'll turn it over to Hannah to talk about what's happening in our states. Thanks, Angela. And so while there's a lot happening at the federal level, which is really exciting to see, there's also a lot of work that has to happen at the state level. Federal action has created an opportunity for states to transform crisis response, but states will have to choose to act to make sure that comprehensive crisis services are available on the other end of the phone when people dial 988. So far, nearly two dozen states have introduced legislation related to implementation of 988. No two bills look alike, but that's not surprising given that no two states are starting from the same starting point. States have very different models for crisis care. However, there is model legislation that is out there that tries to address some of the core components of a crisis response system. And a lot of states are taking that and modifying it for their situation. The National Association of State Mental Health Program Directors created this model legislation late last year, informed by NAMI and other mental health advocacy organizations to really act as a roadmap for states on what to consider and address in legislation. It includes specifying requirements for 988 hotline centers and crisis response services, including the availability of mobile crisis teams and crisis stabilization programs. The model legislation also enacts that monthly user fee that we've mentioned so many times to ensure a sustainable funding mechanism. And this is really, really important because it would reduce some of the instability that we see when we rely solely on general funds. Most states have to have a balanced budget. And so in times of economic hardship, they have to make cuts. And often those are across the board cuts. But too often, we have seen mental health as one of the first things on the chopping block. We're hoping that that has changed and people recognize the importance of mental health. But at the same time, when the budget has to be restricted, everything is going to see some cutbacks. And so having this user fee in place really does create that sustainable funding stream that we know will be there year after year. And that's incredibly important. And again, this is similar to how 9-1-1 is funded. States have 9-1-1 fees to help fund the 9-1-1 infrastructure. And the average for those fees is about a dollar per month per phone line. So there's a lot of opportunity there for this new funding stream that will really help us make sure that crisis services are available. And to protect those funds, the model legislation also creates a trust fund to collect and protect 988 revenue as well as state general funds to prevent those funds from being used for any non-988 use or crisis services use. Additionally, there's a state oversight body that the model bill creates to oversee 988 implementation and ensure cooperation among all the state entities. And in some cases, it also defines who should be involved in that oversight body. Finally, the legislation also ensures interoperability between 988 and other state emergency systems like 9-1-1. It is going to be critical that these different systems talk to each other to ensure that they are getting people the help that they need in a timely manner and connecting them to the right resources. Again, some people will continue to call 9-1-1, but that doesn't mean that's the best resource to respond. So in front of you is a map of where active legislation stands this year. And again, the federal legislation only passed in October of last year. That's really late for a state legislature to take something up. But despite that, we saw a lot of action in 2021. Four states passed legislation this year that creates a crisis system infrastructure and also includes that monthly fee on phone bills to help fund the system. And those are the states that are in dark blue, Washington, Nevada, Colorado, and Virginia. California's bill has passed the assembly is now at the Senate and it would do the same. Massachusetts and New Jersey bills are also in progress and would do that as well. The bills really do vary. For example, Virginia's fee is 12 cents on most phones and 8 cents on prepaid phones. And Virginia's legislation only would fund crisis call centers. And it's unique in that way. It is funding it through an increase in the 9-1-1 fee rather than a separate 9-8-8 fee. But Virginia also addressed the other components of a crisis response system separately this year. They had separate legislation to create mobile crisis teams across the state funded by state general funds. They did not ignore that component of the crisis response system. Colorado's bill caps fees at 30 cents per month, but it does not immediately set the annual fee amount. Instead, it urges the state to determine what the annual costs will be and set the amount depending on those annual costs. So, not knowing what the demand will actually be when 9-8-8 goes live provides a mechanism for states to address it and meet that demand. Similarly, Nevada's bill caps fees at 35 cents, but does not set a fee. And both Nevada and Colorado fund the full spectrum of crisis services. So, whatever revenue is brought in from that monthly user fee can be used not only to fund the call center capacity, but also mobile crisis teams and crisis stabilization programs. And finally, Washington passed legislation, and they start with a 24-cent fee this year, and that'll increase to 40 cents in 2023. And like Nevada and Colorado, it funds the full spectrum of crisis services, which again is really important to make sure that you fill any gaps that federal funding, state general funds, insurance coverage are not meeting and have the resources to do so. Indiana, Illinois, Oregon, and Utah passed bills that help set up 9-8-8 system infrastructure, but do not include fees. That being said, those states in some cases did appropriate state general funds to help cover those costs. And in some of those states, we expect the legislature to take up action in the future to possibly implement a user fee. And a few states are wisely using this year to really get input. And to do that, they are collecting critical information and studying the gaps in their existing crisis infrastructure. So, that's Texas, New York, and Nebraska. They're taking this time to really look at what the demand is, what there's need for, and then how do we fund those services that we need to add to fill those gaps within the state. So we anticipate that all of those states will take that information and use it to implement legislation in the future that really addresses the full spectrum of crisis services. There's lots of opportunities to engage at the state and local level. We encourage you to reach out to your state NAMI organization, your state APA, state planning groups. Again, Angela mentioned that there are 988 planning grants in most states, and many states now have also taken that mobile crisis team planning grant that was made possible by the American Rescue Plan Act earlier this year. So there's a lot of work that is already happening at the state level to plan for crisis care. It's really critical that a variety of stakeholders and partners are at the table, including providers, the voice of lived experience, law enforcement, hospital systems, all those impacted by our inadequate crisis system and have insight and expertise to offer really need to be together at the table to ensure that the system that is built is sustainable, effective, and really serves the needs of people with mental health conditions who are in suicidal crises, mental health crises, or substance use crises. And there are a lot of like-minded partners out there, ones I just mentioned, but there are also non-traditional partners that are impacted. We are looking at groups that represent communities of color because law enforcement involvement in crises presents additional challenges for those communities. And even though they may not work on mental health as their top priority, they certainly see the impact of this within their community, and we want to make sure they're at the table as well. Also, making sure local media are aware of this effort and are following implementation. This helps hold all stakeholders accountable for implementation, but also creates awareness among the general public of this new resource, especially again, we're only 10 and a half months away from 988 going live, which is incredibly fast in this world and trying to reimagine our crisis response system. We have a lot of work to do to really get that full continuum of crisis services available to appropriately respond to 988 calls. Additionally, promoting culturally competent care and culturally and linguistically specific services is critical to ensure that the crisis system addresses the needs of all communities. And finally, as I said, ensuring that peers and families are at the table is essential to make sure crisis system meets the needs of those it's intended to serve. This should include representation from historically marginalized and underserved populations, communities who often pay the highest price of law enforcement involvement in crises. As I mentioned before, there is model legislation out there for 988 implementation that states can take and use. And a lot of those planning groups are working from this legislation, they're working with their state mental health agency, their state Medicaid agency, and other interested and relevant agencies to adapt that to where their state is. Again, all states are starting from a different point and that makes it hard, but it's really important that this legislation defines the crisis standard of care that's available across the state. It provides funding mechanism in some way to adequately support crisis services. Ideally, that's a monthly user fee as well as state general funds. There's a lot of different funding streams that must come together to provide for this. And it creates oversight, coordination, and reporting mechanisms to ensure smooth implementation and accountability to make sure that this is a system that is working and addressing the needs it's intended to address. There's a few principles we think are really important in state implementation. First, every step is an important one. We are talking about re-imagining our crisis system, and that is not going to happen in the next 10 and a half months. This is going to be a multi-year process, and it's going to require the support of many different stakeholders and partners to make it possible. Every success, every movement in that continuum is an important one, but it may take time to get to our ideal state. We also, we mentioned a lot these monthly user fees on phone bills, and we really think that this is vital to ultimate success because of their consistency. Wherever possible, giving the relevant state agencies the ability to set that fee annually based on anticipated costs will be most effective, rather than tying it to a specific fee amount. We don't know what demand will be for 988 once it goes live. There are estimates out there, they are educated estimates, but this is something new and it's something we're building. Having the flexibility to truly provide the resources, because all of us are aware of the implications of an underfunded mental health system. If we do that with this re-imagined crisis system, we are not going to be improving our ultimate outcome. We really need to be thoughtful and provide for that flexibility, and provide opportunities make changes along the way as we learn from initial implementation efforts. With that, I'm going to stop. Here is some of our citations for stats that we presented today, and I will turn it back over to our hosts. Thank you so much for both an informative and thorough presentation. From someone like me who's been following along with 988, the amount of information you presented today in just 45 minutes is amazing. I'm in awe of the work that NAMI is doing in this effort around 988. Before we shift into question and answers, I want to take a moment to let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download our app now at smiadvisor.org forward slash app. Let me dive into a few questions. I think we were all looking at that state map and looking at our states that we're in. Not surprisingly, someone asked, if a state doesn't do anything, in July of 2022, what will happen if someone calls 988? That's such a great question. The great thing about 988 is it's going to be available everywhere. No matter where somebody is located, whether a state takes action or not, they will still, when they dial that number, be connected to the National Suicide Prevention Lifeline. If their state has local call centers, they'll be connected to a local call center, but at the very least, they'll be connected to the National Backup Center, which has trained call takers who can de-escalate the situation. The question is really what happens from there. So if a state doesn't act, that person may not be able to be connected to an in-person response or connected to the local community. Angela mentioned that we would like to have call centers have the capability of setting up same-day or next-day appointments and conducting follow-up calls. We're not going to have that with the National Backup Center. So the level of additional services and interaction and support that can be provided will be severely limited. That being said, 988 will be available everywhere. Angela, I'm sorry, I talked over you at the beginning. Do you have something to add? No, you answered that beautifully. But however, I will add, though, that essentially, if a state does nothing and if they don't have a crisis system of care like we described, it could very well be that despite calling 988 and getting a response from the lifeline, there may not be that mobile crisis, that crisis stabilization. And in fact, law enforcement could still be called. So it's worrisome if states don't act. It doesn't mean that there will be nothing available, but essentially, it is more of a status quo. So if I'm thinking about this, this is just me, this wasn't somebody writing in. So if your state does nothing or does very little, the fear is that there will be more police response and more ER visits and inpatient, rather than being able to keep them in the community and handle it, you know, in some sort of continuum, rather than going straight to ER inpatient. Is that right? That's a good point. So if a state doesn't act, it's not that there'll be more law enforcement response, but rather the absence, potentially, of alternatives to a law enforcement response. And we know right now that emergency departments are typically very strained. We have emergency department boarding going on all across the country for people who are presenting and needing inpatient psychiatric care. So what we're really looking at with a crisis standard of care, as we've presented, is really having a system that provides alternatives. If states don't act, we get a new number, but we don't get a new response. If I'm in a state and I work at a place that could be part of this continuum of care, how could I let my state know that we want to take part and be, you know, a referral source? That's a great question. I think the best place to start is your state mental health agency. They should be able to connect you to the state planning committee that really needs to have an accurate view of what resources are available in the state. And if you are an entity that can serve the crisis call center capacity, you really would need to be connected to the national lifeline, to Vibrant Emotional Health, because 988 calls are going to be directed to call centers that are within the lifeline network. So any call center needs to be part of that network. And there are some steps to take and standards to meet, but that's a really good opportunity to engage. But for the other services within the continuum, connecting with the state mental health agency and the state planning committee are really the key to start so they can make the connections with all the other components of the system. Can you talk a little bit about what kind of marketing to the everyman will happen around 988? When will, how will people learn that 988 exists and that it, and what it's for? That's such a good question. And actually it's an open-ended question right now, because we all know that marketing is going to be important. One of the challenges is with so little time for states to give up systems, it's a little unclear marketing what, what kind of response will people get and how, how does that get fashioned up, that messaging, given the variations across the country. So that is something that I know SAMHSA and Vibrant and other parts of the system are thinking about right now, but it is unclear exactly how that marketing will roll out. Okay. Can you talk a little bit about, are sort of state mental health commissioners or state authorities working with other states? Is there a sense that some of the more rural states can learn from other rural states? I'm just thinking about how we can build on the states that are sort of early adopters to help other states. I know that Nashville is taking a very strong leadership role in this. And so state mental health directors are talking to each other. And I think one of the fortunate things is that the standard of care we described today is not out of the blue. It's well-described in SAMHSA's guidelines to an effective crisis care system and echoed in a much more extensive report recently put out by the National Council for Mental Well-Being, formerly the National Council for Community Behavioral Health. And we have examples of these services already in play in various parts of the country. And so those are states that already have lessons learned that they are more than willing to share with other states. For example, Georgia is a state that has a very robust statewide crisis line that a lot of states are looking to because of the kind of capabilities that they have. Not only the ability to dispatch, they have master's level clinicians that are able to do assessments on a call, they're able to book same-day and next-day appointments, and they have online capability to see bed availability throughout the state. So for example, that's an example of a state that others are looking to. Arizona is a state that I mentioned that has pretty robust mobile crisis teams and very sophisticated crisis stabilization services that really encompass a broad array of services and supports, including really strong integration of peers in the delivery of services and doing follow-up in connection to not just clinical care, but the kinds of services and supports people need to get on a path of recovery. So remember the question where we asked, if you don't do anything, what will happen? Well, we've heard from that audience member again, and this person's from California. And they're asking, if the state doesn't act, but a county is building a really robust crisis response team, could they be accessed through 988? So could counties in and of themselves be the level at which it's connected, or does it have to go through the state, I guess, is what we're asking? That's such a good question. And the answer is, this can happen at a local level. So as long as those crisis services are connected to the local lifelines serving that area, then 988 will get to those local crisis services. So I know California was in your gray. What do you know about, and I know there are several very big counties, obviously Los Angeles County, et cetera, who have great services. I'm wondering if you can say a little bit more about California's efforts towards a system for 988. So California has very much a county-based mental health system, as do a number of states. And so you have a number of counties that are working very concertedly to develop a robust crisis response system. That as long as it's connected to the 988 number, will allow people to access that kind of care, absent any action by the state. What the state does have in front of it right now is AB 988, which is in flux, given the political realities in the state right now. But that state bill would essentially create an additional funding stream through a user fee to help finance these services. That said, there are still counties that are moving ahead because they want to serve the people in their community. Wonderful. Well, thank you so much. Go ahead. Yes. So as I said, AB 988 has passed the assembly in California, and it's with the Senate now. So it's a question of whether it's going to get through in the short term, or whether it might be punted to early next year. We do anticipate a lot of states will take action next year. And local level activity is really important, and the reason we're pushing for states to act is so there is consistency, because somebody may be very close to the edge of a county and have different resources than their friend down the road. And so having consistency across the state and ultimately across the country is what we're going for. That being said, we're very happy that many local communities and counties are moving forward regardless, but we hope states will step up to the plate. Wonderful. Let me move on. If anybody has any follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. And I would just say, one question came in here at the end about recording, and it will be available in the SMI Advisor catalog in just a couple weeks, so please check back to our catalog for recording of this talk today. SMI Advisor is proud to partner with the American Psychiatric Association on the Mental Health Services Conference this year, which takes place virtually on October 14th through 15th. The keynote address of this conference features Dr. Miriam Delfin-Rittman. She is the newly appointed Assistant Secretary of Mental Health and Substance Use for DHHS and the Administrator of SAMHSA, who, as we've heard today, is overseeing the 988 rollout. The conference agenda features topics such as climate change and mental health, sociopolitical determinants, structural racism, mental health in rural and indigenous populations, and much, much more. I really encourage you to learn more and register at psychiatry.org forward slash MHSC, stands for Mental Health Services Conference. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before claiming your credit. And please join us next week on September 10th, 2021, as Eugenia Flores-Millender from Florida State University presents Culturally Informed Psychopharmacology for Patients with Mood Disorders. This free webinar will be September 10th, 2021 at noon Eastern time. Thank you for joining us today. Thank you to our faculty speakers, and until next time, take care.

Dr. Amy Cohen

SMI Advisor

Reimagining Crisis Response

988

Crisis Standard of Care

National Alliance on Mental Illness

24/7 crisis call centers

diverting mental health crises

federal funding

comprehensive crisis response systems