Hello, and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director of SMI Advisor. I am pleased that you are joining us today for our SMI Advisor webinar called Update on 9-8-8, What Mental Health Professionals Need to Know Now. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoting 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. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one CE credit for psychologists, one CE credit for social workers, and one Nursing Continuing Professional Development contact hour. Credit for participating in today's webinar will be available until December 5, 2022. Next slide. Slides from the presentation today are available in the handouts area, found in the lower portion of your control panel. Click the link to download the PDF. Next slide. And please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation today for your questions and our answers. Next slide. Now, I'd like to introduce you to the faculty for today's webinar, Jennifer Snow. Jennifer Snow is the National Director of Government Relations and Policy for NAMI. She is responsible for developing and implementing NAMI's overall federal agenda to advance public policies that support people with mental health conditions. She and her team work to ensure an integrated federal strategy, overseeing the analysis of and the strategic response to congressional and administrative activities. Thank you, Jennifer, for leading today's webinar. Thank you, Dr. Cohen. I'm delighted to be here today and to talk to you all about the important topic of 988 and crisis response services. So let's get started. Here we go. I have no relationships or conflicts of interest related to the subject matter of this presentation. Let's move on to the learning objectives. As you can see on the screen, my hope is that completion of this activity or at the end of this webinar, that you'll be able to understand the differences between the old lifeline and the new 988 suicide and crisis lifeline, assess how 988 can be an effective resource for patients and people within your communities, and evaluate the level of mental health crisis response that exists in a given community. So let's just jump into an outline of what we'll cover. First we're going to start off by discussing a vision for a mental health response to mental health crisis, because really the overarching issue that unifies a lot of our work around this topic is that we believe strongly that people in a mental health crisis deserve a mental health response. Next we'll move into an overview of what is 988 and what exactly happened on July 16th. We're going to talk a little bit about how 988 is going to work and how that's different from how 911 works. We're going to talk about where we are today, and then most importantly, what else needs to happen in order for us to have a truly responsive mental health crisis response system that helps all people in a mental health crisis get a mental health response. And along with that, I'll give you an overview of our work with our hashtag Reimagined Crisis Response Coalition. So before we start, I want to give you a quick introduction to NAMI. I suspect that many of you or some of you listening to this webinar are very familiar with NAMI. But for those who might not be, we are the nation's largest grassroots mental health organization, and our mission is to provide advocacy, education, support, and public awareness so that people with mental health conditions and their families can build better lives. We represent the one in five Americans who have a mental health condition, which means it's everybody. It's youth and young adults, it's veterans, it's people involved in the criminal justice system, people who are homeless, family caregivers, really every person in this country who is impacted by mental health conditions we look at as the reason that we exist as an organization. And we're all connected by the shared hope of recovery and that we can live with mental health conditions and be supported by a community that cares. I have the privilege of working in NAMI's national office on national policy, but we have a nationwide presence with 49 state organizations and over 600 local affiliates. So I know that you are all attending this in your professional capacity, but thinking about you and your personal capacity. If you or someone you love is suffering or needs resources, you are not alone and NAMI is here to help. You can go to NAMI.org, find a local NAMI in your community, and there'll be lots of whether it's support groups, education programs, or resources that might be of help to you and they're all free. So just know that you are not alone and we are here to help. So first I'd like to talk a little bit about the unfortunate status quo in this country when it comes to people with mental health conditions who are experiencing crisis. So level setting a little bit, and I imagine that many of you who are listening are very familiar with this, but just to have a level set, when we talk about a mental health or suicide crisis, we're really looking broadly at any situation where a person is at risk of hurting themselves or others, or prevents them from being able to effectively function within the community. So for some examples of a person in crisis, they might experience one or more of the bullets that you see on the screen, whether it's actively thinking about suicide or self-harm, erratic, unusual behaviors, delusions, paranoia, other psychotic symptoms, substance use disorder, extreme withdrawal from everyday life. We look at mental health or suicidal crisis within a large umbrella and that we are hopeful that the 98 in crisis response system will be able to help people in whatever state they might be in. So before we jump in to talk about today's reality, unfortunate reality, I want to share some sobering statistics. So one in four people who are involved in fatal police shootings have been people with mental illness. About 2 million times a year, people with mental illness are booked into our nation's jails. So it's not 2 million people, but 2 million times a year, because we know for some people cycling in and out of jails, because in many cases, because of symptoms of mental illness is an all too common phenomenon. Over 100,000 people have died of drug overdoses. And every year for the past number of years, 45,000 people have died by suicide. It doesn't have to be this way. But in part, it is, that is the unfortunate reality, because when someone is experiencing a mental health crisis, they are more often likely to interact with a law enforcement officer than with a medical professional. And the patchwork of crisis response systems really varies significantly around the country. We know that there is a really inequitable response for many underserved and historically marginalized communities. We know that communities have also done amazing things and set up different numbers and different resources available in the local communities, but that creates a patchwork of many times 10 digit numbers and trying to remember when you need a number at a given time can make it difficult when you're in a crisis to figure out how you get the help you need. In many cases, police response is the only emergency service available. We also know that overcrowded emergency departments are ill-equipped to handle people in crisis and can lead to people just languishing in ERs where we know that that's not the best place for people to get care or to get on a patch recovery. There's also high rates of arrest and incarceration, hospitalization, ED visits, homelessness. These are all negative situations that we hope that a reimagined crisis response system can help with. We can do better. And we really hope we are moving on the track to doing better because we know how to do better. There are national guidelines for crisis care. These are created by the Substance Abuse and Mental Health Service Administration and they established really these three pillars of a best practice standard of care for crisis response for people with mental health conditions. So you can see the three pillars on the screen in front of you. The first is the 24-7 crisis call centers or someone to talk to said in an easy way. This is the idea. This is really 9-8-8 at its heart, 24-7, 365 days a year that you are able to call a number, call, text or chat a number, I should be careful with my words, and receive a response by someone who is trained in mental health crisis and who is able to in many cases talk to the person, assess the situation, deescalate, and then hopefully connect them to follow-up services in the community if needed. The next level of care are mobile crisis teams or otherwise referred or thought of as someone to respond. Because while in most cases someone to talk to might be all that's needed in a situation, we know for some individuals they need a little more help and they could need someone to respond in person. But the idea with mobile crisis teams is that a law enforcement officer with a gun is not who shows up at your door. It is a trained mental health professional who can help assess the situation, deescalate, and connect to follow-up care, in some cases transport to crisis stabilization or other services. But in many cases, mobile crisis teams are all that might be needed to fix the immediate crisis at hand. But for those who that's not enough, there's the third and final pillar, which is crisis stabilization or thinking about it a safe place to go. And these really are living room type settings, so kind of one step removed from a hospital ER department. You know, you might have not beds, but chairs, a welcoming place for someone to be able to continue to deescalate, stabilize, or, you know, continue to detox if it's a substance use issue, and then really connect them to follow-up care with a warm handoff. So as I said, we know what the best practice standard of care is. We have these wonderful three pillars that are really fairly straightforward, someone to talk to, someone to respond, and a safe place to go. But what we need to do is help ensure that we build these out. So let's start with that first pillar for the someone to talk to, which is really 988, the crux of this presentation. So let's step back to the basics. What is 988? It is now the three-digit universal dialing code for suicide crisis, substance use, and mental health crisis. It is available nationwide, all 50 states, five territories, and D.C. No matter where you are, if you call 988, you will get connected to what was the National Suicide Prevention Lifeline, now called the 988 Crisis Lifeline. And really, our goal is that 988 is that entry point to a reimagined crisis response system and an alternative to law enforcement. So let's get a little brass tacks. How does it work? 988 operates through the existing National Suicide Prevention Lifeline, which is not a new service. It has been available since 2005. It is funded with federal funds appropriated by Congress and funded through SAMHSA. And it's SAMHSA who then funds vibrant emotional health, who is the administrator of the Lifeline. It is free, confidential. It's available 24-7, 365 days a year. When you dial 988, your call is going to be routed to one of the 200 local crisis centers. So you're not getting someone who is in kind of a main, you know, one massive facility answering calls. The whole notion is that you are connected to local care. Right now, you are connected to a call center based on your local area code. This is problematic and an issue that we are working on because many people have cell phone numbers that are not associated with where they live right now. I have a colleague who grew up in New Hampshire. She has a New Hampshire cell phone number. She lives in Washington, D.C. She dials 988. She will get connected to New Hampshire Crisis Call Center. And we know that that is less than ideal because we want people to be able to be connected to follow-up care in the community when at all possible. So we'll talk about that a little bit more, but know that when you dial 988, you will get connected to a local call center, but it is based on that area code. So when you dial 988, you will be asked to press 1 if you want to get connected to the Veterans Crisis Line. So this provides an easy option for specialized services for those veterans who want to identify as a veteran and get transferred over to the Veterans Crisis Line. If you press 2, you'll be connected to the Spanish subnetwork, so where there's robust Spanish-speaking language ability. If you don't press either 1 or 2, you will be routed to the local call center, as I said, based on your area code. If for some reason that local call center is unable to answer, the call will be routed to a national backup network. And I really walked through that when it comes to calling 988, but it is important to know that the functionality also exists if you text 988 or you can go online and chat as well. So I don't want to miss out on those two important ways for reaching out for help, particularly for young people. As we know, the data shows that texting is a preferred way to communicate, and having those services available through the Wi-Fi is critical to reaching the audience that we are hoping to be able to reach. So a thing that's important to keep in mind is that we had lots of work establishing 988 at the federal level as this new three-digit number to access help. But if we don't do anything, a number is all we're going to have. It's going to be an easier way to get to the lifeline, just like 911 is an easy way to get to emergency services. That in and of itself is wonderful, and we know will save lives. However, we are really looking at 988 as the possibility, the starting point of a reimagined crisis response system, one that can help more people regardless of where they are and what their needs might be. We want it to be so much more than just a three-digit number. As we think about that, let's spend a little bit of time talking about the differences between 911 and 988, because we've seen, especially in the media, I think the attempts to simplify what 988 is and describe it to the public, I've seen in print in many circumstances that it's the 911 for mental health. And certainly there's some truth to that, but at the same time, there are really important differences between 988 and 911s. I want to talk through some of them here. With 911, your calls are answered by operators. With 988, your calls are answered by trained counselors. So really the notion is 988 is the intervention. 911 was always designed with the intent to dispatch emergency responses, not to be the intervention itself, whereas 988 is the intervention. With 911, you have an operator that's collecting information. As I said, ultimately the goal or the end result is dispatching those emergency services, whether it's fire, police, EMS, the notion you call, you get a response. 988, in most situations, you call and no response is needed, because 988 is the intervention. The calls being answered by trained counselors who are there to identify the situation, try to resolve it, de-escalate, connect people to care, really provide an intensive service rather than connecting to care. As I said, ideally, the counselors would be able, the 988 counselors would be able to dispatch mobile crisis teams when an in-person response is needed. However, that is not the norm, that is not the standard, that's not the expectation. The expectation when you call 911 is that you are going to get a response. The expectation when you call 988 is not the same, and in most situations, the data tells us so far, an in-person response is not needed. You'll see at the bottom, one thing that we are working closely on is that the notion, the connection between 911 and 988 is pretty significant, and we know we need to work to make sure that there are standard operating procedures to transfer calls between 988 and 911 where appropriate, because there might be some, we know that there are instances right now when people call 911, and they really might not need an in-person response. There are certainly situations where someone might call 988, where a 911 response is the more appropriate response. We know the systems need to communicate together, and there's been some great work done already, but it's something we are going to continue to advocate for. So let's spend a little bit of time talking about, as I had mentioned, the intervention is the 988 services in most cases, and most cases are resolved on the phone. This wonderful image that I hope you can appreciate and take a look at, because there's a lot of really great information on this slide, is based on a wonderful, well-developed crisis response system in Tucson, Arizona. So this is data from their system, but we take it as a data point for us to consider as 988 is expanded nationwide, and as more communities build out crisis response services. So as we said, the end point is the whole notion of an easy access for people to connect to care, instead of having a police or law enforcement response. So you have the person in crisis, see they're waving their hand over there on the left side, reaching out to the crisis line, or in this case, 988, and it's estimated that 80% of those calls can be resolved on the phone. That is the number through the Tucson model. SAMHSA has estimated, based on some vibrant data, that their number is closer to 98% that it can be resolved on the phone. This is a data point that we will certainly learn more about in the future as 988 continues to be implemented. But so thinking somewhere between 80% and 98% of situations can be resolved over the phone with no additional follow-up needed, so they kind of fall off. But for that, let's say 2% to 20% of individuals who might need more help and need someone to respond, that second pillar of an ideal crisis response system, we have a mobile crisis team available. Again, that's the notion that it's a behavioral health professional who is arriving on the scene and providing mental health services rather than a law enforcement response. For most instances, when mobile crisis is needed, the estimate here is that 70% are resolved in the field and do not need any additional, any immediate follow-up care. We certainly hope in a lot of these situations that people can get connected to ongoing care in the community, but that the crisis is resolved by the mobile crisis team in the community. For those individuals who might need something more, then that goes to that third level of the crisis, the ideal crisis response system, which is crisis stabilization facilities. And of that amount, we know the vast majority, 60% to 70%, are discharged to the community and hopefully connected to follow-up care to avoid crisis in the future. We do have some individuals who require post-crisis care, whether that's wraparound services or even crisis residential or crisis respite services. But in the Tucson model, about 85% remain stable in the community. Again, this is all the notion that, to the extent possible, by building out a full crisis response system, we have the opportunity to get people the mental health care that they need in the moment of crisis and then connect them to follow-up care so that they're able to live healthier lives and avoid future hospitalization avoid future crisis, avoid future interactions with law enforcement. That is the goal behind this whole reimagined crisis response system. So let's spend a moment talking then about, we've got those three pillars of care, the crisis response system. How are we doing as a country when it comes to those three pillars? So really, where are we today? So we've got, we have 988 available nationwide, a huge step in the right directions. We said connected to about 200 local call centers. Those crisis call centers are doing amazing work, but we know that they desperately need more funds to be able to continue to provide the life-saving services that they are providing to individuals, and in many cases, on a fairly shoestring budget. There's been significant federal investment in funding the 988 lifeline overall and having money go down to the local call centers, but we still identify a huge need for it to be able to actually serve and meet the demand of people who can benefit from the 988 system. So the first pillar, drastically underfunded. Mobile crisis teams right now are only available in certain areas. I'd like to say that every day the availability increases so that there are more communities that have access to mobile crisis teams. We've had a number of funding streams to local communities. There's also a new Medicaid option for states to leverage federal Medicaid dollars for mobile crisis teams. All of these things are, you know, kind of set the stage for more and more communities to expand access to mobile crisis teams, but right now, they are far from being available nationwide. And that final pillar, that crisis stabilization or a safe place to go, they really are very limited. Where they are working, they are working wonderfully, as you saw from the slide previously from the Tucson model. We know that they're working wonderfully. We just know that they are not available to really any significant extent nationwide. So we've got a lot of work to do. And I wish I could tell you that there was a one-stop shop where you could go to identify what services are available in your local community, but unfortunately, it's not so straightforward. There is no national database right now of crisis response systems or, you know, whether your community has mobile crisis or crisis stabilization. So the best way to figure out what's in your community is just to be, you know, call around, become familiar with what your community offers, whether that's reaching out to your local call center, whether it's calling the police and understanding, you know, do you offer a mobile crisis team? Do you have behavioral health professionals on staff? It's also things as easy as connecting with your local NAMI who will be able to explain what services are available, especially if you have a loved one who, you know, who you might imagine could find themselves in a situation of crisis in the future. Knowing what's available in your local community can be extraordinarily helpful. So you can, you know, make informed choices and be aware of what the response might be if your loved one is in crisis. So while the slide kind of presents a little bit as a sad situation that, you know, we're underfunded, not available everywhere, only available in certain communities, the good news is there is overwhelming public support for increased action and to reimagine our crisis response system. The information that you see, the poll numbers that you see on your screen now are from a poll that was taken back in May. So it's a number of months ago. I hope that you will stay tuned, that we will have updated data on, to see where the public is on this issue fairly shortly. But let's look at what they were a couple of months ago. Four in five believe that when someone is in a mental health or suicide crisis, they should receive a mental health response, not a police response. Overwhelming support. Ninety-one percent of Americans support the creation of 90 Day, of the 24-7 crisis call line. Interestingly, when you talk about funding, which can often result in not as much universal support, 85 percent of people supported state funding for 90 Day call centers and crisis response services, and 83 percent supported federal funding. Nearly three in four would be willing to pay a monthly fee on their cell phone bills for 988 services. And this one was pretty striking to me, that that overwhelming amount would be willing themselves to pay an additional fee for 988 services. We'll talk about this a little more in a moment, but the federal law that established 988 really envisioned states establishing these monthly user fees as a way, as an option to fund crisis response services. Because as many of you, if you've ever taken the time to look deeply at your cell phone bill, you'll see that in most cases, in most states, you are paying a fee right now for 911 services. So having a comparable 988 fee on the cell phone, you know, certainly would provide a funding source for the three pillars of crisis response services. And so, you know, I was delighted to see such a high number of respondents say that they would be willing to pay a monthly fee for those services. So let's take a moment to talk about what's happened so far. As I said, that we, you know, like so much in life, things come down to dollars and cents. And we know that in order to build a system, we are going to need funds. We have been looking at this in the context of what we've called kind of a braided funding approach. That's a combination of federal, state, and local investments in both the 988 number itself, and then those associated crisis response systems. As I said, there's significant federal money coming to states in a variety of bills that have passed this year. I mean, it's almost been overwhelming, the amount of money that has been become available to states for 988 and crisis response system. We also know a number of states have taken action. And as I've mentioned previously, the federal law envisions states require establishing user fees for 988. And we have a number of states who have acted on that front. We'll talk about that more in a second. But also local investment is so critical because in many cases, you know, the local community knows best what they need, what the needs of the community are and how they can respond. But kind of cross cutting that, we look at, you know, in order for this continuum of crisis response services to remain sustainable, we need sustainable funding. And that includes insurance coverage of crisis response services. Medicaid is really leading the way. As I mentioned earlier, there's an option for states to take advantage of Medicaid funding for mobile crisis teams. And we have a number of states who have already put forward proposals to pay for crisis stabilization within their state. So while Medicaid is leading the way, private health insurance is a little bit more of a question mark. We know that some plans will cover crisis response services, but really understand that it's far from the norm or the standard at this point in time. So it's something that we are looking at our advocacy, both at the federal level, as well as with individual providers who ultimately can make those decisions when there's not a clear cut federal requirement for coverage. We're also looking at it in the context of Medicare. So let's spend a moment, as I mentioned, the state telecommunication fees. And forgive me, we have wonderful news that makes this map that you are looking at slightly out of date, because late last week, California became the fifth state to enact a telecommunication fee, basically a user fee on people's cell phone bills. So you'll see the gold states that are listed on this slide were the four states that had passed 988 fees up until a week ago. We are up to now five states, including California. And basically, it's an average of a dollar a month on your phone line. I live in Virginia, so I very happily have looked at my cell phone bill and see that line for 988, and I couldn't be more delighted to pay for it each month, as much as I'm delighted about paying any bills. But really, you can see here the states that are, one of the things that NAMI is doing is we are tracking state legislation, because while we only have five states that are over the line with kind of the best practice established for crisis response funding at the state level, there are a number of other states, you can see in the green and the purple, who have taken action on 988. It might be studying it, it might be establishing a council to look at it. So if you're interested in knowing more about what your state is doing when it comes to crisis response funding, please go to reimaginecrisis.org slash map, and you'll be able to click on your state and learn the specific details of what's going on in your legislature, and hopefully provides an opportunity for advocacy. So what happened on July 16th? That date certainly we were tracking very closely, it might be some of you on the phone were familiar, some of you probably might not have any idea that July 16th was the date that the Federal Communication Commission established that all telecommunications carriers had to connect people who dialed 988 to the lifeline, which means that anyone now throughout the country who dials 988 will be connected to the suicide and crisis line. And importantly, originally, the suicide prevention lifeline was focused exclusively on suicide, but it is explicitly now established to address a wide range of mental health, substance use and suicide crisis. So really anyone experiencing any type of emotional distress and also being a kind of a term that is used. So let's talk about what has happened, what's the early data? You know, we're now a month and a half, am I doing my math right? July, August, September, October, into having 988 as the way to get to the lifeline. Fairly recently, SAMHSA released numbers looking at the number of contacts in calls, chats and texts. You can see that in the chart in front of you. Overall, the bottom line number is that a call volume increased 45% when you looked at August, 2020 versus last year at that same time. So, you know, kind of the notion, if you build it, they will come. And I think this increase really shows that the availability of an easy to access number increased call volume. You know, we do know some of those calls where people just calling to say, oh, I wanted to make sure it worked. I wanted to see how it worked. Who are you? How, where do you, where are you? How am I connected to you? But we know that there's also a significant number of additional help seekers within that 45% increase. Encouragingly, the data also shows higher answer rates, reduced wait time and a reduced abandonment. So is the system perfect? Is this data that I'm showing you ideal? I don't think anyone would say it's ideal, but it is improving over what was previously looked at as the call volume. So to draw your attention to a few things that really struck me, the average speed of answer for calls was 36 seconds, which I know, you know, I think about all the times that I've had a call, you know, someone or something to, whether it's to get help or not necessarily in an emergency situation, but where I'm on hold for a really long time, 36 seconds, I'm sure we can do better, but that certainly is an average answer speed that is continuing to decrease. And I imagine we'll continue to do so. You know, I'd also look at the 12% figure when it comes to overall abandoned calls. That is something that I know folks are looking at because really we wanna have a situation where we don't have calls abandoned, you know, whether people are unhappy with the wait time or whatever might cause them to abandon a call, we know that we need to work to decrease that. But surprisingly, if you see the text, only about 2% of texts were abandoned, which is certainly a fairly low percentage. So I presented a little bit on kind of what happened so far, where's the data, you know, where would we like to be? So now let's think about what are our priorities moving forward? And I'll really talk about the way that NAMI View is looking at trying to help communities build out that ideal crisis response system. But what are the things that we are particularly paying attention to? First is funding for specialized services, both for LGBTQI folks, youth and young adults, as well as Spanish text and chat services, because we want the 988 crisis response system to be accessible to everyone who needs it. And that includes historically marginalized populations who need specialized services and that we want to have available through this 988 system. We also want more funding for local call centers. We know they could all use additional resources to help make sure that they are not abandoning calls, as we saw on the last slide, and that they have the resources needed to be responsive to the people within their community. We also know that there are, Congress funded a mobile crisis team pilot program, which is wonderful in providing funds to local communities. There is also, as I mentioned, the Medicaid option to provide federal matching dollars for mobile crisis teams. We want to make that enhanced matching rate permanent. Right now it is a temporary enhanced rate. It is a kind of a permanent change in terms of a covered service, but a temporary FMAP boost. So we are hopeful that that can be permanent to clearly incentivize states to expanding services within their community, given that having such a robust federal investment in this services is only helpful to make sure that you have the needed funding to pay for what's required in terms of establishing those crisis teams and keeping them available. When you might be a situation where your team isn't actively helping someone 24 hours a day, how do you make sure that you have the ability to fund so it's available at all times, even if it's not used every minute of every day. As I mentioned, a backbone of our advocacy is really around insurance coverage of crisis response to ensure that individuals with insurance are able to receive the care and have that paid for in a routine way, just like we pay for any other healthcare services for physical health needs. And we always want to have the focus, the overall goal of this is really a reduced dependence on law enforcement so that people in mental health crisis don't get unnecessarily caught up in the criminal justice system. I mentioned earlier, geolocation or routing of calls is also an issue that we have been working with the Federal Communications Commission or FCC on. Because as I'm sure you'll remember when I described earlier how 988 works, you are connected to the local call center based on your area code. And that system, I would presume, might have worked perfectly in a pre-cell phone world where people were calling from a landline. So that was a local area code and you were connected appropriately. But nowadays with cell phones being the predominant form of communication and people not necessarily having a cell phone number where they are geographically located creates a situation where you're connected to a call center that might not be your local call center. And that really hamstrings the ability to connect people to local services, connect them to resources within their community, but also in an instance where someone needs more than just someone to talk to, needs that mobile crisis response, it can make it more complicated to activate a mobile crisis response team if you live in D.C. but are connected to a New Hampshire call center, for example. So NAMI can't do this alone. That was a big list of our priorities moving forward, which is why I want to spend a moment talking about our Reimagine Crisis Response coalition and effort. This is a, we created the crisis response activities and coalition really with the overall thought that it is not just the mental health community that looks at today's answer to people in mental health crisis as needing to be improved. So we've partnered with over 45 organizations. You can see many of their logos on the screen. I suspect that many of you might be associated with some of these organizations. We really have a lot of kind of the, our frequent partners in the mental health community are all locked arms and standing together on this initiative. But because this is something that impacts many other facets of life and many other stakeholders, we really tried to take a very broad view of who we targeted for this coalition. And you'll see we were wonderfully able to bring together many, you know, kind of in some ways odd bedfellows, people who have never worked together before. For the medical professionals, you see we have the pediatricians, the emergency physicians, social workers. We also have people in the social justice space, like the Legal Action Center and LULAC and ACLU. When it comes to criminal justice organizations, we have the major county sheriffs of America and PTAC. People who not necessarily work together on a normal basis, but that everyone could be united in the notion that the way we respond to people in a mental health crisis today is not ideal and that we need to work together to make it better. And, you know, as I lead federal policy at NAMI, and when we were talking to policymakers, it is wonderful to be able to say, look at this vast array of organizations who are standing before you today, united in our ask for whatever it might be. Because while these organizations don't necessarily agree on everything, when it comes to crisis response, there is very little disagreement. So we are delighted to be able to run this coalition and really look to continue to move the ball down the road and advance crisis response and expand it nationwide. So I'm going to move to this additional resources slide. I know that you have access to these slides and you can connect to the links that are available, whether it's connecting with NAMI, with our Reimagined Crisis Coalition partners. If you are part of a professional organization that you did not see on that list, but you think might be interested in working with us on crisis response, please reach out. I know my email is available. It's jsnow at NAMI.org. And then up on your screen now is the bibliography. These are our different sources that I used in this presentation. And I think at this point, I turn it back over to Dr. Cohen. Thank you so much. We really are at a transformative moment. Not sure why we're getting feedback. We're really at a transformative moment now. And it's really exciting to hear your vision, NAMI's vision, and the vision of the coalition and SAMHSA about what we had and where we're going and why we need to go there. So I thank you so much for your interesting presentation. And I'm just going to say a few words and then we'll move right into Q&A. So I want to take a moment and let the audience 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 the app now at smiadvisor.org forward slash app. So Jennifer, I want to turn to, first of all, I want to encourage everybody to download the slides because that slide that you have with the links for resources is really critical. And I know we ran over that really quickly. I think the two things that are incredible take-homes are, one, the map so that people can find out about their state, what's your state doing? And two, the resources. And I would encourage people to go to the SAMHSA website that's located on there. There are posters you can get for your clinic. There are stickers. There are magnets that you can order and they'll send to you. And you can put that up at your clinic or your waiting room or whatever. So I really encourage you to do that. They also have little tidbits that you can pull and put on your LinkedIn or your Facebook or any place where you have a network and you want to talk a little bit about 988. They've got sort of talking points. So there's quite a bit there at SAMHSA. So I would encourage people to look at that. So let me turn to some of the questions. We've got some, like, very operational specific questions and some overarching questions. So, and a lot of people, I'll just tell you, said amazing presentation. I agree with them 100 percent. Thank you. So here's one. So is a safe place that you're talking about, the third tier in your thing, is that the same as a respite, like a respite home, a respite site? You know, that's a really great question. And I think the crisis stabilization is, you know, a safe place to go is the least built out part of this system. The SAMHSA national guidelines have some best practices for those. I think it's feasible that it could be that crisis respite would serve as a crisis stabilization facility. You know, I think that more often than not, though, you're thinking about facilities that really their purpose is very short term, you know, kind of 23 hours, really just a place for someone to continue to, you know, whether it's deescalate, decompress, detox, whatever it might be, which I think can be a little different than what crisis respite can be. But this is an area, some of the legislative proposals that we have been working with members of Congress on are kind of trying to establish a better framework for what does it mean to be a crisis stabilization facility and what are some best practices that can be used? You know, I know I live in Arlington County in Virginia, and they thankfully have a wonderful crisis stabilization facility. You know, we hear stories of some where it's kind of a separate room off of an ER staffed with behavioral health professionals. So it is within kind of a hospital structure, but yet a separate facility, not taking up that emergency ER bed that might be needed for someone whether, you know, with a physical health emergency, whether, you know, a gunshot, a heart attack. We want to make sure those facilities, those beds are available as needed there too. Right. I mean, the way I think about respite is it's a bigger umbrella than crisis stabilization. So it's not exactly a one-to-one, but I get where this person's going. And in some ways, some of the respites that we have right now might be transformed into crisis stabilization with the new monies that are flowing into the state. So, it's a great question. You know, a couple people wrote in and asked, what if I am a witness to a friend, a family member who's in crisis? Can I call 988 on their behalf or should I be calling 911? Is 988 just for the person in crisis? Oh, I am so glad that this question came up and I'm actually kicking myself now that I did not address this at all. No, 988 is intended to also serve kind of secondhand individuals. So, family members, loved ones. The goal is that those trained crisis counselors can take calls not only from the individual immediately impacted, but also by family members, loved ones. Now, I want to be clear though, there could be a circumstance if your physical health is in jeopardy, where it might be that you need an emergency response immediately. And I don't want to ever make it out as if 988 is a replacement for 911. There are circumstances where we need emergency dispatch immediately. But if you're someone with a family member that is in crisis, 988 can be a resource for you and certainly should be looked at as that way. Perfect. So, I'm going to kind of put some of these questions on our continuum line. So, we just answered who can call. So, another question that came up is, what does it mean if, how do they decide when I call if I am in a crisis, I have a gun, it's next to me, I'm really like, I have the means right there. What happens? Do they immediately say, hey, you're going over to 911 or we're sending the police right now? So, talk to us a little bit about someone who's in an escalated crisis situation. Absolutely. And this is where, in some ways, I wish that we also had Vibrant on the call because they can talk in much more detail that I can of the operational procedures that the Lifeline has established for situations like that. Basically, I believe they call it their eminent harm protocol. And I can say that they have protocol established to help those counselors assess when a situation warrants immediate intervention. And these are things that really we're starting to think about more and more because it can get tricky when it comes to whether a person is, in most cases, we understand that individuals will self-disclose their location so that if emergency response is needed instantly, that they are able to provide that. But in those instances when it's not, it really triggers an emergency contingency circumstance where they have a process that kind of is activated and privacy issues come up and we want to make sure that people seeking help use 988 as a resource, but it does get complicated. If it's helpful, I am happy to share. I know that the Vibrant protocols for the contingent circumstances are something that is available. And I'm sorry that I don't know them well enough to speak directly to the circumstances, but I'm happy to connect offline with the questioner and to connect to them with folks who could really describe the process that the crisis counselor goes through when someone, I mean, to your point, has a gun in their hand and is considering using it and what happens in those types of situations. What I'm hearing from you and what I also understand from my exposure to the work around 988 is that there is a very rigorous training and retraining protocol for anybody who works at a crisis center. So this idea of at what point do they shift it over to 911 or crisis response, that's all laid out. And there's lots of role plays. And the crisis centers can handle some very significant situations. So, and in terms of somebody else asked, well, then when, if you don't have a mobile care team in your neighborhood, who comes if it needs to, if we get that situation where we need someone to come right away? So do you wanna speak to that? I mean, there's not the right answer to that because we're building that out. But sure, yeah. No, absolutely happy to answer that. And you were just to start off, you were so right that the training that these individuals go through is significant. And I think we can see that in the data that the vast majority of situations are deescalated on the phone. We won't know what the precise percentage is, but we have a data point of 80%, a data point of 98%. The reality is probably somewhere in that notion. So you have to think of all of the situations where, so, I mean, no one is calling a 988 or previously the suicide prevention lifeline kind of on a win. I mean, the very significant calls are what the norm and that they're able to resolve the majority is really telling to the skill and the training that those crisis counselors receive. You should have a very good question. You live in a rural community, there is no mobile crisis team, what happens? And really the answer is you are most likely going to have a police officer show up at your door if in-person intervention is needed and there is no mobile crisis available. This is where we are, we, you know, thankfully a number of communities across the country, I shouldn't even say a number, a vast majority, a significant number have some officers who've been trained in crisis intervention services. And, you know, certainly having an officer who is a trained CIT officer arrive on scene, I mean, that's a step in the right direction. That's someone who's familiar with the notion of someone in crisis and how to respond and help them deescalate. So that is something that I know, you know, for communities that don't have mobile crisis, if, you know, having some trained, you know, CIT officers, again, that is not the ideal. I mean, an ideal is having a mental health professional, but we realize that that's, you know, something that many communities are working towards, but don't have yet. So that crisis intervention trained officer is certainly equipped with additional skill sets to help respond to that person. And I mean, I'll just put in a plug here, like you kind of said at the beginning, this is where you can get involved with your local area to advocate for money that's being filtered down to the states to help build out this continuum. You know, it's our voices that help them know where to put this money to really build out so that we aren't ending up with people who are in a mental health crisis, sitting in the ER for hours or sitting in the back of a police car. We don't want that. So let's help our legislators know where to use their money to build out this, what we're calling a continuum of care. A lot of different places along the continuum where people can get help that's tailored to where they're at. I have so many good questions here and I know we need to end. I mean, I think one of the other things that people are kind of wondering about is what is going on with these kind of, what about people on the streets who are in crisis? I know we don't have the answer for this, but do you have any insights into that? I know across the country, we're all struggling with seeing folks who might be unhoused, who are struggling probably with a mental health crisis. Any thoughts on that? You know, that is a great question and a significant problem, and a significant issue that NAMI, that we work on at the national level, but that really our local NAMIs tell us about almost every day. It's housing, housing, housing. How do we get people who are unhoused in a better situation? And I really wish that I could say we have a solution or honestly, I wish I could say that that this crisis response system is gonna provide that solution. But I'm a pragmatist at heart and I'd say in the vast majority of the situation, having access to crisis response helps in that immediate crisis, but it really doesn't do anything for the people who are unhoused, who need long-term, stable, affordable housing. You know, I wish I could say that this solution in and of itself would get at that, but I think it is our advocacy around other issues related to housing is really what's needed. You know, certainly you can talk about addition of the need for a full continuum of care, including inpatient beds for people who might need a more intensive level of care, but it is so much of this comes back to that safe, stable, affordable housing. So to the extent that the folks are interested in that, I mean, we have lots of advocacy work we are doing on that front, but it is, you know, in tandem with our work on crisis response system, not as much directly linking it. We can only tackle so much at once. I know, no, and let's, none of these are siloed. As we build up a continuum, that may also help with the folks who are unhoused, who are having, so I feel like the work that we're doing on 988 is going to impact a lot of other things that we're also trying to work on, because if nothing else, it's raising awareness that a lot of people are having mental health crises or are struggling, and the more we talk about that, the more we kind of expand how we can help those folks, us, whoever is in crisis. So what a great conversation it was to have with you today. I just really have enjoyed this, and I know our audience has as well. 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This service is available to all mental health clinicians, peer support specialists, administrators, anyone else in the mental health field who works with individuals who have SMI. Completely free, confidential, and you'll see here it's backslash submit dash consult. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available in the Mental Health Addiction and Prevention TTCs as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. And to claim your credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance takes up to about five minutes after we end. You'll then be able to select next, advance, and complete the program evaluation, which is needed before you can claim your credit. Thank you for joining us today, and please join us on October 19th as Dr. Vanessa Kladnick and Rebecca Johnson present Enhancing Individual Placement and Support, Supported Employment for Transitional-Age Youth, the Career and Occupational Readiness Experience. Again, this free webinar will be held on October 19th at 3 o'clock Eastern time, which is a Wednesday. Thank you for joining us today. Thank you again, Jennifer. And until next time, everyone, take care.

Dr. Amy Cohen

SMI Advisor

9-8-8 crisis hotline

webinar

Jennifer Snow

NAMI

mental health crisis response system

funding

advocacy efforts

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