988 is a great start, but it’s just the tip of the iceberg

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(BPT) - By Colin LeClair

You’re walking to your neighborhood corner store when you see it: a man across the street is grabbing his left arm and keeled over on the sidewalk. You immediately call 911, speak to someone on the line and within minutes the paramedics are on the scene performing emergency services and taking the man to the hospital. Later that week, the man’s family calls you and thanks you for your quick reaction and for saving his life.

Now imagine you see the same man across the street but he’s experiencing psychosis, disorientation, or hallucination. You want to help, but what do you do? Instead of calling 911 you call 988, quickly dispatching a mobile crisis team of behavioral health professionals who provide emergency services on the scene and take the man to a crisis center where he receives personalized emergency psychiatric care. Later that week, the man’s family calls you and thanks you for your quick reaction and for saving his life. You may feel undeserving of their gratitude, but his family shares some statistics from the National Alliance on Mental Illness (NAMI) to show why your support was essential:

  • One in four fatal police shootings between 2015 and 2020 involved someone with mental illness
  • 44% of people incarcerated in county jails have a mental health condition
  • 37% of people incarcerated in federal prison have a mental health condition
  • Every year, tens of millions of people with mental illnesses end up in emergency departments that are not well equipped to treat mental health emergencies

Will this all change with 988? Yes, but the full benefit of 988 is months or years out. The nationwide rollout of 988 is effective on July 16, 2022, providing a memorable three-digit phone number to match 911 for suicide prevention and other mental health crises. The potential impact is massive. Millions of calls could be diverted from 911, providing people experiencing a mental health crisis with the compassionate care they need while simultaneously streamlining efforts for emergency response, hospitals and law enforcement to focus their time and effort where they are most valuable. The vision and intention are a terrific first step, but the follow-through described in the scenario above is still a long way off.

While the ideal function of 988 is to provide patients with immediate access to psychiatric support, as well as a release valve for overburdened hospital emergency departments and law enforcement, there is currently a lack of nationwide infrastructure to support 988 calls. What’s missing are the trained behavioral health professionals to respond immediately to those 988 calls, an integrated continuum of mobile crisis responders to respond to patients in the community (instead of, or alongside police), a network of qualified behavioral crisis facilities that are equipped to treat any patient at any time of day and a network of outpatient psychiatric professionals large enough to treat those patients for the long term. Where those services do exist, they are often sub-scale, underfunded and disconnected from one another.

Until that crisis response system is developed, the goals and ideal state of 988 will fall short of expectations. Instead, an abundance of 988 calls will continue to be diverted back to hospitals and law enforcement, creating the same responses 988 was intended to minimize. Rather than receiving targeted and compassionate behavioral health care, individuals experiencing a behavioral health crisis will be greeted by police and taken to emergency departments where they may wait hours to receive care from a team that is generally not well-equipped to treat mental health emergencies, or they will continue to be taken to jail and left in a harmful cycle of recidivism.

The good news is there is a proven solution that has successfully treated crisis in Arizona for the last decade. As outlined in “The Roadmap to the Ideal Behavioral Crisis System” published by the National Council for Mental Wellbeing and co-written by Dr. Margie Balfour, Connections Health Solutions’ Chief Clinical Quality Officer, it is possible to develop a holistic crisis ecosystem that proactively treats crisis with targeted, compassionate care across a continuum of services. The success of this ecosystem relies on developing an array of coordinated services designed to meet the patient where they are, much like is done for physical health conditions.

As outlined in “The Roadmap to the Ideal Crisis System,” the crisis ecosystem supporting 988 should go well beyond the direct point-of-care response from 988’s mobile teams. While 988 may be the entry point for many individuals in crisis, it is just one part of the continuum, and its success relies on the existence and intentional development of a holistic crisis ecosystem. To best serve those in crisis, the infrastructure supporting 988 should include:

  1. Pre-crisis services that provide preemptive care to help prevent crisis before it occurs through community outreach, education and easy access to community mental health clinics and other community services;
  2. Acute crisis services that provide a welcoming and therapeutic environment for all while giving patients dedicated, person-centered treatment from a provider and intentionally trained staff;
  3. Post-crisis services throughout the community that coordinate with pre-crisis and acute crisis services to provide needed long-term care outside of a hospital setting and assist the patient in staying connected with family and community-based supports.

Without this infrastructure, the rollout of 988 may fall short of expectations and delegitimize its own existence. If a 988 call is immediately triaged to 911 and causes law enforcement to arrive at the point of crisis or overloads emergency departments, the crisis hotline will lose trust and may ultimately fail. A dedicated, person-centered crisis ecosystem is vital to 988’s success and to providing impactful treatment for those in crisis.

Ultimately, the goal of 988 and the broader crisis ecosystem should be to not only treat crisis where it is, but to also support crisis avoidance, crisis de-escalation and promotion of community-based outpatient care. As the nation rolls out 988, this is an opportunity to invest in crisis infrastructure across the continuum so that we may provide compassionate, person-centered care to our most vulnerable populations.

LeClair is the CEO of Connections Health Solutions.