A three-digit mental health crisis line launches Saturday with the ambitious goals of reducing emergency department visits and encounters with law enforcement and providing ongoing care for those experiencing mental health crises.
But in many states, aspirations are a way off from being a reality.
People seeking help will be able to text or call 988 to contact trained counselors through the existing National Suicide Prevention Lifeline, a network of more than 180 call centers that has been using a 10-digit, toll-free phone number for years. With the revamp, providers hope to assist people with mental health concerns and emotional distress, in addition to suicide crises, by directing them to resources and connecting them with response teams and programs.
The Federal Communications Commission designated 988 for suicide prevention and mental health emergencies in 2020. Later that year, President Donald Trump signed the National Suicide Hotline Designation Act into law, which established 988 as the new number for the National Suicide Prevention Lifeline and the Veterans Crisis Line.
The Substance Abuse and Mental Health Services Administration distributed nearly $300 million in grants to states last year. The funds are meant to strengthen and expand Lifeline network operations and technology infrastructure, and to staff local crisis call centers. The American Rescue Plan Act also enables states to request Medicaid funding for mobile crisis services.
"What's different and ambitious about the 988 project is that over time there are goals to have every call to the lifeline answered within local communities as opposed to as part of a national network, and also to couple the availability of call response in communities with a continuum of care to respond to and provide follow up for individuals who contact the lifeline," said Dr. Rebecca Brendel, president of the American Psychiatric Association.
Local crisis centers are in "different phases of readiness" for the 988 rollout, owing to hiring challenges and to unfinished efforts to coordinate 988 services with others, such as 911 emergency response.
It likely will take years for the full array of 988 mental health resources to be available to people in every state, said Dr. Brian Hepburn, executive director of the National Association of State Mental Health Program Directors. For example, even states with well-prepared call centers may lack mobile crisis teams and crisis stabilization programs, he said.
SAMHSA expects the volume of texts and calls to the National Suicide Prevention Lifeline to rise to 7.6 million next year, compared to 3.1 million in 2021 and 3.6 million so far this year.
One concern in the healthcare industry is the absence of national standards for the rollout, which will cause variation in funding and policies among states.
Only a few state legislatures have enacted or even introduced legislation to build crisis stabilization systems with physical settings for diagnosis and observation and experienced staff, which the 988 project requires, said Caitlin Gillooley, director of quality and behavioral health policy at the American Hospital Association. The AHA is compiling resources for behavioral health crisis care that will complement SAMSHA guidelines to states, she said.
"We're trying to identify where the gaps are and what still needs to be done," Gillooley said. "That's advocating for additional funding at the state and local level, as well as workforce and staffing allowances to actually staff the crisis call centers."
The 988 project has sufficient start-up funding, but sustaining the financial support will be a challenge, Hepburn said. State and local authorities will need money over time to staff call centers, mobilize response teams and manage operations, he said.
"It's coming down from the federal level, but it's being implemented in state- and local-based ways," said Jason Lerner, who is senior portfolio director for emergency response for the Health Lab at University of Chicago Urban Labs.
Many call centers are scrambling and competing with similarly understaffed systems such as 911 to hire more counselors, Lerner said.
Workforce shortages, staff retention and burnout were the largest barriers to the 988 launch, according to a survey of 180 behavioral health directors the RAND Corp. conducted in February and March.
Fewer than half of respondents were involved in the development of strategic rollout plans, the survey found. Only one in seven had created budgets to support 988. That suggests inadequate financing for infrastructure and critical service coordination between 988 and 911, said Jonathan Cantor, a RAND policy researcher.
SAMHSA expects that 90% of people who need support will be able to access the call line and 80% have access to mobile crisis teams by 2025, Hepburn said. The goal is for 80% of people who need crisis stabilization to be able to get it by 2027.
The federal agency identified a number of tasks ahead for state authorities, including determining local organizations' readiness to answer calls or texts, developing plans to integrate technology platforms and consolidate data across crisis services providers, and identifying sustainable funding for the 988 hotline.
Local communities should create processes to ensure crisis care is distributed equitably, according to SAMHSA. "There are going to be areas that are doing really well and other areas that are going to do particularly poorly," Cantor said. "It's going to be critical that we identify areas that need help and to get them whatever they need."