On July 16, the new, three-digit 988 Suicide and Crisis Lifeline formally launched nationwide, replacing the 10-digit number for the National Suicide Prevention Lifeline. While the Substance Abuse and Mental Health Services Administration (SAMHSA) “sees 988 as a first step towards a transformed crisis care system in America,” advocates, stakeholders, policymakers, mental health experts, and others recognize that major barriers—such as limited resources and a lack of coordination between relevant state and federal agencies—exist in the effort to bring all fifty states to the same baseline for crisis response.
In June, BPC released a report outlining recommendations for Congress and the administration to help states overcome these barriers and build out crisis systems that are more equitable and accessible to the increasing number of Americans in need. In the wake of 988’s official launch, we asked three well-respected experts in the behavioral health space—all of whom participated in our event on the topic—to address some outstanding questions regarding 988’s implementation.
How Do We Better Communicate the Functions of—and Build Trust In—988?
In a poll released by the National Alliance on Mental Illness, about three-quarters of U.S. adults (77%) had never heard of 988. Although SAMHSA and others have provided toolkits with sample communications, key messages, and FAQs, their scopes remain narrow, and messages were not tested on people through focus groups or other means so they may not resonate with the general population. In addition, complex messages may need to be clarified and adjusted depending on availability of services in a specific community. For instance, in some states and communities, there are robust crisis response systems with mobile teams and crisis stabilization facilities while in others, there are not, and police and EMS remain first responders in many instances. Crisis services for children also vary by location.
Additionally, messaging to engage historically and continually marginalized populations has not been researched and widely promulgated. While some communities may be concerned about how calling 988 will affect their immigration status, others may be troubled by the risk of possible police involvement and racial discrimination. Furthermore, 988 text support will not be available in any language other than English, potentially alienating youth who prefer to communicate by text. Communications research and messaging would help reach all stakeholders who will interact with the new system in order to differentiate between responses from police, emergency medical technicians, hospital staff, and others.
While there have been increased communications since 988’s launch, no one has fully engaged in the research and testing that is fundamental to a public health campaign designed to influence a national population. Much work should be done to ensure adequate information is provided, including information that has been tailored to the unique needs of different stakeholders and communities. To instill trust in the system, future messaging must be further developed, tested, and customized to the communities they serve to convey exactly what services will be available.
How Do We Increase the Role of Peer Support Specialists in Crisis Response?
Peer support specialists are trained individuals with their own lived experiences who can assist others in treatment and recovery. The involvement of these individuals in the implementation, delivery, and evaluation of 988 is critical, as is their involvement as part of a well-trained, deployed, and supported behavioral health crisis workforce.
Unfortunately, it is unknown exactly how peer support specialists were or are involved in 988 planning and implementation. According to a recent, yet-to-be-published survey of the field, only about half of participants agreed that there was meaningful involvement of those with lived experience in crisis response planning within their respective state and local jurisdictions. Furthermore, the number of peer support specialists remains relatively low. According to a 2018 U.S. Government Accountability Office report, the largest share of funding for peer support providers nationwide is from Medicaid to state mental health agencies. Nearly all states, the District of Columbia, and the U.S. Department of Veterans Affairs certify peer support providers, yet a 2016 study on trends in peer certification identified only 25,317 certified peer specialists in the U.S.
Although research continues to expand and support the evidence base for peer support services, the wages of and compensation for the peer support specialist workforce are unknown. Certified peer specialists remain a young but proven guild in research literature without a history of wage and labor statistics to inform early state and insurance reimbursement strategies. To that end, it is unsurprising that the 2016 National Survey of Compensation Among Peer Support Specialists found many survey respondents describing challenges living on the wages paid for their current work roles.
Understanding wages for peer support specialists across geographic region, organizational type, and other demographic differences is an important first step in developing policies to create mechanisms to support a living wage for the peer support workforce. Given Medicaid’s role as the largest funder of peer support, it is also important to advance research and analysis of the relationship between rates for peer services and the contribution of rates to wages across the country. Finally, states and insurers must revisit current wage methodologies for professional peer workers, considering like-industry certifications and adjusting rates and wages to align with market standards.
How Can State Agencies and Community-Based Organizations Work Together to Ensure the Success of 988?
Wendy White Tiegreen, Director, Office of Medicaid Coordination & Health System Innovation, State of Georgia Department of Behavioral Health & Developmental Disabilities
In Georgia, as in most states, the designated state Behavioral Health Authority is leading the 988 efforts, bringing together other state and local health entities (including Medicaid and Public Health organizations) to form comprehensive crisis systems of care. The state’s emergency responders, often known as Public Safety Answering Points, and the state’s designated Emergency Management Agency are also essential partners in the effort. The partnership, including the coordination and operations between all these health and safety response entities, is crucial to the success of the crisis stabilization response from the first call to ultimate stabilization and recovery.
Community-based organizations also play a key role in development and ongoing success. The law which created 988 did not simply define call center response as the only piece of the broader system; instead, it went further to specify necessary supporting services including Mobile Crisis Response, Crisis Stabilization Units, and other crisis supports including Peer Warmlines and Outpatient Crisis Interventions, all of which are integral to 988’s impact.
The state health authorities, in partnership with all behavioral health providers and insurance groups, should define and create innovative capacity and reimbursement for these services to flourish in a variety of communities, especially rural and tribal communities in which traditional health care capacity may not exist. In those communities, other health and non-health entities such as local government, primary care practices, hospitals, religious centers, schools and universities, advocacy organizations, peer-recovery organizations, and others can create coalitions of like-support while formal systems continue to develop and expand to provide aftercare and, in the best model, prevent crisis before it occurs.
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