Call 988? New mental health hotline faces many hurdles as launch looms. Just ask Ohio.

This story was republished with permission from Youthcast Media Group

In one-quarter of Ohio counties, when you dial the 1-800 number for the National Suicide Prevention Lifeline, there’s no one local to answer and callers are automatically routed to a call center out of state.

In July, when the federally-mandated three digit dialing code for mental health emergencies – 988 – is routed into the lifeline, the situation won’t be much better. In fact, it could be worse, as more people learn to use this number rather than 911.

This is just one of the many problems that Ohio– and many other states across the country– face as they try to prepare for the change the 988 rollout brings. Among the others: Where will callers to 988 be referred for help? Who will they send if the caller needs an in-person intervention? Perhaps most critically: who will pay for all these services?

Although the transition to 988 is mandated by federal law, the job of answering these questions, coordinating technology and overseeing and staffing local call centers – as well as the bulk of the funding to make these things possible – has fallen to state and local governments. In most of the country, there are not enough trained professionals, not enough appropriate places to send people in crisis, and not enough money to close these gaps.

In Ohio as of March, there were 17 call centers staffed to respond to mental health crisis calls to the National Suicide Prevention Lifeline.

Though there are plans to open two more call centers, the situation won’t change much by July.

“Success with the 988 (line) ideally will include every community having coverage for every call, text and chat, with high-quality responses,” says Lori Criss, director of Ohio’s Department of Mental Health and Addiction Services.

But it’s going to take a lot of money, training, and time to get there.

Funding an ‘unfunded mandate’

It’s impossible to tell exactly how much it will cost to fully fund the changes needed to create a complete continuum of mental health crisis care in every community across the country. But the amount won’t be small.

Ohio estimates it will cost about $7 million to fund the initial six months of necessary capacity building from the launch of 988 in July to the end of the year, which will be funded by the state using American Rescue Plan Act and COVID relief money, in part. In 2023, the estimated cost to build and maintain 988 capacity is $15.6 million, and will rise to more than $35 million in 2027.

And in Ohio – as in many other states – it’s unclear where exactly that money will come from.

In its 90-page 988 implementation plan submitted to the federal government in January, Ohio Department of Mental Health officials said while the state supports 988, federal funds are not sufficient to support the transition and the “expectation of fully funding the system is a primarily unfunded mandate from the federal government.”

In Ohio, there’s been a $69 million investment of “flexible funds” to Criss’s department to support the effort since Gov. Mike DeWine took office in 2019.

But, as in many other states, there’s no dedicated state-level funding source for 988 providers or to support the 988 contacts’ responses. In its 988 plan, the state said it expects a mix of state, local and private funding, but does not yet have a sustainable funding source in place beyond next year.

Ohio officials have proposed that the state legislature provide funding when a new state budget is passed in the summer of 2023. They have also introduced a bill to establish a state-level 988 administrator and 988 fund, but it has yet to pass.

The state has considered adding a user fee to telecom bills, as was provided for in the federal mandate, but the state’s 988 bill does not include this.

As of April 18, only four states have passed 988 infrastructure bills with a fee, and only five others have passed 988 infrastructure bills without a fee.  Fourteen have pending 988 legislation. In three states – Florida, Idaho and Montana – 988 bills failed to pass.

Workforce vs. demand imbalance

Beyond the technology needed to field and route 988 calls, there’s another problem: there aren’t enough trained, qualified people to staff call centers, or the behavioral health crisis centers and mobile response units that most states envision as part of an ideal 988 system.

Ohio has capacity to answer only 8% of the chats and texts it receives through the National Suicide Prevention Lifeline now. The state’s goal is for 90% of calls to 988 and at least 50% of texts and chats to the line to be answered in-state by July.

Demand for behavioral health services in Ohio has increased over 350% in the last 10 years, Criss said, while the workforce has not kept up. Half of the state’s population lives in eight urban areas, she said, and  “the preponderance of our workforce is in those metropolitan areas as well,” leaving many communities without adequate mental health resources.

For the foreseeable future, Criss said, many in the state – particularly those in rural communities – will have to continue to rely on 911, and police, to respond to mental health emergencies.

Rick Kellar, president of Peg’s Foundation, a northeast Ohio philanthropy that promotes innovations that support mental illness sufferers, said it’s important to recognize that “people are still going to call 911, and people are still going to land in and around the jail.”

That’s why training police officers to respond to mental health crises is critical, he said.

“Crisis Intervention Team” (CIT) programs and training, introduced first in the 1980s, have spread across the country to 2,700 communities, according to the National Alliance on Mental Illness. In theory, CITs use teams of hospital workers, patient advocates and specially trained police officers to recognize and defuse potentially dangerous situations caused by an individual suffering from a mental health crisis.

The programs, criticized in some places as being ineffective without a broader mental health support system in place, have shown both positive and negative results in studies.

Over the past 20 years, more than 12,000 of Ohio’s nearly 25,000 sworn police officers have received CIT training, according to the Ohio CIT Training report.

“Not everyone’s excited about CIT, but we are in Ohio,” says Peg’s Foundation’s Kellar. “Our police embrace ‘give me more tools so I can be better at my job.’ ”

Building a new system 

Still, even in areas where many or most officers receive CIT training, law enforcement officials say they’d rather not be in the position of responding to mental health crisis calls.

“We’re police officers – we’re trained to be police officers,” said Shaker Heights Police Chief Jeffrey DeMuth. “We’ve never been trained to appropriately respond to a mental health type of call.”

In September, Shaker Heights, in collaboration with a local behavioral health service provider and public hospital, announced a pilot mental health crisis response program that aimed to hire a social worker to assist the city’s police and fire departments in responding to mental health crisis calls.

Six months later, they’ve struggled to find someone to fill the role. They are instead offering follow-up calls from a social worker after police have responded to a mental health call, and only occasionally taking a social worker out on these calls when available.

DeMuth, and his counterpart at Shaker Heights Fire Department, Chief Patrick Sweeney, weren’t aware of the imminent rollout of 988, but said they don’t believe it will greatly impact the way they respond to these calls.

In Dayton and Columbus, similar pilots that are diverting mental health crisis calls from police to EMS have shown early promise in reducing police involvement in such calls. The programs are thus far only operating during limited hours on certain days of the week, however.

Ohio officials and their counterparts in other states emphasize the long-term nature of the transition to a fully-functioning, community-based 988 system.

Ohio leaders point to the success of Arizona’s “Crisis Now” model of coordinated crisis care as an example of the outcomes it hopes to achieve.

That model, which took 20 years to develop, uses trained crisis staff to intercept mental health emergencies that come into 911 call centers and a “No Wrong Door” policy to allow police, at any time, to drop off people in mental health crisis to a stabilization center.

“The crisis center was really meant to make it easier and faster to use than jail,” said Dr. Margie Balfour, a psychiatrist and one of the architects behind Crisis Now. “So the officers are in and out in 5 to 10 minutes, and they’re never ever turned away. No matter how agitated, violent, psychotic, intoxicated the person is, we never turn them away, which is why they like using us.”

By some local estimates, the model has decreased spending on inpatient care by 40%, said Balfour, who is the Chief of Quality and Clinical Innovation at Connections Health Solutions, which runs the Tucson Crisis Response Center.

In southern Arizona, the crisis line receives about 10,000 calls a month, and 80% of them are resolved over the phone. When a face-to-face intervention is needed, they can be resolved 70% of the time. Of people who need to be taken to one of the region’s crisis stabilization centers, 60-70% are discharged within a day, Balfour said.

“We are aiming for the same or better results in Ohio,” Criss said.

It’s a tall order, particularly because one of the keys to Arizona’s success is  centralized regional behavioral health authorities (there are three) that combine and manage all the mental health care funds available to pay for these services. These include state and federal Medicaid funds, block grants from the Substance Abuse and Mental Health Services Administration and state funds for uncompensated care for the uninsured as well as crisis care.

Ohio – like many other states – does not have such a centralized system.

Criss and other stakeholders emphasize the long-term nature of their work and plans.

“It’s going to take a lot of time to get the system response that we need so that it doesn’t matter what zip code you live in order to get good access to the care you need in crisis, or not in crisis,” Kellar of Peg’s Foundation says.

Still, they agree that with the July deadline looming, the time is now.

“With 988 coming, we really have the opportunity to completely transform the way we respond to mental health and substance-use emergencies,” Balfour said.

Zeltner, a former reporter at the Plain Dealer, is Youthcast Media Group’s Director of Content & Programs. Cortes, who will be a college freshman at University of Georgia this fall, covered the Sozosei Foundation’s annual Summit in December 2021 for YMG. Willing is a former USA TODAY national correspondent covering law enforcement and a YMG volunteer instructor and editor. YMG was formerly known as the Urban Health Media Project.