Update: Overcoming Challenges in Launching 988 Mental Health Hotline

In this episode, Margie Balfour, MD, PhD, of Connections Health Solutions, speaks about the challenges in launching the new 3-digit code for people experiencing a mental health crisis, including the challenges at the local, state, and federal levels. The 988 hotline launched on July 16, 2022.

Additional Resources:

This is a follow-up to Dr Balfour’s previous podcast “988 Is the New 911 for Mental Health."

Margie Balfour, MD, PhD, is a psychiatrist, the Chief of Quality and Clinical Innovation at Connections Health Solutions, and a professor of psychiatry at the University of Arizona (Tucson, AZ).



Jessica Bard: Hello everyone. And welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant 360, a multidisciplinary medical information network.

988 launched across the United States on July 16th, 2022. It's a number to call or text if a person is experiencing a mental health crisis. A survey of a large group of public health officials found that fewer than one-half of the officials surveyed expressed confidence that their jurisdiction was prepared for the rollout of the 988 mental health hotline.

Dr. Margie Balfour is here to speak with us today about some of the challenges in launching 988. Dr. Balfour is a psychiatrist, the chief of quality and clinical innovation at Connections Health Solutions, and a professor of psychiatry at the University of Arizona in Tucson, Arizona. Thank you for joining us today Dr. Balfour. Can you please give us some insights into some of those challenges?

Dr. Margie Balfour: Yeah, that's exactly why 988 is really a soft launch rather than a flip a switch. And now, there is a brand new system launch. What 988 is doing is, it is providing an easy-to-remember, less stigmatizing, easy-to-advertise entry point into the mental health crisis system. It gives everybody a number to call, but then what happens after that call is very variable, depending on where you live. Just like 911 at one point, back in the past, not every community had ambulances and trauma centers and things like that. And that took 20 years or so to evolve into the system that we take for granted today. Where now, you can't even think of 911 without thinking about the ambulances and the trauma centers and all of the response that goes with it. That is currently being built and is expected to mature as 988 gets implemented and is rolled out.

Jessica Bard: What areas do you think need to be addressed in many jurisdictions in order for the launch to be successful? I know we talked about state and federal levels.

Dr. Margie Balfour: Well, there are a couple of different things. Some things are at the federal level. One of the biggest challenges for the response to 988, is that the way the calls are routed, it's based on the area code of the phone that you're calling from. If you have a landline, then that's no problem. It just goes to the nearest call center. But if you're like me and many other people in the US, your cell phone doesn't necessarily match where you live. If I were to call 988 from my home in Tucson, I'll get a call center in Texas, because that's where my phone comes from. And although that call center may have access to mobile teams and crisis services and things, they can't get me a mobile team in Arizona where I live. That's expected to be resolved near the end of the year.

It's interesting, one of the issues that's come up with that is that 911 can tell exactly where you are because they want to be able to send rescue, police, and ambulances as quickly as possible to where that person is. Whereas, 988 grew out of the suicide hotline world, where the research from years ago showed that there's this concern for anonymity and that some people may not call if they can't be guaranteed that their call is anonymous and people may not want people sent to their location. There's been some really interesting discussions at the federal level. And the FCC has recommended that there be an advisory board to look at some of these questions, but it's possible to at least route the calls based on where you are, if not your exact location. That is expected to be resolved by the end of the year, so that will help a lot in the messaging. It's confusing to explain that area code issue right now. When that's not an issue, then you can be assured that when you call 988, you will get the call center that has access to your local resources, so that's one challenge.

The challenge with the local level is the availability of crisis services. Different communities are at very different stages of developing a comprehensive crisis system. Some communities from Arizona is one example that's being frequently looked at as a national model, has a very robust crisis system where crisis call results in crisis hotline that can access the mental health system and make appointments. If needed, they can dispatch mobile crisis teams that can respond within an hour. There are facilities that people can be taken to, but a lot of communities don't have those services.

What 988 has done though, what's come with it, is funds and technical support for planning. Every single state has gotten planning grants to plan how 988's going to work, and then also plan what happens after the call. States are starting to develop mobile crisis teams. Some of the coronavirus relief packages had funding to incentivize states to use their Medicaid system to start to fund some of these things. The next piece of that is having a place to go. There's attention in some of the federal legislation that's percolating around on funding for crisis centers and crisis facilities. But all the communities are in different phases of this, so that poses a challenge. It's both a challenge and an opportunity.

Jessica Bard: What do you believe that clinicians and mental health professionals need to know and understand about this launch?

Dr. Margie Balfour: I think it's important to realize that the messaging around it is local. You need to understand what's available in your local system, so that you can manage expectations and give the people that you're taking care of or their families, the right information about what they can expect when they call. It's important to you reach out to the local advocate groups, your local county health system, or your local mental health system to understand what planning have they done and what are the options and what can people expect when they get a call?

Jessica Bard: And in that same vein, how can they communicate messaging to patients and members of their community?

Dr. Margie Balfour: The messaging is really local. It's important to reach out to the people that have been working on this for the past year. The mental health system, whoever the crisis line is, and see what their messaging is and what messaging that they're recommending, because it's your local system that is going to be most plugged into the details of what actual callers can expect and what kind of services are available. And that should be expected to change over time as well. It's one of the reasons why they're doing a soft launch is because one, they don't want a repeat of, where there was this huge surge of unmeetable demand. Having the soft launch where it's more and more marketing and messaging comes out over time. And the other reason is because that also gives the system the room and the time to mature and develop these services that you need for after the call.

The messaging today may be very different in the messaging six months from now, as communities start to bring these additional crisis services online. If you're a service provider, one way that you can help ensure the success of 988 is to reach out to your local system partners and have consistent messaging. But also, you expect when any new service comes out, that there'll be glitches. You collect data on what's working well and what's not, and give that as feedback to your local mental health system and your local call center. Part of the reason for this soft launch is, it is an intentional quality improvement process because by doing this slower rollout, there's time to factor in this feedback as the services get developed from over time.

Jessica Bard: What do you believe that lawmakers need to understand about this launch?

Dr. Margie Balfour: For lawmakers, I think it's really important for them to realize that 988 is just one step in a long journey to build the kind of emergency response system that we take for granted for medical emergencies. You can't even think about 911 without thinking about the response that comes with it; ambulances and trauma centers and hospitals, and we don't have that yet for mental health. 988 is a great start, but there's a lot of work that needs to be done to create the infrastructure and the funding and the development of the kind of crisis services that you need to respond to mental health emergencies.

There's been a lot of good work thus far on funding. Things like mobile crisis teams, and facilities are next. We need a parody in how these things are reimbursed. Right now, systems that have really robust crisis systems have been doing that based on the backbone of Medicaid while private insurance and Medicare doesn't cover these services. They've been subsidized by these other public systems. That's one thing that needs to change. And that's the message I think is that this is one step in creating a larger system and there's going to need to be the funding for developing that system and creating a sustainable model.

Jessica Bard: Thank you so much for joining us on the podcast today. We appreciate your time.

Dr. Margie Balfour: Thanks