“What happens after 988 answers the call?” How to send help when and where it’s needed

The 988 Lifeline: “A Direct Connection to Compassionate, Accessible Care

On July 16, 2022, the new 988 Suicide and Crisis Lifeline went live across the United States. Designed to “strengthen and expand” the National Suicide Prevention Hotline, the new 988 Lifeline is tasked with providing “a direct connection to compassionate, accessible care and support for anyone experiencing mental health-related distress”, according to the Substance Abuse and Mental Health Administration (SAMHSA), the federal agency funding the Lifeline. “Over time, the vision for 988 is to have additional crisis services available in communities across the nation, much the way emergency medical services work.”

Yet, as SAMHSA correctly points out, “the full vision of a transformed crisis care system with 988 at its core will not be built overnight. Transformation of this scale will take time, and we must all work together to make it happen.”

The reality is that the actual status of the 988 Lifeline will vary greatly across the country, following a similar trajectory to the rollout of 911 as the nation’s universal access number.

The NAMI Framework for 988: “Someone to talk to. Someone to respond. Somewhere to go.”

Despite the massive task of rolling out the new 988 Lifeline, real progress is evident, and SAMHSA’s “full vision … to build a robust crisis care response system across the country that links callers to community-based providers who can deliver a full range of crisis care service” is becoming a reality.

Among the most prominent groups clarifying the vision is the National Alliance for Mental Illness (NAMI) who has established a very useful standard of care for what each 988 call center should aim for, specifcally: “A crisis system that provides people with someone to talk to, someone to respond and somewhere to go”.

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One Step Forward, Two Steps Remaining

Prior to the launch of 988, the majority of efforts in the rollout were rightfully focused on the first part of NAMI’s standard of care: Someone to talk to. States and municipalities have been busy working through the technological and staffing challenges needed to ensure that when someone calls 988, the call will be, per NAMI, “answered locally by staff who are well-trained and experienced in responding to a wide range of mental health, substance use and suicidal crises.”

But that still leaves us with the next two steps in NAMI’s standard of care: “Someone to respond and somewhere to go“? In our own experience working with a wide range of alternative response teams, we’ve seen that there’s still a lot of work to be done in fulfilling the second two parts of NAMI’s standard of care. The reasons for this are myriad and complex, but in many cases it’s simply owing to a lack of know-how: Without realizing it, standing up a crisis response team is very much like launching a volunteer fire department.

To help policymakers and program manages begin working through these challenges, we’ve put together a list of considerations for 988 call centers to ensure that NAMI’s standard of care can be met.

“Someone to Respond”: Getting from over-the-phone consultation to in-person intervention

When you call 911, emergency dispatchers are trained to determine your location and the nature of your emergency as quickly and as accurately as possible in order to begin dispatching the appropriate responders and resources. Historically, this means dispatching police, fire and/or emergency medical services (EMS). While the National Suicide Prevention Hotline has thus far been used exclusively to provide over-the-phone counseling, 988 presents a fantastic opportunity to dispatch crisis counselors who typically aren’t alerted by 911. Doing so, however, will require you to think like a volunteer fire department and always keep on top of a number of variables, including:

  • Availability — Which resources are currently available to respond? What’s their location?
  • Scope of Practice — Are all of your responders the same or do they have different training and skills? Do they carry different supplies and equipment? Can they respond alone or do they need other responders/resources to be dispatched along with them?
    • Keep in mind that dispatching emergency responders is not the same thing as dispatching taxis — i.e., what works for Uber/Lyft isn’t necessarily going to work for you
  • Communications — How will you alert and maintain communications with your responders?
    • A lot of crisis response teams are under the impression that all they need are radios like formal 911 responders use. This is not the case at all. 911 radios are very expensive, have severe limitations, and are just one of many tools in 911 communications — they are not the end-all, be-all communications solutions that they may appear to be.
  • Dispatching — How will you dispatch your responders when they’re needed? Will you crowdsource them or will you designate specific responders to each call?
    • One of the prevailing assumptions we see among 988 planners is that their dispatchers will call alternative responders directly on their personal phones whenever they want to dispatch them. Simply put, that doesn’t work well: it’s very inefficient, it makes documentation very difficult and it’s prone to miscommunication (i.e., “Where’d you say the address was again?”). Instead, 988 planners should send call information digitally so that responders can reference it as many times as needed.
  • Coordination — How will you keep track of your responders once they’ve been dispatched? How will you know when they’re en route, on scene, transporting, or when they’ve finished the call?
    • Similar to the points raised above, calling responders directly on their personal phones and/or using radios only are very inefficient solutions. While they were popular in the analog area, that was largely because digital communications like mobile phones didn’t exist. These days, there’s really no good excuse for relying on analog technologies unless mobile phone connectivity simply isn’t available.
  • 911 Integration — Will your responders receive alerts from 911, from 988 or both? Will they be dispatched alongside, or in lieu of, 911?
  • Backup/Mutual Aid — What happens if your responders find themselves in over their heads? What if an emotionally unstable person gets violent or hurts themselves? What happens if you have more people requesting in-person assistance than you have responders available to help?
    • As much as we want to believe that trained mental health experts are better equipped to respond to mental health crises than police or EMS, the reality is that true emergencies are dynamic and unpredictable situations. Giving your alternative responders a way to hit the “panic button” and get additional resources on scene is absolutely essential. Equally important is having “surge” protocols in case the volume of incoming requests surpasses available responders.
  • Documentation — How will you prove that your system is effective? How can you show that your responders are doing what they’re supposed to be doing?
    • To be considered an effective emergency response system, you have to show evidence, at a minimum, that your responders are getting to the right location in a short amount of time. But beyond that, you also need to have thorough documentation of a range of key milestones and data points collected throughout the entire response. As mentioned before, relying exclusively on radios and phone calls will make this a very cumbersome effort — something 911 doesn’t even try to do.

“Somewhere to Go”: Getting from the street to definitive care

The last step in NAMI’s proposed standard of care for 988, “Somewhere to go“, is a little more ambiguous and harder to plan for given the wide (or narrow) range of possibilities available in communities around the country. Nonetheless, there are some considerations that can be kept in mind that are applicable for any crisis response program.

  • Transport Options — How is transport going to be arranged and provided? Will it be by the same responders dispatched by 988? Will it be by EMS? Will it be by taxi? Or could it be a mix of all of the above?
    • Understanding the different types of patients that will require transport, and the resources needed to provide transport safely, is an essential component of successful planning.
  • Liability — If 988 responders provide transport, what types of legal risks do they need to account for?
    • EMS transport is highly regulated at the federal and state levels, and for both transporting agencies and receiving facilities. While transport by alternative responders isn’t aswell-defined, consulting with legal experts ahead of time will go a long way to ensure safety for all.
  • Destination Options — What types of facilities are available? When can and can’t patients be transported to them? If more than one receiving facility is available, what are the protocols for determining who is brought where and when?
  • Advanced Notice — How will communications with the transport destination be handled?
    • Even though ambulances are legally allowed to show up at the emergency department without any advanced notice, it’s always in everyone’s best interest to give as much of a heads-up as possible. Ensuring that “warm hand-offs” are the norm is key to maximizing positive patient outcomes and fostering collaboration between transporting units and receiving facilities.

Conclusion

The 988 Suicide and Crisis Lifeline is a pioneering effort that is transforming access to mental health services across the United States. But it’s going to be a work-in-progress for some time. While 988 planners have been busy working to ensure that a trained mental health expert answers the phone every time someone calls the number, more discussion is needed to establish what happens when someone can’t be helped over the phone.

Fortunately, there’s growing precedent for alternative response programs operating alongside and/or in lieu of 911. We know this because we’re working hand-in-hand with many of them everyday through our Beacon Emergency Dispatch platform, a cloud-based community response platform that’s used to alert, coordinate and track alternative responders for mental health emergencies in San Diego, opioid overdoses in Hartford and domestic violence crises in Las Vegas. Each of these programs is proving on a daily basis that crisis response teams can provide response services as effectively as traditional 911 does — and we’re excited to help turn more of these “alternative” programs into “pillars” of the local response network.

To learn more about how these programs work, you can watch these short webinar features below. If you’re interested in learning more about our Beacon Emergency Dispatch platform, you can sign up here for a free 90-day trial today, or contact us directly at info@trekmedics.org to speak with one of our support staff.

Need a better way to alert and coordinate crisis responders?

The Beacon Community Response Platform may be exactly what you’re looking for. Sign up for your free 90-day trial today!

Mental Health Emergencies (San Diego, CA)

Domestic Violence Crises (Las Vegas, NV)

Opioid Overdoses (Hartford, CT)

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