New Opportunities to Improve Mental Health Crisis Systems

The most important actions to improve mental health crisis care will capitalize on a remarkable new development. There has been increased recognition of the rising tide of suicide, the effectiveness of the NSPL in responding to suicidal callers, and the role that a national crisis line plays in addressing mental health and suicidal crises (6, 7). In response, the FCC has recently approved designation of a nationwide three-digit phone number (988) to be assigned for suicide prevention and crisis response (8). Expanding the mission of the NSPL from suicide prevention to mental health crises is a foundational step toward establishing a national crisis care infrastructure. Many other steps, including complex telecommunications arrangements, are needed to implement the 988 number, and additional federal financial support will be required to stabilize the network of over 170 local and state-based call centers that are now part of the NSPL. These centers are already connected by a single national phone number (800–273-TALK) and an infrastructure managed by the nonprofit Vibrant Behavioral Health.

Currently, federal funds support the national infrastructure but do not substantially support the centers themselves. Federal funds should be directed to both—to the new mental health crisis response agenda and to the suicide prevention mission of the NSPL. Taking advantage of this opportunity to standardize and expand the national mental health crisis infrastructure is essential.

To create a crisis care system, call centers must move beyond the core functions of a suicide hotline. Enabled by innovative technologies, call centers are well positioned to form the backbone of a national infrastructure that finally enables reliable access to adequate mental health crisis services across the United States. An increase in federal funding can support much-needed activities, such as providing technical assistance to local and state mental health authorities, supporting 988-receiving NSPL call centers as they augment their roles in suicide prevention to include crisis care coordination, expanding and training the call center workforce, and collecting metrics aimed at ensuring meaningful expansion of access to crisis care across localities.

Developing this national crisis call and dispatch network is a crucial first step, but other actions are required to create the capacity for crisis care. The task of advancing crisis systems must take place at the state and local levels, but national leadership and modest funding support are required. Section 9007 of the 21st Century Cures Act authorized a national discretionary grant program for “states to develop, maintain, or enhance a database of beds at inpatient psychiatric facilities, crisis stabilization units, and residential community mental health and residential substance use disorder treatment facilities, for adults with a serious mental illness, children with a serious emotional disturbance, or individuals with a substance use disorder.” Although the Cures Act authorized $12.5 million annually over 5 years to be overseen by SAMHSA, this provision was not adequate in purpose or scope to drive the improvements in crisis care that are now understood to be necessary, and funding was never appropriated. Nevertheless, this was an important first step, confirming congressional awareness of the problem and an intention to address it.

A recent example of federal leadership on mental health suggests a focused path to improving crisis care services nationwide. Following the Sandy Hook school shooting in 2012, Congress expanded the MHBG—a federal grant program that allocates funds to all U.S. states and territories—specifically to facilitate development of services for young people in the early stages of psychotic illness (e.g., schizophrenia). This targeted federal investment in modestly expanding services in all states for individuals experiencing a first episode of psychosis, paired with a widely disseminated technical assistance program, has galvanized a remarkably successful national effort to engage young people in individualized care by using the evidence-based coordinated specialty care model.

Initial steps to apply this approach to crisis care have been noted by advocates and applied to crisis care. In both 2019 and 2020, the House budget proposal included a similar 5% set-aside, with $35 million to be added to the MHBG to help states expand crisis care services. But the proposal has not yet been included in an enacted budget. Remarkably, the President’s 2021 budget followed the House’s example and included an MHBG set-aside for crisis services. A broad coalition of mental health groups are advocating strongly for both houses of Congress to incorporate these provisions in future appropriations.

As crisis services continue to develop, steps must be taken to strengthen the data and evidence about which approaches are most effective. Although broad consensus exists about the need to improve crisis care and about the essential elements of strong systems, there is considerable heterogeneity among crisis services currently being offered and a lack of definitive data on which workflows and service modalities are most effective. The evidence base is strong regarding the effectiveness of suicide prevention crisis calls (6, 7), which is reflected in the NSPL standards and American Association of Suicidology accreditation. Mobile crisis teams and crisis facilities have been studied, but there is not yet consensus on best practices in these unique clinical settings. The National Institute of Mental Health has acknowledged the need for research into the efficacy and implementation of high-functioning crisis programs across a range of contexts (e.g., urban versus rural) (9). Clinical protocols defining preferred types of interventions and expectations for follow-up care should be standardized, including when nonlicensed professionals are providing direct services. Additional efforts must be made to conduct evaluations of existing programs operating in real-world settings, where a wide range of clinical presentations, psychosocial factors, cultural considerations and health disparities regularly influence the types of care that are provided. Development of quality measures for crisis care is also needed to improve accountability (e.g., by regional health authorities and payers) and facilitate accreditation.

Initial state and local efforts could be facilitated by expanded MHBG funding to be used essentially as a down payment on much-needed long-term investments. Often the leadership for crisis programs is within mental health agencies, and as with other mental health services, state Medicaid programs are major payers for crisis care—yet there is tremendous variability. Some state Medicaid programs, such as the Arizona Health Care Cost Containment System, have developed robust financing models for crisis call centers, mobile teams, and crisis facilities that have resulted in millions of dollars of savings for the overall system by diverting individuals from expensive hospitalizations, lengthy ED stays, and inappropriate jail and prison terms (10, 11). However, some states do not even provide Medicaid coverage of discrete services, such as mobile crisis teams or care in crisis facilities.

Financing options differ for the various elements of crisis systems. Crisis call centers have been financed primarily by state mental health authorities and, less frequently, Medicaid agencies. Mobile crisis teams have been financed via mental health grants and reimbursed on a per-visit basis by Medicaid. Crisis facility construction has been achieved through state and local mental health construction grants and from state and local bond funds, and care in crisis facilities has been reimbursed by Medicaid. Finally, payment for mobile crisis and crisis facility services from commercial health insurance has been provided in some states.