988 mental health hotline use rises

The suicide and mental health crisis hotline has seen a dramatic increase in call volumes since converting its number to 988, presenting a big opportunity for healthcare systems to better coordinate mental and behavioral health services.

But providers are still figuring out where they fit into the new system and how they can be reimbursed for mobile response and call services beyond government grants. The number of monthly calls to the hotline has increased 45% since the 988 rollout in July. In August, centers responded to 152,000 more calls, chats and texts than a year before. A total of 413,425 contacts were made last month. 

Those contacts are being answered and resolved at higher rates, too, which indicates government spending to bolster call center infrastructure has so far been successful, said Hannah Wesolowski, chief advocacy officer for National Alliance on Mental Illness. According to federal data, 84% of calls and 98% of texts were answered. Overall, 88% of calls were connected to a center and handed off to a counselor. 

The volume of 988 calls is expected to continue rising as the hotline gains familiarity. Mental health advocates are still educating communities, first responders and healthcare providers on how to use the service. Health systems already involved with 988 see opportunities for the hotline to be a front door to a continuum of mental health services. 

In Springfield, Illinois, the not-for-profit health system Memorial Health has a team that takes 988 calls 24 hours a day, Monday through Friday. Calls made over weekends are diverted to a statewide call center. Prior to the rollout of the three-digit number, Memorial Health was one of six centers in the state fielding calls for the suicide hotline. Calls were sporadic and the response was inconsistent, said Diana Knaebe, president of Memorial Behavioral Health.

Call volumes have nearly doubled since the new number was launched, Knaebe said. The health system’s answer rate is also increasing after it hired staff members to meet demand. When someone in the six-county region surrounding Springfield calls 988, the Memorial Health employees answer. Trained crisis counselors can resolve some problems over the phone or dispatch mobile response units. They can also schedule appointments with outpatient services and make follow-up calls to check on callers who request them.

Memorial Health is in the process of launching mobile crisis response teams in the six counties it serves. In Illinois, approximately 80% of calls can be handled over the phone without extra response and the remainder require crisis teams to be dispatched, Knaebe said. Of those that lead to in-person interventions, a very small number end with visits to emergency departments or inpatient psychiatric facilities, she said. 

The next step is creating community-based crisis stabilization centers to provide urgent care for people who don’t need emergency services, Knaebe said. These have been difficult to establish because they will require sustainable funding, which hasn’t been available until recently, Wesolowski said.

Government grants finance services provided to people who contact 988, but providers are keenly watching to see what role health insurance companies will have in the future.

The Centers for Medicare and Medicaid Services informed Medicaid insurers in December they can apply for crisis response and stabilization funding. Georgia’s Medicaid program is spending dollars to support 988 call centers and mobile response teams. Arizona added a behavioral health hotline Medicaid billing code. More states are seeking federal approval for similar initiatives, according to the Georgetown University Health Policy Institute. On Monday, the Health and Human Services Department cleared Oregon’s first-in-the-nation plan to expand mobile mental health crisis intervention units and stabilization services under Medicaid.

States and mental health advocates would like private health insurers to pay for these services. According to Knaebe, insurers have historically refused to cover services rendered by people without clinical licenses. But staffing the hotline with such highly trained and credentialed workers would be costly and unrealistic, given the current healthcare workforce shortage, she said.

“There’s a lot of pressure right now from mental health advocates on commercial insurance,” Knabe said. “Commercial insurance needs to figure out some way that they’re going to reimburse providers.”

The hotline also brings the promise of cost savings by diverting calls away from emergency departments and toward more appropriate services. 

In Reno, Nevada, emergency medical service provider Regional Emergency Medical Services Authority Health (REMSA) has integrated 988 with its emergency command center. Mental health calls that don’t constitute immediate medical emergencies are filtered to 988, even when users have called 911. For those that cannot be resolved over the phone, REMSA has various teams that can respond depending on the situation, including some without law enforcement officers.

Most situations can be resolved over the phone or through a community response, said Adam Heinz, executive director for integrated healthcare at REMSA. Only 2% of 988 callers visit emergency departments, he said.

“We really work hard to reduce the utilization of emergency services just because it’s a finite resource. We cannot send an ambulance, lights and sirens, across town, barreling through intersections for things in which potentially we could provide more optimal care,” Heinz said. “The standard of care now is—even if an ambulance responds or if you call 911—we are now looking to navigate you to the right resource.”

Results have been difficult to measure. More data on utilization and outcomes is needed to understand if people are getting the care they need, but it’s not yet being collected. Response systems are localized not standardized. More federal funding might come with new reporting mandates, Wesolowski said.

“The federal government is making more investments and more money is going down to the states, and that presents an opportunity to have more standards and metrics tied to that funding,” she said. “We’re starting to see a tide shift on that front. But it’s going to be a longer-term process to get there.”

By 2025, the Substance Abuse and Mental Health Services Administration projects that 90% of people who need support will be able to access 988 and 80% will have access to mobile crisis teams.