NASMHPD Reimagining a Sustainable and 

Robust Continuum of Psychiatric Care

September 2021
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foreword 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the federal agency 

charged with reducing the impact of substance use and mental illness on America’s communities. It’s 

work has helped shaped funding and policy and supported innovation and growth in programs and 

services to help drive positive outcomes for these conditions. SAMHSA partners with stakeholders at all 

levels to further its mission. The National Association of State Mental Health Program Directors 

(NASMHPD) is the organization that brings together state mental health leadership from around the 

country, many of whom also have responsibility for substance use services, to share and promote ideas 

to help improve the lives of individuals with serious mental illnesses and youth with serious emotional 

disorders across each U.S. jurisdiction. Together, SAMHSA and NASMHPD have been working diligently 

to stay abreast of and be responsive to the needs of local communities and state leaders. 

With the ongoing COVID-19 pandemic, the pre-pandemic rising suicide rates, the opioid crisis and 

numerous challenges in meeting demands for mental health services across the country, the 2021 

Compendium of Ready to Respond: Mental Health Beyond Crisis and COVID-19, comes at a critical time. 

Commissioned by SAMHSA and executed by NASMHPD, the Ready to Respond compendium provides 10 

authoritative papers on critical topics of our time related to crisis services and post-COVID-19 vision for 

mental health services. 

Mental health system leaders on a local, state, and national level need ongoing resources to help 

providers deliver needed services and supports, help set policy agendas, inform legislators about best 

practices to advocate for funding, and promote tools to help establish needed programs to continue to 

build out a robust mental health continuum of care. This compendium offers just such a resource, and 

we are delighted to offer it as a coordinated set of guiding documents richly written and full of helpful 

information from the nation’s leading experts in areas ranging from children in crisis to financing and 

data collection, partnership with law enforcement in crisis response, suicide prevention and disaster 

behavioral health response. Throughout the series the authors contemplate issues of diversity and 

equity to help continue to drive services in the direction of equal access to all. As the single federal 

authority focused on the impacts of mental illness and substance use disorders, it is critical that our 

nation is indeed ready to respond. We are grateful to the numerous contributors who have helped 

shape such an important overview. 

Anita Everett, M.D. 

Director, Center for Mental Health Services 

Substance Abuse and Mental Health Services Administration 
 

 

 

 

 

 

 

 

 

2021 Compendium Editors 

Debra A. Pinals, M.D. 

Elizabeth S. Hancq, MPH 

Acknowledgements 

We are grateful for the work done to put these papers together, both in their original conceptualization 

in partnership between the Substance Abuse and Mental Health Services Administration and the 

National Association of State Mental Health Program Directors, and in their writing by the individual 

authors. We also wish to express our gratitude to both Debra A. Pinals, M.D. for her leadership and 

subject matter expertise and to Elizabeth Sinclair Hancq, MPH for her skillful research and technical 

assistance as both helped edit, design and compile this series of papers to make it what it is. Also, thanks 

to Malkah Pinals for her graphic design skills for a cover that portrays the images of a continuum of care 

linked together across an array of crisis supports and services, all drafted and executed in between shifts 

doing direct care for persons with serious mental illness. Thank you to the lead authors and co-authors 

of the papers: Debra Pinals, M.D.; Arlene Hahn Stephenson, M.A.S.; Madelyn S. Gould, Ph.D., M.P.H.; 

Alison Lake, M.A.; Matthew L. Edwards, M.D.; Kristin A. Neylon, M.A.; Kenneth M. Rogers, M.D.; Louise 

Johnson, M.S.W.; Jayla O’Neal, M.D.; David de Voursney, M.P.P.; Francine Arienti, M.A.; Kevin Martone, 

L.S.W.; Kirsten K. Beronio, J.D.; Stephen Phillippi, Ph.D.; Brian Bumbarger, Ph.D.; and Robert Shaw, M.A. 

Thank you to the NASMHPD team for their collaborative efforts in developing this year’s series, including 

David Miller, Project Director, for overseeing this important effort and Aaron Walker for his excellent 

work and dedication in coordinating the development of these key resources. This series is an 

outstanding set of resources that will help in improving services for people in crisis with mental health 

and substance use issues across the life span and in unique geographical areas. We especially thank the 

public health and behavioral health leaders across the country that helped inform this series and help 

people in crisis every day. 

Brian Hepburn MD 

CEO NASMHPD 

Disclaimer 

The information presented and views expressed in the individual papers of the compendium papers are 

solely those of authors and do not necessarily reflect the views or opinions of the editors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 
Table of Contents 

Ready to Respond: Mental Health Beyond Crisis and COVID-19 1

Disaster Behavioral Health Through the Lens of COVID-19 26

Suicide Prevention and 988: Before, During and After COVID19 46

Law Enforcement and Crisis Services: Past Lessons for New Partnerships and 64

the Future of 988 

Strategies and Considerations for Providing a More Equitable Crisis 86

Continuum for People of Color in the United States 

The Effects of COVID-19 on Children, Youth and Families 125

Mental Health System Development in Rural and Remote Areas during 140

COVID-19 

Funding Opportunities for Expanding Crisis Stabilization Systems and 162

Services 

Technology's Acceleration in Behavioral Health: COVID, 988, Social Media, 209

Treatment and More 

Using Data to Manage State and Local-level Mental Health Crisis Services 228
NASMHPD Reimagining a Sustainable and 

Robust Continuum of Psychiatric Care

September 2021

1
 

 

 

Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

Debra A. Pinals, MD 

Clinical Professor of Psychiatry 

Director, Program in Psychiatry, Law and Ethics, University of Michigan 

Medical Director, Behavioral Health and Forensic Programs 

Michigan Department of Health and Human Services 

Chair, Medical Director’s Division 

National Association of State Mental Health Program Directors 

Technical Research Assistant: Elizabeth Sinclair Hancq, MPH 

Cover Art by Malkah Pinals 

First in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

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Acknowledgements: 

Working on these papers is an honor and a privilege, and they could not be done as well without the 

able and steady assistance of Elizabeth Sinclair Hancq, MPH, who demonstrated her calm editorial 

and research skills as the Technical Research Assistant for this paper, and assisted in the editing and 

formatting, design and formatting process of the entire compendium of 2021 technical assistance 

papers. Special thanks as always go to the NASMHPD team, with gratitude to Brian Hepburn, M.D., 

NASMHPD Executive Director, for giving me this opportunity to focus on this series and contribute to the 

national dialogue, as well as to Aaron Walker, Meighan Haupt, and Greg Schmidt, for their patience and 

diligence behind the scenes. Thanks to Ms. Doris Fuller who helped create the Beyond Beds construct 

and more. Thanks go to Malkah Pinals this year for her graphic art skills and patience, with input and 

comments from the SGERP team. Also, acknowledgements go to colleagues from the Behavioral Health 

and Developmental Disabilities Administration at the Michigan Department of Health and Human 

Services for continually striving to improve behavioral health services in that state. This year as always I 

wish to acknowledge collaborators from around the country in systems in mental health, developmental 

disabilities, and substance use services, along with other key partners including those who come from 

legislatures, courts, correctional systems, child welfare and juvenile justice that have helped inform not 

only the content of this paper but who have helped us navigate COVID-19 and make a difference to 

people with complex needs every day. 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, or 

other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Pinals, D. A. (2021). Ready to Respond: Mental Health Beyond Crisis and COVID-19. Technical Assistance 

Collaborative Paper No. 1. Alexandria, VA: National Association of State Mental Health Program 

Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

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Abstract: 

The current landscape of mental health services reflects both tremendous challenges and 

opportunities. With the impact of COVID-19 front and center in the national discourse, and the 

planning for a system involving a 988-crisis response, there is much work ahead. This paper, Ready to 

Respond, is the umbrella paper for the 2021 technical assistance coalition series developed through 

the National Association of State Mental Health Program Directors in partnership with the Substance 

Abuse and Mental Health Services Administration. It aims to lay out a roadmap as states emerge 

from the pandemic and need, more than ever, a full continuum of psychiatric care. As an outgrowth 

of a policy framework looking “beyond beds” within inpatient state hospitals as a single solution to 

improving mental health outcomes, the current discourse centers around access to crisis services. 

Yet, in order to best respond to demand, an entire array of services is needed both to prevent crises 

in the first place and to provide longer term supports beyond a crisis period for diverse populations 

of all ages with mental illness and substance use disorders, as well as those with co-occurring 

complex conditions. These services will require coordinated funding and planning with a broad group 

of stakeholders to address among other things equity and reducing the likelihood of suicide, 

overdose, criminal legal entanglements, homelessness, unemployment, or other untoward 

outcomes. The paper reviews recent behavioral health system demands and highlights seven key 

priority areas for consideration to build a sustainable, robust and more complete psychiatric care 

continuum. 

Highlights: 

• There have been significant catalysts that have culminated in the focus on building out a more 

robust crisis continuum of care. 

• The emotional toll of COVID-19 is an area that requires the attention of state mental health 

leaders 

• Health equity may help shape future reductions in disparities in mental health outcomes 

• Workforce challenges are highlighted as a major potential barrier to developing a more robust 

system of services, though the use of telepractices may help expand work opportunities and 

access to care. 

Recommendations for the Post-COVID-19 Future: 

1. Expand and achieve a full continuum of crisis services. 

2. Rebuild and reboot a robust, diverse, and well-qualified workforce. 

3. Expand telehealth practices while ensuring ongoing quality and access. 

4. Foster integration of disaster behavioral health into emergency preparedness and response. 

5. Consider creative financial opportunities to maximize access to crisis response and other 

community-based mental health and substance use services with no wrong door. 

6. Focus intentionally on diversity, equity and inclusion to reduce disparities in mental health 

outcomes. 

7. Enhance interconnectedness with other systems and across borders for improved global responses 

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he National Association of State Mental Health Program Directors (NASMHPD), on behalf of the 

Substance Abuse and Mental Health Services Administration (SAMHSA), issued in 2017 a series of 

technical assistance papers on the need to shift the focus from building more state hospital beds 

to building a full and complete psychiatric continuum of care. The first paper in that series, Beyond Beds: 

The Vital Role of a Full Continuum of Psychiatric Care, laid a foundation from which national and 

international dialogue ensued.1 The notion that psychiatric hospitalization is a key part of psychiatric 

care for those who need it has not shifted. However, there is increasing recognition that persons with 

serious mental illness, many of whom also have substance use disorders, need more than just 

psychiatric hospital beds. Just like in medical care, a complete continuum of services is necessary to 

meet the demands of persons with mental illness who may have any number of co-occurring complex 

conditions. In the four years surrounding the time of release of Beyond Beds, efforts around the country 

grew to examine and expand the behavioral health continuum, looking at models and goals both from 

the national and international literature. Each year, new NASMHPD technical assistance papers followed 

the theme of Beyond Beds, with approximately 10 papers and an overarching umbrella paper to 

establish a road map (Figure 1).2,3,4,5 

Figure 1: NASMHPD Technical Assistance Coalition Series Umbrella Papers 2017-2020 

2017 Beyond Beds: The Vital Role of a Full Continuum of Psychiatric Care: set forth policy priorities of 

establishing a robust psychiatric continuum of care and looking beyond inpatient services as a single 

solution to the challenges for persons seeking services for mental illness. 

2018 Bolder Goals, Better Results: Seven Breakthrough Strategies to Improve Mental Illness 

Outcomes: delineated seven bold goals, from ending homelessness and suicide to getting immediate 

access to care, as a way to build a roadmap to better mental illness outcomes. 

2019 Beyond the Borders: Lessons from the International Community to Improve Mental Health 

Outcomes: examined nine key areas where examples from countries outside the United States have 

paved a way for improved mental health services. 

2020 Crisis Services: Meeting Needs, Saving Lives: built upon SAMHSA’s Crisis Toolkit guidelines to 

help drive forward the need for a capacity for crisis services along its own continuum that is 

interconnected and equally accessible to diverse population. 

In the years since the first paper in the Beyond Beds series was published, its tenets both reflected the 

national conversation and helped NASMHPD and state mental health leaders shape policy and planning. 

In 2021, the Beyond Beds dialogue calling for a complete continuum of psychiatric care is as important 

as ever, only it comes with the lessons learned from COVID-19 and a strong emphasis on continuing to 

enhance the crisis continuum of care. There are several reasons for this emphasis on prevention and 

crisis response that make these key considerations far beyond simply relying on “beds.” 

This paper, Ready to Respond, is the umbrella paper for the 2021 NASMHPD technical assistance 

coalition series and aims to lay out a roadmap for the years to come as we emerge from the pandemic 

and need, more than ever, a full continuum of psychiatric care. Although there are daily discussions 

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about crisis services, a complete continuum will need to incorporate integrated and interconnected 

services that can both prevent crisis and respond to them, as well as provide supports for individuals 

beyond crises. It will be critical to look ahead beyond COVID-19 and beyond inpatient psychiatric beds 

toward building out an improved, accessible and sustainable mental health service continuum that can 

be equally available across all demographics, in rural and urban regions, to meet what undoubtedly will 

remain growing demand.6 The paper outlines the current landscape of the crisis response continuum 

and overall behavioral health system demands and finishes highlighting seven key priority areas for 

consideration. 

Catalysts for Enhanced Crisis Response as a Critical Aspect of the Psychiatric 

Continuum of Care 

The activity of SAMHSA and NASMHPD along with countless interested stakeholders in mental health 

outcomes have been galvanized to pay attention and fund a growing number of programs for persons in 

behavioral health systems. Advocacy has played a key role, though demand for these services has also 

been borne out of the many failures and tragic negative outcomes seen across a depleted and 

fragmented mental health system. As such, several themes have been prominent in pushing forward a 

dialogue around crisis services that pre-date but have been heightened by COVID-19. Although the 

impetus for current system change is multifactorial, below six major themes are delineated as catalysts 

that have spawned planning for enhanced crisis response systems as a key aspect of the psychiatric 

continuum of care (Figure 2). 

One major theme that has catalyzed a discussion Figure 2: Catalysts Driving Toward Enhanced

regarding crisis services as a vital part of the Crisis Response Systems 

continuum of care is the rise in suicide rates across 

1. Suicide rates the country. Data from the American Foundation of 

2. COVID-19 and its impacts Suicide Prevention showed 48,344 individuals died by 

3. Opioid overdose deaths suicide in America in 2018, and there were a 

4. Jail diversion efforts and need to revisit recorded 1.4 million suicide attempts.7 According to 

the role of law enforcement in crisis the Centers for Disease Control and Prevention (CDC), 

encounters suicide was the second leading cause of death after 

5. Need for prevention and augmented accidents for individuals age 10 to 34 in 2019 and the 

services for children and adolescents fourth leading cause of death for individuals age 35 

with serious emotional disturbances to 54.

8 Suicide rates between 2007 and 2017 

6. Litigation and regulation increased 56% among people ages 10 to 24 years.9 In 

response, the U.S. Surgeon General issued a report in 

2021 outlining a national strategy for suicide prevention.

10 

Relatedly, as COVID-19’s impact was increasingly causing distress, suicide prevention advocates had 

been pursuing a way to simplify the use of the National Suicide Prevention Lifeline. In July 2020, the 

Federal Communications Commission (FCC) announced that 988 would become Lifeline’s designated 

number. This decision has jump-started a movement to help achieve its promise starting in July 2022. 

Many believe the need for a simplified crisis line access point could not be coming soon enough. Yet, as 

noted below, there remain challenges to achieving its implementation that will require ongoing diligent 

effort. 

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The second catalyst for change has been the impact of the COVID-19 pandemic on mental health. 

Although initial reports indicate there was no increases in overall suicide deaths during the pandemic,

11 

survey data has shown more alarming rates of distress. The CDC’s Monthly Morbidity and Mortality 

Weekly Report showed that in June 2020, the U.S. adult population reported experiencing increased 

levels of mental health symptoms including anxiety, depression, trauma-related symptoms, increased 

substance use and increased reports of serious suicidal ideation compared to earlier pre-pandemic 

data.12 These findings were heightened for specific populations, including Black and Hispanic 

populations, essential workers and younger respondents.

13,14 Additionally, surveillance data has shown 

increased emergency department visits for youth between ages 12-17, especially girls, presenting with 

suspected suicide attempts.

15 Reger and colleagues noted that although there may be a “pullingtogether” of additional supports that could reduce suicide risk post-disaster, they point to several 

factors that could increase the risk of suicides in the wake of the pandemic. 16 This includes the 

economic strain resulting from closed business, cancelled events and other economic downturns, social 

isolation, decreased access to community and religious supports, barriers to mental health treatment, 

illness and exacerbated medical problems, increased national anxiety, suicide rates among health care 

professionals, increased firearm sales, and shifting suicide rates across seasons. Thus, overall, as we 

move through and beyond the pandemic, attention to suicide prevention is a key component of needed 

services going forward. 

The opioid crisis and the growing number of opioid overdose deaths represents a third catalyst for crisis 

service development. The increasing number of opioid overdose fatalities over the last half-decade or 

more created a need for intensive authorizations for funding through the State Targeted Response and 

subsequent Statewide Opioid Response discretionary grants and subsequent similar funding 

streams.17,18 Although states were finally seeing some improvements in opioid overdose death rates 

through these funding initiatives and other avenues, with the impact of COVID-19, the overdose 

numbers are sadly on the rise again and efforts must be redoubled to get ahead of those curves that 

have contributed to reduced life expectancy of younger populations.19 Methamphetamine associated 

deaths are also on the rise, which requires other specialized interventions.20 The use of substances 

overall has increased while the percentage of persons of all ages receiving treatment has not.21 

A fourth catalyst for change that produced some of the current press for system expansion to is the 

ever-increasing attention on jail diversion. It has long been recognized that individuals with mental 

illness and substance use disorders are over-represented 

Beyond Beds in the criminal-legal system and juvenile justice system. In 

2006, Munetz and Griffin proposed a strategy that 

Recommendation #10: Partnerships emphasized the need to identify and divert individuals 

Recognize the vital role families and non- from criminal processes along multiple points of 

traditional partners outside the mental interception coalescing at five stages, from law 

health system can play in improving enforcement contact, to courts to reentry and community 

mental health outcomes and encourage probation or parole supervision, which became known as 

and support the inclusion of a broader the Sequential Intercept Model.22 In 2017, a sixth 

range of invited stakeholders around intercept, Intercept 0, was added with recognition that a 

mental illness policy and practice. more robust behavioral health crisis system might offer 

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opportunities for deflection and diversion from arrest altogether.23 The Sequential Intercept Model was 

codified into the 21st Century Cures act, landmark mental health Federal legislation signed into law in 

2016, driving grant programs and other initiatives.24 At the same time, the Stepping Up initiative has 

helped county leaders and other stakeholders examine and reduce numbers of individuals with mental 

illness from jails.25 In the wake of the murder of George Floyd, Breonna Taylor and others, anger over 

the disproportionate killing of black and brown people by police was raised to a feverish pitch, with one 

author calling the impact on emerging adults the “crisis within a crisis.” 26 Resultant cries to “defund 

police” and to find better alternatives to manage crisis than a law enforcement response have 

contributed to re-examining partnerships and responses that can minimize police contact and maximize 

alternative approaches to managing community members in distress. Mobile crisis responses with 

alternative responders are a key part of these ideas. Examples such as the CAHOOTS model out of 

Oregon have gained increased attention for their crisis work uses models outside of police response.

27,28 

A report by The Center for Law and Policy examined mobile response for youth with mental health 

issues and proposed key principles for effective mobile response programs as an alternative to law 

enforcement as first responders.29 The key principles include ensuring responses do not include law 

enforcement, responders shouldn’t always need professional degrees and should include peers and that 

the services should be reimbursable from Medicaid to promote equity. At the same time as the need to 

reduce excessive use of force in crisis response, the importance of jail diversion continues. 

A fifth catalyst for change is with regard to children and adolescents and the growing and alarming 

trends for youth waiting in emergency rooms for psychiatric inpatient care.

30 Many states have faced 

litigation for failing to meet Medicaid’s statutory Early and Periodic Screening, Diagnosis and Treatment 

(EPSDT) requirement for Medicaid beneficiaries.

31 This trend has shifted planning to create an intensive 

expansion of service arrays in many states to attempt to meet the needs of youth with serious 

emotional disturbances (SED). There is a large overlap with youth in the child welfare systems and the 

2018 Family First Prevention Services Act now requires that treatment centers, known as Qualified 

Residential Treatment Programs for youth with psychological, behavioral or substance use challenges, 

must provide trauma-informed care and licensed staff that is more akin to a treatment model than a 

model that provides only structure and housing for youth involved in the child welfare system.

32 Often, 

EPSDT lawsuits incorporate an additional focus on youth involved in the child welfare and/or juvenile 

justice systems, given the propensity of those youth to be likely to have serious emotional disturbances 

stemming from any number of conditions. And remedies for these cases often include intensive mobile 

crisis services and follow up supports,33 which again is a path that leads to expanded crisis services for 

Medicaid eligible youth. Although these are youth-focused programs, their design creates other 

discussion that can support adults in crisis as well as other populations, including those with complex 

needs such as those with intellectual and developmental disabilities. 

Media reports and litigation against states and jurisdictions have been a sixth catalyst for change. Pivotal 

cases have called for remedies for waitlists of individuals found incompetent to stand trial waiting in 

jail34,35 and other forensic populations.36 Recent cases in Washington37 and New Hampshire38 have sided 

with plaintiffs against the states related to the boarding of patients in emergency departments with 

findings that states are failing to meet constitutional r standards by leaving individuals languishing in 

emergency departments when they have been determined in need of psychiatric hospitalization.39 The 

case in Washington supported advocacy for additional funding for more robust services with the state 

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legislature.40 In addition, Olmstead v. L.C. (1999), a case often used in litigation to drive improved 

services, has catalyzed shifts for state mental health systems to help prioritize the terms of the 

Americans with Disabilities Act by providing adequate constitutional protections for persons with 

disabilities that require them to be served in the least restrictive environments and appropriate 

community-based services.41 These cases dovetail the Final Rule that was set forth in 2014 related to 

Home and Community-Based Services Waivers, that was aimed to enhance the quality of these services 

and provide additional protections such that Medicaid beneficiaries receiving these services have full 

access to the benefits of community living.42 Home and community based services rules and associated 

new dollars that are being made available through the American Rescue Plan Act related to COVID-19 

have fostered states to spend resources building out these types of services. 

Together, these examples of change drivers have called for system transformation and development of a 

more accessible and complete psychiatric crisis care continuum. Many of these issues predated COVID19 and culminated in February 2020 in the release by SAMHSA of the National Guidelines for Behavioral 

Health Crisis Care-Best Practice Toolkit,

43 which called for practices that would yield better outcomes for 

individuals in acute need while reducing unnecessary hospitalizations and arrests. This was followed by 

the 2020 series of Crisis Services: Meeting Needs, Saving Lives44 as well as the National Council for 

Wellbeing and the Group for the Advancement of Psychiatry’s Roadmap to the Ideal Crisis System.

45 

Unimaginable as it was, however, as the original SAMHSA Toolkit was being written, on January 20, 

2020, the first case of COVID-19 infection was reported in the United States,

46 and by the time of The 

Toolkit’s release, the world was facing a global pandemic. 

Much has happened since those first COVID-19 cases were identified. As the virus spread around the 

world, everything as society knew it quickly and forever changed. The emotional toll of this pandemic, 

comingled with a tragic spotlight on the murder of George Floyd and other Black and Brown men at the 

hands of police as well as general healthcare disparities seen in the pandemic’s impacts, has no doubt 

further driven the need for preparedness and availability of adept crisis responses. 

As the world sorts through the massive disruption Beyond Beds and loss of life caused in this moment, policy 

makers in mental health and other public services Recommendation #1: The Vital Continuum 

are called to the task of developing and building Prioritize and fund the development of a back a sustainable and improved mental health comprehensive continuum of mental health 

continuum of care that is more adept at meeting care that incorporates a full spectrum of 

the needs of more people, including those with integrated, complementary services known to 

more complex presentations. Too many people improve outcomes for individuals of all ages 

with serious mental illness remain homeless, with serious mental illness. 

unemployed or incarcerated with insufficient 

access to services. With the roll out of vaccines 

comes the hope of having COVID-19 immunity more widespread including for vulnerable populations. 

Yet, the Delta variant has produced a trail of viral spread and new questions. With all these factors 

coalescing, there is so much to do to help ensure that access to mental health and substance use 

services are robust and immediate. The calls for enhanced crisis services that arose prior to the 

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pandemic have only been heightened. It is important to take stock and continue pursuit of policies and 

programs to realize improved outcomes for all. 

Taking Stock: Key Areas of Focus that Will Shape Future Outcomes 

Moving from Beyond Beds to Beyond Crises and to a Full Continuum of Psychiatric Care 

NASMHPD polled state mental health leaders in June 2021 asking for their perspectives in reviewing the 

10 key original recommendations from the 2017 Beyond Beds paper. A self-selected group of 25 

respondents provided feedback on which of the recommendations had yielded accomplishments and 

which were needed to be prioritized in the coming years to ensure an infrastructure of a continuum of 

mental health services achieved (Table 1). In addition, this same group of state leaders who are 

enthusiastically and diligently working on the development of the 988 infrastructure were also 

forthcoming about barriers that exist today that will need additional attention and focus (Table 2). 

Table 1: Top Three Beyond Beds Recommendations from State Mental Health Leaders 

Recommendations where 

significant progress has been 

made 

Recommendations 

where more progress is 

needed 

Recommendations more 

important after COVID-19 

First The Vital Continuum The Vital Continuum Workforce 

Second 

Criminal and Juvenile Justice 

Diversion Workforce The Vital Continuum 

Third Partnerships 

Criminal and Juvenile 

Justice Technology 

Table 2: Identified Barriers to 988 Implementation from State Mental Health Leaders 

Count 

% of 

respondents 

Workforce shortages 16 64% 

Rural/geographic concerns for mobile crisis 13 52% 

Technology/IT 9 36% 

Not enough crisis system infrastructure 9 36% 

Lack of funding 8 32% 

Meeting needs of diverse populations and 

geographies 6 24% 

Insufficient crisis bed capacity 4 16% 

Ensuring 24/7 availability 3 12% 

Limited collaboration across law enforcement, 

emergency medical and mental health systems 3 12% 

Legislative barriers 2 8% 

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The results of this informal survey of state mental health leaders is telling and helps set the stage for 

areas of emphasis needed as states navigate new budgets and plan for future directions. Other 

information available about the public’s well-being further helps inform priorities. 

Surveys Regarding the Emotional Impact of the COVID-19 Pandemic 

As leaders in behavioral health systems examine what is needed for the future, part of planning must 

include information about the emotional impact of COVID-19. In March 2020, Brooks and colleagues 

published a rapid review of the psychological impacts of quarantine from prior outbreaks such as SARS, 

Ebola, and the H1N1 influenza pandemics.47 Their findings synthesized 24 papers examining these issues 

and found negative emotional effects including post-traumatic stress symptoms, confusion, and anger 

especially related to longer quarantine duration, fears of infection, boredom, frustration, insufficient 

information and supplies, and financial strain. During the COVID-19 pandemic, similar findings were 

seen, including from the CDC showing marked increases in mental distress and suicidal ideation 

compared to the previous year.

48 

Regular household “pulse” surveys (HPS) of persons across the U.S. over the age of 18 during the 

pandemic were conducted through the CDC in partnership with the U.S. Census Bureau. A report on the 

findings of the HPS data showed that between August 19, 2020 and February 1, 2021, there were 

significant increases (from 36.4% to 41.5%) of adults who reported symptoms of anxiety or depressive 

disorders during the past seven days.

49 This increase in symptom reporting also corresponded with 

increased reports of needing mental health counseling but had not received it (9.2% to 11.7%), with 

findings of the greatest increases for those individuals between 18 and 29 years old and those with less 

than a high school education. 

New data is consistently emerging from around the world looking at the emotional impact of the 

pandemic on populations. For example, Pieh and colleagues50 examined the mental health of high 

school students in Austria during social distancing and remote schooling and found, compared to similar 

data from 2018, increased symptoms of depression, anxiety, insomnia and disordered eating and 

suicidal ideation. One third of respondents also reported suicidal thoughts. In addition, the authors 

found increased smartphone use associated with worse mental health.51 Findings in adults treated for 

high blood pressure showed that the stress and anxiety during the COVID-19 pandemic lead to a 

worsening of blood pressure control.52 A study by the American Psychological Association reported that 

more than 50% of respondents reported “re-entry anxiety,” which was a term used to explain the 

emotional distress associated with opening back up and returning to work and social events after so 

many months of staying at home.53 

Prior studies also showed healthcare workers reporting post-traumatic stress symptoms during 

outbreaks that pre-dated COVID-19, with depression, insomnia and anxiety sometimes lasting for one to 

three years afterward.54 Frontline workers dealing with COVID-19 patients directly may be particularly 

impacted emotionally with burnout.55 The behavioral health workforce has had similar strains in dealing 

with the demand for services in the face of limited supplies and numerous resource challenges.56 More 

recent data with responses from over 26,000 state, tribal, local and territorial public health workers 

suggest that 53% reported symptoms of at least one mental health condition in the prior two weeks, 

with worse symptoms for those who did not take time off work or worked more than 41 hours per 

week.57 Although suicide rate data has not yet shown marked increases, this is an ongoing concern. 

11
Figure 3: Lessons from History on Disparities in

Health Outcomes During Prior Pandemics 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Taken together, these trends inform policy makers that the need is now and the demand for mental 

health services is likely to rise further. 

Diversity, Equity and Inclusion Call to Action 

Disparities in how COVID-19 impacted populations galvanized action to more intentionally focus on 

health disparities. History teaches us that the disparities in how diseases spread is not new (Figure 3). 

58,59,60 The magnitude of COVID-19’s impact was, however, new to this century, and called out more 

about potential vulnerabilities, including those to specific underserved populations. In addition to how 

COVID-19 impacted persons of color and other ethnic groups, in the field of behavioral health, there 

were other disparities of note. Studies found individuals with substance use disorders61, serious mental 

illness62 and intellectual and developmental disabilities63 have been at disproportionate risk of acquiring 

COVID-19 and its related impacts. 

In the context of increased awareness of the uneven distribution of COVID-19, in May 2020, the murder 

of George Floyd created outrage and protests that transformed the dialogue to an even broader one 

related to diversity, equity and inclusion across 

the board. State and federal leaders have focused 

on more inclusion in hiring key positions with 

diverse backgrounds at the highest levels. The 

election of the Biden-Harris Administration 

embodies this priority, with Vice President Harris 

representing the first person of color-- and the 

first woman-- to be elected to this powerful 

position. Diversity has been a hallmark of 

President Biden’s selection of key leaders. Some 

states have mirrored these activities. 

In addition to leadership selection, policies and 

practices have focused on issues related to 

diversity and equity. President Biden issued an 

executive order on January 21, 2021, titled 

Ensuring an Equitable Pandemic Response and 

Studies examining previous pandemics indicate that 

persons of the lowest socioeconomic status had the 

highest mortality rates from pandemics in 1918 and 

in 2009. Although there was some indication that 

there were two waves, with the first hitting the poor, 

and the second hitting the rich. Another study of the 

influenza pandemic of 1918 showed that Black 

Americans had lower morbidity but higher case 

fatality rates for unclear reasons. 

(Mamelund et al 2019; Mamelund et al. 2018; 

Økland et al 2019) 

Recovery, which established a COVID-19 Health Equity Task Force to provide government-wide efforts to 

“identify and eliminate health and social disparities that result in disproportionately higher rates of 

exposure, illness, hospitalization and death related to COVID-19.”64 This has been true among behavioral 

health leaders and in behavioral health policy making around the country. On behalf of SAMHSA, the 

2020 Compendium of technical assistance coalition papers, Crisis Services: Meeting Needs, Saving 

Lives,65 had a focus on structural racism and the need for health equity. One of its papers solely focused 

on how crisis services needed to attend to diverse populations if crisis services were to truly be able to 

serve anyone, at any time, as directed in the SAMHSA Best Practice Toolkit.66 

The importance of attending to diversity and equity is not only just the right thing to do. It is increasing 

clear that outcomes for mental illness, substance use disorders and serious emotional disturbances are 

tied to social determinants of health.67 The social determinants themselves are clearly impacting 

populations such as persons of color or Native Americans disproportionately. Not only were these 

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populations disproportionately impacted byCOVID-19,

68 but data on the emotional impact of COVID-19 

seen in the health pulse surveys also show these differences.69 Suicide rates, drug overdoses and access 

to care all must therefore be priorities for populations for whom there are differences and 

disadvantages today. 

The Promise of 988 and Crisis Best Practices to Service Anyone, Anywhere, at Anytime 

As described above, in July 2020, the FCC approved rules that established 988 as the three-digit number 

that would serve as the national suicide prevention lifeline to aid callers to get access to supports and 

services.70 This paved the way for the October 2020 passage of The National Suicide Hotline Designation 

Act, touted as a landmark piece of legislation that will change the landscape of crisis response. The 

signing of this suicide prevention bill was celebrated by many stakeholders, including diverse 

communities far and wide, such as LGBTQ+ communities,71 and has been celebrated as a way to reduce 

police violence toward persons of color by creating alternative pathways to respond to crisis.72 

There is a recognition that 988 is more than just a suicide prevention lifeline but an entry point for any 

needed crisis response for any type of behavioral health crisis including suicide, mental health, or youth 

in distress. The implementation of 988 and a robust crisis continuum of care will require vigilant 

stakeholder buy-in, appropriate funding, and infrastructure development. 

Funding of the future of crisis services is an important area Beyond Beds of consideration. In a report to Congress by the Medicaid 

and CHIP Payment Access Commission (MACPAC), a non- Recommendation #3: Criminal and 

partisan legislative branch agency that provides policy and Juvenile Justice Diversion 

data analysis to make recommendations to Congress and 

Fund and foster evidence-based the U.S. Department of Human Services, the Commission 

analyzed government datasets to create a series of programs to divert adults with serious 

recommendations regarding access and Medicaid mental illness and youth with serious 

payment of mental health services.

73 The authors mental illness or emotional disorders 

highlighted the unmet need of mental health services, from justice settings to the treatment 

including that 50% of Medicaid beneficiaries with serious system. These programs should operate 

mental illness said they needed but did not receive at all intercept points across the 

treatment and that access to treatment is affected greatly sequential intercept framework and be 

by the extent of which states cover services and the required to function in collaboration with 

willingness of providers to accept new Medicaid patients. correctional and other systems. 

It is estimated that one out of every four individuals with 

serious mental illness are covered by Medicaid, and one out of every six individuals with a substance use 

disorder,

74 and as such Medicaid remains a big player in the infrastructure of a robust behavioral health 

continuum of care. 

With regard to funding crisis services, many states are working toward legislation that taxes citizens to 

collect funding support 988 similar to how 911 is funded, with Virginia being the first state to pass such 

legislation.75 NASMHPD has been working with state leaders to help in these efforts. In addition, since 

many crisis service recipients receive their behavioral health care through Medicaid or are individuals 

with serious mental illness or substance use disorders, SAMHSA and the Center for Medicaid and 

Medicare Services (CMS) have major roles in developing funding pathways. This includes significant set 

asides in federal block grant dollars, including those that are coming to the states via the American 

Rescue Plan Act (ARPA) as well as other funding mechanisms. Yet there will also be the need to engage 

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with private insurers and other funding streams to help ensure the success of crisis services, since they 

will be accessible to all. 

Another consideration is that it is believed that the implementation of 988 will increase the demand for 

crisis services. Although Medicaid programs can play a critical role in financing them, states have little 

guidance on how to implement funding to support this work. To that end, MACPAC recommends that 

joint sub regulatory guidance from the federal government should address how Medicaid and CHIP can 

be used to fund a crisis continuum for beneficiaries experiencing mental health crises. An analysis 

published by Vikki Wachino and Natasha Camhi for the Well Being Trust provides five policy pathways 

through Medicaid, referred to in their paper as building blocks, in how Medicaid can help states pay for 

and build robust crisis systems. These include 1) expanding benefits to cover crisis services through state 

options, 2) using waiver authorities to increase access to home and community based services (HCBS), 3) 

using managed care delivery systems to provide crisis services, 4) expanding crisis services through 1115 

demonstration waivers and 5) financing administrative spending for Medicaid beneficiaries in call 

centers.

76 These guiding recommendations may serve as a roadmap for states as they also balance 

funding coming in through the ARPA funds and the provisions for enhanced Home and Community 

Based Services (HCBS). 

The expectation of the authorizing legislation for 988 is that it be operational by July 2022. As such, 

states are working to ensure that they are ready for the 988 launch. To help foster collaboration and 

inspire the development of 988 activities, SAMHSA, NASMHPD and other partners have helped develop 

a weekly virtual “Crisis Jam” that has been hosted through RI International, in partnership with the 

National Action Alliance for Suicide Prevention, the National Suicide Prevention Lifeline, Vibrant 

Emotional health and NASMHPD, where leaders from around the country inform each other on best 

practices and next steps for 988 roll out. Each week more than 200 individuals attend. As part of this 

effort, NASMHPD also helped launch #CrisisTalk,77 which provides a wealth of information and newstype reports related to crisis services role out. 

The promise of 988, envisions high call volumes responded to via crisis call centers with full GPS 

information on a caller’s location. Through this technology, call responders will help inform individuals 

about local behavioral health resources and be able to deploy a mobile crisis team if necessary. 

Workforce Needs 

A robust continuum of psychiatric care requires the workforce infrastructure to make it effective. There 

are major concerns that workforce shortages will impede the ability to respond to the tsunami of mental 

health needs. In 2018, the National Council for Mental Wellbeing Medical Directors Institute put forth a 

report titled Psychiatric Shortages: Causes and Solutions,

78 highlighting years of psychiatric workforce 

shortages and the need to expand care to integrated multi-disciplinary care teams to help ensure access 

to services. Direct care workers and direct support professionals have also been highlighted as a priority 

area of need.79,80,81 The General Accounting Office noted in 2001 of the need to attend to critical 

shortage areas of direct care workers, including those that work for older adults and others.82 

All levels of care in the continuum seem to be impacted, and in some places, staffing is at a critical level. 

Take Oregon, for example, where its state hospitals were found to be in dire conditions with more than 

45% of its direct care staff taking leave, necessitating in the spring of 2021 the state to call in the 

National Guard to assist.83 

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Beyond Beds 

Recommendation #9: Workforce 

Initiate assessments to identify, establish, and 

implement public policies and public-private 

partnerships that will reduce structural 

obstacles to people’s entering or staying in the 

mental health workforce, including peer 

support for adults and parent partners for 

youth and their families. These assessments 

should include but not be limited to 

educational and training opportunities, pay 

disparities, and workplace safety issues. The 

assessments should be conducted for the 

workforce across all positions. 

Several states and legislators are attempting to 

create solutions to workforce shortages. For 

example, faced with new legislation that was 

expanding an autism benefit, Michigan worked to 

expand the availability of board-certified behavior 

analysts by expanding certification programs to 

ten universities throughout the state.84 As another 

example, although the state declared a staffing 

crisis in its state hospitals, CareOregon is making a 

major investment of $7.5 million in 25 behavioral 

health provider organizations to help them recruit 

and retain staff as part of the CareOregon 

Emergency Behavioral Health Workforce 

Stabilization Fund proposal. 

85 In Congress, 

Representative Debbie Dingell (MI) proposed the 

Better Care Better Jobs Act to help stabilize and 

expand the workforce providing home and community-based services.86 These efforts are important 

steps forward. However, as noted by the survey of Commissioners outlined above, workforce shortages 

represent one of the most significant concerns for state mental health leaders and will remain a key 

priority area of focus in order to meet the demands for mental health services. 

Advancing Technology 

Expanding and strengthening telepractice was highlighted as another significant priority area in the 

Commissioners’ survey. Even before the pandemic, the use of telepsychiatry was gaining traction and 

studies were showing positive outcomes.87 In the massive transition to address the COVID-19 pandemic, 

the use of technology become an imperative. Mental health and substance use services saw remarkable 

shifts in care delivery to almost total video or 

telephonic use in order to facilitate access and 

social distancing related to the pandemic.88 During 

the pandemic, the federal government assisted in 

the transition by supporting polices that helped to 

minimize disruptions to care delivery during the 

emergency declaration.89 As the workforce got 

comfortable with virtual platforms, many 

organizations attempted to provide guidance 

regarding the provision of telepractices.90 A review 

of the literature synthesized from international 

experiences highlighted practical guidance and the 

need to understand hybrid approaches in the postCOVID-19 world.91 

Beyond Beds 

Recommendation #8: Technology 

Create and expand programs that incentivize 

and reward the use of technology to advance 

care delivery, promote appropriate 

information sharing, and maximize continuity 

of care. Policymakers should require as a 

condition of such incentives that outcome data 

be utilized to help identify the most effective 

technologies, and they should actively 

incorporate proven technologies and 

computer modeling in public policy and 

practice. 

Although virtual platforms helped maintain a specific level of service, certain areas where broadband 

access or for populations for whom access to cell phone minutes were more limited created disparities 

in access.92 In addition to these types of challenges, there have been ongoing questions about whether 

telephone-only services will yield the same payment structures as video-based clinical interventions. 

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More work is also needed to examine whether the shift to emphasize virtual technology over in-person 

over the long-term will have the same positive benefits it seems to have had during the crisis. 

Key Areas for Priority in Behavioral Health Services Beyond COVID-19 and Beyond 

Beds 

Mental health services are rapidly shifting and have proven both nimble and resilient in the face of 

unprecedented demands and a fluid environmental context with the emergence of COVID-19. At the 

same time, mental health and substance use challenges remain, and their development requires 

ongoing vigilance. Now is the time to be ready to respond to need and to anticipate avenues that can 

support a sustained, improved, and robust continuum of psychiatric care. The recommendations from 

the 2017 Beyond Beds remain relevant today. It is clear that psychiatric inpatient services, although 

necessary, are not sufficient as a single solution to the mental health needs of the population. In the 

COVID-19 recovery period, key priority recommendations must be highlighted-- some as spin offs from 

the 2017 recommendations, and some with a newer focus. Details surrounding these recommendations 

are delineated in this 2021 Ready to Respond compendium’s individual technical assistance papers as 

outlined in Table 3. Each theme helps shape aspects of a reimagined sustainable and robust continuum 

of psychiatric care. 

Table 3: 2021 NASMHPD Ready to Respond Compendium of Technical Assistance Coalition Papers 

No. Compendium Topics 

1 Ready to Respond: Mental Health Beyond Crisis and COVID-19 

2 Disaster Behavioral Health Through the Lens of COVID-19 

3 Suicide Prevention and 988: Before, During and After COVID19 

4 Law Enforcement and Crisis Services: Past Lessons for New Partnerships and the 

Future of 988 

5 Strategies and Considerations for Providing a More Equitable Crisis Continuum for 

People of Color in the United States 

6 The Effects of COVID-19 on Children, Youth and Families 

7 Mental Health System Development in Rural and Remote Areas during COVID-19 

8 Funding Opportunities for Expanding Crisis Stabilization Systems and Services 

9 Technology's Acceleration in Behavioral Health: COVID, 988, Social Media, Treatment 

and More 

10 Using Data to Manage State and Local-level Mental Health Crisis Services 

Within this “Ready to Respond” framework, key areas of priority have emerged across the various 

topics. These priority policy recommendations are highlighted below: 

1. Expand and achieve a full continuum of crisis services. 

Through the crisis of the pandemic, a greater push for crisis response enhancement has been achieved. 

Important changes are on the horizon with the revamping of the National Suicide Prevention Lifeline 

number to an easy-to remember 3-digit number, 988, expanding the Lifeline network for better 

coverage across the states, and making investments in quality assurance to improve the provision of 

quality care. The Lifeline will provide expanded capacity for a surge of calls during any future 

disaster/emergency. 

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The Vital 

Continuum 

Given that the launch of 988 is less than a year ahead of this writing and 

the growing demands for improved responses from law enforcement and 

behavioral health supports, prioritization of the crisis work must continue. 

This will mean the expansion of interconnected lifeline centers, bringing 

together 911 and 988 activities, as well as the launch of an increased 

number of mobile crisis intervention (MCI) and mobile crisis services 

(MCS) for persons of all ages. There is a need for increasing research and empirical evidence for what 

types of mobile response are best for which populations, what types of staffing models are ideal, and 

what roles behavioral health staff play when emergency medical services and law enforcement are each 

called to a scene. The role of peers and recovery coaches will need to be expanded and further refined 

for these services. Crisis text lines, peer warm lines and information about resources such as domestic 

violence, grief support, housing and employment services must all be available for callers to receive. 

High risk situations during a crisis, including working with armed individuals, though rare, must also be 

triaged addressed with the most appropriate and least restrictive interventions without compromising 

safety. And persons in crisis must be linked to care, whether its MAT for opioid use disorder, or 

psychotropic medications for acute psychotic conditions, there must be immediate access to evidencebased therapies available through the crisis network. 

2. Rebuild and reboot a robust, diverse, and well-qualified workforce. 

As noted above, burnout rates of frontline workers are profound, and the gaps in workforce seem to be 

at an all-time alarming rate. With the needs for mental health and substance use services on the rise, 

now is the time to regenerate a workforce that is ready, willing and able to serve Rebuild and Reboot in the public and private behavioral health systems and provide care for each a Robust 

other. Just as in the Beyond Beds recommendations, this includes expanding the Workforce 

workforce beyond the traditional professionals, integrating expanded roles for 

peer supports, recovery coaches and even lay staff to help support some of the 

infrastructure of services for individuals to help them remain. Highlighting the 

need for greater education and pay for direct care workers and direct support 

professionals is also going to be necessary to support the home and communitybased services tenets. As the workforce is being developed, they will also need a greater intentional 

focus on their own well-being, and flexible job options such as flex schedules and virtual options where 

feasible. Working with schools to grow and develop workforce is another avenue that warrants further 

exploration, along with loan repayment programs and attention to health professional shortage area 

designations. Innovation to grow the workforce will be needed, and many states are already embarking 

on dialogue to implement new ideas along these lines. 

3. Expand telehealth practices while ensuring ongoing quality and access. 

The pivot to the use of technology in response to the COVID-19 pandemic catalyzed major changes in 

the workplace that will likely never return to pre-COVID-19 operations. Technological advances in 

providing care will continue to require research and innovation as the technology Expand Telehealth 

develops still further. Hybrid approaches that allow for some in-person connections 

as well as telehealth activities need to be studied to help determine best practices 

for particular individuals, settings and conditions. Given the workforce challenges, 

the use of telehealth has allowed for expanded crisis responses in more remote 

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areas. The potential for increasing broadband access to regions currently less served opens a myriad of 

possibilities for enhancements. Lessons learned from the COVID-19 experience should be taken to help 

shore up responses to future disasters, and future enhancements should be driven by data. Telehealth 

has proven lifesaving, both because it allowed for mitigation of viral spread at the height of the early 

pandemic outbreak, and because it helped keep people in mental health services who may have 

otherwise been at risk of decompensation or suicide. The effort now should be focused on how to 

sustain the most impactful aspects of telehealth and continue to enhance quality and access not as a 

replacement for all in-person services but as another quality tool in the array of services available. 

4. Foster integration of disaster behavioral health into emergency preparedness and response. 

Although COVID-19 has caused immeasurable pain and loss, it has catalyzed opportunities to improve 

the behavioral health system’s integration into emergency preparedness and to assist in future 

continuity of operations. Disaster behavioral health (DBH) should continue to be implemented with 

three immediate foci: 

• Ensure that vulnerable populations with serious mental illness, serious emotional disturbances, 

substance use disorder, persons with intellectual and developmental disabilities, neurocognitive 

conditions and traumatic brain injuries who require additional supports are well served without 

disruption during emergencies. 

• Coordination of DBH requires efforts to address the general emotional impacts of emergencies 

on the population as a whole. 

• DBH activities should also center around serving the emotional needs of the public health and 

behavioral health workforce as a separate and focused effort. 

Planning as part of disaster preparedness should include developing culturally and linguistically tailored 

messages to provide information and identify supports for diverse populations. The benefits of self-care, 

the skills of peers and peer navigators, the willingness of faith-based messengers and influencers, and 

the value of warmlines, telehealth and provider mutual aid agreements locally or with Emergency Preparedness 

neighboring states became more evident during COVID-19, and these resources should 

be augmented. The SAMHSA Disaster Distress Helpline and Crisis Text Lines handled 

substantial increases in volume, reflecting anxiety and distress brought on by COVID-19’s 

many uncertainties and the critical importance of these types of assets. Grants available 

through FEMA’s Crisis Counseling Program (CCP) for short-term support to states and 

special grant opportunities93 and increased Medicaid matching helped states to cover service 

needs related to COVID-19, and advocacy and access to these resources proved invaluable and should 

continue. 

In 2019, Beyond the Borders: Lessons from the International Community to Improve Mental Health 

Outcomes examined the experience of other countries in responding to disaster and building sustained 

improvements in mental health services.94 Similarly, Yox reviewed the lessons learned about global 

health, and called out some of the global health conceptualizations as placing priorities on improved 

health and achieving equity in health worldwide. 

95 She describes work of the National Association of 

County and City Health Officials (NACCHO) and local health departments (LHDs) and the importance of 

focusing on global health, allowing and shifting to bidirectional learning so that those LHDs in the United 

States can also learn from the experiences of other countries in dealing with local health crises. She 

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notes that given the inherent risks of long-term impact of COVID-19 on social isolation, mental health 

and substance use the need to look beyond one’s borders and continue to improve in a global sense is 

paramount. By focusing on global health, and examining physical and mental health simultaneously, 

there may continue to be evolving strategies that can foster greater healing and recovery from disasters. 

5. Consider creative financial opportunities to maximize access to crisis response and other 

community-based mental health and substance use services with no wrong door. 

Funding streams for crisis services will likely be needed from a variety of sources, including Medicaid, 

CHIP, general funds, new tax levies on 988 calls, federal discretionary grants such as block grant dollars, 

private insurers and more immediate funds coming through the American Rescue Plan Act. The 

challenge is that each of these sources of funding have their own mandates, limitations and 

requirements. They also are managed at state and local levels by different entities which can create 

barriers to uniform planning for a service that cuts across all sectors. Even outside of Financial Opportunities the traditional mental health and substance use state authorities, there is the need 

to serve individuals with intellectual and developmental disabilities, older adults, schools, 

child welfare, juvenile justice, criminal legal and court systems who send referrals either in 

a moment of crisis or as part of the full array of supports needed. This will include 

leveraging waiver options for Medicaid services to maximize federal dollars, as well as 

considering options to manage finances through population based initiatives such as health homes, 

accountable care organizations or managed type entities, as well as using demonstration opportunities 

for community level comprehensive services such as in the Certified Community Behavioral Health 

Center Model. Opportunities for creative options exist for states to help serve individuals that did not 

exist previously, and policymakers therefore are given a golden opportunity to use the funds wisely. 

6. Focus intentionally on diversity, equity and inclusion to reduce disparities in mental health 

outcomes. 

Tragically, disparities in healthcare have not dissipated. In fact, the impact of COVID-19 has made them 

only more apparent. Leadership at the highest level of the federal government has recognized the 

critical importance of ensuring diversity of representation and intentional efforts to Focus on diversity, study health outcomes from an equity lens. In the space of crisis services and the equity and inclusion 

broader continuum of psychiatric services for all ages, attending to diverse 

populations and their unique needs is critical. The needs of Black and Brown persons, 

Latinos, American Indian and Alaska Natives, among individuals with serious mental 

illness or other behavioral health type condition, just to name a few, require and 

deserve targeted approaches to eliminate the disparities in mental health outcomes such as suicide 

rates, overdose rates, child welfare removals, and others that can lead to downstream consequences 

and impact generations. Policymakers should take every possible action to eliminate needless tragic 

outcomes associated with law enforcement encounters with persons of color and persons with mental 

illness that all too often are reported. Still, it is important to recognize that law enforcement will remain 

a partner in the crisis response system, and therefore efforts will be needed to engage them and focus 

those responses on the right situations and with attention to equity in access to jail diversion and 

reduced use of force as much as possible. Equitable, accessible, and just quality care must be front and 

center and cultural humility should enter service delivery. Much work is needed to reduce disparities. 

Calling these issues out is only the first step. 

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7. Enhance interconnectedness with other systems and across borders for improved global responses. 

State mental health authorities have a unique role to play in expanding the crisis continuum, but they 

cannot do this in isolation. Collaborations are needed and bringing in stakeholders as advisors in 

program development aligns with federal funding requirements, such as is seen in mental health 

advisory bodies at state and local leadership levels. Collaborations between behavioral health and public 

health has been critical in addressing the COVID-19 pandemic and brought out the Interconnectedness for need to integrate these efforts in a sustainable way. As noted above, global health now Global Responses 

has meaning and relevance to the human experience. Shifts away from traditional law 

enforcement responses in many cases, and ongoing needs of jail diversion and reentry 

supports, juvenile justice diversion remain key priority areas. Work must continue building 

bridges between child welfare, schools, and children’s behavioral health services. Local 

hospitals must be interconnected with community-based services. Persons with substance 

use disorders require warm handoffs and MAT must be available because it can literally save 

lives. Persons with traumatic brain injuries, intellectual and developmental disabilities and other 

challenges often appear in the behavioral health systems. Given these needs, establishing and 

enhancing interconnectedness has never been more important. Network analyses should demand policy 

makers to make sure that they have all the partners at the table and that they get input from various 

perspectives to roll out the best services possible. 

Conclusions 

Although there have been many advances in improving mental illness outcomes, too many people with 

serious mental illness, serious emotional disorders, and co-occurring substance use disorders are still 

waiting too long to receive needed services. Too many are homeless, too many are being arrested, are 

incarcerated or in the juvenile justice settings, too many are overdosing and dying by suicide. With 

COVID-19 so many lives have been lost, and many people are in need of emotional support. Now, as 

COVID-19 vaccines roll out, and new funding is being distributed, there is hope on the horizon. Yet, 

while the virus remains present, there are even broader population mental health needs that will 

require immediate access through no wrong door policies. The daily dialogues are replete with ideas 

about how to build crisis services along a continuum. Looking beyond COVID-19 and beyond crisis, there 

continues to be a need for interventions across a continuum of care, the funding to support them, and a 

workforce to deliver them. Ready to Respond aims to provide a level-setting overview of the current 

landscape and highlights areas needed for prioritization. The resilience of our communities is profoundly 

humbling given the individual and collective experiences throughout this pandemic. Taking that strength 

forward, there is no better time than now to collaboratively pursue improved services for better 

outcomes. 

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Association of State Mental Health Program Directors, 2017. 

https://www.nasmhpd.org/sites/default/files/TAC.Paper_.1Beyond_Beds.pdf 

2 Ibid 

3 Pinals DA, Fuller DA: Bolder goals, better results: Seven breakthrough strategies to improve mental illness 

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mitigation strategies. Subst Abus. 2020;41(3):286-291 62 Volkow N: Study reveals adults with mental disorders are at significantly higher risk of COVID0-19 and have 

poorer outcomes. New York, NY, Brain and Behavior Research Foundation, 2020. 

https://www.bbrfoundation.org/content/study-reveals-adults-mental-disorders-are-significantly-higher-risk-covid19-and-have-poorer 63 Turk MA, Landes SD, Formica MK, et al: Intellectual and developmental disability and COVID-19 case-fatality 

trends: TriNetX analysis. Disabil Health J. 2020;13(3):100942 64 COVID-19 Health Equity Task Force. Washington, DC, U.S. Department of Health and Human Services Office of 

Minority Health. https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=100 65 Pinals DA” Crisis Services: Meeting Needs, Saving Lives. Alexandria, VA, National Association of State Mental 

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67 Alegria M, NeMoyer A, Falgas I, et al: Social determinants of mental health: Where we are and where we need to 

go. Curr Psychiatry Rep 2018; 20(11): 95 68 Racial data transparency. Baltimore, MD, Coronavirus Resource Center, Johns Hopkins University of Medicine. 

https://coronavirus.jhu.edu/data/racial-data-transparency 69 Household pulse survey. Atlanta, GA, Centers for Disease Control and Prevention, 2021. 

https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm 70 Implementation of the National Suicide Hotline Improvement Act of 2018. Washington, DC, Federal 

Communications Commission, 2020. https://www.fcc.gov/document/designating-988-national-suicide-preventionlifeline-0 71 988 officially becomes law. West Hollywood, CA, The Trevor Project 2020, October 19. 

https://www.thetrevorproject.org/2020/10/19/988-officially-becomes-law/ 72 Rankin K: New national mental health crisis line can save black lives. Health Central 2020, December 9. 

https://www.healthcentral.com/article/mental-health-hotline-black-lives 73 Access to Mental Health Services for Adults Covered by Medicaid. Washington, DC, Medicaid and CHIP Payment 

Access Commission 2021. https://www.macpac.gov/wp-content/uploads/2021/06/Chapter-2-Access-to-MentalHealth-Services-for-Adults-Covered-by-Medicaid.pdf 74 Results from the 2019 National Survey on Drug Use and Health: Detailed tables. Rockville, MD, Center for 

Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 2020. 

https://www.samhsa.gov/data/ 

75 Hepburn S: Virginia is first state to pass 988 service fee legislation. Alexandria, VA, Crisis Talk 2021, May 4. 

https://talk.crisisnow.com/virginia-is-first-state-to-pass-988-service-fee-legislation/ 76 Wachino V, Camhi N: Building Blocks: How Medicaid Can Advance Mental Health and Substance Use Crisis 

Response. Well Being Trust, May 2021. https://wellbeingtrust.org/news/how-medicaid-can-advance-mentalhealth-and-substance-use-crisis-response/ 77 Crisis now. Alexandria, VA, National Association for State Mental Health Program Directors. 

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78 The psychiatric shortage: Causes and Solutions. Washington, DC, National Council for Mental Wellbeing, 2018. 

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.pdf?daf=375ateTbd56 

79 Retooling for an Aging America: Building the Health Care Workforce. Washington, DC, National Academies Press, 

2008. https://www.ncbi.nlm.nih.gov/books/NBK215393/ 80 Yorkunas R: A workforce in crisis: Disability services are seeing a shortage of direct support staff. Fox 43 2021, 

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b88f-43cf-b0dc-3f7f9349b715 81 2019 Direct Support Professional Compensation Study. Blue Bell, PA, Moving Agencies toward Excellence, 2020. 

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States General Accounting Office, 2021. 

83 Wilson C: ‘Dire’ staffing situation at Oregon State Hospital prompts call for National Guard to assist. OPB, 2021, 

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84 Lt. Gov. Calley: Michigan autism progress includes top 10 ranking for certified behavior analysts. Lansing, MI, 

State of Michigan, 2018. https://www.michigan.gov/som/0,4669,7-192-29701_74909_74922-484306--,00.html 85 CareOregon to invest $7.5 million in 25 behavioral health provider organizations to improve processional 

recruiting & retention. Open Minds 2021. https://openminds.com/market-intelligence/news/careoregon-to-invest7-5-million-in-25-behavioral-health-provider-organizations-to-address-clinical-professionalburnout/?utm_source=mailchimp&utm_medium=email&utm_campaign=weekly-news&utm_content=2021-07-02 86 117th Congress 1st Session. https://debbiedingell.house.gov/uploadedfiles/hcbs_01_xml.pdf 87 Hubley S, Lynch SB, Schneck C, et al: Review of key telepsychiatry outcomes. World J Psychiatry 2016;6(2):269-82 

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25
Disaster 

Behavioral 

Health Through 

the Lens of 

COVID-19 

No. 2 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

26
 

 

 

 

 

Disaster Behavioral Health through the Lens of 

COVID-19 

Debra A. Pinals, M.D. 

Clinical Professor of Psychiatry, Director 

Program in Psychiatry, Law and Ethics 

University of Michigan 

Medical Director 

Behavioral Health and Forensic Programs 

Michigan Department of Health and Human Services 

Chair 

Medical Director’s Division 

National Association of State Mental Health Program Directors 

Arlene Hahn Stephenson, MAS 

Consultant 

National Association of State Mental Health Program Directors 

Former Deputy Secretary for Public Health 

Maryland Department of Health 

Cover Art by Malkah Pinals 

Second in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

27
 

 

 

 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, or 

other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Pinals, D. A., Stephenson, A.H. (2021). Disaster Behavioral Health Through the lens of COVID-19. 

Technical Assistance Collaborative Paper No. 2. Alexandria, VA: National Association of State Mental 

Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

28
 

 

 

 

 

 

 

 

 

 

 

Abstract: 

Disaster planning and response in the U.S. is structured by the National Incident Management 

System (NIMS) that focuses on the safety and protection of life, assets, and the environment. 

Additionally, the Federal Emergency Management Agency (FEMA) issues specific guidance related to 

such planning and response. Part of this planning includes the need to attend to the emotional wellbeing of those impacted by disasters, as well as the need to ensure continuity of operations and 

access to behavioral health care during emergencies. COVID-19 resulted in a declaration of 

emergency and by early 2020 was codified as a global pandemic. Unlike a more common, local, or 

sudden disaster emergency such as a tornado or an explosion, COVID-19 was global and long-term. It 

overwhelmed health care systems, caused the death of millions, created economic and social 

disruption around the world, and dramatically changed life as we knew it. From this experience, 

health disparities and the unique needs of public behavioral health populations became increasingly 

apparent. Additionally, the human toll from COVID-19 and the resultant need for expanded 

behavioral health crisis response suggests there are lessons to be learned from the widespread loss, 

quarantine, and social shifts to connections via technology. The pandemic also highlighted some of 

the progress that has occurred over the last several decades related to incorporating behavioral 

health responses into overall emergency preparedness. This paper reviews the history and 

framework of emergency planning and response and addresses aspects related to COVID-19. 

Recommendations for how best to incorporate behavioral health responses into future disaster 

emergency planning are offered. 

Highlights: 

• Emergency preparedness continues to evolve, integrating disaster behavioral health planning 

into overall preparedness. 

• COVID-19 highlighted gaps in planning for epidemics and pandemics, including disaster 

behavioral health. 

• Disparities in outcomes from COVID-19 and its impact on minority populations requires an 

intentional focus on health equity in emergency management. 

Recommendations for the post-COVID-19 future: 

1. Bolster the integration of disaster behavioral health into public health emergency preparedness 

and response. 

2. Attend to health equity with specific efforts focused on the needs of high-risk populations. 

3. Conduct mass psychological distress screenings and opportunities to provide emotional support. 

4. Continue to promote behavioral health surveillance and research. 

5. Foster communications focused on behavioral health needs. 

6. Attend to the mental health of health care workers and responders. 

7. Continue to build telehealth capacity. 

8. Continue to foster training on aspects of disaster behavioral health. 

9. Maximize continuity and access to treatment for behavioral health populations. 

10. Continue efforts to expand and develop a robust crisis care system. 

29
 

 

 

 

 

 

 

 

 

 

 

 

 

mergency planning and response in the U.S. is structured by the National Incident Management 

System (NIMS), which focuses on the safety and protection of life, assets, and the environment. 

Guidance for this structure was established first in 2004 by the Federal Emergency Management 

Agency (FEMA) within the U.S. Department of Homeland 

Security.1 The COVID-19 pandemic presented new challenges Coronavirus disease 2019 (COVID-19) 

in all areas related to emergency planning and response. Unlike is an infectious disease caused by the 

a more common, local, or sudden disaster emergency such as a novel coronavirus SARS-CoV-2. The 

tornado or an explosion, COVID-19 ultimately resulted in a initial lack of immunity caused it to 

declaration of emergency in all states and territories and by spread rapidly throughout the world 

early 2020 was codified as a global pandemic. It overwhelmed causing millions to become ill and die. 

health care systems, caused the death of millions and 

economic and social disruption around the world, and dramatically changed life as we knew it. 

Behavioral health systems were not spared. Public behavioral health systems, which not only serve the 

public behavioral health needs, but as state mental health authorities must attend to the emotional 

needs of the entire population, were especially impacted. This technical assistance paper focuses on 

Disaster Behavioral Health through this newly emerged COVID-19 lens and with thoughts for future 

planning and preparedness. 

Overview of Disaster Preparedness 

Three major components of emergency management are: an Emergency Operations Plan (EOP) that is 

utilized to prepare for and respond to an emergency; an Incident Command System (ICS) which is a 

management structure that defines who is in charge (Incident Commander), who reports to whom and 

who has responsibility for overseeing duties related to Operations, Planning, Logistics, and 

Administration/Finance; and a Continuity of Operation Plan (COOP) that is typically activated in order 

to assist the agency with reconstituting or continuing regular operations. All federal and state agencies 

are required to develop EOPs using an “all-hazards” approach, meaning they are sufficiently flexible to 

address a full spectrum of emergencies or disasters, including man-made emergencies (e.g. chemical 

spills, explosions, chemical or biological attacks, nuclear blasts, 

plane crashes) and naturally occurring disasters/emergencies The authors of this technical 

(e.g. tornadoes, hurricanes, floods, viruses, toxins). EOPs must assistance paper have a combined 40 

also include planning for pandemic influenza, given the plus years of experience in state 

experience of the 1918 Pandemic and the expectation that one government and disaster 

would emerge. An EOP is a requirement for government preparedness and response. Much of 

agencies but should also be a practice for all other the content of this report is drawn 

organizations and businesses. It should be noted that much of from this experience in the field. 

the initial response is at the local level. 

The COVID-19 pandemic is a unique type of emergency because it necessitated all five phases of the 

emergency management planning cycle to be addressed virtually simultaneously rather than one phase 

at a time. Table 1 depicts these five phases and how they took place during COVID-19. 

30
 

 

 

Table 1: Five phases of emergency management planning cycle and COVID-19 response 

Phase Description Sample COVID-19 response 

1. Preparedness Includes emergency preparedness 

plans to save lives and minimize 

damage that can occur during a 

disaster. 

• Developed knowledge base of 

COVID-19 symptoms; 

• Acquired supplies and 

pharmaceuticals. 

2. Prevention Activities to increase the community’s 

ability to respond when a disaster 

occurs. This can include: 

• deterrence operations and 

surveillance, 

• assessing the hazards, risks and 

vulnerabilities, 

• backing up information, 

• developing mutual aid 

agreements, 

• training for both response 

personnel and concerned 

citizens, 

• conducting disaster exercises to 

reinforce training and test 

capabilities, and 

• presenting all-hazards education 

campaigns. 

• Developed pandemic influenza 

plans; 

• Moved vaccines through the 

approval process; 

• Current vaccination efforts. 

3. Mitigation Putting in place measures that 

prevent an emergency, reduce the 

chance of an emergency happening, 

or reduce the damaging effects of 

unavoidable emergencies. This phase 

involves developing policies to reduce 

risks to people and property during a 

disaster and determining which 

groups are most at risk and what 

resources are needed. 

• Emphasis and orders for 

consistent and correct use of 

masks, physical distancing and 

procedures for infection control; 

• Contact tracing in combination 

with isolation and quarantine; 

• Identification of seniors and 

some minority populations as 

being at greater risk. 

4. Response Activating the emergency operations 

plans and taking actions aimed at 

saving lives, reducing economic 

losses, and alleviating suffering. 

• Deployment of personnel, 

information, protective 

equipment; 

• Activation of the Strategic 

National Stockpile; 

• COVID-19 vaccinations 

messaging regarding its efficacy 

and safety, distribution and 

administration. 

5. Recovery Actions taken to return a community 

to normal or near-normal conditions. 

• Returning to the workplace; 

• Relaxation of mask mandates. 

Activating an Incident Command System (ICS) provides a flexible, yet standardized core mechanism for 

coordinated and collaborative incident management internally, and particularly when multiple agencies, 

31
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

organizations or jurisdictions are involved thus requiring cross-jurisdictional coordination. The ICS is 

designed to enable effective, efficient incident management by integrating a combination of facilities, 

equipment, personnel, procedures, and communications operating within a common organizational 

structure. ICS enables incident managers to identify key concerns associated with the incident—often 

under urgent conditions—without sacrificing attention to any component of the command system or 

the response. It represents organizational "best practices" and, as an element of the Command and 

Management Component of NIMS, has become the standard for emergency management across the 

country.2 

A Continuity of Operations Plan (COOP) is a companion plan to an EOP. It establishes policy and 

guidance ensuring that an organization can continue critical functions in the event of a disaster. In order 

to achieve that goal, the organizations begin plan development by identifying their essential functions 

and further developing it ensure that those functions can be continued throughout, or resumed rapidly 

after, a disruption of normal activities. The overarching continuity requirements include: 

1. Orders of succession – who takes over if leadership are unavailable or unable to execute their 

duties; 

2. Delegations of authority – identification, by position, of the authorities for making policy 

determinations and decisions at all levels and at all other organizational locations; 

3. Continuity facilities – if necessary, personnel and resources are relocated to an alternate 

location until operations return to normal or are directed to work from home; 

4. Continuity communications – keep communications systems operational and provide the 

capability to perform essential functions internally and remotely as needed; 

5. Vital records management – identification, protection and ready availability of electronic and 

hard copy documents as well as hardware, software and equipment needed to support essential 

functions during a continuity situation; 

6. Human capital – ICS and/or COOP assigned employees and other special categories of 

employees who are activated to perform assigned response duties; 

7. Tests, training, and exercises (TT&E) – drills or exercises conducted to ensure that plans can 

support the continued execution of essential functions throughout the duration of a continuity 

event; 

8. Devolution of control and direction – capability to transfer authority for essential functions from 

primary operating staff and facilities to other employees and facilities; and 

9. Reconstitution – the process by which surviving and/or replacement personnel resume normal 

organization operations from the original or replacement primary operating facility. 

The pandemic has been so disruptive to most government agencies and businesses for such a prolonged 

period that they have been utilizing both their EOPs and their COOPs simultaneously throughout the 

pandemic.

3 

Functions of Government Agencies in Disaster Response 

During an emergency FEMA’s function is to serve in a support role to other federal and state 

government agencies overwhelmed by disaster. For a biological emergency FEMA would support the 

Department of Health and Human Services (DHHS) and, if needed, state health departments. However, 

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on March 19, 2020, FEMA’s role in the pandemic response was changed by the White House 

Coronavirus Task Force from supporting DHHS, which was designated as the initial lead federal agency 

for the COVID-19 pandemic response, to coordinating the Whole-of-Government response to the 

pandemic. In his testimony to Congress on July 24, 2020, the FEMA Administrator, Peter Gaynor, 

explained that for the first time in U.S. history the entire nation was in a state of emergency. There were 

114 concurrent Major Disaster Declarations —one or more in every state and the District of Columbia, 

five territories and the Seminole Tribe of Florida. The scale of this historic event required FEMA to adapt 

its response practices and workforce posture to both respond to COVID-19 and simultaneously maintain 

readiness for more common disasters such as hurricanes, earthquakes, floods, or wildfires. The agency 

became responsible for building “surge capacity” (ability to manage a high volume of patients), 

managing critical shortages of health supplies, distributing DHHS’ Strategic National Stockpile (SNS), 

overseeing the Supply Chain Stabilization Task Force and Project Airbridge which increased 

manufacturing and expedited shipping of consumer goods, and assumed authority for The Defense 

Production Act, Next-Generation SNS, and deployment of over 50,000 federal personnel.

4 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency within DHHS 

whose emergency planning role is to provide states, communities and responders with behavioral 

health resources that help them prepare, respond, and recover from disasters. SAMHSA has assisted in 

the response to COVID-19 by making available products and resources in various media that can be 

useful when coping with the effects of widespread public health crises for individuals, employers and 

populations at increased risk. They emphasized the immediate and potential long-term effects of the 

pandemic on the public and health care providers and responders and the importance for self-care and 

seeking help if needed. SAMHSA issued alerts providing guidance for many services such as opioid 

treatment programs, vaccine usage and continued to promote best practices for crisis counseling 

through their Disaster Behavioral Health relief efforts. Due to the pandemic and its associated economic 

stressors, SAMHSA has been assisting state behavioral health and Medicaid agencies with the financial 

challenges to meet both existing needs as well as an increase in demand, by issuing grants to address 

service demands and easing regulations to make telehealth more readily available. The Centers for 

Disease Control and Prevention’s (CDC) issued a report showing the immense and growing need for 

behavioral health services – four out of 10 individuals struggling with mental health and/or substance 

use and 11% having considered suicide.5 A blog published in Health Affairs aptly described the pandemic 

as the “perfect storm for psychological stress ... long-lasting storm will widen already massive mental 

health disparities among marginalized populations.”6 

The Evolution of Disaster Behavioral Health 

Disaster behavioral health is defined as the provision of mental health, substance abuse, and stress 

management services to disaster survivors and responders.7 Disaster Behavioral Health as a field was 

first established in the wake of the terrorist attacks on September 11, 2001, natural disasters, and other 

emergencies of the last several years. Research and studies have highlighted the close interplay 

between behavioral health and physical health and the importance of integrating them both into all 

33
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

aspects of public health and medical disaster management.

8 However, 

disaster behavioral health as we know it today became an integral part 

of emergency management when the Disaster Mental Health 

Subcommittee of the National Biodefense Science Board (NBSB). The 

Board was created by President George W. Bush in October 2007 

through the Homeland Security Presidential Directive 21, paragraph 31 

and was charged with submitting recommendations to the NBSB for 

protecting, preserving, and restoring individual and community mental 

health in catastrophic health event settings.

9 In its report, the NBSB 

Subcommittee on Disaster Mental Health conceptualized “disaster 

mental and behavioral health” as including “the interconnected 

psychological, emotional, cognitive, developmental, and social 

influences on behavior and mental health and the impact of those 

factors on preparedness, response, and recovery from disasters or 

traumatic events.”10 The recommendations were presented to the 

NBSB in November 2008 and the NBSB sent its recommendations to the 

Secretary of DHHS describing the importance and context of the 

integration and provided details of the subcommittee’s assessment and 

recommendations regarding integration. 

Since that time, the need for behavioral health disaster capabilities has 

been demonstrated by research that has linked the exposure to trauma and the onset of other health 

care needs immediately following an emergency event.

11 For example, research suggests that after a 

traumatic event, individuals could later present with cardiovascular, musculoskeletal, and neurological 

illness, as well as psychiatric diagnoses such as post-traumatic stress disorder (PTSD), anxiety, 

depression, and substance use disorders, even years after the event occurred. There is also data 

demonstrating that costs associated with the treatment of these conditions also increase.

12 

It is now considered a best practice to integrate behavioral health into disaster EOPs and into elements 

of disaster response education and training and based on and advanced through research. However, in 

practice this integration is not be as robust across all jurisdictions. An important factor for integration is 

that it must be supported in underlying policies with clear lines of responsibility for implementing policy 

in practice.

13 Just as emergency planners develop EOPs that incorporate a component for pandemics, 

they must also incorporate a behavioral health component. 

SAMHSA has taken a comprehensive approach to providing guidance to states that simplifies the task of 

developing an emergency plan for disaster behavioral health. TAP 34: Disaster Planning Handbook for 

Behavioral Health Service Programs is SAMHSA’s most recent technical assistance publication, updated 

in 2021.

14 It provides guidance for mental health and substance use disorder treatment programs 

wanting to develop or update a comprehensive, scalable, and flexible disaster plan. It addresses 

planning needs specific to programs that offer prevention services, outpatient or residential treatment, 

medically supervised withdrawal, and pharmacotherapy. In addition, SAMHSA developed a disaster kit 

to arm disaster recovery workers with materials that aid in responding effectively to the public during 

and after a disaster, and in dealing with any accompanying workplace stress. Other materials include 

supporting seniors, tips for healthcare professionals, trauma-informed care materials, and a disaster 

smart phone app. Finally, SAMHSA provides free disaster technical assistance, training, and consultation 

Residents and responders who 

experience a new disaster are at greater 

risk for adverse stress reactions. People 

may display symptoms and reactions 

such as: 

• Emotional symptoms including as 

irritability or excessive sadness; 

• cognitive dysfunction such as 

difficulty making decisions or 

following directions; 

• physical symptoms such as 

headache, stomach pain, or difficulty 

breathing; 

• behavioral reactions such as 

consuming more alcohol or 

interpersonal conflict; and 

• failure to adhere to needed physical 

or psychiatric medication needs.8 

34
 

 

 

 

 

 

 

 

 

 

 

 

efforts to help states, territories, tribes, and other disaster behavioral health providers plan for and 

respond effectively to mental health and substance use needs related to disaster events.15 

COVID-19 Challenges for Behavioral Health and Future Directions 

In conventional natural disasters, technological accidents, and intentional acts of mass destruction, a 

primary mental health concern is PTSD arising from exposure to trauma. Experiencing a pandemic was 

not contemplated to meet the current criteria for trauma required for a diagnosis of PTSD in the most 

formal sense, even though the experience of the pandemic can be considered traumatic in a general 

sense. However, one would expect other psychopathology, such as depressive and anxiety disorders, 

which have been fairly common sequelae.

16 Unlike an acute traumatic stressor that has a discrete 

beginning and end, the COVID-19 pandemic is an ongoing event that has the potential to cause chronic 

stress. Chronic stress causes the body to stay in a constant state of alertness, despite being in no 

immediate danger. Prolonged chronic stress can disturb all major systems in the body (e.g., immune, 

digestive, cardiovascular, sleep) and can increase risk for psychiatric disorders and some physical 

disorders such as cardiovascular diseases and diabetes.17 Widespread trauma-informed care, which 

involves first recognizing that trauma is common among individuals, serves both in the immediate crisis 

and as a preventative measure against unforeseen future traumatic contexts.18 

In its analysis of the current COVID-19 pandemic, UNICEF identified several potential negative 

consequences for children and adolescents, including the increased risk of child maltreatment and 

exposure to violence.19 The necessary public health strategies employed, including confinement and 

school closures, have underlined the hurdles of current protective systems to offer services to support 

vulnerable families and provide targeted and effective services to meet their needs. Leaders have 

already and will continue to make efforts to assist children and families by understanding what puts 

individuals at higher risk for traumatic stress, as well as adopting stress mediation strategies.20 A trauma 

informed approach may never have been so important as during a pandemic to promote the health and 

well-being of all and to protect our marginalized populations at greatest risk. 

Despite efforts that have been made in behavioral health emergency planning and integration into all 

hazards planning, many challenges remain in order to achieve the best possible responses. Additionally, 

many new lessons have emerged after the COVID-19 experience that can inform future disaster 

preparedness. These include the following: 

1. Safety as a primary concern of providers. Staff and client safety related to infection control 

were critical to the ability to provide behavioral health treatment. Initially, safety guidance for 

protocols, social distancing and COVID-19 testing was not widely available or accessible. 

Personal protective equipment shortages and shortages of cleaning and sanitizing products 

added to cases and exacerbated fear. Testing supplies and strategies took time to become 

widely available. A well-operating manufacturing and supply chain would prevent these 

shortages in the future. 

2. Increased recognition of the significant psychological impacts of disasters. According to a 

recent study, the prevalence of PTSD six years after a disaster was 11.3%, and the previous 

baseline prevalence was 4.2%, with onset mainly within 1 month and remission within 3 years 

35
 

 

 

 

 

 

 

 

post-disaster.

12 During COVID-19 providers identified major problems with business operations, 

service provision, telehealth, client concerns, staff concerns, supplies, technology, 

illness/grief/loss, and communications.21 In addition, safety concerns surfaced related to child 

abuse, intimate partner violence, and substance abuse.22 

3. Need for integration of appropriate disaster behavioral health interventions and services into 

all phases of emergency management. Some lessons learned from COVID-19 include the need 

for a cultural change for emergency planners from that of a medical response/public health 

response to one that fully appreciates and integrates behavioral health concepts. This includes 

responses to mitigate mental health impacts and incorporate planning for behavioral health 

populations. In short, acknowledging that behavioral health is part of public health.23 However, 

this will need to be facilitated by national policy that establishes the joint roles and 

responsibilities between behavioral health and public health. 

Engaging all facets of the community from political leaders, faith-based institutions and 

community members would assist in addressing local concerns.24 

4. Limited access to providers, medication and other evidence-based therapies. Existing problems 

with lack of access to care were exacerbated by pandemic-created demand. Behavioral health 

professional workforce shortages and geographic imbalances in available care became 

increasingly problematic as case counts and fear continued to rise. Access to effective 

medication and other evidence-based therapies for individuals was difficult due to 

manufacturing and shipping delays. There is a Strategic National Stockpile of medications to be 

used in emergencies. During the annual reviews of SNS formulary policy recommendations, it 

has been strongly suggested that psychotropic medications be included in the SNS.25 To provide 

necessary access, it should incorporate a full range of psychoactive and SUD medications. 

Behavioral health issues related to the pandemic will continue into the future for those with 

behavioral health conditions or those whose conditions emerge during the disaster. Therefore, 

sustainable behavioral health treatment and simplified referral pathways must be available and 

continue beyond the emergencies. 

5. Telehealth and remote service provision. Telehealth, which ultimately has included telephonic 

and video technology, was exceedingly helpful in solving many safety, access and workflow 

concerns. However, provider access was initially hampered by telehealth regulations. Access by 

clients was hampered by those who had limited access to technology and reliable internet 

services or had difficulty utilizing the technology. Utilization of the technology by staff without 

adequate training was also problematic. Other related problems that were reported included 

requirements for HIPAA compliant platforms and emergency exceptions to some of these 

restrictions and an inability to access electronic medical records. These created challenges to 

business operations and consumers initially, but regulation waivers and training eventually 

resolved these issues, and it quickly became invaluable. Actions taken now to unify regulations, 

simplify technology, expand internet access and provide training will serve us well in the future. 

6. Challenges in anticipating and meeting needs of priority populations. Early determinations of 

populations anticipated to sustain the greatest negative impact, i.e. priority populations, and 

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how to reach out to them could have had the potential to reduce negative outcomes. As COVID19 was increasing in prevalence, it was becoming clear that congregate living facilities were 

being impacted quickly, such as nursing homes, some state psychiatric hospitals, jails and 

prisons and others. Other priority populations often include individuals with existing mental 

health, developmental disabilities, and substance use disorders, as well as health care workers,26 

first responders, marginalized populations, older adults and children, among others. 

Preparedness that includes planning across settings for these populations is needed. 

7. Financial concerns of providers and consumers. Financial relief for providers made available by 

various government agencies was helpful, but vehicles to make it available more quickly would 

also be beneficial. A survey conducted by The National Council for Mental Wellbeing reported 

that behavioral health providers on average lost 24.3% of revenue. Organizations with more 

diversified payment methodologies (e.g. Prospective Payment System) managed better 

financially.27 

Assistance with client loss of income that could have been used to pay for services also arrived 

slowly. The DHHS Office of the Inspector General’s ability to reduce or waive beneficiary cost 

sharing for federal health care programs was impactful for Medicare and Medicaid 

beneficiaries.

28 However, some consumers faced unpaid insurance claims because their private 

or employer-based health insurance coverage violated the provisions of the Mental Health 

Parity and Addiction Equity Act (MHPAEA) by providing lesser coverage for behavioral health 

benefits than for physical health.29 Parity compliance and enforcement programs should be 

supported and coordinated with state authorities as appropriate to avert this problem in the 

future.

30 Policy makers must take steps to improve access including the continuation of policies 

implemented during the pandemic, such as insurance coverage for telehealth, copayment 

waivers, and license reciprocity to enable telehealth across state lines. 

8. Vaccines and hesitancy/refusal among persons with mental illness. Many organizations have 

spoken out on behalf of individuals with mental illness to encourage vaccination prioritization. 

The British Medical Journal suggested that extra support would be needed as individuals living 

with mental health challenges have a historically low uptake of preventive health programs, 

such as the influenza vaccine.

31 They expressed concerns that this population may simply get 

left behind because the nature of mental illness can stigmatize and impact sufferers’ ability to 

speak and be heard. They suggest that prioritization is justified because within the larger 

population of those with serious mental illness there is considerable multimorbidity putting 

them at higher risk for COVID-19.32 During the pandemic, then American Psychiatric Association 

called on state public health authorities to include people with serious mental illness and 

substance use disorders in the high-risk priority categories with individuals over 65 years-old 

and those with high-risk medical conditions ages 16-64.33 Solutions offered to improve 

vaccination rates are to embed vaccination clinics within mental health services, provide direct 

access to existing immunization registries which assists in both monitoring and coordination 

and/or to develop emergency legislation to allow for a wider group of health care professionals 

to administer the vaccinations.34 

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State Behavioral Health System Leadership in Disaster Behavioral Health 

Governors and their senior health and human services leadership play an essential role in incorporating 

a behavioral health strategy into the states’ COVID-19 response and recovery approach. There are many 

key issues that are currently challenging state behavioral health systems. Some of these include 

challenges in maintaining access to treatment and services due to workforce shortages. Flow through 

systems is frequently impeded such as is seen with emergency department boarding, waitlists for 

admissions into state hospitals, waitlists for community placements and appointments for psychiatrists 

and other services. All of this is under the pressures of seemingly endless increasing demand for 

services. It will be critical to continue to advocate for flexibility of policies, program rules, and 

regulations, such as pursuing federal waivers for provider qualifications, telehealth coverage, prior 

authorization requirements, and where services can be delivered. Additionally, providing guidance, 

training, support, and resources (e.g., purchasing virtual meeting licenses and equipment) for behavioral 

health providers will be an ongoing need as the workforce shifts to flexibly modalities on a more longterm basis. Ongoing technical assistance for capacity building will be critical. There will be an ongoing 

need to continue to ensure that behavioral health system needs are among the priorities for federal 

funding and policy development. Many of the issues identified are still emerging and state and federal 

actions will require ongoing research to identify opportunities and follow up to determine outcomes.35 

To that end, it is critical for leadership within the behavioral health system to have a seat within policy 

conversations. COVID-19 has provided an increased opportunity for these partnerships to continue to 

forge a path forward. 

Recommendations for the Post-COVID-19 future 

1. Bolster the integration of disaster behavioral health into public health emergency preparedness 

and response. 

The strength of a public health system rests on its capacity to effectively deliver the 10 Essential 

Public Health Services specifically laid out by the CDC and revised again in September 2020 to more 

specifically aim to address the needs to “protect and promote health of all people in all 

communities,” while removing structural barriers. The identified services include: 

1) Assess and monitor factors related to public health 

2) Investigate, diagnose and attend to population health problems 

3) Communication to inform and educate 

4) Strengthen, support and mobilize communities 

5) Create, champion and implement policies, plans and laws 

6) Utilize regulatory or legal actions to improve public health. 

7) Enable equitable access to services 

8) Enhance and sustain a diverse capable public health workforce 

9) Improve functioning through evaluation and research 

10) Build and maintain public health infrastructure.36 

The 10 Essential Public Health Services provide a framework for public health to protect and 

promote the health of all people in all communities. Behavioral health system leaders, along with 

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public health leaders, are increasingly recognizing that behavioral health is a subset of public health 

and as such behavioral health should assess which of the 10 Essential Public Health Services may 

need strengthening to best serve individuals with behavioral health needs. 

2. Attend to health equity with specific efforts focused on the needs of high-risk populations. 

SAMHSA defines behavioral health equity as the right to access quality health care for all 

populations, regardless of the individual’s race, ethnicity, gender, socioeconomic status, sexual 

orientation, or geographical location.37 This includes access to prevention, treatment, and recovery 

services for mental and substance use disorders. In March 2021, the CDC announced a plan to 

invest $2.25 billion over two years to address COVID-19-related health disparities and advance 

health equity among populations that are at high-risk and underserved, including racial and ethnic 

minority groups and people living in rural areas. This funding represents CDC’s largest investment 

to date to support health disparities in communities affected by COVID-19. Behavioral health 

services, both in-person and remote, are included in this funding as they are considered clinical 

care.38 In addition to the CDC funding, the American Psychiatric Association (APA) has made specific 

recommendations advocating for more public health funding especially for vulnerable populations 

and eliminating racism in the justice system. In addition, the APA guidance called for education 

about intrinsic bias against persons with mental illness and minority populations, as well as reduced 

bureaucratic and logistical barriers to healthcare access including helplines, telehealth/Internet 

access, among others. served.39 These tenets reflect important strategic direction to address the 

needs equitably for diverse populations. 

3. Conduct mass psychological distress screenings and opportunities to provide emotional support. 

In addition to providing medical care, already stretched health care providers have an important 

role in monitoring psychosocial needs and delivering psychosocial support to their patients, other 

health care providers, and the public. These activities should be integrated into general pandemic 

health and there should be widespread information sharing about emotional responses to disaster 

and supports available. Efforts by SAMHSA, through its Disaster Technical Assistance Center, in 

partnership with FEMA have helped infuse these types of resources and supports through a variety 

of grant mechanisms, including the Crisis Counseling Program grants.40 These funding streams have 

provided tremendous opportunities for states to help support their communities through the 

emotional challenges with the pandemic. As these supports are available, following psychological 

distress screenings, support opportunities could be and have been offered at vaccine sites, in 

offices upon return to work and school and with special emphasis on high-risk groups, and as a 

sustainable model. This would create easy accessibility and maximize the number of individuals 

who could benefit. Providers conducting the screenings can offer suggestions for stress 

management and coping (such as structuring activities and maintaining routines), link patients to 

social and mental health services, and counsel patients to seek professional mental health 

assistance when needed.

41 

4. Continue to promote behavioral health surveillance and research. 

Prioritization of behavioral health surveillance and research through monitoring and collection of 

quality longitudinal data will inform public health policies and disaster planning for the future. 

Although standard surveillance techniques such as daily and cumulative infections and deaths from 

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COVID-19 have been helpful, they provide a static view of what has already occurred. Trends in 

clinical outcomes will provide a look into how effectively care has been provided. Deaths by suicide, 

hospital admissions and readmissions, COVID-19 infections, improved symptom management, 

reduction in symptoms and critical incident reports, each yield data that can lead to ongoing policy 

and programmatic activity for improvement.

42 The U.S. Census Bureau Pulse Household Survey had 

been conducted weekly or every two weeks and throughout the pandemic findings have been 

available on mental health symptoms, services and vaccination behaviors. It provides a point in 

time view but knowledge such as reasons for “not receiving the vaccine or not planning to” and 

“prevention actions among the vaccinated” are examples of data that would be helpful in planning 

as they explain thought processes and point us to barriers. Collection of varying levels of local and 

national data can help inform areas where mitigation measures may be most impactful.

43 

Although most people with COVID-19 recover, another lesson learned leading to considered 

thought for the future relates to the” COVID long-haulers” experiences with COVID-19 Syndrome. 

This condition is associated with longer duration and lingering symptoms that look different from 

acute COVID-19 and can include persistent somatic symptoms including brain fog, fatigue, 

headaches, dizziness and shortness of breath, among others. Individuals with this syndrome can 

experience mental health symptoms such as anxiety, depression and PTSD. Ongoing surveillance 

and research will be needed to understand these types of long-term impacts. 

5. Foster communications focused on behavioral health needs. 

After action reports are generated by emergency managers following every emergency event to 

analyze how well an emergency was handled and to use feedback to improve future responses. 

These reports often reveal that roles, responsibilities and problematic communication can be 

common sources of confusion.

44 The efficacy of the response to COVID-19 has in part depended on 

the speed, scale and consistency of governmental intervention and communication, but also how 

communities have received, perceived, and acted on the information provided by governments and 

other agencies. The communication of information by government and receipt of information by 

the public has been complicated by the ever-changing nature of a pandemic, where new scientific 

information becomes available and the variability and trustworthiness of information sources. 

Government agencies must coordinate messaging to remove ambiguity. 

Pandemic risk communication requires ongoing engagement with communities as effective 

communications and leadership are crucial to the management of pandemics and the rapidly 

changing societal and economic landscape. It takes transparency, civic engagement and 

development of trust in order to effectively communicate. Engaging in clear communication is 

essential to provide specific information on what to do and what to avoid, which can reduce 

anxiety and maintain order. 

Leaders should also listen to the community’s needs and concerns. Communication should be 

adjusted to consider variations in health literacy and understanding of numbers across audiences, It 

is vital to recognize that communities may not be affected by a pandemic in the same way and to 

the same degree. For example, people with disabilities have specific and varied needs and others 

may have linguistic needs. Because the pandemic has also seen a surge in misinformation and 

confusing messages, transparently providing factual and current information prevents subsequent 

susceptibility to emerging misinformation and conspiracy theories.45 At the same time as 

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information about public health issues is shared, there should be ongoing attention to 

communicating about resources to help alleviate anxiety, answer questions and point people to 

distress supports. This became evident with the increased volume of activity for the Disaster 

Distress Helpline when the pandemic was emerging.46 

6. Attend to the mental health of health care workers. 

Health care workers including first responders were particularly vulnerable to emotional distress 

during the pandemic given their risk of exposure to the virus, concern about infecting and caring 

for their loved ones, initial shortages of personal protective equipment, longer work hours, and 

involvement in emotionally and ethically fraught resource-allocation decisions. Prevention efforts 

such as screening for mental health problems, psychoeducation, and psychosocial support should 

focus on health care workers and first responders at risk for adverse psychological outcomes. 

Previous research suggests that health care workers suffer from mental distress during and even 

years after previous epidemics.47 Therefore, attending to the mental health of health care workers 

during epidemics should include universal screenings, early interventions, long term follow up, 

support groups, expansion of resources and employer programs that teach coping strategies. 

7. Continue to build telehealth capacity. 

Behavioral health professionals were thrust into telehealth as a matter of safety and necessity as 

the pandemic grew. Many embarked enthusiastically on this adventure but with little experience. A 

telehealth resource center in Minnesota cleverly developed “Telehealth in a Public Health 

Emergency: A Quick-Start Guide” with topics covering definitions, modalities, and basics of 

delivering psychotherapy and other specialty mental health services.48 As telehealth will continue 

and expand, and with the knowledge and confidence that providers have obtained thus far, 

telehealth policy should be reformed. Utilization of telehealth necessitates a thorough review to 

identify obstacles (e.g. regulations, insurance) and opportunities (e.g. license reciprocity across 

state lines, expansion of coverage and amending beneficiary cost sharing). 

8. Continue to foster training on aspects of disaster behavioral health. 

Mitigation works best when behavioral health care training is consistent with critical importance of 

disaster behavioral health themes and efforts in the overall response. Standardized training based 

on core curricula will prepare a cadre of qualified, trained professional counselors and 

paraprofessional outreach workers to respond to the psychosocial needs of impacted individuals 

and communities.49 The SAMHSA Disaster Technical Assistance Center, for example, created the 

Just in Time training to provide training about emotional responses and how to address them 

(https://www.samhsa.gov/dtac/ccp-toolkit/just-time-web-based-training). Since the populations 

with the greatest need for services are people of color and other marginalized populations, it is 

time to add cultural and linguistic needs to the training curricula. It will also open the door to a 

larger workforce with more relevant and improved skills to care for a population that has been 

underserved. 

9. Maximize continuity and access to treatment for behavioral health populations. 

The COVID-19 pandemic has complicated the continuous administration of individuals with 

behavioral health disorders with medication needs. This includes medication assisted treatment for 

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substance use disorders to individuals with opioid use disorders. and needed laboratory analyses 

for individuals on medications such as Clozapine or Lithium. Given the need for face to face visits 

for blood draws and other assessments, providing these medications became challenging. 

However, necessary flexibilities have been put in place by SAMHSA and other Federal entities to 

help ameliorate these challenges during this public health emergency. For medication assisted 

treatment, these actions include ongoing work with the Drug Enforcement Agency to ensure 

consensus around prescribing/dispensing opioid therapies, telehealth flexibilities, and mid-level 

practitioner clinical responsibilities. 

10. Continue efforts to expand and develop a robust crisis care system. 

COVID-19 has stretched the behavioral health crisis response system beyond what was ever 

imagined. Since it is anticipated that the pandemic will continue for some time, even in an 

attenuated state, a good preventive measure would be to improve the structure and capacity of 

our crisis services and crisis systems of care. This would include more and better linkages to the 

soon to emerge 988, re-routing of behavioral health calls from 911. A sea change is on the horizon 

with countless communities around the country working toward shifting crisis responders from 

police officers to behavioral health professionals, re-routing of individuals experiencing a crisis 

away from emergency departments to crisis stabilization centers, and improving community 

capacity to avert or lessen the number of crises through prevention efforts.50 Whether in the 

context of COVID-19 or beyond, it is now clear that the role of crisis services must include 

operations to provide support in the context of a disaster. Planning these services with disaster 

behavioral health elements in mind will set the stage for much needed preparedness. 

Conclusion 

The spread of COVID-19 highlighted the importance of transforming behavioral health care. This unique 

virus presented a unique threat, and its aftermath will be just as unique and is still unfolding. The 

importance of immediate efforts focused on prevention and direct intervention continue to be needed 

to address the impact of the pandemic on individual and population level behavioral health. The 

pressing question is what have we really learned from this experience? Will we continue taking actions 

from lessons learned? Who is planning for the next pandemic so that our response is nimble, very well 

communicated, better coordinated and overall more effective? This paper in part aimed to document 

some of the lessons learned and potential avenues for future direction. We owe it to those we lost, to 

those who are currently ill or dying, and to those who could become victims of the next pandemic to 

take stock and keep improving in the field of disaster behavioral health. 

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https://www.phe.gov/Preparedness/legal/boards/nbsb/Documents/nsbs-dmhreport-final.pdf 10 Ibid (p. 1). 11 Public Health Emergency: Public Health and Emergency Medical Support for a Nation Prepared. Washington, DC, 

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Perspectives in Public Health 2020; 140(6) 13 Pfefferbaum B, Flynn B, Schonfeld D, et al: The integration of mental and behavioral health into disaster 

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https://store.samhsa.gov/product/tap-34-disaster-planning-handbook-for-behavioral-health-serviceprograms/pep21-02-01-001 15 Ibid. 16 Pfefferbaum B, North CS: Mental health and the Covid-19 pandemic. N Eng J Med 2020; 383: 510–512. 17 Brymer M, Jacobs A, Layne C, et al: Psychological first aid: Field operations guide (2nd ed.), 

2006. http://www.nctsn.org/nccts/nav.do?pid=typ_terr_resources_pfa 18 Collin-Vézina D, Brend D, Beeman I: When it counts the most: Trauma-informed care and the COVID-19 global 

pandemic. Developmental Child Welfare 2020; 2(3) 19 Ibid. 20 Coping with the COVID-19 crisis: The importance of care for the caregivers: Tips for administrators and crisis 

teams. Bethesda, MD, National Association of School Psychologists, 2020. https://www.nasponline.org/resourcesand-publications/resources-and-podcasts/covid-19-resource-center/crisis-and-mental-health-resources/copingwith-the-covid-19-crisis-the-importance-of-care-for-caregivers 21 Murphy AA, Karyczak S, Dolce JN, et al: Challenges experienced by behavioral health organizations in New York 

resulting from COVID-19: A qualitative analysis. Community Ment Health J 2021; 57:111–120 

43
 

 

 

 

 

 

 

22 Intimate Partner Violence and Child Abuse Considerations During COVID-19. Rockville, MD, Substance Abuse and 

Mental Health Services Administration, 2020. https://www.samhsa.gov/sites/default/files/social-distancingdomestic-violence.pdf 23 National Association of State Mental Health Program Directors, Multi-State Disaster Behavioral Health 

Consortium. https://www.nasmhpd.org/content/multi-state-disaster-behavioral-health-consortium 24 Bork RH, Gendelman M: Supporting a nation in crisis: Solutions for local leaders to improve mental health and 

well-being during and post-COVID-19. Well Being Trust, August 2020. https://debeaumont.org/wpcontent/uploads/2020/08/mental-health-action-guide.pdf 25 The Nation's Medical Countermeasure Stockpile: Opportunities to Improve the Efficiency, Effectiveness, and 

Sustainability of the CDC Strategic National Stockpile: Workshop Summary. Washington, DC, Board on Health 

Sciences Policy; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine, 2016. 

26 Executive Order Savings Lives Through Increased Support for Mental Health and Behavioral Health Needs. 

Rockville, MD, Substance Abuse and Mental Health Services Administration, 2020. 

https://www.samhsa.gov/sites/default/files/saving-lives-mental-behavioral-health-needs.pdf 27 The Financial Viability of the Nation’s Mental Health and Addiction Treatment Organizations is in Jeopardy. 

Washington, DC, National Council for Wellbeing. https://www.thenationalcouncil.org/wpcontent/uploads/2020/06/June_Survey_06.21.2020.pdf?daf=375ateTbd56 

28 HHS Office of Inspector General Policy Statement on Practitioners That Reduce, Waive Amounts Owed by 

Beneficiaries for Telehealth Services During the COVID-19 Outbreak, March 2020. 29 The Financial Viability of the Nation’s Mental Health and Addiction Treatment Organizations is in Jeopardy. 

Washington, DC, National Council for Wellbeing. https://www.thenationalcouncil.org/wpcontent/uploads/2020/06/June_Survey_06.21.2020.pdf?daf=375ateTbd56 

30 Executive Order Savings Lives Through Increased Support for Mental Health and Behavioral Health Needs. 

Rockville, MD, Substance Abuse and Mental Health Services Administration, 2020. 

https://www.samhsa.gov/sites/default/files/saving-lives-mental-behavioral-health-needs.pdf 31 Cipriani A, Smith K, MacDonald O: Covid-19 vaccination programme: where do people with mental health 

difficulties lie within the order of priority? BMJ Opinion 2021. https://blogs.bmj.com/bmj/2021/02/16/covid-19-

vaccination-programme-where-do-people-with-mental-health-difficulties-lie-within-the-order-of-priority/ 32 Ibid. 33 Statement on COVID-19 Vaccine Distribution for People with Serious Mental Illness and Substance Use 

Disorders. Washington, DC, February 18, 2021. https://www.psychiatry.org/newsroom/news-releases/apastatement-on-covid-19-vaccine-distribution-for-people-with-serious-mental-illness-and-substance-use-disorders 34 Warren N, Kisely S, Siskind D: Maximizing the uptake of a COVID-19 vaccine in people with severe mental illness 

a public health priority. JAMA Psychiatry 2020; 78(6):589–590 35 Supporting State Behavioral Health Systems During COVID-19 Response and Recovery. Washington, DC, National 

Governors Association, Nov. 17, 2020. https://www.nga.org/center/publications/supporting-state-behaviorhealth-systems-covid-19/ 36 10 Essential Public Health Services. Atlanta, GA, Centers for Disease Control and Prevention, 2021. 

https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html 

37 Question and Answer Document CDC-RFA-OT21-2103, March 30, 2021 Informational Calls National Initiative to 

Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic 

Minority Populations and Rural Communities. Atlanta, GA, Centers for Disease Control and Prevention, 2021. 

https://www.cdc.gov/publichealthgateway/docs/partnerships/OT21-2103-NOFO-Informational-Call-QandA.pdf 38 Informational Calls National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk 

and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities Question and Answer 

Document CDC-RFA-OT21-2103. Atlanta, GA, Centers for Disease Control and Prevention, March 30, 2021. 

https://www.cdc.gov/publichealthgateway/docs/partnerships/OT21-2103-NOFO-Informational-Call-QandA.pdf 39 COVID-19 Pandemic Guidance Document: Health Equity and COVID-19. Alexandria, VA, National Association of 

State Mental Health Program Directors, 2020. https://www.NASMHPD.org/APA-Guidance-Health-Equity-COVID19.pdf 

40 Crisis Counseling Assistance and Training Program. Rockville, MD, Substance Abuse and Mental Health Services 

Administration, 2019. https://www.samhsa.gov/dtac/ccp 

44
 

 

 

 

 

 

 

 

 

 

41 Pfefferbaum B, North CS: Mental health and the Covid-19 pandemic. N Eng J Med 2020; 383: 510–512. 42 Resilience-Oriented COVID-19 Navigation: Next Steps Towards a Better Normal. Washington, DC, The National 

Council for Wellbeing, 2021. 

https://www.thenationalcouncil.org/wp-content/uploads/2021/05/051721_Resilienceoriented_COVID19_Navigation_Toolkit_v2.pdf?daf=375ateTbd56 

43 Post LA, Issa TZ, Boctor MJ, et al: Dynamic public health surveillance to track and mitigate the US COVID-19 

epidemic: Longitudinal trend analysis study. Journal of Medical Internet Research 2020;22(12): e24286 44 Abdoulaziz A: Common areas for improvement from After Action Reports generated after exercises or actual 

disasters, as reported by a national sample of U.S. hospitals. Theses & Dissertations 2019; 380. 

https://digitalcommons.unmc.edu/etd/380 

45 Hyland-Wood B, Gardner J, Leask J, et al: Toward effective government communication strategies in the era of 

COVID-19. Humanities & Social Sci Com 2021; 8(30) 46 Jackson, A: A crisis mental-health hotline has seen an 891% spike in calls. CNN April 10, 2020. 

https://www.cnn.com/2020/04/10/us/disaster-hotline-call-increase-wellness-trnd/index.html 47 Wu P, Fang Y, Guan Z, et al: The psychological impact of the SARS epidemic on hospital employees in China: 

exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009; 54(5):302-311 48 Telehealth in a Public Health Emergency: A Quick-Start Guide. Madison, WI, Great Lakes Mental Health 

Technology Transfer Center, May 5, 2020. 

https://mhttcnetwork.org/centers/great-lakes-mhttc/product/telehealth-public-health-emergency-quick-startguide 

49 Multi-State Disaster Behavioral Health Consortium. Alexandria, VA, National Association of State Mental Health 

Program Directors. 

https://www.nasmhpd.org/content/multi-state-disaster-behavioral-health-consortium 50 Kozasa EH, Lacerda SS, Polissici MA, et al: An intervention to increase situational awareness and the culture of 

mutual care (Foco) and its effects during COVID-19 pandemic: A randomized controlled trial and qualitative 

analysis. Front Psychiatry 2020; 11 

45
Suicide Prevention 

and 988: Before, 

During and After 

COVID-19 

No. 3 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

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Suicide Prevention and 988: Beyond Beds 

Before, During and After COVID 19 

Madelyn S., Gould, Ph.D., M.P.H 

Irving Philips Professor of Epidemiology in Psychiatry 

Division of Child and Adolescent Psychiatry (College of Physicians & Surgeons) 

Department of Epidemiology (School of Public Health) 

Columbia University 

Research Scientist 

New York State Psychiatric Institute 

Alison M. Lake, M.A. 

Senior Project Director in the Division of Child and Adolescent Psychiatry at the New York State 

Psychiatric Institute. 

Cover Art by Malkah Pinals 

Third in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

47
 

 

 

 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, or 

other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Gould, M. S., Lake, A. M. (2021). Suicide Prevention and 988: Beyond Beds Before, During and After 

COVID-19. Technical Assistance Collaborative Paper No. 3. Alexandria, VA: National Association of State 

Mental Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

48
 

 

 

 

 

 

 

 

 

 

 

 

Abstract: 

Evaluations of crisis line networks in the U.S. have established the effectiveness of crisis line services 

as suicide prevention tools while also identifying the need for continued development of a robust 

and integrated crisis response system to meet the needs of individuals in suicidal and mental health 

crisis. These evaluation findings bolstered the rationale for the establishment of 988 as the new 

three-digit dialing code for the National Suicide Prevention Lifeline (Lifeline) beginning in July 2022. 

The upcoming transition to 988 will require expanded crisis center capacity and enhanced 

collaboration and communication across the crisis response system. The Lifeline responded to the 

COVID-19 pandemic by supporting crisis counselors’ transition to remote work and remote 

supervision, and by providing online resources and information about stress management, COVID-19, 

and the expectable stages of psychological response to a disaster. An increase in calls to the Disaster 

Distress Helpline (a Lifeline subsidiary) was observed during the height of the pandemic, but an 

increase in Lifeline calls was not. Finally, testimony from Lifeline callers offers insight into their 

perceptions of their crisis call’s effectiveness in preventing their suicide. 

Highlights: 

• Suicidal crisis callers report significant reductions in intent to die, hopelessness, and 

psychological pain over the course of their crisis call 

• Crisis counselors are able to secure the caller’s collaboration on an intervention on over 75% of 

imminent risk calls 

• Emergency services are involved on 43% of imminent risk calls, and on 58% of third-party calls 

about a person at imminent risk 

• When emergency services are involved, crisis centers often do not know the outcome of the 

intervention (i.e., whether the service was dispatched, whether the person-at-risk was located, 

or whether the person-at-risk was transported to a hospital) 

• Users of crisis chat services are younger and more likely to report suicidal ideation than crisis 

callers 

Recommendations for the Transition to 988: 

1. Higher levels of funding will be needed to support the expansion of capacity at Lifeline call 

centers 

2. In addition to crisis call centers, expanded access to mobile crisis teams and crisis stabilization 

facilities will be needed to support the diversion of callers from 911 

3. Enhanced communication between crisis call centers and other crisis and emergency services 

will be needed to support continuity of care 

4. Ongoing research should be supported to evaluate components of crisis services in order for 

systems to continue to be informed by evidence. 

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he National Suicide Hotline Designation Act of 2020 designates 988 as the national number for 

suicide prevention and mental health crisis response.

1 This has propelled crisis centers, 

specifically those within the National Suicide Prevention Lifeline (Lifeline) network, into the 

epicenter of plans for an improved mental health and suicide crisis response system in the U.S. When 

988 becomes functional on July 16, 2022, the Lifeline will have an ever-increasing role in providing and 

coordinating crisis interventions in the U.S. 

Suicide Prevention and 988 presents evidence on crisis lines as effective suicide prevention tools and 

discusses the challenges posed by COVID-19 and the upcoming implementation of 988. This includes: 

• empirical evidence on the effectiveness of crisis lines in the U.S. that have helped establish 

them as a critical resource for individuals at risk for suicide 

• an overview of current operations at the Lifeline, the Veterans Crisis Line (VCL), and the 

Disaster Distress Helpline (DDH), including responses to COVID-19 

• the vision of 988 and the goal of a comprehensive behavioral health crisis response system 

• challenges faced by crisis centers to meet the extra demands generated by 988 

• examples of insights from Lifeline callers into the effectiveness of their crisis calls 

Evaluations of U.S. Crisis Line Networks 

National crisis lines were first highlighted in the 2012 National Strategy for Suicide Prevention and have 

continued their prominent position in the 2021 Surgeon General’s Call to Action to Implement the 

National Strategy for Suicide Prevention.

2,3 Yet, in 2001 when the first National Strategy was published, 

suicide crisis lines were noticeably absent. At that time, the evidence base for crisis lines’ effectiveness 

was considered insufficient to include them in the National Strategy. The major milestone in the 

advance of crisis lines in the U.S. was the funding of a national network of local, certified call centers by 

the Substance Abuse and Mental Health Services Administration 

(SAMHSA) in 2001. This network which since 2005 has been The National Suicide Prevention called the National Suicide Prevention Lifeline (Lifeline), serves as 

Lifeline can be reached by a central switchboard, connecting callers to a crisis center dialing 1-800-273-TALK (8255) geographically nearest the caller from among a national network 

of more than 180 crisis centers in 50 states and the District of Starting on July 16, 2022, the 

Columbia. The Lifeline added crisis chat services in 2013, and Lifeline number will be replaced crisis text services in 2021. The Lifeline provides 24/7/365 free with a three-digit number, 988, and confidential support directly to individuals in distress and to with the goal of making the those calling, chatting, or texting out of concern for the well- Lifeline more accessible. being and safety of someone else. The Lifeline receives 

consultation and guidance from suicide prevention experts, 

consumer advocates and other stakeholders though the Lifeline’s 

Steering, Lived Experience, and Standards, Training and Practices committees.1 The evaluation of the 

national network has been ongoing since the network’s inception in 2001. Results from the evaluations 

have been used by SAMHSA and the Lifeline to shape best practice standards across the network. 

The earliest evaluations of SAMHSA’s crisis line initiatives examined proximal outcomes of crisis centers’ 

effectiveness. One means to evaluate proximal outcomes involved silent monitoring of calls.

4,5 Another 

1 More information on current Lifeline operations is provided in a separate section below. 

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means was through follow up assessments with callers to this network.6,7 For example, in one study, 

researchers monitored 2,611 calls to 14 crisis lines in the Hopeline Network (the precursor to the 

Lifeline), observing counselor behaviors, caller characteristics, and changes during the calls.8,9 The 

authors found that better call outcomes were associated with intervention styles that involved a 

supportive approach, good contact, and collaborative problem-solving – counselor behaviors that have 

been adopted as Lifeline standards. Other research studies assessed the outcomes of calls by employing 

callers' own ratings of their mental state and suicidality, in response to a standardized set of inquiries by 

the crisis counselors at the beginning and end of the call, to assess the immediate proximal effect of the 

crisis intervention.10,11 A follow-up assessment, two to four weeks later, was then conducted to assess 

the duration of the effect and the impact of the telephone intervention on future suicidal risk and 

behavior. The study of adult suicidal (n=1085) and non-suicidal crisis (n=1617) callers, sampled from 

eight crisis hotlines in the Hopeline network, demonstrated that seriously suicidal individuals were 

calling telephone crisis services (e.g., 8% in midst of an attempt, 58% had made a prior attempt); and 

that significant reductions in callers' self-reported crisis and suicide states occurred from the beginning 

to the end of the calls. Specifically, there were significant decreases in callers’ reports of intent to die, 

hopelessness, and psychological pain over the course of the call. 

In addition to the demonstration of crisis lines’ effectiveness, early evaluations also identified a need for 

improvement in risk assessments, practices with imminent risk callers, and continuity of care for suicidal 

callers – areas foundational to a behavioral health crisis system. The evaluation findings in each of these 

areas are discussed below. Evaluations of the Lifeline Crisis Chat (LCC) intervention and those 

specifically focusing on the Veteran’s Crisis Line will be discussed separately. 

Risk Assessments 

While providing support for the clinical effectiveness of the crisis lines, the results of the early 

evaluations also raised concerns about the adequacy of suicide risk assessments conducted by some 

crisis line staff.

12,13 For example, researchers found that counselors did not consistently evaluate suicide 

risk and when evaluations were conducted they were usually incomplete.14 Furthermore, another study 

found that of the callers who were rated as non-suicidal crisis callers by crisis staff, 12% reported at the 

study’s follow-up assessment that they had been feeling suicidal either during or since their calls to the 

center.15 Half of these callers reported being suicidal at the time of their crisis call, but this was not 

known or recognized by the counselor during their call. 

In response, SAMHSA and the Lifeline focused attention on the standardization of crisis counselors’ 

practices and training across the network.

16 SAMHSA and the Lifeline began disseminating LivingWorks’ 

Applied Suicide Intervention Skills Training (ASIST) across its network of centers.17 The evaluation of the 

impact of the implementation of ASIST across the Lifeline 

network utilized data from 1,507 monitored calls from 1,410 LivingWorks’ Applied Suicide 

suicidal individuals to 17 Lifeline centers.

18 Callers were Intervention Skills Training is an 

significantly more likely to feel less depressed, less suicidal, less internationally disseminated 

overwhelmed, and more hopeful by the end of calls handled by gatekeeper training program 

ASIST-trained counselors. Improvements in callers’ outcomes designed as “suicide first aid.” 

were associated with ASIST-related counselor interventions, 

including exploring reasons for living and exploring informal 

support contacts. Despite these positive findings, most of the counselor interventions that were 

assessed did not differ between ASIST-trained counselors and non-ASIST-trained counselors. These 

findings may be explained by the considerable overlap in the content of the Lifeline centers’ routine 

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trainings and the ASIST training, particularly with regard to risk assessments, as evidenced by the finding 

that both ASIST-trained and non-ASIST-trained counselors asked about or explored suicidal thoughts on 

over 90% of calls where callers acknowledged being suicidal. A more recent study involving the 

monitoring of 241 calls to ten California suicide prevention crisis lines also showed that most counselors 

asked about current suicidal ideation, but occurrence varied significantly across sites.19 Of note, they 

found that counselors at Lifeline centers were more likely to inquire about current suicidal ideation, 

recent ideation, and past attempts. Moreover, callers to centers that were part of the Lifeline network 

were more likely to experience reduced distress than callers to centers that were not part of the Lifeline. 

Interventions with Imminent Risk Callers 

The need for a clear and explicit policy for high-risk callers to the Lifeline was highlighted by the early 

evaluations of network crisis lines published in 2007.

20,21,22 On monitored calls where a suicide attempt 

was in progress, one study found that emergency services were known to be dispatched in 18% of cases, 

and the caller changed his/her mind about the attempt in 24%, leaving 58% of calls without an observed 

mitigation of the caller’s risk.23 Another study found that emergency responses for callers deemed to be 

at imminent suicide risk varied considerably across eight crisis centers.24 Overall, emergency rescue was 

initiated in 38% of cases in which callers had taken some action to kill themselves immediately before 

calling the centers. 

In response to these shortcomings, the Lifeline published a Policy for Helping Callers at Imminent Risk of 

Suicide that provides guidance on making a judgment regarding imminent risk and outlines 

recommended practices for reducing imminent risk through crisis line interventions.25 The Lifeline’s 

Imminent Risk policy encourages counselors to actively seek collaboration with callers at imminent risk 

and to enable these callers “to work toward securing their own safety” (“active engagement”);

26 the 

policy furthermore encourages counselors to use the least invasive interventions capable of preserving 

the caller’s safety. Involuntary interventions (“active rescues”) are to be used as a last resort because 

they may be unnecessarily stigmatizing and traumatizing and may deter future outreach for help.

27 

Nevertheless, the Lifeline policy highlights the importance of initiating an active (i.e., involuntary) rescue 

when all other possible actions to prevent a caller from dying by suicide have been exhausted. 

An evaluation of the assessment and management of imminent risk callers to the Lifeline employed data 

from 491 call reports completed by 132 counselors at eight crisis centers.

28 Findings demonstrated that 

crisis counselors obtained the collaboration of the vast majority (over 75%) of callers they identified as 

being at imminent risk, consistent with the Lifeline Imminent Risk policy. On 19% of imminent risk calls, 

the counselors sent emergency services (police, sheriff, EMS) with the collaboration of the callers, while 

on a quarter of the imminent risk calls, the counselors sent emergency services without the caller’s 

collaboration. Overall, emergency services were involved on 43% of imminent risk calls. Other types of 

collaborative interventions implemented on imminent risk calls included getting rid of means (i.e, means 

that an individual might use to harm themselves), involving a third party, collaborating on a safety plan, 

and the caller’s agreeing to receive follow-up from the crisis center. At least one collaborative, nonemergency intervention was implemented on 68% of all imminent risk calls, and on 37% of imminent 

risk calls where emergency services were involved. 

The Lifeline is widely promoted as a resource not only for individuals in crisis but also for people who are 

concerned for the safety of someone in their social network. Given the reluctance of many suicidal 

individuals to seek help for themselves, working with individuals calling on behalf of someone else 

(“third-party callers”) is as much a Lifeline priority as working with individuals calling on their own behalf 

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(“direct callers”). It is believed that those who do not call on their own behalf may be at higher risk of 

suicide than those who do.

29 A recent study provided information on “third-party calls.”30 Reports on 

172 third-party calls concerning individuals deemed to be at imminent suicide risk were completed by 

30 crisis counselors at six Lifeline crisis centers. The study found that third-party callers were most likely 

to be calling about a family member or friend and were significantly more likely than the people about 

whom they were calling to be female and middle-aged or older. Counselors were able to collect 

information about suicide risk from the third parties, and counselors and third parties were nearly 

always able to identify at least one intervention to aid the person-at-risk. 

Interventions identified were varied. Emergency services were contacted on 58% of the third-party 

imminent risk calls, which represents a somewhat higher rate of emergency services involvement than 

previously reported on imminent risk calls placed by the person-at-risk.31 The odds of emergency 

services involvement were higher if the third party was a high school student or young adult in contrast 

to middle-aged or older, if the third party was a friend or acquaintance of the person-at-risk in contrast 

to a family member, and if the third party’s information was based on sources other than face-to-face 

contact with the person-at-risk. Odds of emergency services involvement were also higher if the personat-risk was in the midst of an attempt or planned to act on suicidal thoughts within a few hours, or if 

these risk factors could not be ruled out. Counselor characteristics did not predict emergency services 

involvement. Non-emergency interventions, such as having the third party maintain a watch over the 

person-at-risk, or involving a mobile crisis team for evaluation or follow-up, were implemented on 69% 

of all calls, and on 47% of calls where an emergency intervention was also implemented. The study 

demonstrated that individuals calling the Lifeline when they are worried about someone are provided a 

range of interventions that can supplement, and at times replace, calling 911. Information about the 

outcome of emergency services dispatch was unavailable to the crisis counselors over half the time, 

indicating a need for improvements in information sharing across services. 

Continuity of Care for Suicidal Callers 

The early evaluation published in 2007 by Gould and colleagues highlighted the need for crisis centers to 

heighten outreach strategies to minimize suicide risk and enhance follow through with referrals.32 

Follow-up assessments conducted two to four weeks after the crisis call found that a substantial 

proportion (42%) of callers continued to express suicidal ideation, 7.4% had made a suicide plan and 

nearly 3 percent had made a suicide attempt. Furthermore, only 23% of suicidal callers had been seen 

by the behavioral health care system to which they had been referred. 

In response, SAMHSA funded an initiative in 2008 to have crisis center staff offer and provide follow-up 

calls to all Lifeline callers who reported suicidal ideation during or within 48 hours before making a call 

to the Lifeline. An evaluation of this follow-up initiative included 550 callers followed by 41 counselors at 

six crisis centers. Findings indicated that follow-up had a positive impact. In interviews with these 

follow-up clients, 80% indicated that the follow-up intervention stopped them from killing themselves 

and 91% reported that it kept them safe.33 Clients were more likely to report perceived benefits of 

follow-up if they had higher baseline risk scores or if they had a previous suicide attempt.

34 Another 

evaluation demonstrated that a Lifeline crisis call can also play an important role in connecting at-risk 

callers to ongoing mental health care.35 This study of 376 suicidal callers and 278 non-suicidal crisis 

callers showed that 52% of callers who received mental healthcare referrals ended up accessing care 

after their call. Thus, the Lifeline is enhancing the continuity of care for suicidal individuals, which is a 

priority of the U.S. National Strategy for Suicide Prevention.

36 

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New Media: Lifeline Crisis Chat 

To increase access to crisis services, Lifeline’s service format has evolved to include not only telephone 

but also synchronous (i.e., in real time) chat crisis interventions. The Lifeline Crisis Chat (LCC) network, 

which serves all ages, has grown extensively since its formal establishment in 2013, answering 231,335 

chats in 2020.37 The availability of crisis interventions via chat is particularly critical for young people 

who are more likely to choose online rather than telephone crisis services,

38,39 and who are also more 

likely to discuss “weighty problems,” such as mental health problems and suicide on an online crisis 

service than by telephone.

40,41 

A study assessing the effectiveness of the LCC employed 13,130 linked pre- and post-chat surveys 

completed by recipients of Lifeline’s online crisis chat services in 2017-2018.

42 Findings indicated that 

chatters were significantly and substantially less distressed at the end of the chat intervention than they 

were at the beginning. This is of particular import because the vast majority of individuals seeking help 

from the LCC were highly distressed when they contacted the service. Moreover, almost 84% of LCC 

chatters endorsed either current or recent suicidal ideation on the pre-chat survey, which is markedly 

higher than the estimated 23% of Lifeline callers who were identified by silent monitors as being suicidal 

on the day of or the day before their calls.

43 Findings were consistent with other research that also 

reported that crisis chatters reveal higher rates of suicidal ideation than crisis callers.

44,45,46 By the end of 

the chat, two-thirds of suicidal chatters reported that the chat had been helpful and nearly half reported 

they were less suicidal, which offered some empirical evidence for the effectiveness of Lifeline’s online 

crisis chat services. 

A second study analyzed pre-chat survey data and data abstracted from the transcripts of 1,034 Lifeline 

crisis chats in 2015 and found that chatters are younger on average than crisis callers and as noted 

previously are more likely than callers to disclose suicidal ideation at the time of the crisis intervention.

47 

Lifeline chat counselors engage in rapport-building on nearly every chat with a suicidal visitor, and 

engage in problem-solving on over two thirds of such chats, demonstrating what seems to be a more 

balanced approach than has been observed in other evaluations of online counseling interventions.

48 

However, counselors were not observed to assess suicide risk on all chats, and appeared to base their 

risk assessment activity to a significant degree on the visitor’s Pre-Chat Survey response. Information on 

current suicidal ideation was unavailable (i.e., current suicidal ideation was not discussed sufficiently to 

enable the coder to confirm it as present or absent) in the transcripts of a third of chats where the 

chatter had endorsed current suicidal thoughts on the pre-chat survey, over half of chats where the 

chatter had endorsed recent suicidal thoughts, and nearly three-quarters of chats where the chatter had 

denied suicidal thoughts on the pre-chat survey. 

Veterans Crisis Line 

The Veterans Health Administration (VHA) has set suicide prevention as a top priority given veterans’ 

increased risk of suicide compared to the general U.S. population.

49 To address this heightened suicide 

risk, in 2007, the Veterans Suicide Prevention Hotline (now called the Veteran’s Crisis Line (VCL)) was 

founded. Veterans, active-duty service members, and their families are connected to this line by calling 

the Lifeline number and pressing “1” when prompted. An online chat service was added in 2009, 

followed by a text-message service in 2011. Originally comprised of one call center, the VCL opened a 

second and third call center in 2016 and 2018. Since its creation, the VCL has received more than 5.4 

million calls, 630,000 chats, and 204,000 texts.

50 Additional information about VCL is provided under 

Current Operations, below. 

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There have been few studies examining the effectiveness of the VCL. Employing VCL responders’ 

evaluation of 646 calls from October 1 through 7, 2010 made by veterans who had endorsed current or 

recent suicidal ideation or a lifetime history of suicide attempt, the findings indicated that 84% of calls 

ended with a resolution, a referral to a local provider, or both.

51 High-risk callers, as determined by 

responders’ observations of intent to die and absence of future plans, had greater odds of ending the 

call with a referral (77%) compared to lower-risk callers (49%). A recent study interviewed 155 VCL 

users who were referred to a Veterans Affairs Medical Center Suicide Prevention Team.

52 VCL users’ 

responses to questions adapted from previous research indicated that 87 percent of interviewees 

expressed satisfaction with the intervention, nearly 82% reported that the VCL was helpful, and 72.9% 

said that the VCL helped keep them safe.53 Nearly 83% of those with suicidal thoughts reported that the 

crisis contact helped stop them from killing themselves. 

Overall, the empirical demonstration of the effectiveness of crisis lines in the U.S. for the past two 

decades helped to bolster arguments and lay a foundation for the new three-digit dialing code (988) for 

the national suicide prevention and mental crisis hotline system. 

Current Operations and Response to COVID-19 

The volume of calls, chats and texts received by centers in the National Suicide Prevention Lifeline 

Network in 2020 is presented in Table 1. 

Table 1. Volume of Calls, Chats, and Texts Received in 2020 

Centers Calls 

received 

Chats 

received 

Texts 

received 

National Suicide Prevention Lifeline Over 180i 1,833,953ii 586,703 34,166 

Veterans Crisis Line (VCL) 3iii 679,549 80,053 35,489 

Disaster Distress Helpline (DDH) 3iv 60,188 n/a 11,444 

i Over 30 of these centers handle chats and texts in addition to calls 

ii This figure excludes calls to the VCL, which is reached by dialing the Lifeline number and then pressing ‘1’ 

iii VCL calls are routed to three dedicated VCL centers 

iv DDH calls are received on dedicated lines at three Lifeline centers, with two centers also handling texts 

Callers are routed to the center closest to the area code they are dialing from, with the goal being for 

calls to be handled locally by counselors who are familiar with local resources and culture. States vary in 

their ability to answer calls in-state, with the top third answering 82% or more and the bottom third 

answering 66% or less. Nine centers serve as national backup centers, handling calls that roll over when 

local centers have reached capacity. Individual Lifeline centers may maintain separate “warm lines” with 

their own telephone numbers, some of which are answered by individuals with lived experienced of 

suicidal or mental health crises (also called peer-support lines); however the Lifeline does not administer 

a warm line or peer-support line at the national level. As Lifeline members, centers receive access to 

information, training, technology, networking, and a small annual stipend. Center operations are stateand locally funded. Centers range from stand-alone call centers to larger behavioral health organizations 

incorporating a call center along with one or more other services such as onsite outpatient treatment, 

crisis stabilization units, or mobile crisis teams. Lifeline centers may be non-profit, for profit, or 

governmental (e.g., county-run), and they may be staffed by licensed mental health clinicians, by other 

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paid employees, by volunteers, or by a combination of these. To standardize the crisis response 

provided across these diverse institutions, the Lifeline provides guidance regarding best practices in 

suicide prevention and crisis intervention through newsletters, webinars, and on its members-only 

Network Resource Center website (https://networkresourcecenter.org/). Crisis centers seeking to join 

the Lifeline network must be certified, accredited, or licensed by an external body, must have written 

policies or guidelines addressing counselor training, referrals, and suicide risk assessment, and must be 

willing to participate in Lifeline evaluation activities. Application is possible through the Lifeline website 

(https://suicidepreventionlifeline.org/our-network/). As described above, the Lifeline bases its policies 

and practices on ongoing evaluation research and on consultation with academic subject area experts 

and individuals with lived experience of suicide (see https://suicidepreventionlifeline.org/livedexperience-committee/ and https://www.activatinghope.com/). 

As noted above, although the Veterans Crisis Line (https://www.veteranscrisisline.net/) shares the 

Lifeline’s national toll-free telephone number, callers who press ‘1’ to reach the VCL are routed to one of 

three call centers specifically dedicated to veterans’ care. Unlike many Lifeline call centers, VCL call 

centers do not utilize volunteers. VCL responders are clinicians trained in both crisis intervention and 

military culture, and may be Veterans themselves. They have the capacity to make referrals within the 

United States Department of Veterans’ Affairs (VA) mental healthcare system,

54 and to link callers to a 

Suicide Prevention Coordinator at their local VA medical center, if needed and desired. The VCL thus 

provides a model of integrating crisis lines within larger health-care settings. The volume of calls, chats 

and texts received by VCL centers in 2020 is presented in Table 1. 

The Disaster Distress Helpline (DDH, https://www.samhsa.gov/find-help/disaster-distress-helpline and 

https://strengthafterdisaster.org/) is a SAMHSA-funded national hotline dedicated to responding to 

distress caused by natural or human-caused disasters. DDH, a subsidiary of the Lifeline with a separate 

telephone number, was launched in 2012 and is accessible via telephone, text, or video phone for 

speakers of American Sign Language. DDH calls are routed to dedicated lines at three Lifeline call 

centers, with two centers also handling texts. DDH is now launching its first three Online Peer Support 

Communities, to be moderated by trained peer supporters with oversight by a Lifeline crisis center, 

accessible via Facebook Groups. These communities will be specifically targeted to healthcare workers 

impacted by COVID-19, parents and caregivers of children and youth impacted by COVID-19, and 

survivors of and responders to mass shootings in the U.S. 

In response to the COVID-19 pandemic, SAMHSA increased its promotion of DDH, which saw a dramatic 

increase in calls, peaking in April 2020 at approximately 500% of pre-pandemic call volume, and 

stabilizing by August 2020 at approximately 250% of pre-pandemic call volume, a “new normal” which 

can still be considered part of the COVID-19 surge. The volume of DDH calls and texts received in 2020 is 

presented in Table 1. It should be noted that DDH call volume was relatively low prior to this surge, with 

centers receiving only 12,171 DDH calls and 1,543 DDH texts in 2019, roughly 1/5th and 1/7th the call and 

text volume in 2020, respectively. Unlike DDH, the Lifeline itself did not see an increase in calls during 

the height of COVID-19. This difference is likely to reflect both targeted efforts to promote DDH during 

this period, as well as the prevalence of DDH callers experiencing distress, but not suicidality, in 

response to the pandemic. Less than 1% of DDH callers and texters were identified by counselors as 

suicidal during their contacts with DDH.

55 Globally, no increase in suicide deaths has been observed 

since the onset of the pandemic;

56 however, an online survey of a nationally representative sample of 

US adults in late April 2020 found rates of moderate and serious mental distress elevated to three times 

their 2018 levels, portending possible increases in mental illness and suicide risk in future.

57 A survey of 

US adults conducted by the Centers for Disease Control in June 2020 demonstrated elevated levels of 

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988 

suicidal ideation, particularly among young people, Black and Hispanic respondents, unpaid caregivers 

for adults, and essential workers.

58 Moreover, an examination of National Syndromic Surveillance 

Program (NSSP) data has identified an increase in emergency department visits for suspected suicide 

attempts among adolescents aged 12-17, especially girls, beginning in May 2020.

59 The more distal 

impact of COVID-19 on suicidal ideation and attempts, rates of completed suicide, and help-seeking by 

suicidal individuals is yet to be determined. 

The Lifeline’s response to COVID-19 to date has included offering the public information, coping tips, 

and digital resources accessible via the Lifeline website (https://suicidepreventionlifeline.org/currentevents/supporting-your-emotional-well-being-during-the-covid-19-outbreak/). To facilitate engagement 

with Lifeline callers impacted by COVID-19, the director of the DDH offered Lifeline counselors guidance 

on the phases of reactions to disaster. Also for counselors, the Lifeline created a self-paced training 

entitled “Disaster Mental Health: COVID-19,” housed on the Network Resource Center (NRC) and 

designed to familiarize Lifeline counselors with the types of mental health issues callers might be facing 

as a result of COVID. As many centers closed temporarily in early to mid-2020, the NRC offered guidance 

on the transition to remote work and remote supervision for crisis counselors. 

In a 2019 Washington Post opinion piece titled “Let’s dial 988 to stop suicides,” Representatives Chris 

Stewart (R-Utah) and Seth Moulton (D-MA) described the National Suicide Hotline Improvement Act of 

2018 as an effort to streamline access to the National Suicide Prevention Lifeline (Lifeline) for individuals 

in suicidal crisis by replacing its 10-digit telephone number (1-800-273-8255) with an easy-to-remember 

three-digit dialing code.60 They referenced high rates of veteran suicide in particular as motivating their 

involvement in this legislation. In compliance with the directives of this Act, the FCC submitted to 

Congress a “Report on the National Suicide Hotline Improvement Act of 2018” based on reports from 

SAMHSA, the VA, and the NANC.

61 Findings from the Lifeline evaluations were included in this report, 

and supported the FCC’s conclusion that the Lifeline was an effective crisis intervention tool and that its 

reach and functioning could be improved by the implementation of a three-digit dialing code. The report 

recommended the use of 988 as the new number for “a national suicide prevention and mental health 

crisis hotline system... a 911 for the brain.”62 

Following the FCC’s recommendation that 988 be designated as the new Lifeline dialing code, Stewart 

and Moulton introduced to Congress the National Suicide Hotline Designation Act of 2020, in a further 

effort to improve Lifeline services by empowering states to collect fees to finance local crisis call centers 

in the Lifeline’s national network. They envisioned this funding enabling Lifeline centers to improve 

response times and increase the percentage of Lifeline calls that are answered in-state rather than 

rolling over to a backup center. This legislation also created a legal basis to enable real-time 

communication between Lifeline crisis centers, 911/emergency dispatch, and hospitals. The legislation 

establishing 988 as the national number for suicidal and mental health crises thus takes concrete steps 

to streamline and support the connection of individuals in crisis to a Lifeline crisis counselor, while at the 

same time pointing in the direction of much more far-reaching reforms and toward the development of 

a comprehensive crisis response system. 

When 988 is implemented, calls to 988 will be routed to Lifeline crisis centers, and callers will press ‘1’ 

after dialing 988 to reach the VCL. DDH will continue to be reached via its current, ten-digit, toll-free 

number. With the increased visibility, promotion, and accessibility of 988, and given the intention 

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(discussed further below) of diverting substantial numbers of mental health-related calls away from 911, 

major increases in Lifeline call volume can be anticipated. 

Comprehensive Behavioral Health Crisis System (Crisis Now model) 

The National Action Alliance for Suicide Prevention’s Crisis Now: Transforming services is within our 

reach63 and SAMHSA’s National Guidelines for Behavioral Health Crisis Care: A Best Practice Toolkit64 

present a vision of a robust and integrated behavioral health crisis response system able to achieve the 

following aims: to divert individuals in mental health crisis away from jails and emergency departments, 

to reduce unnecessary psychiatric hospitalizations, and to reduce law enforcement involvement in 

mental health crises. The urgency of the need for crisis response reform is reflected in recent reporting 

by The Washington Post that “about a quarter of all fatal police shootings in the last six years involved 

someone in the throes of a mental health crisis.”65 The Crisis Now model places crisis call centers at the 

hub of an integrated crisis care system, which also involves universal access to mobile crisis teams and 

crisis stabilization facilities. According to this model, crisis call centers would be responsible not only for 

fielding calls, de-escalating crises, and referring callers to additional services as needed, but also for 

tracking and coordinating individuals’ use of these other services, in a role described as “care traffic 

control.” This might involve the use of real-time dashboards showing the locations of mobile crisis 

teams, available respite beds, available outpatient appointments, and so forth, reflecting levels of 

available resources and of information sharing which many US communities can currently only dream of. 

Whereas some Lifeline call centers have integrated mobile crisis teams and crisis stabilization facilities, 

and others have relationships with other organizations offering these services, still others are located in 

communities where these services are lacking. One mechanism for ensuring these resources are 

available to Lifeline counselors for callers who need them is the establishment of Certified Community 

Behavioral Health Clinics (CCBHCs), which are mandated to include mobile crisis services and which 

utilize Medicaid funding to support such things as competitive wages for clinic staff and the purchase of 

technology to enable electronic information exchange.

66 As of this writing, 21 Lifeline centers have been 

certified as CCBHCs. 

Conclusions and Next Steps Toward the Realization of 988 

Evaluations of crisis hotlines in general and the National Suicide Prevention Lifeline specifically informed 

the push to designate a three-digit dialing code for mental health and suicidal crises in the US, and these 

evaluations will continue to inform the implementation of 988. Key points from these evaluations are: 

• Individuals at risk of suicide do utilize suicide hotlines, 

• Callers experience reductions in their crisis and suicidal states over the course of the crisis call, 

• Crisis counselors can collaborate with callers to deescalate imminent suicide risk without the use 

of 911 or an emergency department, 

• Callers may experience continued or recurring suicidal thoughts in the weeks following their 

crisis call, indicating a need for continuity of care, 

• Follow-up calls are important suicide prevention tools, 

• Crisis chat services are utilized by a young and high-risk population, and are important adjuncts 

to telephone hotlines, and 

• Lifeline centers have been shown to be more effective than centers outside the network. 

Key challenges to the implementation of 988 include: 

58
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Dramatic increases in call volume can be anticipated, which will necessitate rapid increases in 

staffing and technological capacity at crisis centers; 

• Crisis centers’ ability to effectively resolve high risk mental health and suicidal crises without 

recourse to 911 will depend in part on improved access to mobile crisis teams and crisis 

stabilization facilities, services which are not now universally available; 

• Coordination of care across the crisis response system will require enhanced communication 

between call centers, 911, EDs, and other crisis and emergency services; 

• Given that 988 will be implemented on a state-by-state basis, some state-level infrastructure 

may be needed to ensure the availability and coordination of crisis response resources;

67 

• Higher levels of funding will be needed to enable the expansion of call center capacity, reduce 

staff turnover, and facilitate the overall transformation of the US crisis response system. 

Appendix: Insights from Lifeline Callers 

Lifeline callers interviewed as part of an ongoing evaluation of the Lifeline who reported that the Lifeline 

call stopped them from killing themselves made the following comments in response to an open-ended 

question about what it was about the call that stopped them from killing themselves. These examples 

illustrate instances of crises being deescalated by the Lifeline call itself, and of high-risk callers being 

connected to additional resources without necessarily involving 911. 

• “I was at crisis point, I was very much considering killing myself and talking with the person got me 

from crisis to being very sad about the situation which is an emotion I can handle.” 

• “At first, I started off talking with complete honesty about how I had the knife to myself. At some 

point, the focus became less about the knife and more about what was going on in my life. It was 

very validating for me to be able to talk about the whole picture and vent for a bit. That really 

stopped me because I felt heard and understood. It felt very real and very raw. I got to talk about my 

life and the weight was lifted off my chest. The temptations went away after that.” 

• “She had me go and try to find the item that I was trying to end my life with and made sure I was 

comfortable throwing them away and helped me realize that I had a part that wanted me to live and 

helped me focus on that part and make it stronger.” 

• “I think it's bringing down the frantic energy because you get in this very volatile, emotional state 

where it feels like everything is happening so fast. You feel like you need to think and do everything 

so fast to keep up because you're panicking. I think that call slowed me down and made me realize I 

didn't have to make decisions in that moment.” 

• “She just kept talking to me and distracting me from that [killing myself]. She distracted me long 

enough until my brother was able to get there. They made sure my brother got there before they 

ended the call.” 

• “Without the call I would have never gone to the [community mental health] center. She helped me 

realize my breaking point and realize that I needed more help than I was getting. She helped me 

realize that I needed help.” 

59
 

 

 

• “I guess the way the person was talking to me and how they didn't assume things about me. They let 

me call somebody to come and pick me up and take me to the hospital. They let me choose to go to 

the hospital, but they also made me promise to go.” 

• “I think that if I hadn't called anybody that night, I would've acted on my plan. I think it really saved 

my life that night. I had somebody to call and talk to, but it didn't involve cops and stuff. It was 

private and confidential.” 

60
 

 

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https://www.congress.gov/bill/116th-congress/senate-bill/2661 2 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: U.S. Department 

of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide 

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Suicide Life Threat Behav 2007; 37:322–37 16 Joiner T, Kalafat J, Draper J, et al: Established standards for the assessment of suicide risk among callers to the 

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Suicide Prevention Lifeline Counselor. Suicide Life Threat Behav 2013; 43(6):10.111 19 Ramchand R, Jaycox L, Ebener P, et al: Characteristics and proximal outcomes of calls made to suicide crisis 

hotlines in California. The Journal of Crisis Intervention and Suicide Prevention 2017; 38:26–35 20 Mishara BL, Chagnon F, Daigle M, et al: Which helper behaviors and intervention styles are related to better 

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21 Mishara BL, Chagnon F, Daigle M, et al: Comparing models of helper behavior to actual practice in telephone 

crisis intervention: a silent monitoring study of calls to the U.S. 1–800-SUICIDE network. Suicide Life Threat Behav 

2007; 37:308–21 22 Gould MS, Kalafat J, Munfakh JLH, et al: An evaluation of crisis hotline outcomes, Part II: suicidal callers. Suicide 

Life Threat Behav 2007; 37:338–52 23 Mishara BL, Chagnon F, Daigle M, et al: Comparing models of helper behavior to actual practice in telephone 

crisis intervention: a silent monitoring study of calls to the U.S. 1–800-SUICIDE network. Suicide Life Threat Behav 

2007; 37:308–21 24 Gould MS, Kalafat J, Munfakh JLH, et al: An evaluation of crisis hotline outcomes, Part II: suicidal callers. Suicide 

Life Threat Behav 2007;37:338–52 25 Draper J, Murphy G, Vega E, et al: Helping callers to the National Suicide Prevention Lifeline who are at 

imminent risk of suicide: the importance of active engagement, active rescue, and collaboration between crisis and 

emergency services. Suicide Life Threat Behav 2015; 45:261–70 26 Ibid, page 3. 27 Ibid. 28 Gould MS, Lake AM, Munfakh JL, et al: Helping callers to the National Suicide Prevention Lifeline who are at 

imminent risk of suicide: evaluation of caller risk profiles and interventions implemented. Suicide Life Threat Behav 

2016; 46:172–90 29 Mishara, BL, Houle, J & Lavoie, B: Comparison of the effects of four suicide prevention programs for family and 

friends of high-risk suicidal men who do not seek help themselves. Suicide Life Threat Behav 2005; 35(3):329–342 30 Gould, MS, Lake, AM, Kleinman, M, et al: Third-party callers to the National Suicide Prevention Lifeline: Seeking 

assistance on behalf of people at imminent risk of suicide. Suicide Life Threat Behav 2021; doi: 10.1111/sltb.12769 31 Ibid. 32 Gould MS, Kalafat J, Munfakh JLH, et al: An evaluation of crisis hotline outcomes, Part II: suicidal callers. Suicide 

Life Threat Behav 2007; 37:338–52 33 Gould MS, Lake AM, Galfalvy H, et al: Follow-up with callers to the National Suicide Prevention Lifeline: 

Evaluation of callers’ perceptions of care. Suicide Life Threat Behav 2018; 48:75–86 34 Ibid. 35 Gould MS, Munfakh JLH, Kleinman M, et al: National Suicide Prevention Lifeline: enhancing mental health care 

for suicidal individuals and other people in crisis. Suicide Life Threat Behav 2012; 42:601–13 36 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: U.S. 

Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for 

Suicide Prevention, 2012. https://www.ncbi.nlm.nih.gov/books/NBK109917/ 37 Gould, MS, Chowdhury, S, Lake, AM, et al: National Suicide Prevention Lifeline Crisis Chat interventions: 

Evaluation of chatter’s perceptions of effectiveness, Suicide Life Threat Behav (in press) 38 Haner D, Pepler, D: “Live Chat” clients at kids help phone: individual characteristics and problem topics. Journal 

of the Canadian Academy of Child and Adolescent Psychiatry 2016; 25:138-144 39 Mokkenstorm, JK, Eikelenboom, M, Huisman, A, et al: Evaluation of the 113Online suicide prevention crisis chat 

service: outcomes, helper behaviors and comparison to telephone hotlines. Suicide Life Threat Behav 2017; 

47:282-296 40 Haner D, Pepler, D: “Live Chat” clients at kids help phone: individual characteristics and problem topics. Journal 

of the Canadian Academy of Child and Adolescent Psychiatry 2016; 25:138-144 41 Fukkink, RG, Hermanns, JMA: Children’s experiences with chat support and telephone support. Journal of Child 

Psychology and Psychiatry 2009; 50(6):759-766 42 Gould, MS, Chowdhury, S, Lake, AM, et al: National Suicide Prevention Lifeline Crisis Chat interventions: 

Evaluation of chatter’s perceptions of effectiveness, Suicide Life Threat Behav (in press) 43 Gould MS, Cross W, Pisani HR, et al: Impact of applied suicide intervention skills training (ASIST) on National 

Suicide Prevention Lifeline Counselor. Suicide Life Threat Behav 2013; 43(6):10.111 44 Haner D, Pepler, D: “Live Chat” clients at kids help phone: individual characteristics and problem topics. Journal 

of the Canadian Academy of Child and Adolescent Psychiatry 2016; 25:138-144 45 Fukkink, RG, Hermanns, JMA: Children’s experiences with chat support and telephone support. Journal of Child 

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46 Lake AM, Niederkrotenthaler T, Aspden R, et al: Lifeline Crisis Chat: Coding form development and findings on 

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https://www.veteranscrisisline.net/about/what-is-vcl 51 Britton PC, Bossarte RM, Thompson C, et al: Influences on call outcomes among veteran callers to the National 

Veterans Crisis Line. Suicide Life Threat Behav 2013; 43:494–502 52 Johnson LL, Muehler T, Stacy MA: Veterans’ satisfaction and perspectives on helpfulness of the Veterans Crisis 

Line. Suicide Life Threat Behav 2021; 51:263-273 53Gould MS, Lake AM, Galfalvy H, et al: Follow-up with callers to the National Suicide Prevention Lifeline: 

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Emotional Health. Webinar presented online on May 6, 2021. https://www.youtube.com/watch?v=j-iWKLbYCqI 56 Pirkis J, John A, Shin S, et al: Suicide trends in the early months of the COVID-19 pandemic: an interrupted time 

series analysis of preliminary data from 21 countries. Lancet Psychiatry (Epub ahead of print April 13, 2021) 57 Twenge, JM, Joiner, TE: Mental distress among U.S. adults during the COVID-19 pandemic. Journal of Clinical 

Psychology 2020; 76:2170-2182 58 Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 

Pandemic — United States, June 24–30, 2020. MMWR Morbidity and Mortality Weekly Report 2020; 69:1049–1057 59 Yard E, Radhakrishnan L, Ballasteros MF, et al: Emergency Department Visits for Suspected Suicide Attempts 

Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 

2021. MMWR Morbidity and Mortality Weekly Report 2021; 70(24):888-894 60 Stewart C & Moulton S.: Opinion: Let’s dial 988 to stop suicides. The Washington Post August 20, 2019. 

https://www.washingtonpost.com/opinions/2019/08/20/its-time-replace-suicide-hotline-with-three-digit-dialingcode/ 

61 Report on the National Suicide Hotline Improvement Act of 2018. Washington, DC, Federal Communications 

Commission, Wireline Competition Bureau, Office of Economics and Analytics, August 14, 2019. 

https://docs.fcc.gov/public/attachments/DOC-359095A1.pdf 62 Stewart C & Moulton S.: Opinion: Let’s dial 988 to stop suicides. The Washington Post August 20, 2019. 

https://www.washingtonpost.com/opinions/2019/08/20/its-time-replace-suicide-hotline-with-three-digit-dialingcode/ (pp.3-4) 63 Crisis now: Transforming services is within our reach. Washington, DC: Education Development Center, Inc. 

National Action Alliance for Suicide Prevention: Crisis Services Task Force, 2016 

64 National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit. Rockville, MD, Substance Abuse and 

Mental Health Services Administration, 2020. https://www.samhsa.gov/sites/default/files/national-guidelines-forbehavioral-health-crisis-care-02242020.pdf 65 Tan, R.: Crisis counselors are being hailed as police alternatives. It’s too heavy a burden, some say. The 

Washington Post June 16, 2021. https://www.washingtonpost.com/dc-md-va/2021/06/16/police-reform-mentalhealth-counselors-montgomery-maryland/ 66 (see https://www.thenationalcouncil.org/ccbhc-success-center/ccbhcta-overview/). 67 Quinlan K, Nickerson K, Ebin J, et al: Supporting a public health approach to suicide prevention: 

Recommendations for state infrastructure. Suicide Life Threat Behav 2021; 51(2):352-357 

63
 

Law Enforcement 

and Crisis Services: 

Past Lessons for New 

Partnerships and the 

Future of 988 

No. 4 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

64
 

 

Law Enforcement and Crisis Services: 

Past Lessons for New Partnerships and the 

Future of 988 

Debra A. Pinals, M.D. 

Clinical Professor of Psychiatry, Director 

Program in Psychiatry, Law and Ethics 

University of Michigan 

Medical Director 

Behavioral Health and Forensic Programs 

Michigan Department of Health and Human Services 

Chair 

Medical Director’s Division 

National Association of State Mental Health Program Directors 

Matthew L. Edwards, M.D. 

Fellow in Forensic Psychiatry, Psychiatry and Law Service 

Department of Psychiatry and Behavioral Sciences 

Emory University School of Medicine 

Cover Art by Malkah Pinals 

Fourth in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

65
 

 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the authors and 

do not necessarily represent or reflect the official views, opinions, or policies of any 

governmental, academic, or other institution with whom the authors are affiliated; nor does 

mention of trade names, commercial practices, or organizations imply endorsement by the U.S. 

government, any state government, academic or other institution. 

Recommended Citation: 

Pinals, D. A., Edwards M. L. (2021). Law Enforcement and Crisis Services: Past Lessons for New 

Partnerships and the Future of 988. Technical Assistance Collaborative Paper No. 4. Alexandria, 

VA: National Association of State Mental Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

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Abstract: 

Lessons from history are essential to consider as policymakers reimagine a robust behavioral health 

crisis continuum that meets community needs. The role of law enforcement in crisis response has 

become fraught, with some advocates calling to defund police to prevent repetitions of tragic 

outcomes of police encounters, especially with Black and Brown men and individuals with mental 

illness. Yet, there are additional concerns that the elimination of law enforcement would have 

potential unintended consequences that could shift critical responses to ill-equipped mental health 

providers in high-risk situations. More and more, the dialogue has therefore moved to creating 

partnerships to enhance the community crisis response infrastructure. As 988 soon becomes 

operational, it is more important than ever to ensure that there is seamless connectivity between 911 

and 988 for the proper response and responders for any situation. This may also reduce the use of 

law enforcement when not needed, while being mindful that situations will arise when risks might 

necessitate multiple responders on a scene. This paper aims to help shape future planning by 

highlighting current behavioral health crisis response services and current and historical emergency 

medical out-of-hospital response mechanics. It also reviews theories that help shed light on decades 

of racial inequities in police approaches to marginalized communities. Lastly, we offer considerations 

for high-risk situations to help policymakers consider some of the more challenging issues that may 

arise in crisis service development. 

Highlights: 

• Law enforcement, emergency medical services, and behavioral health will increasingly need to 

partner to plan and coordinate 988 and 911. 

• The critical infrastructure of crisis services has become more apparent in the aftermath of 

COVID-19. Building adequate infrastructure will require more clarity in how communities may 

best execute responses. 

• Mental health and law enforcement have a long and complex history of collaboration to help 

individuals get into treatment and keep communities safe, with important lessons to help 

improve outcomes in the future. 

Recommendations for the post-COVID-19 future: 

1. Efforts to leverage partnerships should continue across first responders of all types. 

2. Training and cross-training is a critical component of maximizing the quality and dignity of crisis 

responses. 

3. Trauma-informed crisis services should include an understanding of the traumatizing nature of 

being a first responder and stakeholders should make efforts to support law enforcement and 

other emergency personnel who serve their communities. 

4. Enhancing the role of peer support specialists to work with law enforcement holds promise for 

achieving positive outcomes. 

5. Training and policies must acknowledge and prepare for high-risk encounters in the crisis 

continuum. 

6. Stakeholders can address racial disparities by taking stock of history and intentionally developing 

programs that focus on diversity and equity. 

7. Empirical evidence should be pursued to help identify the effectiveness of specific partnership 

type behavioral health crisis response models. 

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There is a growing discussion advocating for reforming crisis responses in the wake of the recent 

killings of individuals with mental illness by law enforcement,1 including Black men and women.

2 

Policymakers, advocates, and scholars have called for interventions that decenter and even 

“defund” police,

3 while promoting unarmed mental health or other clinicians to respond to individuals 

with mental illness or emotional disturbances when they are in crisis. Although some advocates consider 

such large-scale change in approaches to policing unrealistic, there is growing momentum to expand 

partnerships and the capacity of non-law enforcement clinicians from both the behavioral health system 

and the larger health system to respond and limit the role of law enforcement to those situations when 

possible. In some jurisdictions policymakers and legislators have weighed in on these partnerships. Take 

Connecticut for example, which passed a law enforcement “accountability” bill that puts more emphasis 

on oversight and review of police actions and has a section that mandates exploring the feasibility of 

partnering with social workers in certain responses.4 Even before the latest attention to these issues, 

mobile crisis services managed through local mental health authorities had been growing in number and 

availability across the United States. Parallel or integrated systems for youth mobile response and adult 

mobile response may exist in particular regions. Additionally, emergency medical responders may also 

be part of the community response to emotional crises. 

Integration and coordination across behavioral health, emergency medical response, and law 

enforcement will be essential components for a robust crisis services system that calls for the right 

response and responders at the right time. These systems share a socially and politically complex past 

within the history of American society, with many aspects rooted in the history of American medicine. 

Appreciating the development of emergency medical services, community-oriented models of public 

services, and the role of law enforcement involvement in meeting the needs of individuals with mental 

health crises is essential to understanding the strengths and weaknesses of our current system and to 

informing improvement efforts as the promise of 988 becomes a reality. 

There is an exciting dialogue happening across the United States related to the Crisis Now efforts.5 At 

the same time, history shows examples of both earlier successes of supporting disadvantaged 

communities to improve their health and well-being, but also the harmful effects of surveillance on 

marginalized communities at times in the guise of assistance. Taking stock of that history can augment 

future planning. This paper, Law Enforcement and Crisis Services: Past Lessons for New Partnerships and 

the Future of 988, as part of the NASMHPD 2021 technical assistance papers, aims to provide a historical 

background to community crisis responding between law enforcement and emergency medical 

personnel, to discuss broad structural issues that have contributed to racial inequities in the delivery of 

policing, and to review the current landscape regarding crisis response models in a world with the 

“Promise of 988” on the horizon. The Promise of 988 of the National Action Alliance and partner 

organizations brings the National Suicide Prevention Lifeline to a three-digit number but offers so much 

more in its goal of “crisis care for everyone, everywhere, every time.” 6 Finally, this paper provides 

specific caveats and information regarding the management of high-risk situations where law 

enforcement will likely be involved, where tragedy can ensue if not considered carefully. 

Early Models of Successful Community Engagement in Emergency Responding: 

Pittsburgh’s Freedom House Example 

History provides examples of successful models of community engagement that enabled communities of 

color and others to reimagine health, safety, and well-being. 

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Freedom House emerged during the 1960s and 1970s spurred by persistent social inequality and the 

need for improved systems of emergency care. Pittsburgh’s Freedom House Ambulance Service was a 

novel, socio-medical program that not only displaced police officers from emergency medical response 

roles in which they were not effective but simultaneously set national standards for emergency medical 

services.

7 Before Freedom House, most pre-hospital emergency care was provided by police officers and 

morticians without medical training that utilized a model that emphasized transportation without 

medical treatment.

8 

President Lyndon B. Johnson’s Great Society initiatives, and specifically the War on Poverty’s Office of 

Economic Opportunity (OEO), supported programs “promoting public welfare, education, urban 

development and public health programs.”9 As police performed a large proportion of pre-hospital 

transport, Black citizens relied on them for transportation to local hospitals for medical care. Because of 

the historical discrimination against Black citizens at the hands of police, having Black community 

members provide prehospital transport held promise for better outcomes. Ultimately, the OEO 

recruited Black men and women from low-income neighborhoods in Pittsburgh and partnered with 

physicians from the University of Pittsburgh Medical Center. A concerned group of Black and White 

citizens approached Peter Safar, MD, perhaps best known for developing the principles of 

cardiopulmonary resuscitation, for counsel on equipping vehicles for medical transport. Safar agreed to 

train Black community members to provide prehospital transport, and the Freedom House ambulance 

service thus partnered with Safar and the University of Pittsburgh Medical Center. Through this 

partnership, Safar and his colleague Nancy Caroline, MD, trained a group of Black citizens from 

marginalized communities in Pittsburgh to become paramedics and pioneer the training and delivery of 

emergency medical services.10 

Freedom House proved enormously successful. It provided superior medical care compared to earlier 

models,

11,12 and it advanced the development of a new cadre of emergency medical technicians as 

health care professionals.

13,14,15 Freedom House improved the community morale for paramedics and 

Black and White citizens throughout Pittsburgh as a form of social enterprise. Despite these successes, 

however, racial discrimination and prejudice plagued the program. The program’s reliance on local, 

state, and federal funding made it susceptible to local challenges from predominantly White suburban 

police and fire departments. And the city government sponsored the creation of a majority White 

“superambulance” service. Although the city administration cited Freedom House’s cost as its rationale 

for deprioritizing the program, it simultaneously supported the more expensive “superambulance” 

program. As Edwards (2021) argues, with the shift to the “superambulance” program, the pre-hospital 

functions shifted to primarily white male professionals who came from neighborhoods outside their 

service areas.

16 The history of Freedom House illustrates how community health programs can serve as 

better alternatives to policing and the ongoing dangers of racial inequities that can evolve in service 

delivery. As current crisis services expand, stakeholders cannot overlook the importance of the history 

of local citizens helping each other and of cultural competence in caring for community crisis needs. 

The “Out-of-Hospital” or “Prehospital” Medical Response and growing “Out-ofHospital” Behavioral Health Crisis Responses 

The Freedom House initiative demonstrated the importance of delivering care early and where needed 

outside of hospital contexts. This approach is parallel to the idea of mobile crisis services that go to the 

scene of the behavioral health crisis to meet the needs of the individuals and avoid unnecessary 

hospitalization by taking steps to resolve the crisis in the most effective and least restrictive way 

possible. Whether providing emergency stabilization in trauma situations, administering life-saving 

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medications, or intubating on a scene, first responders employ a host of responses to care for individuals 

in crisis. Local medical authorities dictate protocols used in a particular region. And the on-scene 

responders— such as paramedics or emergency medical technicians—provide the local response under 

that medical authority. With the expanded partnerships with behavioral health, more interventions 

become possible. 

Advances in behavioral health services are expanding this idea of behavioral health “out-of-hospital 

approaches.” For example, for youth mobile crisis services in many jurisdictions, the delivery of in-home 

supports and some post-crisis follow-up has advanced the continuum of crisis care delivery in behavioral 

health. Massachusetts, spurred in part by the Rosie D litigation,

17 and Connecticut with its youth Mobile 

Crisis Intervention Services,

18 are leading examples of such in-home and “out-of-hospital” interventions. 

The CAHOOTS model (Crisis Assistance Helping Out on the Streets)19 has also received national attention 

as the conversation about non-law enforcement responses has become louder. This program runs out of 

Eugene and Springfield, Oregon, and was designed and implemented in the late 1980s as an alternative 

to community police intervention to help persons in a mental health crisis, with substance use disorders 

or facing homelessness. Two-person teams –often a nurse and a paramedic type responder trained to 

deal with behavioral health crises—are sent to the scene of the crisis, where they provide traumainformed responses to attempt to resolve the situation. They only rarely must call the police. 

New tools, technologies, and treatments, from telehealth to naloxone20 and buprenorphine induction21 

for opioid use disorder, dramatically reconfigure the types of care and aid individuals can receive 

outside hospital settings. Perhaps nowhere is the capacity for the democratization of health care and 

the expansion of access to life-saving treatments in mental health and substance use crisis response 

more evident than in naloxone administration and efforts to help individuals with opioid use disorders 

be linked to treatment from the emergency response. This opportunity has been aided in part by Good 

Samaritan laws, which aim to reduce barriers to seeking emergency care. With the rise in opioid deaths 

nationally, most states adopted some form of these Good Samaritan laws to all individuals aware of 

someone’s opioid overdose to call for emergency assistance without fear of prosecution. The application 

of life-saving technologies, aided in part by progressive laws meant to decriminalize substance use, in 

some ways highlight a tension between the medical goals of emergency response and treatment and the 

public safety goals of deterrence. These approaches, however, also further exemplify the promise of a 

mobile response to a behavioral health crisis that can deliver immediate access to care—and eliminate 

the necessity of a justice system response with the help of policies that align these practices. 

Current and Emerging approaches to Crisis Calls: Taking Stock of 9-1-1 in 

Envisioning 9-8-8 

The task of aligning response systems highlights the organizational structures, interconnections and 

jurisdictional variations between crisis services for individuals receiving public mental health supports, 

emergency medical services, and law enforcement responses. These differences may be more apparent 

when systems respond to catastrophic disasters22 or community behavioral crises. Across emergency 

services as they exist today, all jurisdictions have identified “Public Safety Answering Points” or PSAPs, 

which serve as a central hub where 911 calls are routed directly from the control center in each state. 

There are primary PSAPs that get direct calls and secondary PSAPs to which calls are further routed. A 

PSAP registry was started in 2003 by the FCC in December 2003 to gather data regarding the readiness 

of the 911 system to respond to needs.23 When 911 is dialed, there is a triage decision in which the 

caller is generally asked what type of emergency is taking place, with a determination made at that level 

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as to whether to dispatch an EMS response, fire department, or law enforcement. For example, in the 

city of Rochester, when someone calls 911, a telecommunicator is considered the first link in what can 

be referred to as a medical survival chain.24 The telecommunicator is trained to ask questions and 

provide instructions to the caller, including talking the caller through situations ranging from CPR to 

childbirth while the caller waits for the proper assistance to arrive on the scene. The telecommunicator 

dispatches a responder to the scene using computerized systems. 

As it has become clear that mental health situations require their own most appropriate, least restrictive 

available responses, some communities have been examining this triage process and determining how 

best to forge partnerships so that the law enforcement response is shifted from the default response to 

one that is there when needed. As such, some jurisdictions have opted to add a fourth option to the 911 

call to determine if there is a mental health emergency. For example, the city of Austin in February 2021, 

implemented that fourth option for dispatch to ask emergency callers if their call was related to a need 

for mental health services.25 Moreover, many communities have developed mental health crisis access 

lines, which people (especially in the public behavioral health system) are given to call in case of a crisis. 

These behavioral health crisis lines may mobilize an alternative response of a mobile crisis intervention 

team of various designs that also intersect with police responses (Figure 1). 

As noted in Crisis Services: Meeting Needs, Saving Lives26, this growing development of mobile crisis 

responses across communities and partnerships with law enforcement is not a new area. In the last 20 

years, one of the impetuses 

for this growth has been the Figure 1. Basic Designs of Law Enforcement and Mental Health 

national dialogue related to Partnerships (see also Crisis Services: Meeting Needs, Saving Lives) 

the Sequential Intercept 

Model, which added 

Intercept 0 as part of its 

framework27 to help 

communities specifically 

target the development of 

community crisis responses 

both as part of jail diversion 

and law enforcement 

deflection efforts. Studies 

have shown positive results 

related to jail diversion and 

reducing the likelihood of 

individuals with mental 

illness being routed to jail. 

These may include 

specialized responses such 

as those that involve a 

police-friendly crisis drop off 

point or police referral of an 

individual to a mental health 

specialist.28 Primers are 

available to illustrate examples of how these relationships between police and mental health systems 

have been operationalized and enacted around the country over several years. 29,30 31 Many 

communities show tremendous growth in this area of mobile crisis response, and SAMHSA’s National 

Police-based Law enforcement officers who are specifically 

specialized trained to manage behavioral health crises and 

police have knowledge of and access to the system to 

response help support their response. 

Police-based Typically involves behavioral health clinicians 

specialized hired by police departments whose job is to 

mental health accompany officers on calls where an individual 

co-response might be in a behavioral health crisis or for calls 

where a behavioral health specialist might be 

helpful. 

Mental Services also known as mobile crisis services, 

health-based where a mental health unit, staff person or team 

mental health of staff respond directly at the scene of the crisis; 

response Law enforcement may or may not jointly and 

cooperatively appear on the scene. 

Blended and Services that involve unarmed officers, peer 

Innovative support collaborations, community response 

teams that utilize a combination of efforts to 

enhance options for responding. 

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Guidelines for Behavioral Health Crisis Care Best Practice Toolkit32 calls for ongoing efforts as part of 

advancing a crisis services continuum. Thus, in many communities, mobile crisis supports and 

stabilization services are becoming well-recognized and widespread. 

The Vera Institute describes the police and community responders arranged on a continuum, with either 

a police-only response, a combined type of response, or a community-based non-law enforcement 

response to the crisis.33 These conceptualizations of a continuum present an interesting premise and 

one that can help a community conceptualize an infrastructure they are hoping to build. In a recent 

Open Minds executive briefing on “Building New Bridges,” author Monica Oss described several 

examples of innovative and hybrid approaches to behavioral health and law enforcement emerging 

across the country.34 

Because persons with disabilities warrant support rather than criminalization for the manifestations of 

their conditions, and the Americans with Disabilities Act and Olmstead v. L.C.

35 respectively dictate 

attention to meeting the needs of individuals with disabilities and access to care in the least restrictive 

community-based alternatives appropriate to their needs, it is more critical than ever to ensure the 

most robust behavioral health response possible in communities around the country while intentionally 

planning how stakeholders might best construct a response and what roles each of the responders 

might play. To that end, there may be several aspects of the work that can help improve outcomes as 

partnerships are formed discussed below. Before one can get to these areas, however, it is important to 

review critical areas related to race and equity and high-risk encounters that crisis services will need the 

tools to tackle at this interface. 

Mental Illness, Surveillance, and Policing in History and Addressing Race/Equity 

Challenges 

When considering moving toward community-based interventions that may limit the role of the police, 

stakeholders can glean helpful lessons by understanding how historical efforts to address public safety 

needs have furthered structural inequities across communities. As historian Nic John Ramos writes in his 

history of racial liberalism in policing in California, many scholars and advocates viewed the community 

mental health movement as a “benevolent movement,” one that simultaneously paved the way for 

“new surveillance and policing strategies” such as broken windows theory.

36 This theory of policing 

conferred a necessity to address even minor crimes such as vandalism to prevent a more serious crime. 

The broken windows theory was popularized in New York City during the 1970s and 1980s and it 

resulted in heavier policing in disadvantaged communities. On the other coast, psychiatrists at the 

University of California at Los Angeles similarly developed racially liberal approaches to policing. These 

approaches considered Black and White communities similar to each other regardless of what was 

happening in their respective communities. Despite these ostensibly progressive ideologies, scrutiny and 

surveillance for people of color continued to increase across the country, resulting in more “forms of 

incarceration, segregation and discrimination.”37 In arguing for racial sameness, these approaches 

showed the pitfalls of racial liberalism by enabling – and intentionally deprioritizing – the social 

structures and systems that reproduced poverty, health and socio-economic inequity in Black 

communities. 

Partially in response to some of the civil unrest of the late 1960s, as Ramos argues, psychiatrists and 

social scientists pursued a unified agenda to “align anti-poverty policies with the community mental 

health movement and the movement for psychiatric deinstitutionalization.”38 

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As large urban centers increased aggressive policing and surveillance efforts in underserved 

neighborhoods, however, the net effect of this change was that “rioting, crime, drug use, domestic 

abuse, and family dysfunction” were seen more as “race problems”39 than consequences of structural 

racism and discrimination.

40 To this day, these critical infrastructure conceptualizations create disparate 

education, housing, employment, and mental health outcomes. As crisis services evolve to provide more 

just and equitable care for all who need it, these forms of structural problems will continue to create 

parallel systems if not attended to in a more intentional way moving forward. 

Contemporary discourses on crisis services, law enforcement, and the potentials of the 988 federal 

mandate must consider issues of race, structural racism, justice, diversity, equity, and inclusion. Such a 

consideration highlights the importance of partnerships, policies and protocols. To be sure, there have 

been general disparities in police activity across multiple axes of difference, including race, gender, and 

mental health status. Individuals with a mental illness involved in police interactions are 16 times more 

likely to die during such interactions than individuals without mental illness.41,42 Even more devastating, 

Black people with mental illness are 2.8 times more likely to die than their White counterparts.

43,44 

Structural racism explains not only why racially and ethnically oppressed groups have poorer health 

access, opportunities, and outcomes than their White counterparts,

45 but also explains how racialized 

violence by police and others lead to lower rates of sanctions, penalties, and criminalization for law 

enforcement officer-related deaths.

46 Racialized legal status, the legal classifications such as 

criminalization and immigration status that have a disproportionate effect on minority persons further 

reduce access to care, determine health outcomes, and shape the legal circumstances and life 

trajectories that many individuals with mental illness navigate each day.

47,48 

Social inequality is behind much of these disparities, shaped by a longstanding history of structural 

racism. White Americans, for example, have a net worth nearly 10 times greater than their Black 

American counterparts.

49 Historical practices of structural racism have reduced financial, residential, and 

occupational opportunities for minoritized persons in the United States. Exclusion from social and safety 

net programs,

50 neoliberal contractions of social programs during the 1970s and 1980s,51 residential 

segregation driven partly by the Federal Housing Administration,

52,53 and other forms of racial 

discrimination have contributed to the disparities in wealth accumulation in the United States.

54 

Residential segregation, a social determinant of health that impacts downstream factors including 

neighborhood quality and safety, access to food and resources, education,

55 and the climate of police 

officer interactions, has been one of the strongest drivers of health inequities among African American 

populations. 

People who are racially and ethnically oppressed have higher rates of chronic disease; experience earlier 

onset and increased severity of disease; are less likely to have access to medical care; receive poorer 

quality medical care than their White counterparts, are more likely to die prematurely from disease, and 

experience racism as a psychosocial stressor.

56 The fact that nearly one-third, one-fifth, and one-fourth 

of Black, Latinx, and indigenous peoples, respectively, report not seeking medical care due to 

experiences of discrimination 57 also raises concerns about associations between race, policing, and 

mental health. Consider a recent study that found that police killings of unarmed Black Americans have 

“spillover effects” by increasing the number of poor mental health days. Black Americans who have 

faced discrimination in medical care may be less likely to seek care and are at greater risk of the 

deleterious mental health effects of police killings of unarmed Black Americans.

58 

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Disparities in mental health care go beyond experiences of interpersonal racism, extending into mental 

health care outcomes, policies, tools, and diagnostics.

59 The overdiagnosis of schizophrenia among 

African American populations is well-documented.

60 Research suggests that African Americans and 

other minority groups are more likely to present with different illness scripts, which likely increases the 

rate of misdiagnosis of schizophrenia.61 Moreover, mental health clinicians are less likely to elicit 

affective symptoms when evaluating patients, leading to twice the rate of misdiagnosis.

62,63 Even when 

particular symptom pools are observed (i.e., psychosis), clinicians may over-value positive and negative 

symptoms in affective psychosis,

64,65,66,67,68 leading to beliefs that mental illness among Black 

populations is more chronic and persistent.

69 The perception of more severe mental disease leads to 

higher prescribed doses of antipsychotic medication and higher rates of medication-related adverse 

effects such as tardive dyskinesia.

70,71,72,73 Therefore, it is not surprising that non-White patients have a 

greater incidence of restraints despite no difference in violence risk, and are more likely to be placed in 

restraints or seclusion when admitted to psychiatric emergency services.

74,75 

Racial and mental health inequities help drive the penetration of African Americans and other racially 

and ethnically oppressed groups deeper into the forensic and criminal justice systems. Mental illness 

generally, and drug use and addiction in particular, are criminalized in the United States.

76 This increased 

criminalization is more prevalent in communities of color vis-à-vis the compounding effects of structural 

racism and residential segregation. Consider the “two-tiered system” of substance use disorder 

treatment in the United States.

77 Whereas office-based buprenorphine maintenance by monthly 

prescriptions is more heavily concentrated in higher-income predominantly White areas, DEA-regulated 

methadone clinics require daily observed dosing and is heavily concentrated in Black, Latinx, and lowincome neighborhoods. Such disparities are enabled by the very logic of policymakers and advocates for 

mental health policy: In supporting the Drug Addiction and Treatment Act of 1999, one scientist testified 

that “[methadone]... tends to be concentrated in urban areas, [and] is a poor fit for the suburban spread 

of narcotic addiction.” 78 

The history of mental health treatment in the United States helps explain the role that policing plays in 

considering how intersecting identities of being Black and having a mental illness shape outcomes for 

individuals. The deinstitutionalization of the 1970s that increased transitions of men and women from 

state psychiatric hospitals coincided temporally with the popularization of “tough-on-crime policing 

[that] began to drive up incarceration rates,”79 though, the relationship between these policies is more 

complicated than one might read in popular media. Nevertheless, for many different reasons, police 

have become increasingly more likely to engage with persons with mental illness as first-responders.

80 

Often referred to as “quasi-mental health professionals...street corner psychiatrists... and frontline 

mental health workers,” police officers have become an indispensable link in the community mental 

health system.

81 It has been postulated that police would continue to serve in this role as long as the 

mental health system remained fragmented.

82 Police frequently arrest homeless persons and individuals 

discharged from psychiatric treatment facilities, and most officers report responding to mental health 

crises on a weekly to monthly basis.83 Yet, police continually note a lack of adequate mental health 

training despite this vital function of their role. 

Addressing longstanding and pervasive forms of structural violence and institutional racism will require 

active antiracist policies and programs that center the experiences and perspectives of marginalized 

populations.

84,85 This includes an intentional focus on how stigma and mental illness further these 

disparities. Policies and practices should involve these communities as agents as was seen in the 

Freedom House initiative.

86 There must be sufficient workforce diversity to ensure the healthcare 

system meets the needs of the communities it serves, such as a workforce that challenges the use of 

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race-neutral and racially liberal perspectives in diagnosis, treatment, policing, and research that fail to 

address the persistence of structural racism.

87,88 

High-risk Situations 

Fragmentation across responders arriving on the scene of a crisis can contribute to chaos on the scene. 

There may be a deployment of any number of people and professional types that arrive at a scene 

including blue uniforms, white coats, and plain-clothed community responders. When law enforcement, 

emergency medical response, and mental health work together for situation resolution, even in high-risk 

situations, positive outcomes can be seen. For example, during the pandemic in Washtenaw County, 

Michigan, an armed man was reported to be having mental health challenges. The embedded 

community mental health clinicians and other responders assisted a local emergency law enforcement 

SWAT team in bringing all parties to safety after a 36-hour standoff.89 The heroic and coordinated 

response included leadership, patience and strategic planning. 

Yet, first responders coming to a mental health crisis often come from siloed places and may be 

disconnected from each other, making such positive outcomes less likely. There are many lessons that 

can be learned from high-risk encounters between law enforcement and people with mental illness 

including those that have resulted in fatal shootings.90 At best, if well-coordinated and thoughtfully 

executed, there can be a calming effect on the situation. At worst, a situation can escalate with 

potentially avoidable dire consequences in the heat of the moment. 

Most police officers will encounter an individual with mental illness, with estimates that one in ten 

police encounters involve someone with a mental illness.91 Yet, even with crisis services expanding, 

many police departments still lack a specialized system to handle issues specifically related to mental 

health situations. However, without specialized training, policies, or coordinated responses, police may 

not adequately adjust their techniques to appropriately address individuals' special behavioral 

considerations and capacities in mental health crises.92 Moreover, individuals with mental illness may 

not respond effectively to police commands, which may lead police to justify the escalation of force.93 

Training typically focuses on awareness of mental illness, verbal skills, and crisis intervention and deescalation strategies. Still, there are numerous challenges in the field, including working with psychiatric 

hospitalization involuntary commitment laws94 and navigating complex and high-risk situations. Despite 

advances in many areas, it is important to recognize situations that can arise that are too dangerous for 

anyone else. Preparation and acknowledgment that these situations can arise in communities are 

critical. 

One example of a high-risk situation includes “suicide by cop” in addition to firearms or other serious 

weapon-related threats. “Suicide by cop” may also be referred to as “victim-precipitated homicide,” 

“law enforcement forced-assisted suicide,” and “law enforcement officer-assisted suicide.”95 This 

phenomenon occurs when a suicidal individual provokes deadly force from a law enforcement officer 

who is then compelled to act in self-defense or to protect public safety. Police officers may not be 

aware of their instrumental role in assisting an individual’s suicide at the time of an incident. One study 

found that psychiatric and medical illness and substance use accounted for 56% of victim-precipitated 

homicide involving police.

96 Low socioeconomic background, criminal history, prior suicide attempts, 

and many other factors are strongly associated with these incidents.

97 

Dewey and colleagues parsed suicide-by-cop cases into three subtypes: those involving mental illness, 

criminality, and those that were not otherwise specified. Each subtype showed differences in the levels 

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of substance use, symptoms of mental illness, or involvement of criminal behavior.98 The study further 

found that decreasing fragmentation between mental health and law enforcement might be one way to 

help with prevention. 

In situations where police tragically shoot an individual, subsequent psychological autopsies may reveal 

more details about the police actions and the victim’s intent leading up to the incident. As emotional 

and political as it may be, it is critical to review and learn from high-risk encounters in “after-action 

reviews.” Litigation in this area is common, with one San Francisco case recently heard by the U.S. 

Supreme Court examining aspects of the Americans with Disabilities Act (ADA) concerning a police 

encounter with an individual with mental illness.

99 Ultimately, the U.S. Supreme Court did not settle a 

dispute among the circuit courts regarding whether individuals could pursue a lawsuit under the ADA for 

an arrest that failed to provide accommodations for persons with disabilities. In the aftermath of the 

Court’s review, however, one author suggested a “sliding scale” of accommodations that increase as 

threats are diminished and a scene is more secured.

100 This model presents an interesting way to 

consider reviewing incidents and training prospectively. By reviewing both positive and poor outcomes, 

crisis responders may improve the quality of responses and improve understanding of the role of 

mediation skills, emotional regulation, verbal de-escalation, and educating police about mental illness to 

reduce stigma.

101 

Another example of high-risk situations includes hostage and barricade situations, which may also 

benefit from partnerships with mental health professionals. These partnerships already span decades, 

with one study dating back to 1993 showing that 39% of surveyed law enforcement hostage negotiation 

teams worked with mental health professionals and found improved results when doing so.102 In these 

settings, psychiatrists, psychologists, social workers, and other mental health clinicians may help assist in 

crisis negotiation, which typically involves verbal de-escalation to reduce emotional tension and acuity 

aimed at safe resolution of these situations. Psychiatrists and other mental health professionals 

consulting in crisis negotiations often serve in advisory capacities rather than negotiators.

103 They may 

also participate in training, assessments, and debriefings.104 When mental health professionals are 

brought into these roles, it is important for them to receive training and to continue to practice within 

their ethical frames and avoid taking on quasi-law enforcement roles. They may therefore benefit from 

consultation before embarking on these roles and as their work unfolds. Nonetheless, strengthening the 

crisis care continuum involves considering situations that can present high-risk scenarios where law 

enforcement will be instrumental in helping safety be realized. 

Bringing Lessons Forward: Importance of partnerships, policies, peers, and traumainformed practices 

One of the most recognized law enforcement approaches to mental health crises involves the Crisis 

Intervention Team (CIT) model. Although originally seen more as a police-based specialized police 

response model, CIT International’s evolving protocols look to improve systems across multiple 

dimensions, including: 

• increasing safety, 

• increasing connections to mental health services for those who need them, 

• only using law enforcement “strategically” in higher-risk or criminal encounters, 

• increasing the roles of mental health professionals and peers, 

• reducing trauma for individuals in crisis to help support their recovery.105 

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CIT International recently issued its own “Best Practice Guide” to help foster communities attempting to 

meet these goals.106 Although formal CIT may not be suitable for every department and new models are 

emerging recognizing that CIT has its advantages and limits, there are many lessons that CIT can teach 

about building specialized services and establishing partnerships and community problem-solving. 

Furthermore, stakeholders, policymakers, and behavioral health specialists need more data about the 

effectiveness of CIT in reducing use-of-force outcomes.

107 

Policies for emerging 988 response models will also need to be developed and can leverage lessons 

learned from CIT and other practices. Medical control authorities have very rigorous protocols for what 

types of interventions might warrant particular responses, such as medication administration, and these 

protocols for out of hospital responses can make life and death differences. Similarly, because crisis 

responses can involve managing exacerbations of serious mental illness or manifestations of behavioral 

dysregulation by individuals with other complex and co-occurring conditions, 988 responses will need to 

have sound clinical leadership to guide aspects of responses. Additionally, there will need to be 

protocols and policies that maximize safety, provide proper assessments, and help resolve crises in the 

least restrictive manner possible and are guided by mental health laws and general legal and regulatory 

provisions. 

To implement effective responses, partnerships will be key. As described throughout this paper, 

partnerships have been evolving in numerous innovative ways. As noted by Oss,108 reports of law 

enforcement responding daily to overdoses and behavioral health crisis are creating an impetus for 

working together. Models of Law Enforcement Assisted Diversion,109 such as the program started in 

Seattle, Washington, and the Police Assisted Recovery and Addiction Initiative and the Angel Program 

originating in Gloucester, Massachusetts,

110 both demonstrated how police can assist individuals with 

substance use disorders rather than arresting them. They both are excellent examples of law 

enforcement working at the substance use/crisis interface. Other examples highlighted by Oss111 and 

worth repeating include the District of Columbia’s Department of Behavioral Health’s pilot of sending an 

unarmed community response team to respond to behavioral health crises. This came as part of a 

recommendation from a police reform commission that examined practices in the District that realized 

that approximately 90 calls per day to police related to behavioral health crises.112 And New York 

released data showing that consumers were more likely to accept help from their Behavioral Health 

Emergency Assistance Response Division (B-HEARD) pilot in Harlem, where emergency medical 

personnel and social workers responded to specific mental health emergency calls.113 This is a reminder 

of the importance of community interventions being culturally competent with the particular 

communities rather than over-relying on police just like the Freedom House ideas 50 years ago. 

As these models emerge, staff development, recruitment, and retention are other critical issues facing 

law enforcement, emergency medical responders, and behavioral health. Priorities should include 

ensuring diversity and equity in the workforce while enhancing training and quality of services. Many of 

the populations of individuals encountering the crisis system, especially those at substance use, mental 

health, and criminal-legal system interface, may be challenging to engage. This may be especially true in 

communities with longstanding mistrust of the medical system. In those areas, there is a need to rebuild 

broken ties. These communities must enhance engagement strategies –learning in some ways from the 

Freedom House example or NAMI’s framework for engagement114-- to help attract people to services 

rather than inadvertently turning them off from the very supports they may need most. 

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Training can be a crucial area to help give law enforcement and first responders greater confidence and 

tools to help manage crises that they do encounter. It is critical that all parties receive sufficient training 

to be able to provide proper responses to behavioral health crises. Inadequate training in policing 

individuals with mental health is an ongoing issue, with one study going back over 15 years calling for 

training in topics including dangerousness, suicide by cop, decreasing suicide risk, mental health law, 

and liability [risk] management.

115 Since the time of that survey, much has been done to enhance officer 

knowledge and skills. The International Association of Chiefs of Police OneMind Campaign aims to assist 

police in better preparedness for managing crises involving persons with mental illness or 

developmental disabilities.116 The Bureau of Justice Assistance has put forth a police mental health 

collaboration online toolkit.117 Law enforcement training is a cornerstone of the Crisis Intervention Team 

(CIT) model,

118 which includes a robust 40-hour training curriculum that has shown effectiveness in 

several domains, including officers’ cognitive and attitudinal outcomes.119 Training may also help 

address compassion fatigue for law enforcement faced with recurring behavioral health issues in their 

communities, such as overdoses due to opioids.

120 Training and protocols to answer crisis calls have also 

helped address suicide risk among crisis callers.121 

Training can also address issues of stigma. Police see skewed samples of the population because they 

are generally only involved when things are not going well. Despite data showing that only 3-5% of 

violence towards others is attributable to people with mental disorders,

122,123 stigma persists about 

persons with mental illness and beliefs that they are more dangerous than the general population.

124,125 

This can impact how law enforcement officers might respond to an individual with mental illness in 

crisis. It is therefore critical that training involves education about the role of stigma in perceptions of 

violence and mental illness. Given the role of police in protecting all individuals, it is also essential for 

training to include information that individuals with mental illness are more likely to be victims of 

violent crime, theft, assault, and rape than be a perpetrator.

126 

Lastly, training can also enhance community partnerships,

127 especially when different disciplines train 

together. Michigan, for example, through its Mental Health Diversion Council, has been working with 

partners in behavioral health, law enforcement, and emergency medical responses to build out more 

recently updated cross-training for all three systems together.128 

Other specific approaches may also help improve outcomes in overall crisis service delivery. Traumainformed services are recognized as increasingly important given the recognition of the high proportion 

of behavioral health- and justice systems-involved persons who have trauma histories both as victims of 

and witnesses to violence.129 Studies demonstrate that histories of childhood trauma contribute to 

more behavioral health challenges.130 SAMHSA has defined trauma by understanding the three “E’s” of 

events, experiences of the event(s), and the effect of those experiences on an individual. It has noted 

how people can recover and adapt with the right supports despite their traumatic experiences.131 In its 

guiding documents, SAMHSA further recommends that a system is trauma-informed through a 

framework of four “R’s,” which means that the system realizes the impact of trauma and the potential 

for recovery when it recognizes signs of trauma and responds by developing policies and practices to 

help avoid and resist retraumatization. For law enforcement working with emergency medical 

responders and behavioral health crisis response systems, these partnerships should aim to be traumainformed. 

Stakeholders must also address exposure to trauma among the workforce to provide the most 

responsive crisis services. First responders are at increased risk of mental health challenges related to 

their work, with high levels of exposure to traumatic events, challenges with their work schedules, and 

78
 

 

 

 

 

 

 

 

 

 

 

 

 

general work-related stressors unique to their roles.

132 Similarly, first responders and response teams 

have raised concerns about the impact of exposure to suicides in crisis work on their personal lives.133 

Law enforcement officers are not immune from these experiences. Studies have shown them to be at 

increased risk of cardiovascular disease, psychological stress,134 and even suicide.135 

Several law enforcement programs around the country have recognized that their own risk of trauma 

can impact their well-being and have begun to implement peer support programs.

136,137 For example, 

police in Miami-Dade, Florida, surveyed its police and fire departments to better understand how their 

workforce is dealing with post-traumatic stress disorder. As part of their efforts to expand CIT training, 

they have begun developing and delivering models to better support officer mental health.138 These 

models should be considered a basic necessity for all crisis responders- from call center employees to 

those out in the field delivering direct services. The experience of COVID-19 has further highlighted 

these needs. 

Finally, there has been increasing attention to peer support engagement in the crisis response at the 

interface of law enforcement, mobile crisis teams, and emergency responders. The Boston Medical 

Center Emergency Services Program (BMC ESP) provides robust and integrated crisis services in several 

communities, including Boston, Cambridge, Somerville, and Fall River, and actively engages health 

professionals, mental health staff, and peer specialists to provide crisis services that “respects the 

dignity” of those served.139 A learning community to enhance and help train peer support professionals 

in crisis services is offered by C4 Innovations.140 Roles of “forensic peers”- those with criminal legal and 

behavioral health system personal experience has also been shown to have a role for individuals with 

co-occurring disorders in the justice system.141 Peer-led warmlines at the call center interface have also 

been promulgated, and NAMI has actively promoted these lines and disseminated information about 

them.142 History illustrates that peers can play a vital role in helping individuals in crisis and can assist at 

the law enforcement interface to extend the types of supports for individuals being served. 

Conclusion 

The promise of 988 reimagines an alternative pathway for individuals in crisis related to mental health, 

substance use, or other emotional challenges that will result in decreased suicides, safe crisis resolution, 

and linkage to needed treatments. In such a system, the role of law enforcement is de-emphasized in 

favor of utilizing responders through call centers and mobile teams along with emergency medical 

supports that can arrive on the scene as best equipped to manage mental health and substance use 

challenges in the community. This change is a critical step forward in reducing the numbers of 

individuals with behavioral health challenges from being arrested and needlessly criminalized and 

hopefully lowering the disproportionate numbers of individuals with mental illness whose lives end with 

encounters with law enforcement that have gone awry. In those situations, there are no winners, and 

the traumatic impact on communities of these incidents continues for generations. At the same time, 

law enforcement responders will always be needed for situations that are high-risk or where criminal 

conduct is an issue. As such, it is critical to enhance partnerships, develop policies, and plan for and 

support crisis services that acknowledge and coordinate roles of all responders. By taking these steps, 

the promise of 988 has greater potential to maximize safety while shaping improved outcomes that 

recognize the vulnerability of all humans to emotional crises and meet the unique needs of any 

individual in crisis, anywhere, at any time. 

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79 Ramos NJ: Pathologizing the Crisis: Psychiatry, Policing, and Racial Liberalism in the Long Community Mental 

Health Movement. J Hist Med Allied Sci. 2019; 74:57-84 80 Pinals DA, Price M. “Forensic Psychiatry and Law Enforcement.” In Frierson, R. L., In Gold, L. H. (eds). The 

American Psychiatric Association Publishing textbook of forensic psychiatry. American Psychiatric Publishing, 

Washington, DC, 2018 

81 Pinals DA, Price M: Forensic Psychiatry and Law Enforcement. in The American Psychiatric Publishing textbook of 

Forensic Psychiatry. Edited by Simon RI, Gold LH. Washington, D.C., American Psychiatric Publishing, 2012 

82 Ibid. 83 Ibid. 84 Shadravan SM, Edwards ML, Vinson SY: Dying at the Intersections: Police-Involved Killings of Black People with 

Mental Illness. Psychiatr Serv 2021; 72:623-625 85 Mensah M, Ogbu-Nwobodo L, Shim RS: Racism and Mental Health Equity: History Repeating Itself. Psychiatr Serv 

2021; Jan 12, Epub ahead of print 

86 Edwards ML: Race, Policing, and History — Remembering the Freedom House Ambulance Service. N Engl J Med 

2021; 384(15): 1386-1389 87 Ibid. 88 Shadravan SM, Edwards ML, Vinson SY: Dying at the Intersections: Police-Involved Killings of Black People with 

Mental Illness. Psychiatr Serv 2021; 72:623-625 89 Clark N: Barricaded gunman surrenders peacefully after 36-hour standoff in Washtenaw County. MLive, 2021, 

March 25. https://www.mlive.com/news/ann-arbor/2021/03/barricaded-gunman-surrenders-peacefully-after-36-

hour-standoff-in-washtenaw-county.html 90 Borum R: Improving high risk encounters between people with mental illness and the police. J Am Acad 

Psychiatry Law 2000; 28(3):332–337 91 Fuller DA, Lamb R, Biasotti M, et al: Overlooked in the undercounted: the role of mental illness in fatal law 

enforcement encounters. Treatment Advocacy Center 2015. 

http://www.treatmentadvocacycenter.org/storage/documents/overlooked-in-the-undercounted.pdf 92 Sheehan SP: Asserting the Rights of the Mentally Ill in Police Brutality Cases Involving Excessive Force. In Civil 

Rights Litigation and Attorneys’ Fees Annual Handbook. New York, NY, Clark Boardman Callaghan, 2010. 93 Ibid. 94 Pinals DA, Price M: Forensic Psychiatry and Law Enforcement. in The American Psychiatric Publishing textbook of 

Forensic Psychiatry. Edited by Simon RI, Gold LH. Washington, D.C., American Psychiatric Publishing, 2012 

95 Ibid. 96 Lindsay M, Lester D: Criteria for suicide-by-cop incidents. Psychol Re 2008; 102:603-5 97 Ibid. 98 Dewey L, Allwood M, Fava J, Arias E, Pinizzotto A, Schlesinger L. Suicide by cop: clinical risks and subtypes. Arch 

Suicide Res. 2013;17(4):448-61. doi: 10.1080/13811118.2013.801810. PMID: 24224677. 99 City & Cnty. of San Francisco v. Sheehan, 575 U.S. ___ (2015). 

https://supreme.justia.com/cases/federal/us/575/13-1412/ 100 Levin R. Responsiveness to difference: ADA accommodations in the course of an arrest. Stanford Law Rev. 2017 

Jan;69(1):269-320 101 Pinals DA, Price M: Forensic Psychiatry and Law Enforcement. in The American Psychiatric Publishing textbook 

of Forensic Psychiatry. Edited by Simon RI, Gold LH. Washington, D.C., American Psychiatric Publishing, 2012 102 Butler WM, Leitenberg H, Fuselier GD: The use of mental health professional consultants to police hostage 

negotiation teams. Behav Sci Law 1993;11(2):213-21 103 Pinals DA, Price M: Forensic Psychiatry and Law Enforcement. in The American Psychiatric Publishing textbook 

of Forensic Psychiatry. Edited by Simon RI, Gold LH. Washington, D.C., American Psychiatric Publishing, 2012 104 Ibid. 105 Best practices for addressing mental health crises in the community. Community Policing Dispatch 2020;13(7). 

https://cops.usdoj.gov/html/dispatch/07-2020/cit.html#1 106 Crisis Intervention Team (CIT) programs: A best practice guide for transforming community responses to mental 

health crises. Salt Lake City, UT: Crisis Intervention Team International, 2019. 

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https://www.citinternational.org/bestpracticeguide#:~:text=Crisis%20Intervention%20Team%20(CIT)%20Programs 

%3A%20A%20Best%20Practice%20Guide,starting%20and%20sustaining%20their%20CIT 107 Shadravan SM, Edwards ML, Vinson SY: Dying at the Intersections: Police-Involved Killings of Black People with 

Mental Illness. Psychiatr Serv 2021; 72:623-625 108 Oss ME: Building new bridges: Behavioral health & law enforcement. Open Minds 2021. 

https://mailchi.mp/openminds.com/building-new-bridges-behavioral-health-law-enforcement?e=3a7e13ad3e 109 LEAD: Law enforcement assisted diversion. Washington, DC, US Department of Justice, National Institute of 

Corrections. https://nicic.gov/lead-law-enforcement-assisted-diversion 110 The Gloucester ANGEL initiative. Boston, MA, The Police Assisted Addiction and Recovery Initiative. 

https://paariusa.org/gloucester/ 

111 Oss ME: Building new bridges: Behavioral health & law enforcement. Open Minds 2021. 

https://mailchi.mp/openminds.com/building-new-bridges-behavioral-health-law-enforcement?e=3a7e13ad3e 112 Weiner, R: D.C. to divert some mental health calls away from police. The Washington Post, 2021, May 17. 

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b746-11eb-96b9-e949d5397de9_story.html 113 NYC’s non-police mental health pilot increasing rate of those getting aid, data show. NBC New York, 2021, July 

22. https://www.nbcnewyork.com/investigations/nycs-non-police-mental-health-pilot-increasing-rate-of-thosegetting-aid-data-show/3165520/ 114 Engagement: A new standard for mental health care. Arlington, VA, National Alliance on Mental Illness, 2016. 

https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/Engagement-A-NewStandard-for-Mental-Health-Care 115 Vermette HS, Pinals DA, Appelbaum PS: Mental Health Training for Law Enforcement Professionals. Journal of the 

American Academy of Psychiatry and the Law March 2005;33(1):42-46 116 One Mind Campaign. Alexandria, VA, International Association of Chiefs of Police. 

https://www.theiacp.org/projects/one-mind-campaign 117 Police-Mental Health Collaboration Toolkit. Washington, DC, US Department of Justice, Office of Justice 

Programs. https://bja.ojp.gov/program/pmhc 118 Learn about CIT. Salt Lake City, UT, Crisis Intervention Team International. 

https://www.citinternational.org/Learn-About-CIT 119 Watson AC, Compton MT, Draine JN: The crisis intervention team (CIT) model: An evidence-based policing 

practice? Behav Sci Law. 2017;35(5-6):431-441 120 Carroll JJ, Mital S, Wolff J, et a: Knowledge, preparedness, and compassion fatigue among law enforcement 

officers who respond to opioid overdose. Drug Alcohol Depend. 2020; 217:108257 121 Gould MS, Lake AM: Suicide Prevention and 988: Beyond Beds Before, During and After COVID-19. Technical 

Assistance Collaborative Paper No. 3. Alexandria, VA, National Association of State Mental Health Program 

Directors, 2021 

122 Swanson JW: Mental disorder, substance abuse, and community violence: an epidemiology approach. In 

Monahan J, Steadman HJ (eds), Violence and Mental Disorder. Chicago: University of Chicago Press, 1994, 

pp. 101-136. 123 Pinals DA, Appelbaum PS, Bonnie RJ, et al : Resource Document on Access to Firearms by People with Mental 

Disorders. Behav Sci Law 2015;33(2-3):186-94 124 Barry CL, McGinty EE, Vernick JS, et al: After Newtown--public opinion on gun policy and mental illness. N Engl J 

Med. 2013;368(12):1077-81 125 Stuber JP, Rocha A, Christian A, et al: Conceptions of mental illness: attitudes of mental health professionals and 

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129 Miller NA, Najavits LM: Creating trauma-informed correctional care: a balance of goals and environment. 

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130 Wolff N, Shi J: Childhood and adult trauma experiences of incarcerated persons and their relationship to adult 

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and social well-being of ambulance personnel: a systematic review of qualitative research. BMC Psychiatry 

2020;20(1):348 

133 Lyra RL, McKenzie SK, Every-Palmer S, et al: Occupational exposure to suicide: A review of research on the 

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139 Emergency services program. Boston, MA, Boston University School of Medicine. 

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Strategies and 

Considerations for 

Providing a More 

Equitable Crisis Continuum 

for People of Color in the 

United States 

No. 5 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

86
 

 

Strategies and Considerations for 

Providing a More Equitable Crisis 

Continuum for People of Color in the 

United States 

Kristin A. Neylon M.A. 

Senior Project Associate 

National Association of State Mental Health Program Directors Research Institute, Inc. 

kneylon@nri-inc.org 

703-738-8174 

Fifth in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

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Acknowledgements: 

The author would like to thank the following individuals for sharing invaluable insight and providing 

guidance about this important topic: Megan Lee, M.A., L.P.C. and Stephanie Sundberg, M.S.W., with the 

Colorado Office of Behavioral Health’s Crisis Services; Matthew Canuteson, M.A., Shannon Cornwall, 

M.A., Darlene Ebron, Sara Riggins, L.M.S.W., and Talia Santiago with the New York State Office of Mental 

Health’s Bureau of Cultural Competence; Elizabeth Padilla, Kyleen Zimber, Jon Collins, Ph.D., Lori Coyner, 

and Stephanie Jarem, M.A. with the Oregon Health Authority; Diane Marshall, Niambi Shakir, Shelley 

White, and Linda Vukelich with the Minnesota Department of Human Services; Gwendolyn Green, 

L.M.H.C., M.C.A.P., and Danielle Hewitt, L.M.H.C. with Tampa Crossroads; Bryan Carter, Ph.D. with 

Norton Children’s Behavioral and Mental Health at the University of Louisville School of Medicine; Rev. 

Joel A. Bowman, Sr. L.C.S.W. Founding Pastor with the Temple of Faith Baptist Church in Louisville, 

Kentucky; Matthew Goldman, M.D., M.S with the San Francisco Department of Public Health and the 

University of California San Francisco; Wayne Lindstrom, Ph.D., RI International; Debra Pinals, M.D., 

Bryan Hepburn, M.D., Brian Sims, M.D., Aaron Walker, M.P.A., Leah Holmes-Bonilla, M.Ed., Christy 

Malik, M.S.W., and Nili Ezekiel with the National Association of State Mental Health Program Directors 

(NASMHPD); and Jennifer Bronson, Ph.D., Ted Lutterman, and Robert Shaw, M.A. with the NASMHPD 

Research Institute. 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, 

or other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Neylon, K.A. (2021). Strategies and considerations for providing a more equitable crisis continuum for 

people of color in the United States. Technical Assistance Collaborative Paper No. 5. Alexandria, VA: 

National Association of State Mental Health Program Director 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

88
Abstract: 

In the U.S., racism affects all people of color and is an enduring, primary social determinant of racial 

inequities in population health and mental health.1 The goal of this paper is to improve understanding 

about the roles race and racism play in an individual’s social determinants of health, in particular the 

social determinants of healthcare access and quality, and social and community context, and how these 

affect the availability, accessibility, and quality of mental health crisis services. Based on a review of the 

literature and a series of interviews with leaders from SBHAs and providers, multiple strategies were 

identified to help SBHAs and providers create an equitable crisis continuum. Historic, structural racism 

and implicit bias have led to a lack of trust among people of color of systems that involve law 

enforcement and institutionalization, including the mental health crisis system. This distrust also 

contributes to increased stigma among communities of color. To begin to overcome these barriers and 

to create a more equitable and accessible crisis system, it is critical that SBHAs and providers partner 

with trusted community leaders (e.g., clergy in local churches) to both offer supportive services that 

improve social determinants of health and spread the word to build trust and engage more people of 

color into crisis care. To further build trust, SBHAs and providers can improve data collection and 

reporting processes to be more transparent and embark on quality improvement initiatives to identify 

strengths and weaknesses in the crisis system. While it is ideal for law enforcement to be removed from 

crisis response, it is often not feasible to eliminate their role completely, especially in areas with limited 

resources. Therefore, it is critical that law enforcement be trained in how to effectively respond to crises 

without the use of force, and how to divert individuals to appropriate levels of care. These strategies will 

help build trust with communities of color to reach out for help when they are most vulnerable. To make 

these changes and overcome decades, or centuries of institutional bias, it is critical to have leadership 

from the SBHA to self-reflect and identify opportunities for equity. 

 

 

 

 

Highlights: 

• Racism contributes to barriers to health and mental healthcare access and quality, which in turn 

affect the availability, accessibility, and quality of crisis services for People of Color. 

• The police killings of unarmed Black men, the subsequent Black Lives Matter movement, and the 

alarming racial disparities brough to light by the COVID-19 pandemic have placed a spotlight on 

inequities and injustices toward People of Color in the U.S. 

• Recent funding and programmatic opportunities, including American Rescue Plan funds and 

increases to SAMHSA’s Community Services Mental Health Block Grant, as well as the upcoming 

implementation of 988 provide a unique chance for SBHAs and mental health crisis providers to 

address structural racism in their behavioral health crisis services systems. 

Recommendations for the Post-COVID-19 Future: 

1. Build trust with communities of color through transparent data collection and reporting; and 

meaningful engagement and relationship building with trusted community leaders; and the 

improved/reduced use of law enforcement in crisis response. 

2. Address disparities by allowing providers to incorporate supportive services (e.g., housing and 

hygiene), and through a more representative and culturally competent workforce. 

3. Provide leadership at SBHA through organizational priorities and contract language 

modifications that support equity. 

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I n February 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) 

released the National Guidelines for Behavioral Health Crisis Care (referred to from here on as the 

“National Guidelines”), which outline the necessary services and best practices to deliver an effective 

crisis continuum. According to the National Guidelines, a comprehensive crisis service array includes 

three essential services: 1) centralized crisis lines that assess a caller’s needs and dispatch support, 2) 

mobile crisis teams dispatched as needed in the community, and 3) crisis receiving and stabilization 

facilities that are available to “anyone, anywhere, anytime.”2 Ensuring each of these three components 

is available to “anyone, anywhere, anytime” is an admirable goal; however, as with many other system 

in the U.S. there is room for improvement in the public behavioral health system, and specifically the 

behavioral health crisis continuum, to address racial disparities to create a more equitable system for 

people of color. Current events and new funding and programmatic opportunities are aligning for state 

behavioral health authorities (SBHAs) and providers to make meaningful improvements to create a more 

equitable crisis service continuum for people of all races and ethnicities. 

The goal of this paper is to improve understanding about the role race plays in an individual’s social 

determinants of health, in particular the social determinants of healthcare access and quality, and social 

and community context. Given that these social determinants also interplay with the availability, 

accessibility, and quality of behavioral health crisis services, it is critical to unpack various issues, 

including race and structural barriers to improving care for all people. By fostering improved 

understanding of these issues, this paper aims to help SBHAs, policy makers, and providers identify 

strategies to overcome these barriers to provide a more equitable crisis continuum, and ultimately a 

more equitable behavioral health service system that better meets the needs of people of color in the 

U.S. 

Methodology 

A review of the literature was conducted to understand how race affects the availability, accessibility, 

and quality of behavioral health crisis systems. To ensure the most relevant and timely information is 

included, peer-reviewed journal articles, along with publications from national associations and news 

articles published within the last five years are referenced; however, several relevant studies and 

articles older than five years are included. Because this is such a timely and important topic, and news 

and research about racism in U.S. is updated daily, it is likely, though not the author’s intent, that 

important research and news are excluded from this study. 

In addition to a review of the literature, the author and colleagues from the National Association of 

State Mental Health Program Directors Research Institute (NRI) conducted a series of interviews during 

the summer of 2021 with a variety of behavioral health stakeholders, including representatives from 

SBHAs, state Medicaid agencies, universities, behavioral health providers, and African American/Black 

Christian clergy. 

Key Terms: Defining Race, Ethnicity, Racism, Equality, Equity, and Intersectionality 

It is important to note that race and ethnicity are two separate but related social constructs. Race refers 

to an individual’s physical characteristics (e.g., skin color, facial type), while ethnicity refers to common 

national, tribal, religious, linguistic, or cultural origins or backgrounds.

3 

There is consensus among scientists and researchers that race is a social, rather than biological, 

construct.

4 Racism is defined as “a belief that race is a fundamental determinant of human traits and 

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capacity, and that racial differences produce an inherent superiority of a particular race.”5 While many 

dimensions of racism exist, the author considered three types of racism that affect social determinants 

of health, which in turn affect the availability, accessibility, and quality of behavioral health crisis 

services in the U.S.: 

• Structural Racism: “social, economic, or political systems featuring public policies and practices, 

cultural representations, and other norms that perpetuate inequities”6 

• Institutional: “the policies and practices within and across institutions (e.g., schools) that put 

certain racial groups at a disadvantage,” often to the benefit of another. 6 

• Individual/Implicit Bias: “face-to-face or covert actions toward a person that express racial 

prejudice, hate, or bias,” whether realized or not by the individual. 6 

In the U.S. racism affects all people of color and is an enduring, primary social determinant of racial 

inequities in population health and mental health.

1 However, it is also critical to understand that not all 

people of color experience racism the same way, as all individuals have multiple identities, and those 

identities afford individuals different levels of societal privilege that can affect their health outcomes. This 

concept is referred to as intersectionality. For instance, people of color who identify as LGBTQIA+, are 

members of an underrepresented religious group, and/or have fewer socioeconomic means may be 

“more susceptible to negative experiences and decreased mental health... due to chronic stress stemming 

from the marginalized social status they have in U.S. society,” which can result in higher rates of 

depression and suicide risk, and a greater need for behavioral health crisis services.

7 Therefore, it is critical 

for policy makers, researchers, providers, and other behavioral health stakeholders to understand and 

consider how these different identities affect the unique experiences of people of color so they can help 

improve the availability, accessibility, and quality of services for all underrepresented populations. 

Understanding the difference between equity and equality is also critical. Equality means that “each 

individual or group of people is given the same resources or opportunities,” whereas equity “recognizes 

that each person has different circumstances and allocates the exact resources and opportunities 

needed to reach an equal outcome.”8 

Limitations 

Most data sets separate out race and ethnicity, recognizing them as two distinct but intersecting groups 

(e.g., that individuals may identify as both a race and an ethnicity); however, some data sets count 

ethnicities (e.g., Hispanic/Latino) as a distinct race. When this occurs, it is difficult to make comparisons 

and draw conclusions across two distinct data sets. This paper’s author makes every attempt to only 

include data sets that distinguish race from ethnicity, although this is not always possible. Additionally, 

many datasets only include data on White, Black, and Hispanic individuals, eliminating the ability to 

identify trends among smaller population groups (e.g., American Indian/Alaska Native, Asian, and Native 

Hawaiian or Other Pacific Islander). 

Federal government agencies are required to adhere to the 1997 Office of Management and Budget 

(OMB) standards on race and ethnicity. The OMB recognizes the following races:

9 

• White: a person having origins in any of the original peoples of Europe, the Middle East, or 

North Africa. 

• Black or African American: a person having origins in any of the Black racial groups of Africa. 

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• American Indian or Alaska Native: a person having origins in any of the original peoples of

North and South America (including Central America) and who maintains tribal affiliation or

community attachment.

• Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or

the Indian subcontinent.

• Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples

of Hawaii, Guam, Samoa, or other Pacific Islands.

At the writing of this paper, the OMB standards only include “Hispanic or Latino Origin,” and “Not 

Hispanic or Latino Origin” for ethnicities. Hispanic or Latino Origin refers to a person of Cuban, Mexican, 

Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

10 There is 

a push for OMB to expand ethnicities to include a dedicated Middle Eastern or North African response 

category, but that has not yet been adopted.

11 

While the author made a conscious effort to be objective and unbiased in her writing, it is important to 

note that she is a white woman who has never personally experienced racism, thereby eliminating the 

rich context and nuance that a first-person perspective would provide to this report. In an effort to 

reduce bias in the language of this report, the author relied on the definitions and terms outlined by the 

National Institutes of Health and style from the Racial and Ethnic Identity Style Guide developed by the 

American Psychological Association (APA). 

Understanding and Addressing Social Determinants of Health and 

Mental Health to Improve the Availability, Accessibility, and Quality of 

Crisis Services 

A history of cruelty and oppression toward racial minorities in the U.S. persists through laws, policies, 

and attitudes that disadvantage people of color.12 The disparities resulting from structural and 

institutional racism, and implicit bias affect everyone’s social determinants of health, usually benefitting 

White communities while continuing to disadvantage communities of color. 

The Centers for Disease Control and Figure 1: Social Determinants of Health 

Prevention (CDC) defines social 

determinants of health as “conditions in 

the places where people live, learn, work, Quality 

and play that affect a wide range of health 

and quality of life risks and outcomes.”13 Neighborhood 

The five domains of social determinants of

health include: 1) healthcare access and

quality, 2) education access and quality, 3) 

social and community context, 4) 

economic stability, and 5) neighborhood 

and built environment. Each of these five

domains is interconnected and influences 

one another, making the distinction

between each domain somewhat 

arbitrary. Social determinants of health have profound effects on an individual’s health and well-being 14 

S

Eco

ta

n

b

o

ilit

mi

y 

c & Built 

Environment 

Healthcare Social & 

Access & Community 

Quality Context 

.

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Individuals with certain social determinants of health are at an increased risk of poor physical health and 

developing a mental illness, including depression and anxiety, which may result in an increased need for 

crisis services.

15 The World Health Organization recognizes that an individual’s social determinants of 

health are “shaped by the distribution of money, power, and resources at global, local, and national 

levels,” and that they are “mostly responsible for health inequities – the unfair and unavoidable 

differences in health status seen within and between countries.”16 

In the U.S., people of color are at a significant disadvantage compared to White individuals in each of 

these five domains.

17 The COVID-19 pandemic further highlights the racial inequities and disparities in 

the health and behavioral healthcare systems for people of color. Understanding and addressing the 

factors that contribute to poor social determinants of health and mental health is critical to providing 

high-quality services, including crisis services, and improving behavioral health outcomes for people of 

color. 

Although all five domains of social determinants of health have implications for crisis services, this paper 

focuses specifically the two domains that have the most significant effects: healthcare access and quality 

and social and community context. Although the other domains, economic stability, neighborhood and 

built environment, and education access and quality are not specifically discussed in detail, all domains 

are so interconnected that factors related to these domains are included in the discussion. 

Social Determinant of Health: Healthcare Access and Quality 

Healthcare access and quality refers to the connection between an individual’s ability to access health 

and behavioral health care services, as well as their level of literacy related to their own health and the 

health and behavioral health care systems.

16 Issues addressed in this domain include proximity to and 

availability of healthcare services, health literacy, and financing.

16 

People of color face significant disadvantages in healthcare access and quality compared to white 

individuals in the U.S. However, states and providers can take steps to improve healthcare access and 

quality for people of color to create a more equitable crisis continuum, including: 

1. Enhance the crisis continuum so that is available to “anyone, anytime, anywhere,” regardless of 

an individual’s race or ethnicity2 

2. Partner with community organizations and respected leaders to establish and increase 

engagement 

3. Reduce financial barriers to care 

4. Establish trust by improving the role and effectiveness of law enforcement in crisis response 

5. Strategically market the availability of crisis services to diverse populations 

6. Recruit and retain a representative, culturally and linguistically competent workforce that is 

adept at providing trauma-informed care 

7. Improve diagnostic and level-of-care determination processes 

8. Improve transparency and quality in crisis services through data collection and outcomes 

monitoring 

HAQ Strategy 1: Enhance the Crisis Continuum so that it is Available to Anyone, 

Anywhere, Anytime 

Behavioral health crisis services take many forms and look different in different communities across the 

U.S. While SAMHSA recommends three specific services for best practices, including centralized call 

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lines, mobile crisis teams, and “no wrong door” crisis receiving and stabilization facilities, individuals in 

crisis have traditionally relied on emergency response and safety net services, including 911, the 

response of emergency support and first responders (including law enforcement, fire, or ambulance), 

and drop-offs or admissions to general hospital emergency departments (EDs). While these services are 

available to “anyone, anywhere, anytime,” they are often not the most appropriate response for 

behavioral health crises, for either the individual experiencing the crisis or for the person or emergency 

team responding, which can lead to traumatic and devastating outcomes for individuals in crisis.

2 

When someone calls 911 for mental health crisis response, assistance often “arrives in the form of a 

team of police officers, many of whom do not have the information or skills they need to provide 

support.”18 A detailed review of law enforcement and crisis services is provided in the 2020 technical 

assistance paper, Cops or Clinicians, as well as in the 2021 technical assistance paper, Law Enforcement 

and Crisis Services: Past Lessons for New Partnerships and the Future of 988.

19,20 Without these skills, law 

enforcement may not be able to effectively deescalate a crisis situation, resulting in traumatic transport 

to an inappropriate setting, a jail or an ED, where individuals may languish for days without addressing 

their mental health crisis, or worse. Carson, et al. found that “African American men in psychiatric crisis 

care are less likely to be given a psychiatric evaluation for hospitalization than individuals with similar 

symptoms who are white... and [are] more likely to be sent to jail.”21 There are also too many examples 

of tragedy when police respond to crisis calls, especially for people of color. 

According to the Washington Post’s Police Shooting Database, 23% of all people killed by police were 

identified as having a mental illness.

22 Another study estimates that “76% of individuals killed in police 

encounters have had previous mental health treatment.”23 One study by the Treatment Advocacy 

Center estimates that “people with untreated serious mental illness are 16 times more likely to be killed 

during an encounter with [law 

enforcement] than other 

civilians.”24 Furthermore, the 

rate at which Black Americans 

are killed by police is more 

than twice as high as the rate 

for White Americans (see 

figure below), so even though 

the data on killings by police 

on race and mental illness are 

unavailable, it stands to 

reason that African 

Americans/Blacks with mental 

illness are killed at 

significantly higher rates than 

Whites.

22 The death of Daniel 

Prude and Patrick Warren, Sr. 

are two examples of law 

enforcement response to a 

person of color experiencing a 

mental health crisis. 

Figure 2: Number of People Killed by Police by Race, Washington

Post Police Shooting Database22 

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In March 2020, Daniel Prude, a 41-year-old Black man, experienced a mental health crisis. “Shoeless and 

shirtless,” Mr. Prude wandered the cold streets of Rochester, New York shouting fears about the 

coronavirus.

25 In an effort to help, Mr. Prude’s family called 911 twice. The first call resulted in a 

response from EMS (emergency medical services), who discharged Mr. Prude without effectively triaging 

his crisis. The second call later the same day resulted in a law enforcement response, which left Mr. 

Prude naked, restrained, handcuffed, hooded, and pinned face-down to the ground; after more than 

two minutes, he stopped breathing. Efforts to revive him only extended his life by one week, as he later 

died of “complications from asphyxia” in a Rochester hospital.

26 

In January 2021, just 10 months following the death of Mr. Prude, Pastor Patrick Warren, Sr. was 

experiencing a mental health crisis after the poor economy associated with the COVID-19 pandemic 

caused him to lose his job. Mr. Warren’s family noticed behavioral changes that had them concerned 

enough to reach out for help. A mental health resource officer responded and escorted Mr. Warren to a 

local hospital for a mental health evaluation, from which he returned home later that day. The following 

day, his family was still concerned for his mental well-being and again sought help from the Killeen 

Police Department; unfortunately, no mental health resource officer was available to respond, and law 

enforcement officers “not prepared to handle a mental health crisis” responded instead.

27 This 

encounter proved fatal for Mr. Warren, as officers tased and shot him three times. 

A robust crisis continuum, consisting of a centralized hotline, mobile crisis teams, and no-wrong-door 

crisis receiving and stabilization facilities that ensures proper response and follow-up care for all 

individuals can help provide a more equitable system for people of color, avoid tragic outcomes faced by 

Mr. Prude, Mr. Warren, and countless others, and begin to break the cycle of poor health and mental 

health. 

Crisis Hotlines, 988, and Lessons from 911 

Crisis hotlines are clinical call centers that operate 24-hours-per-day, seven-days-per-week. They 

are staffed with clinicians who provide risk assessments to individuals in crisis and engage people 

at imminent risk of suicide. SAMHSA’s National Guidelines recommends that crisis hotlines be 

available through phone, text, and chat methodologies to be available to as many individuals as 

possible. The National Guidelines also recommend that crisis hotlines be centrally located within a 

region and “offer [GPS-capable] air traffic control quality coordination of crisis care in real time.” 

With the Federal Communications Commission (FCC) voting in July 2020 to adopt 988 as the new 

three-digit dialing code to “increase the effectiveness of suicide prevention efforts,” there are new 

opportunities for states to create a more equitable crisis continuum for people of all races and 

avoid the pitfalls of 911.

28,29 

However, people of color may fear calling a crisis hotline or the Lifeline if they expect a similar law 

enforcement response as calling 911; the racist history of 911 and the deaths of Mr. Prude and Mr. 

Warren highlight this very real possibility. Each year, nearly 100,000 trained 911 dispatch workers 

across the country handle 240 million 911 calls.

30 While the 911 crisis service system has helped to 

save a number of lives and de-escalate crisis situations, “the impact could well be negative,” 

especially for people of color.

30 In fact, 911 was developed in the 1960s as a way to quickly 

suppress protests by Black communities against segregation and police brutality.31 Simultaneously, 

the commission charged with the development of the 911 system also “encouraged the 

militarization of local law enforcement.” 31 A 2019 article by Shaun King published by the 

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Associated Press recognized the death of Osaze Osagie, a 29-year-old Black man who was killed in 

State College, Pennsylvania after his family called 911 to help address his mental health crisis. Mr. 

King notes that “Black families remain skeptical of calling the police for help under any 

circumstance – and fatal encounters like the one experienced by the Osagie family confirm those 

doubts.”32 

Because of this fear, it is critical that crisis hotlines, and the Lifeline/988 have qualified, culturally 

competent crisis counselors who are effective at de-escalating crises over the phone, and that 

states have an effective crisis infrastructure in place so that when necessary, crisis call operators 

can connect individuals in crisis to care through mobile crisis response or crisis receiving and 

stabilization facilities. SMHAs and local providers also need to engage with their local communities 

to ensure that the hotline services meet the diverse needs of the community, and that individuals 

understand what to expect when calling the local crisis hotline or the Lifeline/988. To ensure that 

988 does not cultivate the same racist response as 911, several states are ensuring that the 

implementation of 988 be guided by diverse advisory groups, and be available to underserved 

populations, including ensuring that Native American Tribes, who do not have access to 911 

services, have access to 988. 

Colorado Crisis Services is relying on a cultural competency advisory council to guide its activities 

related to the implementation of 988. Megan Lee, L.P.C., Program Manager with Colorado Crisis 

Services notes that “988 is multi-faceted and has a cascade of implications for the rest of the crisis 

system” (Lee, M., Personal Communication, 27 May 2021). Ms. Lee anticipates an increase in crisis 

call volume to 988, which will result in a greater need for mobile crisis response teams who are 

culturally and linguistically competent. 

Washington State recently introduced $1 million in legislation “to develop and operate [a 988 

tribal behavioral health and suicide prevention] line and a tribal 988 subcommittee.”33 The process 

will be guided by a subcommittee that includes representation from the American Indian Health 

Commission (AIHC) of Washington State. Vicki Lowe, Executive Director of AIHC indicates that the 

COVID-19 pandemic fueled this decision as leaders in the state began addressing service gaps to 

provide a more equitable system. In addition to the 988 Lifeline for tribes, the AIHC is working to 

develop the Washington Indian Behavioral Health Hub, which is a coordinating center that serves 

as a bridge between the sovereign tribes and the services offered by the statewide crisis system, 

including community services, crisis beds, and post-crisis follow-up services. Ms. Lowe’s advice for 

others as they plan for 988 is that “states need to think about the populations they serve so they 

don’t repeat the same mistakes; this is a chance to do something different.” 33 

New York’s Office of Diversity and Inclusion is helping to launch 988 while ensuring that the service 

will be culturally competent. It is reviewing all 988 contracts to ensure that the National Standards 

for Culturally and Linguistically Appropriate Services (CLAS) for Health and Health Care are addressed, 

and that mechanisms to support multiple languages are included. Mr. Canuteson notes that “we have to 

set up 988 so seamlessly that a person doesn’t become so frustrated they call 911. This is how 

disparities and bad outcomes occur” (Canuteson, M., Personal Communication, 27 May 2021). 

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Mobile Crisis Response Teams 

Mobile crisis response teams are groups of two or more crisis counselors that are centrally “available to 

reach any person in their service areas in their home, workplace, or any other community-based 

location of the individual.”2 As described in the National Guidelines, mobile crisis response teams serve a 

broader range of individuals in less-acute crisis situations, but are capable of referring individuals to 

crisis receiving and stabilization facilities should they need a higher level of care. A survey of mobile 

crisis response teams shows that they are able to stabilize approximately 70% of all crisis calls in the 

community and make referrals to facility-based care for the remaining 30%.

2 There are several benefits 

to the use of mobile crisis response teams. One benefit is that they meet people in the community, 

ideally where people feel more comfortable, and try to address the crisis where the crisis is occurring 

without use of force. Another benefit of mobile crisis response is that it eliminates the need for law 

enforcement response when appropriate. 

Colorado Crisis Services provides mobile crisis response in a diverse neighborhood of the City of Aurora. 

Aurora, while predominantly White, is significantly more diverse when compared to the rest of the 

state. As of 2016, 84.2% of Colorado residents are White, whereas only 61.1% of City of Aurora are 

White.

34 The remaining 39% of the population is composed of Black/African Americans (16%), Asians 

(6%), individuals who identify as having two or more races (5%), Native Hawaiian or Other Pacific 

Islander (>1%), and American Indian/Alaska Native (>1%).

34 Colorado Crisis Services was struggling to 

serve this marginalized community. They received feedback from a resident, who stated, “you’re failing 

my community; we will not reach out for services because we don’t trust you” (Lee, M., Personal 

Communication. 27 May 2021). After a series of conversations, it was determined that the staffing 

composition of the mobile crisis response team led to distrust in the community because the people 

responding were masters-led clinicians who “did not look like them,” and were not members of the 

community. Many behavioral health providers, and crisis services providers in particular, in the State of 

Colorado “are well-meaning white women in their 30s” who may have trouble engaging with 

communities of color (Lee, M., Personal Communication. 27 May 2021). 

Colorado Crisis Services’ mobile crisis teams are required to have a masters-level clinician respond to 

calls for service, who will sometimes bring along another person. Learning from this, to gain the trust of 

the community leadership at Colorado Crisis Services initiated planning for a pilot program with the 

mobile crisis provider in Aurora, allowing for the masters-trained clinician to bring known community 

leaders with them to respond to calls. As part of this pilot, the crisis encounter with the mobile crisis 

team was to be led by the familiar community leader, with the masters-trained clinician conducting the 

assessment. This approach helps the mobile crisis team to gain respect in the community, allowing them 

to better engage people into care. The pilot is now being explored by the City of Aurora. While the pilot 

is potentially no longer with Colorado Crisis Services, it did “open the door to thinking about the things 

that inadvertently get in the way of an effective community response” (Lee, M., Personal 

Communication, 27 May 2021). 

Following this pilot with the crisis team in the City of Aurora, Colorado Crisis Services began modifying 

its contract language to allow CMHCs to create a pilot program to “eliminate any contract requirement 

that gets in the way of making a program work the way it is supposed to” (Lee, M., Personal 

Communication, 27 May 2021). The contract language specifically states: 

Pilot Programs. The Office of Behavioral Health (OBH) or contractor may propose pilot programs 

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to evaluate potential solutions or enhancements to Administrative Service Organization services. 

Pilots must be time-bound. OBH may waive conflicting contract terms for the duration of the 

pilot period as needed to allow for services to proceed according to the pilot proposal terms. If a 

pilot program is deemed successful at the conclusion of the pilot period, the parties may 

negotiate an amendment to this Contract to the extent necessary to accommodate the pilot 

activities (Lee, M., Email Correspondence, 27 May 2021). 

Feedback from several of the states interviewed for this paper addresses changing contract language to 

ensure that “services are reaching individuals of different identities and intersections, and to focus on 

priority populations from areas that have been historically excluded from services” (Sundberg, S., 

Personal Communication, 27 May 2021). The changes that Colorado has made to its contracting 

language allowing flexibility in provider response and the prioritizing of specific groups helps to achieve 

equity among underrepresented populations; however, beyond changes to contract language, SBHAs 

and providers also need to consider how the contracts are awarded, and strive to improve the culture 

and expand the array of the organizations in which they work. 

To create more equitable contracts and policies related to crisis services, understanding the needs of 

diverse communities is critical. One step to ensuring equity and inclusion is to create an advisory group 

that guides the development of new policies and contracts. Stephanie Sundberg, M.S.W., Manager of 

the Transition-Age Youth and Healthy Transition at the Colorado Office of Behavioral Health, 

recommends that advisory groups be representative of the communities a provider organization or 

SBHA serves, and not just by including one or two representatives from an underrepresented group, 

which is harmful and tokenizes individuals in a symbolic gesture with no substance, purpose, or power in 

their participation. In addition to meaningful representation, SBHAs can implement a variety of 

feedback mechanisms, allowing advisory group members to share their ideas for discussion, and open 

them up for feedback and implementation, ultimately creating intentional space for shared decision 

making to make substantial change. It is also important that these community engagement efforts are 

upheld through the allocation of resources, including funding, to make change happen. The programs an 

SBHA funds clearly identify the agency’s priorities. 

Crisis Receiving and Stabilization Facilities 

Crisis receiving and stabilization facilities provide short-term (usually less-than 24 hours) observation 

and crisis stabilization services to individuals in a home-like, non-hospital environment. Best practices 

for crisis receiving and stabilization facilities outlined in the National Guidelines recommend that they 

have a dedicated first responder drop-off area that allows law enforcement to quickly return to their 

patrol; include beds within a “real-time regional bed registry system” that is accessible by the crisis call 

center and mobile crisis teams “to support efficient connection” to needed resources; and coordinate 

connections to follow-up services.

2 The “no wrong door” approach allowing law enforcement to easily 

drop individuals in crisis off reduces the likelihood that people experiencing a crisis will be brought to 

jails or other inappropriate inpatient settings. 

Incorporating bed registries into the model also allows SBHAs to monitor the utilization of crisis services, 

including demographic information about who uses the services, to ensure that services are accessible 

and available to all communities. Ensuring that crisis services are working as intended (i.e., diverting 

people away from inappropriate settings of jails and hospitals, reducing law enforcement involvement, 

and connecting to follow-up care), bed registries in 20 states are monitoring the following data points:

35 

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• Diversion: 12 states 

• Connection to treatment: 8 states 

• Volume of service usage: 8 states 

• Connections to law enforcement: 5 states 

• Outcomes: 5 states 

• Public perception of the system: 1 state 

Crisis Follow-Up Care 

Regardless of how an individual interacts with the crisis system, it is critical that they be provided with 

follow-up care that meets their mental health and cultural needs. Colorado Crisis Services found that 

individuals in diverse communities tended to not follow through with care post-crisis intervention, 

“because the clinical services were not something they would ever engage in” (Lee, M., Personal 

Communication, 27 May 2021). The feedback Colorado Crisis Services received from the marginalized 

communities was that follow-up would be more effective if it included non-traditional treatment that 

supports the individual. The change to the contract language allowing CMHCs to pilot programs that 

modify their approach gives the crisis provider flexibility to ask the community, “where do you feel 

supported,” and “how can we get you connected with those supports?” (Lee, M., Personal 

Communication, 27 May 2021). The revised contract language also allows CMHCs to refer to nontraditional providers, including community organizations like the Boys and Girls Club, and local churches. 

Megan Lee, L.P.C., Crisis Program Manager with the Colorado Office of Behavioral Health’s Colorado 

Crisis Services, notes that “just because a person doesn’t want to access clinical services, it doesn’t mean 

that we (Colorado Crisis Services) can’t support them” (Lee, M., Personal Communication, 27 May 2021). 

Changing the crisis model to serve the whole person can help to stabilize or improve an individual’s 

economic station, encourage future engagement with behavioral health services, and potentially reduce 

the need for crisis services in the future. 

HAQ Strategy 2: Partner with Community Organizations and Leaders to Establish 

Trust and Increase Engagement 

Individuals of different races have different help-seeking behaviors that are formed by their cultures and 

experiences living in a White-dominated society that fails to recognize their differences and expects 

them to be the same as the dominant community. Understanding the differences between and within 

cultures will help providers identify community partners who can help to better engage with people of 

color. Rev. Joel Bowman Sr., L.C.S.W., and Founding Pastor at the Temple of Faith Baptist Church in 

Louisville, Kentucky notes that “help-seeking behaviors of African Americans are different than the 

general population. African American communities tend to be more communal than White 

communities, and when Black families are having issues, either they will deal with those issues within 

the family system, including fictive kin, or they may go to their faith tradition” (Bowman, J., Personal 

Communication, 6 July 2021). An avenue for outreach includes partnerships between SBHAs, health care 

providers, and others with traditionally Black churches. To gain respect and trust in the African 

American/Black communities, it is critical that SBHAs and crisis providers first gain trust with the senior 

pastors of the churches. According to Rev. Bowman, “the dynamic with Black churches is different from 

White churches; without the buy-in of the senior pastor of the church, it will be difficult to gain the trust 

and respect needed to engage the community.” Brian Sims, M.D., Medical Director at NASMHPD 

reiterated the importance of engaging the faith community improve mental health outcomes, noting 

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that “the Black pastor is such a pivotal person in the Black community, if we’re going to make significant 

inroads, it has to start with clergy” (Bowman, J., Personal Communication, 6 July 2021). 

Reinforcing Rev. Bowman’s comments, Bryan Carter, Ph.D., Service Chief of the Pediatric ConsultationLiaison Service at Norton Children’s Hospital in Louisville, Kentucky notes that immigrant communities 

and communities of color tend to place more value in the family unit (Carter, B., Personal 

Communication, 6 July 2021). Engaging family members in crisis care can help to establish trust in the 

system and increase participation in follow-up services. And, as discussed above, Colorado Crisis Services 

has found similar barriers to engagement with its racially diverse communities, and has allowed 

providers to engage community partners, including churches and local Boys and Girls Club chapters to 

provide non-clinical, supportive services. Sometimes, according to Gwendolyn Green, L.M.H.C., M.C.A.P., 

Executive Director with Tampa Crossroads, the simplest thing that a provider can do to increase 

engagement with a given community is to “simply ask people, instead of making assumptions, about 

what their barriers are and to see if we can correct those” (Green, G., Personal Communication. 29 June 

2021). 

In addition to partnerships with community organizations and churches, SBHAs and providers “should 

not be afraid to reach out to foundations or through the state college systems” (Canuteson, M., Personal 

Communication, 27 May 2021). Mr. Canuteson indicates that “foundations are hot on equity right now,” 

and provide an opportunity for SBHAs and providers to enhance their crisis continuum and ensure 

equity at the state and provider levels (Canuteson, M., Personal Communication, 27 May 2021). 

Providers can also partner with historically Black colleges and universities (HBCUs) to ensure that crisis 

services are available to their diverse student populations (Bronson, J., Personal Communication, 12 

August 2021). 

HAQ Strategy 3: Reduce Financial Barriers to Care 

The cost of accessing mental health crisis services, whether real or perceived, is a barrier to people of 

color. People of color experience poverty at higher rates than White people in the U.S. According to 

2018 Census Data, 25.4% of Native Americans, 20.8% of Black/African Americans, and 17.6% of 

Hispanics (of any race) are impoverished, compared to 10.1% of Whites and Asians.

36 Similarly, African 

Americans, Hispanics, and Native Americans are uninsured at higher rates than Whites and Asians 

(Figure 3).

37 A lack of reliable income and financial resources can prevent people from seeking help, and 

when they do seek help, the quality of services available is often inconsistent or inadequate. 

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Figure 3: Percentage of Individuals Under Age 65 Who are Uninsured by Race, 2014-201837 

 

In 2019, an estimated 75 million individuals were enrolled in Medicaid in the U.S.38 Medicaid provides 

coverage to low-income individuals, pregnant women and children, and individuals with disabilities. 

Since 2014, Medicaid coverage is available to individuals up to 133% of the federal poverty level in the 

39 states that elected to expand Medicaid (as of August 2021). Medicaid is the third largest payer in the 

U.S. healthcare system behind private insurance and Medicare, representing 16% of national healthcare 

spending in 2019.

38 People of color are more likely to be covered by Medicaid than White individuals. 

(See Figure 4 on the following page.) However, even with Medicaid coverage, people of color face 

barriers to care as many mental health providers do not participate in Medicaid plans; certified peer 

support specialists who can bring representation to the behavioral health crisis workforce are often not 

paid a living wage, reducing their utilization; and supportive services, such as housing and other social 

services may not be fully covered to promote equitable social determinants of health. 

Figure 4: Percent of Medicaid Coverage of the Non-Elderly Population by Race/Ethnicity, 201938 

 

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To overcome these barriers, the Oregon Health Authority is applying for an 1115 Medicaid 

Demonstration Waiver that creates “A Pathway to Health Equity.”39 Oregon’s Waiver application for the 

five-year period between 2022 and 2027 strives to achieve equity by: 

• Ensuring access to coverage for all people in Oregon, by “ensuring enrollment of people who are 

eligible and expanding eligibility for those at risk for becoming uninsured.” 39 According to the 

Oregon Health Authority, an estimated 6% of people in the state do not have health insurance, 

with some communities of color, including Hispanics, Native Americans, and African 

Americans/Blacks less likely to be uninsured than Whites or individuals who identify as two or 

more races.

40 To do this, Oregon Health Authority proposes ensuring people who are newly 

enrolled in the Oregon Health Program during the COVID-19 pandemic maintain appropriate 

coverage; ensure that people who are eligible for Oregon Health Program are aware of the 

program and become enrolled; and enhance coverage continuity for both children and adults 

and expand coverage to low-income individuals who are not currently eligible for the Oregon 

Health Program.

39 

• Creating an equity-centered system of health that requires coordination and collaboration with 

systems beyond healthcare. To achieve this goal, the Oregon Health Authority will improve 

transitions across systems, close gaps in coverage and care, and provide “defined packages of 

services and supports for health-related social needs related to this transition.”41 

• Transitions from incarceration and institutional settings are especially challenging when an 

individual does not have stable housing or is going through a tumultuous life event. Often, 

individuals “are left to navigate multiple complex systems independently because [Oregon’s] 

state health care system is not designed to align and coordinate with other social systems and 

providers in a way that allows everyone to come together to support people in accessing 

systems more seamlessly.” 41 The Oregon Health Authority notes that “these challenges are 

exacerbated for tribal members, communities of color, and people with disabilities as systems 

often lack the infrastructure and resources to provide culturally and linguistically appropriate 

care...[that] do not meet people where they are.” 41. To achieve this goal, the Oregon Health 

Authority proposes enhancing care coordination and non-clinical supports to support transitions 

across outcomes; remove barriers to culturally and linguistically competent health services; and 

prioritizing marginalized communities to promote health equity across the system. 41 

• Encourage flexibility in spending on “upstream drivers of health” while prioritizing meaningful, 

equitable improvements in healthcare.

39 Through this action, the Oregon Health Authority plans 

to create a global budget, which entails flexible, service-integrated payments for the state’s 

Coordinated Care Organizations (CCOs). This model enables CCOs to coordinate care across 

multiple sectors of health (physical, mental, and oral), and affords them the flexibility to provide 

individuals with housing and food supports which promotes equity in the communities the CCOs 

serve. To achieve this goal, the Oregon Health Authority will hold the CCOs accountable to a 

sustainable cost growth target, and incentivize CCOs “to focus on health equity, prevention, and 

high-quality services that... reduce costs.”42 In addition, the Oregon Health Authority will “use 

innovative rate methods to set global budgets that encourage efficiency and upstream 

investments” that address health-related social needs,” and will hold CCOs accountable to 

meeting these needs. 42 

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• Reinvest government savings across systems “to address larger or statewide problems that no 

single community can fix on its own.”39 The Oregon Health Authority will prioritize these savings 

on funding initiatives that address large-scale barriers related to health and health equity. 

Savings will be directed toward individual communities “to improve the social, economic, and 

physical environment.”43 To achieve the most effective and efficient progress, the Oregon 

Health Authority and the CCOs will “partner with community leaders to identify and 

operationalize strategies to eliminate health inequities.” 43 

To ensure these goals and processes are meeting the needs of the diverse communities the Oregon 

Health Authority services, it will enhance and expand its feedback mechanisms to collect and 

understand the concerns and needs of providers, advocates, and community members. 42 In 

conversations with representatives from the Oregon Health Authority, there is excitement that this 1115 

Demonstration Waiver will allow the state to “smooth out the edges of coverage” to ensure that people 

are receiving high-quality, culturally and linguistically competent services that meet the specific needs of 

each community (Coyner, L., Personal Communication, 16 June 2021). The state emphasized the value of 

data, both quantitative and qualitative, in ensuring that this new waiver works for everyone. Using data, 

gathering and meaningfully considering input from the communities, and collaborating with respected 

community leaders will help the Oregon Health Authority gain trust within marginalized communities. 

This will be especially helpful in the delivery of crisis services in the state, so that when people are the 

most vulnerable, they will feel comfortable reaching out for the help they need and will receive 

linguistically and culturally competent care in return. 

HAQ Strategy 4: Establish Trust by Improving the Role and Effectiveness of Law 

Enforcement in Crisis Response 

Some communities of color have a mistrust of law enforcement and those who engage with them. This 

is particularly acute for African American/Black communities, due to the legacy of slavery and Jim Crow 

laws. Although it is ideal to remove law enforcement from all crisis response, and many advocacy 

organizations are encouraging just that, it is not always practical or safe to do so. Rev. Bowman 

underscores the need for law enforcement reform. Although there are calls to “defund the police,” Rev. 

Bowman suggests that this call to action does not adequately describe the intent or the need behind the 

movement and can create excessive divisiveness which halts progress. Rev. Bowman indicates a need 

for “a paradigm shift. ‘Defund the police’ has become a sensitive issue, when what it really means is the 

reallocation of funds for improved services and police reform” (Bowman, J., Personal Communication, 6 

July 2021). He suggests that reform needs to happen at the local level, where if police need to be 

involved mental health practitioners work alongside them to respond to calls for service, and for police 

to receive appropriate, thorough, culturally competent training on how to de-escalate crisis situations. 

Equipping law enforcement with the literal and figurative tools they need to safely and effectively 

respond to crises in the community, especially those serving remote areas where crisis infrastructure 

(e.g., workforce, mobile crisis response teams, and crisis receiving and stabilization facilities) may be 

lacking, is critical. Technology can be used by law enforcement responding to crisis to connect 

individuals directly to a mental health crisis counselor. Training in cultural competence and Crisis 

Intervention Team (CIT) education can provide law enforcement with the skills necessary to safely and 

effectively de-escalate crises in the field, which can help lead to more trust among people of color that 

law enforcement response, when it is the only option, can meet their needs. 

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Technology can be used to allow law enforcement instant access to a behavioral health crisis counselor 

while responding to crisis situations. Having ready access to a behavioral health crisis counselor can help 

the officer feel more confident knowing they have the tools to de-escalate crisis situations without 

force. Grand Lake Mental Health Center (GLMHC) in Oklahoma equips all officers with iPads within its 

catchment area. The iPads allow officers to immediately connect with health providers to help triage 

crisis situations in the field, reducing the need for transport. In addition, the tablets offer an application 

for officers to immediately connect to behavioral health providers that specialize in providing crisis 

services to law enforcement. Now, law enforcement officers have a way to reach out for help if they 

need to speak with someone after witnessing a traumatic event, and to deal with any personal and 

professional challenges that have an impact on their own mental health. Beyond officers, GLMHC also 

offers iPads to each recipient of their crisis services upon discharge, allowing individuals to immediately 

connect to qualified staff, 24/7. In 2015, prior to the launch of this program, more than 1,100 individuals 

were admitted to inpatient beds in the region, and almost all were brought in by police. After GLMHC 

opened new crisis facilities, allowing officers to utilize the tablets and facilitate quick drop offs, the 

number of patients admitted to an inpatient crisis bed in 2020 plummeted to one person. The program 

was funded through an incentive program by the SBHA. In 2016, Oklahoma’s SBHA incentivized 

providers to develop alternatives to inpatient care to reduce hospitalization rates and allowed the 

CMHCs to use funds that would normally support inpatient services on community-based services 

instead.

44 

CIT was developed in Memphis, Tennessee to train police to respond more effectively and safely to 

mental health crisis encounters. Officers trained in CIT are equipped with skills to calm individuals 

experiencing a mental health crisis and divert them to mental health services instead of jail. The 

objectives of CIT are to reduce injuries to officers and the individuals in crisis, promote decriminalizing 

individuals with a mental illness, and reduce the stigma associated with the experience of a mental 

health crisis. Training officers in CIT, especially in areas with limited mental health resources, results in 

more effective crisis services when the services recommended in the National Guidelines may be 

unavailable. In order to integrate CIT into the culture of law enforcement, Karl Rosston, M.S.W., suicide 

prevention coordinator with the State of Montana recommends training all new recruits during their 

training at the Academy. To ensure that the CIT model works for all people, it is imperative that the 

cities and counties that implement the program fully integrate it “into the wider behavioral mental 

health care system and route calls away from police.”45 Ron Bruno, a 25-year police veteran and current 

Executive Director of Crisis Team International notes that “if you keep throwing money at training 

officers, and that’s all you do, and not address the system around mental health care, you’ll continue to 

have nothing but problems.” 45 Enhancing the mental health crisis continuum, and training officers in deescalation techniques and how to recognize implicit bias will help create a more equitable response to 

mental health crises by law enforcement. 

Another approach to diversion during or after a crisis is the implementation of the Sequential Intercept 

Model. SAMHSA’s GAINS Center developed the five-point Sequential Intercept Model, which identifies five 

opportunities along the criminal justice continuum to divert individuals with mental illness from the criminal 

justice system and prevent further involvement in the system. The original five “intercepts” include: 1) Law 

Enforcement (including calls to 911); 2) Initial Court Hearings/Initial Detention; 3) Jails and Courts; 4) Reentry; and 5) Community-based criminal justice supervision with behavioral health supports.

46 Recently, a 

new intercept, Intercept Zero, has gained support, encouraging system alignment to connect individuals with 

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care before a behavioral health crisis emerges.

47 Intercept Zero includes the use of community services, peer 

warm lines, and crisis lines. The Sequential Intercept Model can help to reduce racial disparities across 

systems, to reduce the higher arrest rates and disparities in referrals to diversion programs among people of 

color, to reduce the disproportionate prevalence of pretrial incarceration and higher bail amounts for people 

of color, and to improve the chance that people of color are more likely to receive restorative mental health 

services rather than punitive consequences.

48 

CIT and the Sequential Intercept Model can help to reduce rates of incarceration among individuals 

experiencing a mental health crisis, including persons of color, which can contribute to higher rates of 

incarceration – a factor within the social and community context determinant of health. 

Another way to reduce law enforcement involvement in crisis response and to reduce the potential for 

force, which is disproportionately used against people of color, is to embed crisis counselors within the 

911 system.

49 While several models are in operation today, the first to implement this model is The 

Harris Center in Houston. The Crisis Call Diversion (CCD) program embeds behavioral health specialists in 

the City of Houston 911 Dispatch Center. It is a partnership between the Houston Police Department 

(HPD), the Houston Fire Department (HFD), and The Harris Center for Mental Health and Intellectual and 

Developmental Disabilities. When a person calls into 911 experiencing a crisis, the 911 dispatcher 

identifies and redirects mental health related, emergent, non-life-threatening calls for service to 

bachelor’s trained crisis counselors and away from first responders. Since its launch in 2016, the CCD 

program as successfully diverted individuals away from law enforcement and fire department response 

and saved more than $2 million in resources for the HPD, and nearly $4.5 million for HFD. Recently, in 

March 2021, the CCD program began working with The Harris Center’s Mobile Crisis Outreach Rapid 

Response to dispatch teams in the community to respond to calls for service that could not be deescalated over the phone. 

To reduce the unnecessary reliance on law enforcement, which can lead to unnecessary incarceration or 

use of force which disproportionately affects people of color, New York City recently launched a similar 

program where crisis counselors are embedded within precincts in the Harlem and Harlem East 

neighborhoods of the city. 49 In November of 2020, Mayor Bill de Blasio announced plans to have mental 

health workers replace police officers in response to some 911 calls, beginning in 2021. The program is 

being piloted in three neighborhoods in the Burrough of Harlem, which is nearly 62% Black.

50 The 

neighborhoods participating in the pilot accounted for the most 911 calls in the city in 2019. The primary 

goal of the program is to “avoid bad outcomes from police interactions with individuals experiencing a 

mental health crisis.”51 When a person in crisis calls 911 from one of these neighborhoods, rather than 

police response, two Fire Department EMTs and one social worker will respond. The program is available 

16 hours per day. It has been so successful that Mayor de Blasio anticipates extending the project citywide. 

HAQ Strategy 5: Market the Availability of Crisis Services to Diverse Populations 

One of the most common barriers identified during the interviews for this paper is that “many people 

[of color] don’t know what crisis services are, or what they can do” (Shakir, N., Personal Communication, 

9 July 2021). This lack of knowledge can help spur fears among marginalized communities that by calling 

for help in a crisis, law enforcement or child protective services will respond to the call, and instead of 

receiving help for a behavioral health crisis, they may be arrested (or worse, as in the cases of Mr. 

Prude, Mr. Warren, and Mr. Osagie and countless others) or have their children removed from their 

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home. Niambi Shakir, a crisis team lead with the Minnesota Department of Human Services, noted that 

“there is often a misconception of what crisis can do among under-represented communities,” with 

some people expecting a SWAT-style response (Shakir, N., Personal Communication, 9 July 2021). One 

way to overcome this uncertainty and mistrust is by marketing the availability of crisis services 

specifically to these diverse populations, by addressing what crisis services are, how they can help, and 

what to expect. 

A variety of platforms exist to Figure 5: Weekly Reach of Radio, TV, Smartphone by Age, 201752 

advertise the availability of 

behavioral health crisis 

services, including television, 

radio, and mobile applications 

(“apps,” including social 

media). Marketing efforts can 

be targeted based on the 

population an SBHA or provider 

is trying to reach. The overall 

reach of each platform differs 

and varies by age and race. 

According to a 2017 study by 

Nielsen, “radio reaches more 

 

Americans each week than any 

other platform,” although this may have shifted since fewer people are commuting during the current 

COVID-19 pandemic.

52 Figure 5 shows the weekly reach by age group as a percentage of the U.S. 

population for each radio, TV, and smartphone apps. 52 

Looking beyond the age categorizations, Nielsen also found that “African-American and Hispanic 

listening audience[s] now accounts for one-third of the [traditional radio] listening audience, and that 

number continues to grow.”53 Traditional radio reaches 93 percent of African American/Black 

consumers, and 98% of Hispanic consumers. African American/Black and Hispanic consumers also 

frequently consume radio through smartphones and other streaming devices. African American/Black 

listeners tend to listen between 3:00pm and 7:00pm, while Hispanic listeners are more likely to listen to 

the radio between 10:00am and 3:00pm. 53 

In addition to radio and TV, SBHAs can leverage social media to reach a wider, younger, and more 

diverse audiences to promote their services, including crisis services. YouTube, Facebook, and Instagram 

are the most widely used social media platforms in the U.S. Facebook has the widest reach across all 

adults ages 18 and over, while Instagram and SnapChat have the widest reach among youth ages 13 to 

17. Non-Hispanic Black and Hispanic individuals are most likely to use YouTube (84% and 85%, 

respectively, of adults in each demographic group), and are least likely to use NextDoor (10% and 8%, 

respectively’ see Figure 6 below).54 

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Figure 6: Use of Online Platforms by Race, 202154 

 

As discussed further on in the paper, behavioral health stigma among communities of color is a 

significant barrier to preventing individuals with behavioral health needs from seeking help, even in 

times of crisis.

55 social media has the added benefit of normalizing the conversation around the need for 

behavioral health services in racially and ethnically diverse communities. A 2018 study by the Pew 

Research Center found that 80% of Black social media users “value the platforms for magnifying issues 

that aren’t usually discussed,” and 60% of Hispanics and Whites felt the same.

56 Collaborating with 

respected public figures, including athletes, to spread the word about behavioral health crisis services 

can help legitimize the value they offer, especially in diverse communities. 

Regardless of which platform is used to promote the availability of behavioral health crisis services, the 

language used related to behavioral health also matters in overcoming stigma and increasing 

engagement. At least two states, Colorado and Minnesota, noted that instead of using the terms 

“mental health” or “behavioral health,” their outreach efforts to diverse communities focuses instead 

on “mental wellness” (Lee, M., Personal Communication, 27 May 2021; Shakir, N., Personal 

Communication, 9 July 2021). 

Lessons and Examples from Colorado Crisis Services 

In 2019, Colorado Crisis Services began strategizing how to best promote its crisis services, especially to 

diverse, underserved communities (including rural communities and communities of color). During their 

market research, they also discovered, and were surprised to find that radio had a broad reach, 

especially among the Hispanic communities within the state. Based on these findings, Colorado Crisis 

Services began marketing its services on the radio specifically to Hispanic communities. While it took a 

while to see gains, the efforts to promote crisis services on the radio became “fruitful, especially with 

Spanish-speaking audiences” (Lee, M., Personal Communication, 27 May 2021). 

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In addition to the targeted radio ads, Colorado Crisis Services has also tailored its social media and print 

materials for diverse populations, including Hispanic and Black communities. To promote its messages 

and services on social 

media, Colorado Crisis 

Services collaborates 

with local leaders, and 

recruits a more diverse 

group of social media 

influencers in Colorado 

to make its messaging 

more representative. 

One lesson learned in 

using social media 

influencers is that 

SBHAs and providers 

should provide 

guidance on what the 

messages should 

cover, while allow the 

social media 

influencers to craft 

their own messages, 

using language that 

resonates within their 

own communities. 

Figure 7: Colorado Crisis Services Twitter Campaign Example57 

Recommended Text: When you feel overwhelmed, you don’t have to go it alone. 

Colorado Crisis Services can help if you don’t know where to start. Our trained 

counselors and peer specialists will listen to your story, suggest next steps, and even 

connect you to resources in your community. Call 1-844-493-TALK, or text TALK to 

38255. Coloradocrisisservices.org 

A comprehensive list of marketing campaigns used by Colorado Crisis Services, including examples 

designed to better engage people from Black and Hispanic communities, as well as reaching rural and 

LGBTQIA+ communities can be found online (https://coloradocrisisservices.org/toolkit/generalcampaign/). An example of a Twitter post developed by Colorado Crisis Services is provided above.

57 

HAQ Strategy 6: Recruit and Retain a Representative, Culturally and Linguistically 

Competent Workforce that is Adept at Providing Trauma-Informed Care 

A culturally responsive and diverse workforce in mental health services overall, and in crisis services, can 

help restore faith in the system by people of color, and lead to better outcomes for all consumers. A 

2020 technical assistance paper, Crisis Services: Addressing Unique Needs of Diverse Populations, 

provides an overview of the considerations, challenges, and implications for the workforce in various 

crisis settings.19 Investing in efforts to recruit and retain a representative workforce, training providers in 

the National CLAS Standards and trauma-informed care, and recruiting a diverse workforce from local 

institutes of higher education, including historically Black colleges and universities (HBCUs) will help to 

engage marginalized communities. 

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Recruitment and Retention 

A lack of diversity in the behavioral health crisis workforce, and behavioral health workforce overall 

“contributes to poor quality of care, including higher rates of misdiagnoses among racial minorities.” 

Research supports Rev. Bowman’s assertion that there is a lack of representation among people of 

color, and there are a relative few who he would consider to be culturally competent in terms of 

engaging African American clients and patients” (Bowman, J., Personal Communication, 6 July 2021). 

Data from 2016 show that the behavioral health workforce is predominantly white for psychologists, 

although for early career psychologists there is some improvement in diversity. See Figure 8. 

Figure 8: Diversity of the Psychology Workforce58 

Diversity of the Psychology Workforce, 2016 

 

Oregon is taking steps to bolster and diversify its behavioral health workforce through significant 

investments from the legislature. In June of 2021, the Oregon Legislature passed a $474.4 million 

behavioral health package that addresses a wide variety of social determinants, including “housing and 

residential services to community programs to incentives that attract people to the workforce and 

developing mobile crisis units.”59 $80 million of these funds will go toward two incentive programs to 

increase Oregon’s behavioral health workforce, including scholarships, and grants for providers to offer 

clinical supervision for licensure.

60 Language in HB2949 specifically charges the Oregon Health Authority 

to increase the behavioral health workforce to improve access culturally responsive behavioral health 

services, and to help transition individuals from incarceration back into the community, which will have 

profound effects on improving social determinants of health for people of color in Oregon, as Oregon’s 

jail population is disproportionately represented by people of color.

61 

“To improve access to culturally responsive behavioral health services by tribal members, 

people of color, lesbian, gay, bisexual and transgender youth, veterans, persons with disabilities, 

individuals with intellectual and developmental disabilities, individuals with limited English 

proficiency, individuals working in correctional facilities, residents of rural areas and other 

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underserved communities. [The bill also] directs [the Oregon Health Authority] to provide 

funding to counties, community mental health programs and organizations to support 

individuals to transition from incarceration back into [the] community.” 61 

In addition to strengthening the clinical workforce, Shelley White, a Peer Policy Representative with the 

Minnesota Department of Human Services, recommends integrating peers into crisis response teams to 

improve diversity and representation (White, S., Personal Communication, 9 July 2021). She notes that 

peers can be incredibly helpful in crisis situations when they meet an individual experiencing a crisis in 

the community and wait with them until a clinician arrives. On the substance use side in Minnesota, 

they have been successful recruiting African American/Black peers, Muslim peers, and individuals from 

the large Somali community. 

Recruiting from Local Institutes of Higher Education, Including Historically Black Colleges and 

Universities 

Local universities and colleges, including HBCUs, are an excellent resource for SBHAs and providers to 

develop and recruit a diverse, representative, and culturally and linguistically competent crisis 

workforce. Providing scholarships to people of color to pursue degrees in mental health and covering 

the costs of licensure upon graduation help reduce the barriers many people of color face when 

entering the behavioral health workforce. SAMHSA sponsors an Historically Black Colleges and 

Universities Center of Excellence in Behavioral Health, which provides up to $500,000 in funding to 

states to “recruit students to careers in the behavioral health field to address mental and substance use 

disorders, provide training that can lead to careers in the behavioral health field.”62 

National Standards for Culturally and Linguistically Appropriate Services (CLAS) 

In 2013, the Department of Health and Human Services’ Office of Minority Health (OMH) published the 

final, enhanced National CLAS Standards. According to OMH, “cultural and linguistic competency strives 

to improve the quality of care received and to reduce disparities experienced by racial and ethnic 

minorities and other underserved populations.”63 Research suggests that through the implementation of 

CLAS initiatives at the provider level, “there are substantial increases in provider knowledge and skill 

acquisition, and improvements in provider attitudes toward culturally and linguistically diverse 

populations.” 63 In addition to more competent care, that implement the CLAS Standards also show an 

increase in patient satisfaction, higher levels of patient-reported quality of care, and increased levels of 

trust in the organization. 63 The CLAS Standards are made up of one Principle Standard, and 14 standards 

within three themes: 

• Principle Standard 1: Provide effective, equitable, understandable, respectful, and quality care 

and services that are responsive to diverse cultural health beliefs and practices, preferred 

languages, health literacy, and other communication needs. 

• Theme 1: Governance, Leadership, and Workforce 

o Standard 2: Advance and sustain governance and leadership that promotes CLAS and 

health equity 

o Standard 3: Recruit, promote, and support a diverse governance, leadership, and 

workforce 

o Standard 4: Educate and train governance, leadership, and workforce in CLAS 

• Theme 2: Communication and Language Assistance 

o Standard 5: Offer communication and language assistance 

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o Standard 6: Inform individuals of the availability of language assistance 

o Standard 7: Ensure the competence of individuals providing language assistance 

o Standard 8: Provide easy-to-understand materials and signage 

• Theme 3: Engagement, Continuous Improvement, and Accountability 

o Standard 9: Infuse CLAS goals, policies, and management accountability throughout the 

organization’s planning and operations 

o Standard 10: Conduct organizational assessments 

o Standard 11: Collect and maintain demographic data 

o Standard 12: Conduct assessments of community health assets and needs 

o Standard 13: Partner with the community 

o Standard 14: Create conflict and grievance resolution processes 

o Standard 15: Communicate the organization’s progress in implementing and sustaining 

CLAS 

OMH has made available a series of tools and educational courses for behavioral health providers to 

improve their knowledge and understanding of the CLAS standards: 

• An Implementation Checklist for the National CLAS Standards with a CLAS Action Worksheet and 

CLAS Testimonials to evaluate whether ad how well an organization is currently implementing 

the CLAS Standards.

64 

• Think Cultural Health is a free training for behavioral health providers. This 5.5-hour program 

contains four courses and is approved for up to 5.5 contact hours for counselors, nurses, 

psychologists, psychiatrists, and social workers; other professionals can earn a Statement of 

Participation. After completing these courses, participants will be able to describe how culture, 

cultural identity, and intersectionality are related to behavioral health and behavioral health 

care; describe the principles of cultural competency and humility; discuss how our bias, power, 

and privilege can affect the therapeutic relationship; discuss ways to learn more about a client’s 

cultural identity; describe how stereotypes and microaggressions can affect the therapeutic 

relationship; explain how culture and stigma can influence help-seeking behaviors; describe how 

communication styles can differ across cultures; identify strategies to reduce bias during 

assessment and diagnosis; and explain how to elicit a client’s explanatory model.

65 

Training Providers in Trauma-Informed Care 

Training providers in trauma-informed care and providing trauma-informed services can help to engage 

people of color into treatment, including crisis services, and ensure their continued involvement in 

services. 

Trauma is “the result of an event, series of events, or set of circumstances that is experienced by an 

individual as physically or emotionally harmful or life threatening and that has lasting, adverse effects on 

[an] individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”66 People of 

color are at higher risks for exposure to collective and individual trauma, due to racial trauma that has 

been passed through generations.

67 “People who experience extreme events of racial discrimination can 

develop racial trauma, which can lead to [post-traumatic stress disorder] and worsen symptoms of 

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anxiety or depression.

68 Trauma “affects self-esteem and self-worth, especially when your skin color is 

weaponized against you.” 67 Understanding the effects of trauma and minimizing future trauma are key 

components to trauma-informed care. 

Trauma-informed care “views trauma through an ecological and cultural lens and recognizes that 

context plays a significant role in how individuals perceive and process traumatic events.” 66 Traumainformed care requires that providers anticipate and avoid institutional processes and individual 

practices that may retraumatize individuals with a history of trauma. Trauma-informed care values 

consumer participation in the development, delivery, and evaluation of services. 66 

HAQ Strategy 7: Improve Diagnostic and Level-of-Care Determination Processes 

A 2014 review of the literature by Schwartz and Blankenship spanning a 24-year period found that 

African American/Black individuals are diagnosed with psychotic disorders at a rate three-to-four times 

higher than White individuals. Relatedly, African Americans/Blacks are almost five times more likely to 

be diagnosed with schizophrenia when compared to Whites admitted to state psychiatric hospitals. A 

similar trend was found among Hispanic, who were “disproportionately diagnosed at a rate more than 

three times higher than [White] Euro-Americans with a schizophrenia diagnosis.

69 Additionally, African 

Americans/Blacks discharged from state hospitals were “discharged more often with an unspecified 

diagnosis, such as psychosis not otherwise specified,” compared to their White counterparts.

69 In a 

March 2021 Washington Post article, King Davis, Ph.D., former commissioner of the Virginia Department 

of Mental Health, indicated that one of the reasons for high rates of schizophrenia diagnoses is the 

perception that “Black people, Black men” in particular as “being on the cusp always of violence and 

danger.”70 In the same article, Arthur Whaley, Ph.D., M.P.H., notes that “when African Americans 

respond or react to oppression in an appropriate way, because those experiences are not shared by the 

mainstream they’re seen as paranoid, and they’re misdiagnosed.” 70 

In his 30 years of service as a licensed social worker, Rev. Bowman has seen a lot of misdiagnoses among 

African American/Black youth, particularly for ADHD (attention-deficit, hyperactivity disorder) and 

oppositional defiant disorder (ODD). Contributing to this problem, notes Dr. Carter, is that diagnostic 

instruments and guides, including the Diagnostic and Statistical Manual of Mental Disorders (DSM) and 

Intelligent Quotient (IQ) tests were developed based on the experiences of White, Euro-centric 

populations. Inappropriate diagnostic tools and guides that are not culturally sensitive can categorize 

individuals with different cultural backgrounds as being lower functioning, “which is a whole other form 

of discrimination,” as the clinical conclusion is usually that they are not able to be remediated, and 

therefore not given the same opportunities as White youth (Carter, B., Personal Communication, 6 July 

2021). Dr. Carter also notes that, “if we’re going to be equitable in terms of diagnosing, the mental 

health community will have to look at a different diagnostic tool or significantly overhaul what we have 

because generally White males are the population upon which those instruments are based” (Carter, B., 

6 July 2021). 

SAMHSA’s National Guidelines recommend that crisis providers use the LOCUS (Level of Care Utilization 

System), which “is a tool designed to assess level of care needs of individuals experiencing psychiatric 

and addiction challenges... [it] provides a single, easy-to-use instrument that can be used in a multitude 

of settings to clarify an individual’s needs and identify services appropriate to address those needs.”2 By 

using a standardized tool, it can help providers overcome their implicit bias and reduce unnecessary 

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institutionalization among people of color. However, more research may need to be done to ensure that 

these standardized instruments are equitable in their evaluations. 

Dr. Carter also recommends that, “rather than starting with pathology, providers should take a 

strengths-based approach during evaluation,” to avoid inappropriate diagnoses and level-of-care 

placements (Carter, B., Personal Communication, 6 July 2021). A strengths-based approach to mental 

health “moves the focus away from deficits of people with mental illnesses and focuses on [their] 

strengths and resources” (Carter, B., Personal Communication, 6 July 2021).71 

Investing in a representative workforce that is culturally and linguistically competent can help reduce 

inherent bias among providers. According to Schwartz and Blankenship (2014), “the inclusion of cultural 

information within a diagnostic formulation is critical because a diagnostic judgement leading to a 

potential misdiagnosis can have several lasting negative effects for consumers, ranging from having an 

inaccurate healthcare record and complications related to insurance coverage, to being prescribed 

antipsychotropic medications and potential death resulting from self-stigma-induced suicide... Diagnoses 

can greatly influence the future of a consumer’s healthcare, including participation in and trust of the 

healthcare system generally.”69 If clinician biases can be overcome through cultural competence 

training, then the trend of misdiagnoses may begin to decrease. 

Strategy 8: Improve Transparency and Equality in Crisis Services through Data 

Collection and Outcomes Monitoring 

It is critical for states and providers to collect demographic data and monitor outcomes of crisis services 

so that racial inequities in crisis services can be understood and addressed. Data collection can also be 

useful to establishing trust among communities of color. Dr. Sims recommends that to overcome 

mistrust of the system, SBHAs and providers should be “flooding [the public] with transparency” (Sims, 

B., Personal Communication, 8 March 2021). 

Many states and crisis providers do not collect demographic data about the people that use their crisis 

services. An internet search of SBHA data dashboards that display information about crisis services and 

race yields few results. However, Utah and Wisconsin both publish data about race and service access. 

These reports can serve to strengthen trust in the system through transparency, and enable the states 

to monitor the availability, accessibility, and quality of services for people of color. 

Utah publishes reports for health status by race and ethnicity every five years. While not specific to crisis 

services or mental health, the 2015 report analyzes a wide array of health issues, including health care 

quality and accessibility, poverty, infant and maternal health, injuries and violence, and chronic 

disease.

72 

In February 2021, Wisconsin’s Department of Health Services published the report, Differences in Crisis 

Services and Psychiatric Hospitalization across Race and Ethnicity.

73 The report provides information on 

the types of unique individuals that receive crisis services in the states by race and ethnicity and 

identifies potential barriers to care. The report also reviews how crisis services and psychiatric hospitals 

are used by people of color. 

By collecting, analyzing, and publishing these data, Utah’s Department of Health and Wisconsin’s 

Department of Health Services demonstrate their commitment to improving the quality of healthcare 

services and life for people of color in the state. 

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One reason that so few states publish data about who uses crisis services is that data collection in the 

midst of a crisis is inappropriate, as the first priority should be responding to the crisis. However, once a 

crisis is triaged, it is important for the crisis counselor, whether on the phone or in person, to schedule a 

follow-up for post-crisis care. At this point, data can be collected that helps states and providers better 

understand who is being served, the quality of services being offered, and the outcomes of the crisis 

interventions. Once an individual is in the system, it becomes easier to identify them and track their 

outcomes should any subsequent services be needed. SAMHSA’s National Guidelines recommend that 

crisis call centers collect “data elements such as phone numbers of Medicaid-enrolled or privately 

insured individuals” so that they can be “combined with Caller-ID technology.”2 

Social Determinant of Health: Social and Community Context 

Social and community context (SCC) refers to the “connection between characteristics of the contexts 

within which people live, learn, work, and play, and their health and wellbeing.”16 Factors within this 

domain that are pertinent to the delivery of crisis services include stigma and incarceration. 

Understanding and addressing the role stigma has on how people of color approach crisis services, and 

the effects of incarceration on communities of color are critical to providing a more equitable crisis 

continuum. Strategies that SBHAs and providers can use to address social and community context 

include: 

1. Understand and address stigma in diverse communities 

2. Reduce incarceration through diversion and improved law enforcement response 

SCC Strategy 1: Understand and Address Stigma in Diverse Communities 

In addition to reluctance to reaching out for crisis services due to mistrust, many communities of color 

attach stigma to seeking mental health services and see the need for care as taboo or controversial. For 

many African Americans/Blacks, their “story is one of perseverance and resilience,” with the thought 

that “after all, we survived slavery; surely we can survive ‘sadness’ or ‘anxiety.’”74 Many Asian 

communities stigmatize mental health due to the emphasis on family honor and purity, whereas mental 

illness may be seen as shameful, untreatable, and weak.

75 According to Diana Lorenzo, M.D., a 

psychiatrist with the Cleveland Clinic’s Center for Behavioral Health, “many Latinos would prefer to 

ignore [mental health] conditions over talking about them openly.”76 Understanding the stigma 

associated with mental illness among Native American/Alaska Natives is complex, as “the concept of 

mental illness has different meanings and is interpreted in various ways,” as Native American and Alaska 

Natives are not one homogenous group.

77 These attitudes cause some people of color “to believe they 

are exempt from mental health issues.” 77 These beliefs can be dangerous because they cause 

individuals to avoid or delay critical treatment. 

Ms. Green indicates that the first step in overcoming or reducing stigma is understanding how each 

culture perceives mental health treatment. Reframing the system from one that is punitive for people of 

color to one that offers problem solving options, even if mandated treatment, would go a long way 

(Green, G., Personal Communication, 29 June 2021). Other strategies to reduce stigma in communities 

of color to increase engagement with the system include reducing stigmatizing language (as Colorado 

Crisis Services did by changing “Mental Health” to “Mental Wellness) and engaging with community 

partners, as described above, to normalize the conversation around mental health and crisis services. 

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Focused marketing campaigns similar to what Colorado Crisis Services has implemented can also be 

effective at normalizing the conversation around mental health and wellness. By engaging community 

leaders and other respected individuals (e.g., athletes, celebrities, influencers) and allowing them to use 

their own voice to promote messages can help engage communities of color and destigmatize mental 

health crisis care. 

Other strategies for overcoming stigma within communities of color include: 76 

• Removing the language barrier so that providers can fully understand the needs and desires of 

their clients. While interpreters can be helpful, a linguistically diverse workforce is most 

effective at interpreting cultural nuances and jargon. 

• Due to stigma associated with mental health, people of color may be more likely to reach out to 

a primary care physician for help rather than a dedicated mental health or crisis provider. 

Ensuring that primary care providers have the right tools to help diverse populations identify a 

mental health crisis and normalize the need for mental health services can help to destigmatize 

the need for mental health services within diverse communities. 

• Many communities of color emphasize the family unit more than White families in the U.S. 

Recognizing the value of the family unit and encouraging family involvement in care, including 

how to get someone the help they need in a crisis, can help normalize the need for mental 

health services in communities of color. By involving family members up front, it is also more 

likely that an individual will return for follow-up appointments post-crisis. 

SCC Strategy 2: Reduce Incarceration through Diversion and Improved Law 

Enforcement Response 

The U.S. jail census has nearly quadrupled since 1970, with admissions reaching 11 million annually.

44 

Although people of color make up 20.8% of the U.S. population, they are significantly over-represented 

in prisons and jails, especially African Americans/Blacks. In 2019, African Americans/Blacks accounted 

for 26.6% of all arrests, even though they only make up 13.4% of the U.S. population. Similar trends exist 

for American Indians and Alaska Natives, where the percentage of arrests (2.4%) is nearly twice the 

percentage of their population (1.3%). Data also show that people of color are more likely to be arrested 

for minor offenses, including disorderly conduct and vagrancy. See Figures 9 and 10 on the following 

page. 

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Figure 9: Percentage of Arrests Compared to Overall Population by Race, 201978 

 

Figure 10: Arrests by Race and Charge, 201979 

 

Ms. Green observes that even though Tampa Crossroads operates in a predominantly diverse 

neighborhood, the majority of their clients are White. Even though the services provided by Tampa 

Crossroads are covered through a grant from the county, few people from the local area seek out their 

services. In addition to needing more outreach and education on how to access services, her theory for 

why her clientele are predominantly White is because “more people of color are sent to jail, and not 

given the option for treatment” (Green, G., Personal Communication, 29 June 2021). Research supports 

her theory. A study by Carson, et al. in 2014 found that African American/Black men experiencing a 

psychiatric crisis are less likely to be evaluated for hospitalization than White individuals with similar 

symptoms and are more likely to be sent to jail where they are less likely to receive behavioral health 

care than their White counterparts. 21 

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Reducing law enforcement response to crisis services and enhancing training for the times when they 

need to respond will help reduce incarceration among people of color experiencing a crisis. Diverting 

individuals from jail will help to break the cycle of incarceration, and the trauma associated with 

incarceration by allowing parents to reunite with their children, return to work, and participate in their 

communities. 

Making Change Happen: Leadership from the State Behavioral Health 

Authority 

Meaningful change toward a more equitable system requires leadership from the SBHA. Several 

financial opportunities recently became available that SBHAs can leverage to bolster their crisis 

continuum, including the American Rescue Plan Act of 2021 (ARP), and an expansion of SAMHSA’s 

Mental Health Community Services Block Grant (MHBG) Plan. 

The ARP “establishes a new state option to provide community mobile crisis intervention services for a 

five-year period beginning April 2022.”80 To incentivize states to use these funds for the implementation 

of crisis services, “the law allows for an 85% enhanced federal matching rate for qualifying services for 

the first three years of state coverage.” 80 Additionally, the ARP also includes $15 million in state 

planning grants to support the development of a Medicaid state plan amendment or waiver request to 

take up the option. In addition, as part of the ARP, Congress added $1.4 billion to the MHBG with 

SAMHSA emphasizing to the SBHAs that these additional funds can be used to support crisis services.81 

The amount of funds each state receives through the ARP varies, ranging from $181,128 in Wyoming, to 

nearly $9.5 million in California. In addition, as part of the fiscal year 2021 MHBG appropriations to 

SAMHSA, Congress added a new 5% set aside (nearly $42.3 million) dedicated to supporting mental 

health crisis services. 

Multiple SBHAs recognize the need for, and value of diversity and representation in behavioral health 

services. Some states, like New York, have gone beyond simply recognizing the value of diversity and 

representation to creating an Office of Diversity and Inclusion to manage the cultural shift required to 

create a more equitable system. 

For many decades, New York’s Office of Mental Health (OMH) has convened a stakeholder advisory 

group to focus on special populations. The stakeholder group consists of representatives from 

marginalized populations in the state, including people of color, residents from rural areas, veterans, 

and individuals whose native language is something other than English. This stakeholder group 

advocated that there be staff within OMH to work with the commissioner and other state leadership to 

focus on diversity and inclusion. At first, the office consisted of a secretary and “maybe one other 

person,” and was not very high up in the SBHA (Canuteson, M., Personal Communication, 27 May 2021). 

Around two years ago, priorities began to focus on diversity and inclusion within the SBHA and the office 

was elevated officially to the Office of Diversity and Inclusion, complete with senior staff and an 

executive team. Following the murder of George Floyd in May of 2020, the Office of Diversity and 

Inclusion was elevated further to report directly to the commissioner, and now has five staff. Funding 

for this Office comes directly from the SBHA through State General Funds. 

The Office of Diversity and Inclusion is tasked with ensuring that all OMH requests for proposals address 

the CLAS Standards and address equity in a strong way, including diversifying and training the workforce 

to be more culturally competent. The Office of Diversity and Inclusion is also responsible for promoting 

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the message of inclusion and providing guidance on best practices for a culturally competent workplace. 

When working with providers, Matthew Canuteson, M.A., Director of the Bureau of Cultural 

Competence recommends “giving people information in concrete, tangible bites” that can be used 

incrementally to improve their programs (Canuteson, M., Personal Communication, 27 May 2021). 

Messaging should be “consistent and clear. It’s important that people aren’t getting 18 separate ideas 

on what they should be doing!” (Canuteson, M., Personal Communication, 27 May 2021). 

Mr. Canuteson acknowledged that the current political climate is creating opportunities to move the 

conversation around race and ethnicity forward; however, there is some fear that once the world settles 

and COVID is over, that some focus and attention on these important issues will be lost. Because of this 

risk, and the potential for changing priorities, it is important that structural changes to the organization 

of the SBHA be made to sustain the SBHAs leadership in diversity and inclusion. The Office of Diversity 

and Inclusion is also trying to show providers how to make lasting changes within their own 

organizations that support equity. 

When asked what the biggest barrier to change is? Mr. Canuteson simply stated, “racism.” He notes that 

racism is the number one issue that his office deals with. To overcome these challenges, they train from 

a model that everyone has bias. It takes leadership for an agency, a provider, and an individual to selfreflect and find ways to improve. Leadership from the SBHA can create avenues for communication to 

openly discuss bias, and it helps if there is leadership from other agencies, too. (Canuteson, M., Personal 

Communication, 27 May 2021). 

Oregon’s Health Authority is an example of state leadership in equity. In 2020, as part of its response to 

the COVID-19 pandemic, the Oregon Health Authority established a goal to eliminate health inequities 

by 2030. The Oregon Health Authority’s Policy Board developed the following definition of equity that 

highlights its values in achieving the strategic goal:

82 

“Oregon will have established a health system that creates health equity when all people can 

reach their full health potential and well-being and are not disadvantaged by their race, 

ethnicity, language, disability, gender, gender identity, sexual orientation, social class, 

intersections among these communities or identities, or other socially determined 

circumstances. Achieving health equity requires the ongoing collaboration of all regions and 

sectors of the state, including tribal governments, to address: 

• The equitable distribution or redistribution of resources and power; and 

• Recognizing, reconciling, and rectifying historical and contemporary injustices.” 82 

This goal is the driving force behind its 2022-2027 1115 Medicaid waiver application, its COVID-19 

vaccine distribution campaign, and all other activities within the state’s health system. By establishing 

this overarching goal, it has allowed the Oregon Health Authority, and the state legislature, to focus on 

one thing to make change. In order to achieve this goal, the Oregon Health Authority realizes that it 

“must meaningfully engage with communities most impacted and often left out of the decisions that 

affect their lives.” 82 

To meaningfully gather input from marginalized communities and guide efforts related to equity, the 

Oregon Health Authority’s Division of Equity and Inclusion went out to communities around the state. 

State representatives gave presentations in these communities to gain interest in the input process, and 

then offered space for the community to meet in the evenings outside of work hours, at times that 

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would be most convenient to the community. To ensure candidness during these sessions, state 

representatives were not present; however, facilitators from the community were on hand to guide the 

discussion and take notes. From these community engagement sessions, the Oregon Health Authority 

had analysts review the notes and categorize recommendations by themes. Some of the feedback the 

Oregon Health Authority received is that peer support specialists need to be utilized more to create a 

more representative workforce, and that both quantitative and qualitative data should be used to guide 

decision making and quality improvement efforts. This feedback is guiding the state’s equity efforts 

moving forward. According to the state, “this was the most effective community engagement process” 

(Coyner, L., Personal Communication, 16 June 2021). 

Conclusion 

In the U.S., racism affects all people of color and is an enduring, primary social determinant of racial 

inequities in population health and mental health.

1 Historic, structural racism and implicit bias have led 

to a lack of trust among people of color of systems that involve law enforcement and 

institutionalization, including the mental health crisis system. This distrust also contributes to increased 

stigma among communities of color. To begin to overcome these barriers and to create a more 

equitable and accessible crisis system, it is critical that SBHAs and providers partner with trusted 

community leaders (e.g., clergy in local churches) to both offer supportive services that improve social 

determinants of health and spread the word to build trust and engage more people of color into crisis 

care. To further build trust, SBHAs and providers can improve data collection and reporting processes to 

be more transparent and embark on quality improvement initiatives to identify strengths and 

weaknesses in the crisis system. While it is ideal for law enforcement to be removed from crisis 

response, it is often not feasible to eliminate their role completely, especially in areas with limited 

resources. Therefore, it is critical that law enforcement be trained in how to effectively respond to crises 

without the use of force, and how to divert individuals to appropriate levels of care. These strategies will 

help build trust with communities of color to reach out for help when they are most vulnerable. Within 

any system, there will be resistance to change, particularly if the organization or system has amassed a 

lot of influence, and is part of a large, bureaucratic system. This resistance can lead to an oppressive 

culture; however, looking to SBHA leadership to make a commitment to equity and inclusivity helps 

move the efforts forward. 

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References 

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2015; 41:311-330. 2 National guidelines for behavioral health crisis care. Rockville, MD, Substance Abuse and Mental Health Services 

Administration, 2020. https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisiscare-02242020.pdf 3 Mcleod, J.: Understanding racial terms and differences. National Institutes of Health Office of Equity, Diversity, 

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ss%20is%20shameful%2C%20untreatable%2C%20and%20a%20weakness. 76 Overcoming mental health stigma in the Latino community. Cleveland, OH, the Cleveland Clinic. ConsultQD. 

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alth%20issues%20as%20weaknesses%20or%20failures. 78 Total correctional population. Bureau of Justice Statistics. 2019. https://www.bjs.gov/index.cfm?tid=11&ty=tp 79 Crime in the United States. Washington, D.C. U.S. Department of Justice Federal Bureau of Investigation. 2019. 

https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/topic-pages/tables/table-43 80 Traube, A., Guyer, J.A., & Boozang, P.M.: The American Rescue Plan Act’s state option to invest in mobile crisis 

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year%20goal%20to,of%20the%20decisions%20that%20affect%20their%20lives%20 

124
The Effects of 

COVID-19 on 

Children, Youth 

and Families 

No. 6 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

125
 

 

The Effects of COVID-19 on Children, Youth, 

and Families Across Populations 

Kenneth M. Rogers M.D. MSPH MMM 

State Director 

South Carolina Department of Mental Health 

Louise Johnson M.S.W. LISW 

Director 

Children, Adolescents, and Families 

South Carolina Department of Mental Health 

Jayla O’Neal M.D. 

Physician 

Division of Education, Training and Research 

South Carolina Department of Mental Health 

Cover Art by Malkah Pinals 

Sixth in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

126
 

 

 

 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, 

or other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Rogers, K.M., Johnson, L. & O’Neal, J. (2021). The Effects of COVID-19 on Children, Youth, and Families 

Across Populations. Technical Assistance Collaborative Paper No. 6. Alexandria, VA: National Association 

of State Mental Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

127
 

 

 

 

 

 

 

 

 

Abstract: 

COVID-19 has had a devastating mental health effect on children and adolescents, who were, prior to 

the emergence of the Delta variant, largely spared the physical effects of the associated infection. 

However, more recent data has shown an increase in hospitalizations and the need for medical care 

while also demonstrating an increase in mental health conditions, including anxiety and depression. 

Poverty, low educational achievement and other social determinants have further complicated the 

lives of children and adolescents during this pandemic. The medical and mental health impact of 

COVID-19 has been more acute in Black, Latinx and Native American communities. The educational 

system, which serves as a safety net for many youth, has been severely impacted by the pandemic 

with many schools relying on technology and virtual attendance to educate youth. This has meant 

that many youth, especially minority youth, have experienced declines in school attendance as many 

do not have access to computers or broadband to allow them to fully participate. This has resulted in 

these youth falling three to five months behind academically. There is concern that many of these 

youth will never overcome these losses. Furthermore, school has been a safe haven. Youth were 

more likely to experience episodes of domestic violence and abuse without the support and 

reporting mechanisms that are available when teachers and other school personnel are interacting 

with youth on a daily basis. These losses place youth at risk for contact with other systems, including 

juvenile justice and child welfare. It is incumbent upon policymakers to provide adequate support 

and assist youth in navigating these difficult times. 

Highlights: 

• COVID-19 has significantly impacted children and adolescent physical and mental health. 

• Black, Latinx and Native American youth have been disproportionately affected by the 

pandemic. 

• Poverty and financial inequality have further exacerbated the effects of the pandemic among 

poor youth. 

Recommendations: 

1. School systems must think creatively to encourage ongoing learning over the summer. Initiatives 

might include expanding existing summer-school programs, working with agencies that run 

summer camps and youth programs so that they add academics to their activities, and enlisting 

corporations to identify and train volunteer tutors. 

2. Health systems must engage with other systems (school, social welfare, and juvenile justice) to 

educate and encourage youth to engage in behaviors that will prevent COVID-19 infections, but 

also provide preventive measure to prevent or limit the effects of depression and anxiety. 

3. Policymakers should advocate for full funding of social welfare programs for youth and families 

affected by the pandemic so that there will be an adequate safety net. 

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P

ast pandemics, such as the Influenza of 1918, 2009 H1N1 flu, and the 2014 Ebola virus were all 

associated with increases in depression and anxiety in the population.

1 Like these prior 

pandemics, COVID-19 has similarly been associated with increased depression and anxiety; 

however, these mental health issues have been further exacerbated by the social unrest that 

that has occurred concurrently.2 In addition, COVID-19 has impacted people of color 

disproportionately. Infection case rates, hospitalizations, and death rates among Black, Latinx and 

Native Americans in the U.S. were two to five times higher than among the white population.3 Further 

compounding the pandemic stressors among these minority groups are the well-publicized and 

distressing police murders resulting in emotionally charged national protests and a collective outcry 

against racism and inequality. 

Children and adolescents, for the most part, have largely been spared from the physical consequences 

of COVID-19. Although the general population child infection and death rates from COVID-19 have 

remained low over the past year, early findings suggested that Black, Brown and Indigenous children 

and young adults represented an overwhelming number of the COVID-19-related deaths for those under 

the age of 21.4 However, with each new variant, it appears that the medical risk to children and 

adolescents appear to be increasing.5 This is especially true with the Delta variant that appears to have a 

higher rate of infectivity than prior variants.6 

In addition to considering the physical impacts of the virus, much attention has been given to the mental 

and developmental concerns and risks related to the significant disruption to everyday lives of children 

and youth. Although pediatric emergency department visits have decreased overall during the 

pandemic, the number of pediatric emergency department-related visits for mental health 

concerns have increased.

7 These trends continue to be called out, with at least one state—Colorado— 

declaring the gaps in services for youth mental health a “state of emergency” within the overarching 

disaster of the pandemic.8 

Many schools struggled to locate many of their students, and concerns about the increase in domestic 

violence, child trafficking and the health and well-being of America’s children and youth was voiced by 

many child advocates.

9 Psychological distress in families has hit unprecedented levels in the United 

States with 40% of adults struggling with mental health issues by June 2020 during the pandemic.

10 

While the full impact on youth is unclear from the current literature, it has been suggested that there 

are likely long-term repercussions of COVID-19 on children and adolescents.

11 The degree to which 

youth are impacted will depend on vulnerability factors, such as developmental age, pre-existing mental 

health condition, and socioeconomic status, and other social determinants of health. 

The demand for psychiatric acute care beds has also substantially increased.

12 Parents voiced concerns 

about the inability to provide educational support, limited internet access, the struggles to oversee the 

educational needs of multiple children on different grade levels and the noted changes in their 

children’s eating, sleeping patterns and behavior. In 2020, our children were more vulnerable than ever 

to the chronic stress in the home, the social isolation, involvement in, and awareness of the murders at 

the hands of the police to people of color, the social unrest and the lack of support, i.e. meals, provided 

in schools and communities.13 

The abrupt closing of in-person instruction has, for many across the country, continued well into 2021, 

significantly hindering children’s social interactions and activities. The transition to online learning came 

with challenges for many, and the ability of students to effectively work remotely is proving to be 

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disproportionate across socio-demographic groups. Black youth are more likely to be learning solely 

online than their white counterparts,14 which carries a host of immediate and long-term educational 

gaps and developmental consequences. Although the goals have been to return to in-person learning in 

the fall of 2021, there remains tremendous anxiety and uncertainty about this plan, especially with mask 

mandates and other precautions returning by summer of 2021 in the context of the spread of the Delta 

variant. The disruptions that have occurred by the time of this writing and that will likely continue to be 

experienced will undoubtedly impact the social, mental, and physical well-being of youth, adolescents 

and young adults for years to come. 

COVID-19 Educational Disparities in Children and Youth 

The pandemic has negatively impacted school readiness and has resulted in educational gaps for all 

students. Youth from Black, Hispanic, and low-income communities have been negatively impacted 

more than white youth.

15 Many of these youth were already dealing with the loss of loved ones, 

increasingly difficult financial situations, and parental stress. These situations were worsened as the 

pandemic has continued. School shutdowns and transition to online learning presented challenges for 

students from many communities. The United States educational system was not designed to weather 

the effects of a pandemic such as extended closures, rapid changes in teaching methods with an 

increase reliance on technology. 

When students started school in Fall 2020, on average, they were about three months behind in 

mathematics.16 Students of color were about three to five months behind in learning; white students 

were about one to three months behind.17 School districts, business leaders and others have suggested 

plans to address the educational gaps, which if not addressed will translate into wider achievement 

gaps.18 Although all students are suffering in various ways, those who came into the pandemic with the 

fewest academic opportunities are on track to exit with the greatest learning loss. 

Beyond access and quality of instruction, students must be in a physical and emotional state that 

enables them to learn. The COVID-19 pandemic has wreaked havoc on families, leaving many children in 

precarious and vulnerable situations. Feeding America notes that one in four children is at risk of hunger 

during the pandemic.19 Efforts to assist in this area are notable, such as a grant program through the 

National Farm to School Network that stood as one example of targeting communities 

disproportionately impacted by COVID-19 and hunger to assist getting fresh food to children.20 The 

number of children who are housing-insecure has risen as families struggle to pay rent.21 Parental 

supervision and support may be more difficult in families in which both parents need to work outside 

the home, or in which the parents are English-language learners and cannot directly support their child’s 

learning. 

With the COVID-19 pandemic shutting down in-person classes and moving to a virtual learning system, 

families with children who have intellectual and developmental disabilities (IDD) also experienced a new 

set of challenges. According to the National Center for Education Statistics, about 14% of all US public 

school children aged 3-21 received special education services through the Individuals with Disabilities 

Education Act.

22 When schools closed, many families reported a decrease in services offered and some 

children stopped receiving services at all. In a study by Neece et.al where majority Latinx parents that 

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had a child with IDD were asked about their pandemic experience, 79.9% of families report that their 

child’s services were decreased.23 

In addition, many families who still received services virtually, just like other school age children, cited 

issues with the new model of education.24 Virtual learning can be especially difficult for children who are 

vision or hearing impaired. Prior to the pandemic, students with specific learning disabilities often had 

specially trained instructors to create their individual education plans. With the sudden changes, parents 

had to take up the role of educators causing a great deal of stress and many worried that they were not 

able to meet their child’s education needs in addition to balancing work and other responsibilities. This 

was especially amplified in single parent households and low-socioeconomic status families.25 With the 

loss of their general support system and normal routines, many of these children began to display an 

increase in challenging and disruptive behaviors putting further stress on the child and their caretakers. 

In comparative studies, it was shown that parents of children with IDD were more likely to report 

increased problematic behavior and mood changes in their children than families with children without 

disabilities.26 Families also reported that because their child needs were so great, there was significantly 

more worry about losing income and the care of their child if a caretaker were to get sick or pass away 

from COVID-19. With reopening after the lockdowns caused by COVID-19, additional work and planning 

will be needed to make sure these children and their families can transition back to in person classes in 

the safest and least stressful way. In doing so, it will be helpful for policymakers to learn from what went 

right and wrong during this pandemic to make sure in the future there are sufficient plans in place, as 

well as resources, to better support vulnerable families. 

Covid-19 Health Disparities in Children and Youth 

Since the onset of the coronavirus pandemic, the nation's health inequalities have become even more 

glaring, with millions of Americans of color, Black and Latino in particular, experiencing more severe 

illness and death due to COVID-19 than white Americans.

27 Yet, relatively few children have died from 

COVID-19 overall. Only 0.26% of all COVID deaths and less than 1% of COVID hospitalizations are in 

youth less than 18 years.28 However, children have begun to increase in numbers impacted, and by midyear 2021, up 21% of new COVID-19 infections are reported in children. This number is likely to rise with 

the Delta variant growing in prominence in the United States by the summer of 2021 and with plans for 

school opening to in person learning in Fall 2021.29 Furthermore, recent data from the Centers for 

Disease Control and Prevention (CDC) reveals that the same racial and ethnic disparities that have 

affected adults throughout the pandemic, also extend to children of color.30 

When it comes to severe illness and deaths from the virus, as noted above, children of color bear a 

disproportionate burden. Several studies -- and the CDC's database -- reveal that among all children, 

Black and Hispanic children are more likely to die of the disease.31,32According to 2020 data provided by 

the CDC, overall at least 423 children and adolescents have died of COVID-19.

33 Latino and Black children 

currently represent approximately 65% of these deaths. Additionally, children of color are more likely to 

experience a severe COVID-related inflammatory illness, MIS-C. As of July 31, 2021, 4404 U.S. children 

have been diagnosed with MIS-C. This rare and extreme immune system response is linked to COVID-19, 

with 37 MIS-C pediatric deaths according to the C.D.C.34 And at least 63% of reported MIS-C cases have 

occurred in children who are Hispanic or Latino or Black, non-Hispanic. 

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The impact of COVID-19 in pediatric populations mirror racial disparities in the adult population. The 

disproportionately high case rates in Black and Latino children largely reflect how the adults in their lives 

have been impacted. Affected families are more likely to include essential workers who have had to risk 

exposures in order to do their jobs. They are also more likely to live in multigenerational homes or more 

crowded conditions that make distancing or isolating difficult. Communities of color are more likely to 

experience barriers to high-quality health care and testing, or to face cultural or language challenges in 

having access to health care. Underlying chronic health conditions that occur in minority youths can 

adversely affect the course of COVID-19 infection as well. 

Social Isolation and Social Media Effects 

The COVID 19 pandemic and the associated social isolation for extended periods of time have been 

linked to worsening mental health.35 Increased loneliness in children and adolescents has been linked to 

future mental health problems like depression and social anxiety.36 Additionally there has been a 

worsening of pre-existing conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Post 

Traumatic Stress Disorder (PTSD), and developmental disorders.37 Much of the early data has caused 

concern among experts and practitioners that many of these symptoms may lead to chronic symptoms 

that will affect youth years after the pandemic. Despite the relative lack of data related to the pandemic, 

the child development literature has shown that prolonged isolation can have a negative effect on child 

and adolescent development.38 Because peer interaction is such an important developmental factor, the 

lack of stimulation can lead to cognitive, emotional, and psychological changes in youth. Animal studies 

have shown that complete social isolation in adolescents resulted in structural changes in the brain and 

limited peer to peer contact within this developmental stage caused anxiety and reduction of growth in 

the hippocampus.39 Behaviorally, animal models of social isolation have demonstrated resultant 

increased aggressiveness, decreased learning and attention, and increased anxiety and depressive 

symptoms. It is unknown how well the animal studies relate to human development, so more research is 

needed. 

A study by Orben and colleagues demonstrated that social media has had both positive and negative 

influences on youth during this pandemic.40 Technology, such as video chat, has been beneficial in 

maintaining social connectedness. The use of technology has allowed teens to connect with their peers 

with some remediation of the effects of social isolation. However, Guessoum, and colleagues have 

shown that social media, when used passively, can lead to more negative outcomes.41 Increased reliance 

on technology places youth at risk for internet addiction, which has been linked to depression. The 

overuse of social media can also be detrimental as many of these youth are at risk of exposure to cyber 

bullying which has been shown to have a negative impact on mental health among youth.

42 Parents 

vigilance in monitoring the use of the internet, especially in young children, may better protect their 

safely and mental health. However, many parents, especially parents with limited economic means and 

socials supports, may not be in a position to provide adequate supervision during periods when their 

younger children are online. 

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Juvenile Justice Youths and Adults impacted by COVID-19 

Individuals impacted by COVID-19 are from populations that have seen their healthcare vulnerabilities 

exacerbated during the COVID-19 pandemic.

43 Those who are incarcerated are among the most 

vulnerable groups as they frequently do not have the ability to physically distance themselves from 

others or take other precautions to protect themselves from COVID-19 infection. Until May 2021, youth 

in juvenile detention facilities did not have access to vaccinations to help prevent illness and spread of 

disease.44 

Youth impacted by the juvenile justice system are an important, largely overlooked pediatric population 

that experienced many of the devastating consequences from COVID-19 that affected other poor and 

minority youth. COVID-19 among detained youth has been reported in 41 states and the District of 

Columbia. Cases among staff in juvenile detention facilities have been reported in 43 states and the 

District of Columbia.

45 Correctional facilities experienced high likelihood of COVID-19 outbreaks, and 

disproportionate risk for the 44,000 incarcerated youth, which includes 80% who have a mental health 

disorder.46 Multiple correctional facilities became US epicenters for COVID-19. Incarcerated youth and 

youth in contact with adults living or working in corrections experienced heightened risk of contracting 

COVID-19.

47 

The majority of detained youth in the US are poor and from minority groups. They are more likely than 

white youth to be arrested as juveniles48 and are five times more likely than white youth to be 

incarcerated in juvenile facilities.

49 The data on COVID-19 and juvenile justice is limited. Rovner has 

reported that there are at least 1,677 youth in juvenile facilities have tested positive for COVID-19; 

however, this number is likely higher.

50 

Although it can be easy to forget the plight of youth and adults who are disproportionately in custody, 

especially during the COVID-19 global crisis, doing so will also threaten the health and well-being of 

children and their families across the country and the world. Incarceration in the juvenile justice system 

subjects that youth to additional detrimental experiences, such as solitary confinement, that contribute 

to negative long-term outcomes.

51 The stress of being in a juvenile justice facility can be an isolating 

experience. This level of isolation is greatly exacerbated with COVID-19 and places youth at increased 

risk for negative mental health outcomes. Disruptions, including decreased educational opportunities, a 

lack of meaningful programming, no physical contact with family members or visits from professionals 

or their advocates due to the COVID-19 pandemic, can lead to increased loneliness, depression, and 

anxiety.

52 

Institutionalized Children and Youth during COVID-19 

The pandemic has resulted in closures of schools, decreased employment, and shuttering of faith-based 

organizations. Local school districts are reporting that there are an increased number of youth who have 

dropped out of school.

53 These factors have been associated with contract with the juvenile justice 

system.54 The reciprocal links between school engagement, youth problem behaviors, and school dropout 

during adolescence.55 The pandemic has caused detention facilities and residential placements to limit 

the number of youth in confinement care.

56 The pandemic paused the US school-to-prison pipeline: 

potential lessons learned.57 While the number of youth that are in juvenile detention facilities or other 

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residential facilities has decreased during the pandemic, the evidence of disproportionate confinement 

of minority youth became more pronounced.

58 

Youth detention is frequently associated with negative outcomes; however more recent attempts to 

introduce trauma informed care into detention settings have promise in helping youth navigate the 

traumas that are antecedents to their detention.

59 Trauma informed childcare residential placements 

and hospitals often provide a safe space, while catering to the treatment, educational and basic needs of 

children and adolescents. Many of the youth that may have benefitted from being in a residential 

setting have remained in community settings where there is decreased treatment availability and safety 

net services as a result of the pandemic.

60 

For youth that have been detained during the pandemic, social distancing mandates were enacted and, 

non-resident staff and family members had to be kept off the premises during the height of the 

pandemic. The necessity of arranging additional quarantine space for those infected, the supervision of 

children under physical mandated distancing policies with limited staff aggravated the system of care 

needed to support the confined youth and address this crisis. This social isolation has understandably 

resulted in increased anxiety and depression in detained youth.

61 

Although much of the mental health continuum of care for youth is moving towards maintaining youth 

in their natural home environments, given the myriad of challenges facing youth, residential placements 

have also been in demand. As such, capacity building is needed to effectively manage the need for an 

array of mental health services to handle the crisis. Relaxing the eligibility for admissions to adequately 

address the crisis experienced by families and community members could offer another approach to 

providing access to needed supports. 

Financial Inequalities Impacting Youth and their Families During COVID-19 

Loss in income, employment, and food security can have both direct and indirect negative effects on 

children. Family instability, such as that produced by sudden unemployment, can affect children’s socialemotional, cognitive, and academic outcomes. Furthermore, children who experience sustained 

poverty are more likely to drop out of high school, have irregular employment, and experience poverty 

as adults.62 

Families living in households where the rent or mortgage payment was late and where there was not 

enough food have struggled during this pandemic. At the national level, the Household Pulse Survey 

Phase 1 data April 23, 2020-July 1, 2020) indicated that about 11.8 million children live in households 

that missed a mortgage or rent payment or sought a deferment, while roughly 3.9 million children were 

experiencing COVID-19 induced food shortages.63 However, these groups include substantial overlap — 

nearly 1.3 million children live in households facing both food and housing types of insecurities. 

In preparation of future pandemics, narrowing existing equity gaps is critical to ensuring a path to a 

more equitable future that promotes shared prosperity, health and well-being for all. There are policies 

and programs that point the way forward, both in the short and long term. In addition to the funds 

made available through the Coronavirus Aid, Relief, and Economic Security Act, Policymakers can 

also consider steps to reduce the pandemic’s economic effects, such as increasing protection and pay 

for essential workers, supporting efforts to stabilize renters, improving access to refinancing for 

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homeowners, and establishing a federal jobs program to get people back to work and prevent extended 

periods of unemployment and food insecurity for those disproportionately impacted such as families of 

color. 

Telemedicine, COVID-19 and Impact on Youth 

As recently as February 2020, before the current pandemic was declared, there was evidence supporting 

teen interest in and acceptance of receiving primary healthcare virtually. The work by Sequeira et. al 

suggests that many gender-diverse youth were open to using telehealth to receive gender-affirming care 

and were particularly interested in doing so for ongoing care (such as for laboratory monitoring and 

medication refills).64 A potential benefit of virtual visits for children and adolescents includes the ability 

to avoid stigmatized reactions and receive confidential services without alerting caregivers because of 

travel needs. 

As adolescents embrace the use of telemedicine during the COVID-19 pandemic, we must continue to 

work to ensure that care is available as widely as possible. This includes decreasing barriers to care 

including lack of broadband connectivity, lack of equipment, limited knowledge of the technology 

needed to connect, and lack of access to providers offering telemedicine. Ideas for future telemedicine 

uses include increasing school-based telehealth services, partnering with community agencies to help 

reach youth who are homeless or involved in the juvenile justice system. Focus on rural areas and 

provider shortage locations is critical to decreasing the inequalities of health care. One area of 

significant concern is the access to confidential services (reproductive health, contraception, mental 

health, addiction services, and medicine) that may be otherwise difficult to access. 

Policy makers and funders should also consider how to develop care teams that incorporate 

telemedicine even though providers may work remotely, and team members may not in the same 

physical location. More research is needed on 

health care delivery to adolescents and young 

adults using technology-based solutions. 

Guidelines must be developed on how to involve 

learners in care and teach the future adolescent 

health providers how to think creatively about 

solutions for reaching youth without 

compromising safety elements in care delivery, 

such as suicide risk assessment and management. 

One thing is certain moving forward, now that 

patients and providers have experienced digital 

technology for health care, school, and social 

connection, technological innovation is healthcare 

is here to stay and likely increase. Over time, 

specific methodologies and research analytics will 

help drive shifts in how telemedicine is delivered 

for continuous quality improvement. 

Recommendations to strengthen youth and 

families in the context of COVID-19* 

1. Ensure that race and equity are primary 

considerations as policies are developed. 

2. Ensure that physical and mental health is prioritized 

across all youth 

3. Assist youth and families with economic stability and 

recognize its importance in emotional well-being 

4. Advocate for equivalent and adequate funding for 

schools to meet the needs of all youth including 

those disproportionately impacted by the pandemic. 

*Adapted from recommendations by The Annie E. Casey 

Foundation 

https://www.aecf.org/blog/new-report-finds-many-familieswith-children-are-depressed-uninsured-hungry. December 14, 

2020 

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Confidentiality will continue to be a cornerstone of adolescent visits. When using telemedicine, top 

priorities of the health care teams will include ensuring the virtual environment is established to be 

private as well as safe. This is particularly challenging when the youth is meeting with a provider or a 

care team from home, given the often-crowded living environment for youth of color and those in 

crowded urban settings with multi-generational families residing in small residential settings. In the 

office setting, family members and other caregivers are asked to leave the examination room, so the 

provider and adolescent can speak freely. This may not be feasible when providing care to a patient at 

home, so youth may need to be asked to move to a more private location (if available), use a headset, or 

use the chat feature of the video conference tool to obtain and share confidential information. 

Screening for mental health may require providers to send documents via email or utilize an electronic 

health record ahead of scheduled encounters. This pre-visit screening necessitates the need for safety 

protocols to address acute concerns (such as suicidality or disclosed abuse) outside of the telemedicine 

encounter. 

Despite challenges, providers saw patients using telemedicine during the pandemic65 and there is 

growing evidence that telemedicine is feasible for providing care to youth for a variety of health 

concerns, including contraception, gender-affirming care, behavioral health, substance use, eating 

disorder treatment, and for continuing the clinical education of future leaders in adolescent health. 

Conclusion 

More than one year after the death and trauma of so many who succumbed to COVID-19, where are we 

now and what must we do to ensure families, children and communities can move to a state of health 

and wellness? With the toll of Covid-19 hopefully soon more on our heels, how do we begin to address 

racial disparities among children, and families which could impact their health and well-being today as 

well as later in life? The pandemic’s impact has yet to be fully realized as states continue to struggle to 

move beyond the crisis and as the virus continues to evolve. As stated earlier, pandemics of the past 

have always left many young people experiencing anxiety and depression and in need of services and 

supports. How do we meet the needs of those whose mental health challenges have been exasperated 

by the pandemic-- all while engaging families who have never received services for their children? Much 

has been realized with regard to priorities and needs, including: the need to improve the mental health 

care provided for children, adolescents and their families; the need to embrace a workforce of 

professionals to provide the continuity that children, especially children and adolescents struggling with 

anxiety, deserve; and last but not least, the need to build trust during numerous events of highly 

publicized racial injustices. Put simply, the COVID-19 pandemic has brought racial/ethnic disparities in 

health, education, the justice system, income, into plain sight, and this has been alarmingly apparent for 

adults, as well as for children. We can and we must improve the inequities that plague our country. Now 

more than ever silos need to fall, family’s voices should be heard, and faith-based organizations need to 

be acknowledged and embraced as a resource to provide care in many communities of color, while local 

community leaders are more embraced and supported. We need systems of care and these systems 

must be energized to focus on youth who hold the promise of tomorrow. 

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a lifetime. New York, NY, McKinsey & Company, 2020 19 Children facing hunger come from families who face hunger, too. Chicago, IL, Feeding America, 2020. 

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2021. https://data.cdc.gov/NCHS/Provisional-COVID-19-Deaths-Focus-on-Ages-0-18-Yea/nr4s-juj3 34 Health department-reported cases of multisystem inflammatory syndrome in children (MIS-C) in the United 

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and COVID-19 using a brief online tool. Psychiatry Research 2021; 298: 113773 37 Sibley MH, Ortiz M, Gaias LM, et al: Top problems of adolescents and young adults with ADHD during the COVID19 pandemic. Journal of psychiatric research 2021; 136:190-197 38 Loades ME, Chatburn E, Higson-Sweeney N, et al: Rapid systematic review: the impact of social isolation and 

loneliness on the mental health of children and adolescents in the context of COVID-19. Journal of the American 

Academy of Child & Adolescent Psychiatry 2020; 59(11):1218-1239 39 Scaccianoce S, Del Bianco P, Paolone G, et al: Social isolation selectively reduces hippocampal brain-derived 

neurotrophic factor without altering plasma corticosterone. Behavioral brain research 2006, 168(2), 323-325 40 Orben A, Tomova L, Blakemore SJ: The effects of social deprivation on adolescent development and mental 

health. Lancet Child Adolesc Health 2020;4(8):634-640 41 Guessoum SB, et al: Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry 

research 2020; 113264 42 Whittaker E, Kowalski RM: Cyberbullying via social media. Journal of school violence 2015; 14(1):11-29 43 Fortuna LR, Tolou-Shams M, Robles-Ramamurthy B, et al: Inequity and the disproportionate impact of COVID-19 

on communities of color in the United States: The need for a trauma-informed social justice 

response. Psychological Trauma: Theory, Research, Practice, and Policy 2020; 12(5):443 44 Scherer AM, Gedlinske AM, Parker AM, et al: Acceptability of Adolescent COVID-19 vaccination among 

adolescents and parents of adolescents – United States, April 15–23, 2021. MMWR 2021; 70(28):997–1003 45 Rovner J: There are at least 1,677 incarcerated youth who have tested positive for #covid19, a three-person 

increase since Friday. 2020. https://twitter.com/JoshRovner/status/1300436108568920065 46 Ibid 47 Barnert ES: COVID-19 and youth impacted by juvenile and adult criminal justice systems. Pediatrics 2020, 146(2) 48 Rovner J: Racial disparities in youth commitments and arrests. Washington, DC, The Sentencing Project, 2016. 

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49 Black Children Five Times More Likely Than White Youth to be Incarcerated. Montgomery, AL, Equal Justice 

Initiative, 2017. https://eji.org/news/black-children-five-times-morelikely-than- whites-to-be-incarcerated/ 50 Rovner J: There are at least 1,677 incarcerated youth who have tested positive for #covid19, a three-person 

increase since Friday. 2020. https://twitter.com/JoshRovner/status/1300436108568920065 51 Lambie I, Randell I: The impact of incarceration on juvenile offenders. Clinical psychology review 2013; 33(3): 

448-459 52 Kolivoski KM, Berchie E, Student MSW: Black Youth in the Juvenile Justice System, Mental Health, and COVID19. The Black Perspective Monograph 3: Addressing the COVID-19 Pandemic through an Examination of Mental 

Health and Health Disparities in the Black Community 2020, 70 53 McMorris-Santoro E: Thousands of students have dropped out of school due to COVID-19. These are the 

educators trying to track them down. CNN, 2021 Mar 8. https://www.cnn.com/2021/03/06/us/covid-pandemichigh-school-dropout/index.html. 54 Wang MT, Fredricks JA: The reciprocal links between school engagement, youth problem behaviors, and school 

dropout during adolescence. Child development 2014; 85(2):722-737 55 Ibid. 56 Vinson S Y, Waldman R J: The pandemic paused the US school-to-prison pipeline: potential lessons learned. The 

Lancet Child & Adolescent Health 2020; 4(11):799-800 57 Ibid. 58 Juvenile justice is smaller, but more unequal, after first year of COVID-19. Baltimore, MD, The Annie E. Casey 

Foundation, 2021. https://www.aecf.org/blog/juvenile-justice-is-smaller-but-more-unequal-after-first-year-ofcovid-19 59 Pickens I: Laying the groundwork: Conceptualizing a trauma-informed system of care in juvenile 

detention. Journal of Infant, Child, and Adolescent Psychotherapy 2016;15(3):220-230 60 Ellison K: Children’s mental health badly harmed by the pandemic. Therapy is hard to find. The Washington Post, 

2021 Aug 13. https://www.washingtonpost.com/health/child-psychiatrist-counselor-shortage-mental-healthcrisis/2021/08/13/844a036a-f950-11eb-9c0e-97e29906a970_story.html 61 Simkins S, Beyer M, Geis LM: The harmful use of isolation in juvenile facilities: the need for post-disposition 

representation. Washingt. Univ. J. Law Policy 2014; 38:241–287 62 Funk M, Drew N, Knapp M: Mental health, poverty and development. Journal of public mental health 2012; 

11(14):166–185 63 Mont L, O'Donnell S: Adults in Households with Children Report Higher Rate of Late Housing Payments and Food 

Shortages Amid COVID-19. Washington, DC, US Census Bureau, 2020. 

https://www.census.gov/library/stories/2020/06/the-risks-children-face-during-pandemic.html 64 Sequeira G, Kidd KM, Coulter RWS: Transgender youth perspectives on telehealth for delivery of gender 

affirming care. J Adolesc Health 2020 65 Pinals DA, Hepburn B, Parks J, et al: The behavioral health system and its response to COVID-19: A snapshot 

perspective. Psychiatr Serv 2020; 71(10):1070–1074 

139
 

 

Mental Health 

System Development 

in Rural and Remote 

Areas during 

COVID-19 

No. 7 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

140
 

 

Mental Health System Development in Rural 

and Remote Areas during COVID-19 

David de Voursney, M.P.P. 

Director, Division of Service & Systems Improvement, Center for Mental Health Services 

U.S. Substance Abuse and Mental Health Services Administration 

Francine Arienti, M.A. 

Human Services Director 

Technical Assistance Collaborative, Inc. 

Kevin Martone, L.S.W. 

Executive Director 

Technical Assistance Collaborative, Inc. 

Cover Art by Malkah Pinals 

Seventh in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

141
 

 

 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, or 

other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

de Voursney, D., Arienti, F., Martone, K. (2021). Mental Health System Development in Rural and Remote 

Areas during COVID-19. Technical Assistance Collaborative Paper No. 7. Alexandria, VA: National 

Association of State Mental Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

142
 

 

 

 

 

 

 

 

 

 

 

Abstract: 

Mental health service barriers in rural and remote areas, including unmet need, lack of access to 

services, and insufficient workforce capacity have been exacerbated by the COVID-19 pandemic. 

These factors also impact tribal governments and American Indian and Alaska Native (AI/AN) 

populations living in rural and remote areas, which face additional obstacles in mental health service 

delivery, but also have unique cultural and programmatic assets. An existing body of work explores 

problems and solutions faced in the delivery of mental health services in rural, remote, and tribal 

areas. This paper summarizes some of this work and explores the context of COVID-19. In addition to 

a review of the literature, the paper draws on national survey data and interviews with experts. The 

paper examines rural and remote mental health systems during the pandemic within the “Beyond 

Beds” framework, assuming a goal of creating a robust, interconnected, and evidence-based system 

of care. Rural and remote populations have experienced increased prevalence of mental illness a 

result of COVID-19, but the complete impact of the pandemic on mental health and social wellbeing 

remains unknown. Rural and remote mental health systems experienced disruptions to service 

delivery and rapid adoption of tele-behavioral health during the pandemic. While this natural 

experiment demonstrated the value of increased tele-behavioral health care, additional work 

remains to understand the optimal role of telehealth in rural and remote mental health systems. 

Highlights: 

• Rates of mental disorders are generally similar across rural and non-rural areas and the 

substantial negative impacts of COVID-19 on mental health seem also to be similar 

• Overall rates of mental health care receipt are not largely different across rural areas and 

other areas, but access to specialty and intensive care is lower in rural areas. 

• Rural areas continue to face mental health workforce shortages, which may be addressed 

using a range of approaches. 

• More work remains to develop and adapt mental health care models for rural and remote 

areas, including models that are effective for AI/AN communities. 

• COVID-19 led to a massive natural experiment in the rapid and widespread implementation 

of tele-behavioral health care. 

Recommendations for the Post-COVID-19 Future: 

1. Policymakers should try to learn from experiences during the pandemic to develop systems 

that encourage the appropriate role for telehealth, without reflexively reverting to the prepandemic status quo. 

2. Developing the rural mental health workforce should be a continued priority. Efforts to train 

and recruit mental health professionals in rural and remote areas should be combined with 

service adaptations and supports like remote consultation to fully leverage existing 

workforce capacity. 

3. There should be a more concerted effort to examine behavioral health surveillance, facility, 

and claims data by urbanicity, including stratification of data from more remote areas, to 

understand the impact of COVID-19 on systems and people in rural and remote areas. 

4. There is a need for service model innovation and adaptation in rural and remote areas, 

especially to meet the needs of people with intensive and complex mental health needs. 

This work should be attentive to different population groups, including AI/AN populations. 

143
 

 

 

 

 

 

 

 

 

Nearly one in five Americans lives in a rural or remotea area.1 People in these areas experience 

mental disorders at similar rates to people in urban and suburban areas but face barriers to 

accessing needed care.

2 The COVID-19 pandemic has exacerbated challenges in access and 

delivery of mental health services in rural and remote areas, including transportation, high poverty 

rates, and insufficient workforce capacity. Tribal mental health systems and American Indian and Alaska 

Native (AI/AN) populations living in rural and remote areas, who face greater behavioral health 

challenges than other population groups,3 have unique programmatic and cultural assets that can be 

learned from to address challenges associated with mental health care access in rural or remote areas. 

This review, Mental Health System Development in Rural and Remote Areas During COVID-19, explores 

problems and solutions faced in the delivery of mental health services in rural, remote, and tribal areas 

in the context of COVID-19. People living in rural and remote areas, including AI/AN individuals and 

communities, are best served by a robust, interconnected, and evidence-based system of mental health 

care, such as that presented in the Beyond Beds framework.4 With this as the goal, this paper attempts 

to examine the current state of mental health care in rural and remote areas and propose strategies for 

building a better system for the future. 

Mental Health System Development in Rural and Remote Areas during COVID-19 will address the 

following areas related to rural mental health systems as it is and areas of needed development. 

• The impact of COVID-19 

• Prevalence of mental illness and related problems 

• Access to treatment and specialty care 

• Workforce challenges in rural and remote areas 

• The unique needs of AI/AN communities 

• Telehealth services 

• Building the array of effective practices in rural and remote settings 

• Developing rural crisis systems 

Although this paper will discuss rural and remote areas generally, rural and remote areas across the 

United States are varied in terms of their populations, geography, and the mental health systems that 

serve them. Rural areas span all regions across the continental United States as well as Alaska and 

Hawaii. There are also rural areas in U.S. territories like Puerto Rico. Rural demographics also vary 

considerably. In many rural areas, there are significant American Indian, Alaska Native, or Pacific 

Islander populations. Some rural areas have sizable populations of migrant workers and Latino 

populations, others have large black or African American populations, such as rural areas in the south, 

whereas others are predominately white. 

As with the rest of the country, rural areas are also varied in terms of the mental health and substance 

use disorder systems that serve them. Different states provide different health, behavioral health, and 

human service arrays through Medicaid and their public systems. Some states have county and 

regionally driven systems which means that there can be significant variability in mental health and 

a In this paper we have decided to use the term remote instead of frontier. Frontier comes with the connotation that these 

areas are left to be explored and even exploited. We use the term remote to avoid this connotation and to recognize that 

people have lived in these areas for millennia. 

144
 

 

 

 

 

 

 

 

 

 

 

 

 

 

substance use disorder systems within states. States also vary in terms of the groups that are eligible for 

Medicaid and other state provided supports, which can lead to differences in access to care. 

The Impact of COVID-19 

The COVID-19 pandemic has had dramatic impacts across the United States, disrupting work, school, 

social interaction, and economic activity. Not surprisingly, these disruptions have had wide ranging 

impacts on mental health at the same time as disrupting mental health service delivery.5 Initially, death 

rates from COVID-19 were higher in urban areas, but by Summer 2020, rural rates of COVID-19 deaths 

had surpassed urban areas.6 Now, urban populations are being vaccinated at higher rates that rural 

populations,

7 which may result in higher levels of spread in impact in rural areas going forward 

compared with urban areas. 

There has been a marked increase in mental health problems in the United States due to COVID-19. 

According to a June 2020, Center for Disease Control and Prevention (CDC) survey: 8 

• 31% of respondents reported symptoms of anxiety or depression, an increase from 11.0 

percent in January through June of 2019. 

• 13% of people reported that they had started or increased substance use to cope with 

pandemic related stress or emotions. 

• 11% of respondents reported serious consideration of suicide in the previous 30 days, 

compared with 4.3% in a similar 2018 survey. 

There were not statistically significant differences in outcomes reported between urban and rural 

respondents, though at the time of the survey, people in rural areas reported fairing slightly better on 

average compared to urban counterparts across the items being measured.9 Later in the pandemic, the 

CDC reported national data collected between August 2020 and February 2021 which indicated that the 

percentage of adults experiencing symptoms of anxiety or depression increased from 36% to 42% 

without breaking out data for rural areas.

10 A survey of rural adults in December 2020 echoed these 

findings: 56% of rural adults said that they were personally experiencing more mental health challenges 

than a year ago. 53% of the respondents said that that COVID-19 had impacted their individual mental 

health “some” or “a lot,” and 61% said the same about the mental health impact in their 

communities.

11 In general mental health across the country seemed to decline as the pandemic 

continued. Current data does not seem to indicate large differences in impact in mental health across 

rural and non-rural areas, but a more detailed understanding may be possible as more data becomes 

available. 

In addition to impacting the mental health of people in the United States, COVID-19 has also disrupted 

access to mental health services. Comparing the period from March to October 2020 with the same 

period in 2019, there were approximately one-third fewer Medicaid or Children’s Health Insurance 

Program claims for mental health services for children and one-fifth fewer mental health claims for 

adults.12 Given that mental health needs increased during the pandemic, this means that many people 

did not receive needed care. In 2019, 11% of children 12 years and older who accessed mental health 

services did so through schools.

13 School closures potentially disrupted these supports in both rural and 

non-rural areas, which may have further reduced access to care for young people. 

The COVID-19 pandemic has presented additional challenges to providers trying to deliver mental health 

services in rural areas. Rural behavioral health systems were already stressed by the alarming growth of 

opioid use and overdose deaths over the past two decades, and early evidence suggests that the COVID145
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19 pandemic has exacerbated the opioid crisis.

14 Rural and remote areas already faced mental health 

service staffing challenges, and like other areas, were impacted by lack of personal protective 

equipment (PPE) and child care as schools halted in-person learning. Provider organizations had to 

manage the shift to delivering services virtually where possible and work to develop feasible business 

models in the COVID-19 context. The in-person service delivery that was central to most providers’ 

operations prior to the pandemic was no longer feasible and they were forced to adapt in order to 

continue generating needed revenue and delivering services. As Dennis Mohatt, Vice President for 

Behavioral Health and Co-Director of the Mental Health Technology Transfer Center at the Western 

Interstate Commission for Higher Education put it, “Delivering treatment, prevention, and support in 

rural and remote places is a difficult thing on a good day, and it hasn’t been a great day for a while.”15 

Prevalence of mental illness and related problems 

Before the pandemic, overall rates of mental illness and 

Large metropolitan counties: contain cities treatment receipt were similar across large metropolitan 

with a population larger than 1 million people. counties, small metropolitan counties and nonmetropolitan counties. According to data from the Small metropolitan counties: contain cities 

Substance Abuse and Mental Health Services with populations between 50,000 and 1 

Administration (SAMHSA) National Survey on Drug Use and million people. 

Health, in 2019, among people 18 years and older in non- Non-metropolitan counties: contain cities metropolitan counties, 21.2% met criteria for having any with populations no larger than 50,000 

mental illness (AMI), 5.9 percent met criteria for having a people. This is used to identify rural areas by 

serious mental illness (SMI), 7.0 percent met criteria for many surveys and government systems. 

having a substance use disorder (SUD) and 3.6 percent met 

criteria for having a mental illness and a co-occurring SUD. 

This is similar to national rates for AMI (20.6 percent), SMI (5.2 percent), SUD (7.7 percent) and cooccurring AMI and SUD (3.8 percent).16 

In 2018, rural areas experienced a higher suicide rate in than urban areas with 19.1 deaths by suicide per 

100,000 people compared with 13.4 per 100,000 in urban areas. The suicide rate in rural areas increased 

48% from 2000 to 2018.17 There are a number of factors that may contribute to higher suicide rates in 

rural areas including economic disparities, the larger presence of subpopulations that experience higher 

suicide rates, including AI/AN people and non-Hispanic white males, and higher rates of gun ownership, 

which are associated with increased risk of suicide.18 While there is not a clear reason for increases in 

the suicide rate, one leading theory is that they have been driven up as a part of general increase in 

“deaths of despair” resulting from problems in labor markets, educational attainment, marriage and 

family outcomes, and physical health.

19 

Access to treatment and specialty care 

Before COVID-19, total rates of past year mental health service use were similar across rural and nonrural areas. According to 2019 National Survey on Drug Use and Health (NSDUH) data: 

• 46.5% of people with AMI in non-metropolitan counties received mental health services in 

the past year compared with 43.6% in large metropolitan and 46.0% in small metropolitan 

counties. 

• 65.7% of people with SMI in non-metropolitan counties received mental health services 

compared with 65.9% in large metro and 64.9.%in small metropolitan areas.20 

146
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

However, patterns of mental health treatment receipt across rural and urban counties differ by type of 

treatment received. Data from 2010 to 2019 prior to COVID-19 showed that people in non-metropolitan 

counties were significantly less likely to receive outpatient treatment than individuals in large or small 

metropolitan counties and significantly more likely than people in large metropolitan areas to receive 

prescription medication without other forms of treatment (see Table 1 for details). 

Table 1: Past Year Mental Health Treatment Receipt by County Metropolitan Status (2010-2019) 

County 

Metropolitan 

Status 

Total Any 

Mental 

Health 

Treatment 

Any 

Inpatient 

Treatment* 

Any 

Outpatient 

Treatment 

Only 

Outpatient 

Treatment 

Only 

Received 

Prescription 

Medication 

Only 

Received 

Outpatient 

Treatment 

and 

Prescription 

Medication 

Received 

Inpatient and 

Outpatient 

Treatment 

and 

Prescription 

Medication 

Total Number 239,574,000 35,034,000 2,135,000 17,202,000 4,993,000 16,911,000 10,855,000 997,000 

Percent 100.00% 14.60% 0.90% %6.50 2.10% 7.10% 4.50% 0.40% 

95% CI N/A (14.50% -

14.80%) 

(0.80% -

0.90%) 

(6.40% -

6.60%) 

(2.00% -

2.10%) 

(6.90% -

7.20%) 

(4.40% -

4.60%) 

(0.40% -

0.40%) 

Large 

Metro 

Number 129,695,000 18,031,000 1,111,000 9,436,000 3,022,000 8,098,000 5,721,000 502,000 

Percent 100.00% 13.90% 0.90% 6.60% 2.30% 6.20% 4.40% 0.40% 

95% CI N/A (13.70% -

14.10%) 

(0.80% -

0.90%) 

(6.40% -

6.70%) 

(2.20% -

2.40%) 

(6.10% -

6.40%) 

(4.30% -

4.50%) 

(0.40% -

0.40%) 

Small 

Metro 

Number 72,012,000 11,383,000 653,000 5,412,000 1,428,000 5,718,000 3,550,000 330,000 

Percent 100.00% 15.80% 0.90% 6.80% 2.00% 7.90% 4.90% 0.50% 

95% CI N/A (15.50% -

16.10%) 

(0.80% -

1.00%) 

(6.60% -

7.00%) 

(1.90% -

2.10%) 

(7.70% -

8.10%) 

(4.80% -

5.10%) 

(0.40% -

0.50%) 

NonMetro Number 37,867,000 5,620,000 371,000 2,354,000 543,000 3,094,000 1,585,000 165,000 

Percent 100.00% 14.80% 1.00% 5.60% 1.40% 8.20% 4.20% 0.40% 

95% CI N/A (14.50% -

15.20%)** 

(0.90% -

1.10%) 

(5.40% -

5.80%)** 

(1.30% -

1.50%)** 

(7.90% -

8.50%)*** 

(4.00% -

4.40%) 

(0.40% -

0.50%) 

Table populated using National Survey on Drug Use and Health: 10-Year Substate Restricted-use Data Analysis System (2010 to 2019) 

– using the following variables (COUTYP2, AMHSVTY, AUOPTYR, AMHTXRC3, AMHTXRC3, AUINPYR) 

* AUINPYR is not restricted to adults, youth 12-17 were excluded using CATAG18 as a control variable. 

** Non- Metropolitan Area result is statistically different from Large Metropolitan Area and Small Metropolitan Area results at the .05 

level 

*** Non- Metropolitan Area result is statistically different from Large Metropolitan Area results at the .05 level. 

While these numbers point to similar rates of treatment receipt across rural and urban areas, there are 

some important caveats. These data do not capture differences between people in more populous rural 

areas and people in remote areas. There may be more clear disparities in access to mental health 

services between metropolitan areas and more remote areas. These data also do not include 

information about the frequency of treatment receipt. It is possible that people in rural areas exhibit 

similar rates of treatment overall, but access treatment at lower frequency because of access barriers. 

These data also do not capture access to more specialized forms of mental health treatment and 

services, which people in rural areas are less likely to have access to. Compared to urban areas, people 

in rural areas are much more likely to seek mental health care through primary care. According to data 

from 2012–2014 National Ambulatory Medical Care Survey, 29% of physician office visits related to 

mental health in non-metropolitan areas were made to psychiatrists and 54% were made to primary 

care physicians, compared to 55% and 32% nationally.

21 This lack of access to specialized services for 

rural areas extends to other service systems. Veterans who have received mental health services from 

147
148

the Veterans Health Administration are much less likely to receive specialized care, including care for 

SMI, in rural areas.22 An examination of one state system showed that evidence-based programs (EBPs), 

such as Assertive Community Treatment (ACT), Supported Employment, Supportive Housing, and 

Multisystemic Therapy, were less likely to be offered in rural areas and staff in rural areas were less 

likely to be trained in EBPs in rural areas compared with urban areas.23

If the goal is to develop a robust system of care of quality treatment and services in rural and remote 

areas before, during, and after acute episodes of mental illness in keeping with the Beyond Beds 

framework,

24 we must look beyond rates of treatment receipt to examine more specialized supports and 

services. This is particularly true for adults with SMI and Children with Serious Emotional Disturbances 

(SED) who are dependent on public systems and will need access to more specialized and intensive 

supports to facilitate their recovery.

Prior to COVID-19, there were minor differences in the reasons given for not getting treatment by 

people in rural areas compared with more urban areas, according to the NSDUH (Table 2). People in 

rural areas were more likely to report cost as a reason for not seeking treatment compared with people 

in large metropolitan areas. Conversely, people in rural areas were less likely to report that they did not 

know where to go for services or that they didn’t feel that they needed services compared with people 

in large metropolitan areas. They were also less likely to report that they did not have time to access 

services compared with people in large or small metropolitan areas. Rural Americans were not 

significantly more concerned about negative opinions by friends and neighbors or impacts on their job 

than people in other areas but were more concerned about confidential information being shared by 

providers than people in large metropolitan areas. Interestingly, they were more likely to report that 

having no transportation, treatment being too far away, or the hours not being convenient as a reason for 

not seeking treatment compared to people in large urban areas, but not significantly more likely to report 

this as a reason for not seeking treatment than people in small metropolitan areas. Together, these results 

indicate that reasons for not getting treatment are similar across metropolitan and non-metropolitan 

areas. This seems to indicate that attitudinal barriers and even transportation are not driving large 

disparities in access in rural non-metropolitan areas ingeneral.

Table 2: Reasons Given for Not Getting Treatment that Was Felt to Be Needed in Past Year by 

County Metropolitan Status (2010-2019)

Reason Large Metro Small Metro Non-metro 

Could not afford cost 41.40% 

(40.30% - 42.60%) 

44.20% 

(42.80% - 45.60%) 

44.90% 

(42.90% - 47.00%)* 

Concerned about neighbors or community negative

opinion

9.40% 

(8.70% - 10.00%) 

9.80% 

(9.10% - 10.50%) 

10.00% 

(9.00% - 11.10%) 

Concerned about negative effect on job 8.60% 

(8.00% - 9.30%) 

8.20% 

(7.50% - 8.90%) 

8.90% 

(7.90% - 10.00%) 

Health insurance does not cover any mental health 

treatment or counseling

6.90% 

(6.30% - 7.50%) 

7.10% 

(6.50% - 7.80%) 

6.10% 

(5.30% - 7.10%) 

Health insurance does not pay enough for mental

health treatment or counseling

13.90% 

(13.10% - 14.80%) 

13.10% 

(12.10% - 14.10%) 

10.90% 

(9.70% - 12.30%)* 

Did not know where to go to get services 22.60% 

(21.60% - 23.50%) 

20.10% 

(19.00% - 21.10%) 

18.40% 

(17.00% - 19.80%)* 

Concerned information given to counselors might not

be kept confidential

7.90% 

(7.30% - 8.60%) 

8.20% 

(7.60% - 8.90%) 

10.00% 

(8.90% - 11.20%)* 

Concerned that you might be committed to a psychiatric 

hospital or might have to take medicine

10.30% 

(9.70% - 11.00%) 

11.00% 

(10.30% - 11.80%) 

11.20% 

(10.10% - 12.40%) 

Didn't think you needed treatment at the time 9.60% 

(9.00% - 10.30%) 

9.40% 

(8.60% - 10.20%) 

7.70% 

(6.80% - 8.60%)* 
149

Reason Large Metro Small Metro Non-metro 

Thought you could handle the problem without

treatment

26.50% 

(25.50% - 27.60%) 

25.80% 

(24.60% - 27.00%) 

24.10% 

(22.50% - 25.80%) 

Didn't think treatment would help 10.30% 

(9.60% - 11.10%) 

10.40% 

(9.60% - 11.20%) 

9.30% 

(8.20% - 10.40%) 

Didn't have time (because of job, childcare, or other

commitments)

18.70% 

(17.80% - 19.60%) 

17.80% 

(16.80% - 18.80%) 

14.20% 

(13.00% - 15.50%)** 

Didn't want others to find out that you needed

treatment

6.70% 

(6.10% - 7.20%) 

7.20% 

(6.60% - 7.80%) 

6.90% 

(6.10% - 7.80%) 

Had no transportation, or treatment was too far away, or

the hours were not convenient

4.20% 

(3.80% - 4.60%) 

4.50% 

(4.00% - 5.00%) 

5.70% 

(4.80% - 6.70%)* 

Table populated using National Survey on Drug Use and Health: 10-Year Substate Restricted-use Data Analysis System (2010 

to 2019) – using the following variables (COUTYP2, MHRCOST2, MHRNBRS2, MHRJOBS2, MHRNCOV2, MHRENUF2, 

MHRWHER2, MHRCFID2, MHRCMIT2, MHRNOND2, MHRHAND2

MHRNOHP2, MHRTIME2, MHRFOUT2, and MHRTRAN)

* Non- Metropolitan Area result is statistically different from Large Metropolitan Area results at the .05 level.

** Non- Metropolitan Area result is statistically different from Large Metropolitan Area and Small Metropolitan Area results

at the .05 level

Workforce Challenges in Rural and Remote Areas

Rural and remote areas have widespread shortages of mental health professionals. More than 25 million 

people in rural areas, almost half the rural population, live in Health Resources and Services 

Administration (HRSA) designated mental health professional shortage areas.25 Data from the National 

Plan and Provider Enumeration System shows that 65% of non-metropolitan counties do not have a 

psychiatrist and 47% do not have a psychologist.26 Non-metropolitan areas on average have 5.8 

psychiatrists and 13.7 psychologists per 100,000 people compared with 17.5 psychiatrists and 33.2 

psychologists per 100,000 people in metropolitan areas. Behavioral health provider supply was even 

more limited in more remote non-metropolitan counties without any small cites or towns, 80 percent of 

these counties lacked a psychiatrist and 61 percent lacked a psychologist.27 Specialized care is also less 

available in rural areas. People in urban areas have access, on a per capita basis, to 3.5 times as many 

child and adolescent psychiatrists, five times as many geriatric psychiatrists, and almost five times as 

many addiction psychiatrists.28

Building the rural mental health workforce will require a variety of strategies, such as providing financial 

incentives,29providing training and supervision necessary for licensure30 and active recruiting and 

retention efforts.31 Strategies for developing workforce capacity in rural areas includes adapting service 

delivery models because the most specialized and credentialed providers are less likely to be available in 

rural and remote areas. Mental health providers in rural and remote areas may have to adapt service 

models to rely more on providers with less credentials, including peer providers.

Task sharing or shifting tasks from more trained to less trained or specialized individuals is one approach 

to increasing capacity in underserved areas. Task sharing can leverage consultation with specialists to 

support service provision, such as expanding the capability of primary care to provide behavioral health 

services through the Collaborative Care Model.32 As noted earlier, people in rural areas are more likely 

to get behavioral health care from primary care providers. Although these providers may be comfortable 

treating more common mental disorders like anxiety and depression, they are less comfortable 

providing treatment for conditions like schizophrenia and bipolar disorder.33 Primary care providers also 

are unlikely to have the capacity to coordinate care for individuals with SMI that are facing challenges 

with social determinants of health, such as housing or employment challenges. Task sharing may be 

used to free up mental health specialist resources so that they can serve people with more complexor
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

intensive needs. Telehealth is another strategy for improving access, which is discussed in more detail 

below. 

COVID-19 has disrupted the business models and operations of mental health care providers leading to 

additional stressors for mental health care workers. For many mental health workers, shifting to 

telehealth platforms led to new forms of stress and compassion fatigue, while they concurrently 

struggled with disruptions to their personal lives that impacted everyone during the pandemic.34 In the 

near term, mental health systems, including those in rural and remote areas, will need to manage the 

shift to telehealth, support employees through pandemic related stressors, and shift business models to 

adapt to new ways of delivering services.35 The extent to which the shift to telehealth is a permanent 

change remains to be seen. The number of people who will seek care as public health measures relax, 

and the demand they will place on mental health systems is also unknown. Mental health systems will 

have to monitor and adapt, being mindful of the impact on their workforce. 

Meeting the unique needs of AI/AN communities 

AI/AN people come from diverse backgrounds and live in urban, rural, and remote areas across the 

United States: 40% of AI/AN people live in non-metropolitan areas and 22% live on reservations or other 

trust lands.

36 AI/AN people also come from distinct tribal backgrounds. 574 sovereign tribal nations have 

a formal nation-to-nation relationship with the federal government and there are 334 reservations 

across 35 states.37 

As of April 2021, AI/AN people in the United States experienced the highest death rate from COVID-19 

compared with other racial and ethnic groups and were 2.4 times as likely to die from COVID-19 

compared with whites.

38 Recognizing this tragic truth, the pandemic also demonstrated tribal public 

health capacity. Many tribes were able to institute innovative and forward leaning public health 

measures 39 and have also led in vaccine distribution, initially achieving higher rates of vaccination than 

other racial and ethnic groups.

40 

In 2019, among AI/AN people 18 and older, 23.6% met criteria for having AMI, 7.2% met criteria for 

having SMI, 8.9% of met criteria for SUD, and 4.7% met criteria for having AMI and a co-occurring SUD. 

For each of these conditions, AI/AN individuals experience higher rates than national averages across 

racial and ethnic groups. Nationally, AI/AN individuals 18 years and older were less likely to receive 

mental health services (13.9 %) compared with the national rate (16.1 percent).41 AI/AN people also had 

the highest rate of suicide among racial and ethnic groups in 2019, at 22.5 per 100,000 compared with a 

national rate of 13.9 per 100,000.42 

Mental health services for tribal communities often are provided by a mix of Indian Health Service (IHS), 

Tribal, county, state, and nonprofit organizations. In addition to the services and systems available to 

the general population, members of tribes living on or near reservations can receive services funded 

through the IHS. As of 2019, IHS served 2.6 million people across 37 states.43 In rural areas, this care is 

delivered through IHS facilities or through tribally operated facilities. Tribes that receive care through 

IHS are referred to as direct service tribes and tribes that manage their own health systems are referred 

to as self-governance tribes. These programs provide primary care and community health services, 

including behavioral health care through 568 facilities, including hospitals, health centers, health 

stations, Alaska village clinics, school health centers, and youth regional treatment centers. The 

availability of services varies across service units and locations. Specialty services and types of care that 

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are not available at these facilities can be purchased from private providers through the IHS 

purchased/referred care program, but this funding is limited.

44,45 

Tribal communities in rural and remote areas often are built around distinct sovereign tribal nations 

with unique needs and cultures. As a result, it is necessary to develop solutions that are specific to the 

context of each tribal community, that respond to the needs identified by that community and use 

practices that are chosen by and acceptable to that community. A number of strategies hold promise in 

the development of tribal mental health systems, such as developing a culturally competent and 

responsive workforce; adopting culturally adapted treatment approaches; integrating traditional 

practices into behavioral health supports; and using the traditional strengths embodied in tribal 

communities as a part of support systems for people with mental or substance use disorders.46 Given 

the shortage of culturally informed mental health workers in tribal communities, a natural solution is to 

recruit and train AI/AN individuals to become part of the behavioral health workforce. As with other 

rural and remote areas, task sharing with lower credentialed workers is another promising strategy,

47 

exemplified by the Behavioral Health Aides who serve tribal communities in Alaska. These individuals 

are supervised by licensed clinicians and provide a variety of therapeutic supports, including connecting 

people to higher levels of care when needed.48 

State and local mental health systems working with tribal communities need to respect the tribal 

independent status as they work collaboratively to ensure that the mental health needs of tribal 

community members are being met. As noted, IHS and tribal systems provide important mental health 

services including outpatient mental health counseling, access to dual diagnosis services, mental health 

crisis response and triage, case management, community-based prevention programming, and outreach 

and health education activities.

49 Yet, as with almost all local rural and remote behavioral health 

systems at the community level, tribal mental health systems are unlikely to provide all needed services, 

such as inpatient care, or intensive coordinated services for individuals with SMI. In fact, as of 2011, no 

IHS facilities provided inpatient psychiatric services.50 

Building the capacity to serve members of tribes in a culturally responsive manner in collaboration with 

tribal mental health systems is the responsibility of non-tribal public mental health systems, just as it is 

for the services they provide to any individual in their service area. Providers and clinicians working 

within these systems should receive training in cultural humility and these principles and practices 

should be integrated into service delivery for AI/AN individuals. SAMHSA provides useful resources such 

as its Culture Card, designed to enhance cultural competence when serving AI/AN individuals, which 

specifically suggests that training be provided by a member of the particular AI/AN community being 

served.51 SAMHSA’s Tribal Training and Technical Assistance (TTA) Center, sponsored by the Office of 

Tribal Affairs and Policy (OTAP), is another good resource for culturally relevant training and technical 

assistance to support mental health in tribal communities (https://www.samhsa.gov/tribal-ttac). State and 

local mental health systems should consult and work with tribal behavioral health systems to provide an 

effective continuum of supports for AI/AN individuals, particularly people with more complex or 

intensive needs. As these individuals may move in and out of tribal systems to access inpatient care and 

other supports, coordination is especially important across systems to ensure that individuals do not 

become disconnected or have their care and support networks disrupted during transitions. Tribal 

systems will likely face some of the same challenges following COVID-19 as other rural and remote 

systems, determining the appropriate role for telehealth, and trying to address pent up demand for 

services from people who did not seek help during the COVID-19 pandemic. Tribal systems and their 

state and local partners will need to adapt to conditions as they unfold. 

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Telehealth Services 

The most pervasive change in mental health service delivery during the COVID-19 pandemic has been 

the shift to telehealth. The adoption of telehealth in mental health systems saw steady gains in the years 

before the pandemic in rural and non-rural areas.

52, 53 Responding to the need to provide sociallydistanced services, health systems rapidly shifted to telehealth service provision following the spread of 

COVID-19. Adapting to this reality, the federal government and states took swift action. While the 

details differ somewhat across states and federal programs, temporary legal and regulatory flexibilities 

were enacted to enable the provision of telehealth services, including: 

• reducing restrictions on out-of-state providers; 

• allowing telehealth services to be provided by additional provider types; 

• enabling initial provider visits to take place via telehealth; 

• allowing reimbursement for telephone only visits; 

• allowing reimbursement of telehealth visits in a wider variety of settings, including homes; 

• allowing the provision of services through non-HIPAA compliant platforms; and 

• eliminating payment disparities between telehealth services and in-person services.54,55 

Because many of these changes designed to respond to the pandemic are temporary, mental health 

systems and providers face a lot of uncertainty and may have to adapt to a new regulatory and policy 

environment as COVID-19 rates decline. 

A study that analyzed half of all private insurance claims in the United States from February of 2020 to 

April of 2020 found a 2900% increase in mental health telehealth claims. 56 The number of claims 

reduced somewhat in the following months, but remained at 2600% of pre-pandemic levels as of 

December 2020. Medicaid and CHIP also saw a large growth in the use of telehealth during this period.57 

Another study that examined a national sample of commercial and Medicare advantage claims from 

January to June 2020 found that telehealth accounted for 56.8% of total psychiatry visits, 50.8% of social 

work visits, and 49.1% of psychology visits during this period.58 

While the ability to provide services via telehealth enabled access to mental health services during the 

pandemic, it is not a panacea. Telehealth may not be as effective for all interventions and conditions. 

While telehealth’s efficacy for depression and anxiety is more established, there is less evidence for its 

use with conditions like schizophrenia.59 Although initial reports for some providers have indicated 

success in using telehealth to serve individuals with SMI.60 Some types of mental health services, such as 

medication visits, may be better suited to telehealth delivery. As a result, the shift to telehealth may also 

impact the types of services that individuals seek out or continue to access. 

In many rural areas there are technological barriers to accessing telehealth. These include lack of access 

to broadband or limited bandwidth; poor cellular coverage; limitations in clients’ phone plans that limit 

the number of minutes or amount of data that they can use; and lack of access to necessary technology. 

Household bandwidth can also be an issue. During the pandemic multiple members of households are 

often competing for bandwidth with children and youth logging in to school online, and adults working 

remotely when possible.61 Some people do not have access to technology necessary to participate in 

telehealth, and with some groups experiencing less access than others, including older Americans, 

people with disabilities,

62 and people living in poverty.63 It is important to note that these groups are all 

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overrepresented in rural areas and public mental health systems. Some systems and providers have 

attempted to address these concerns by providing devices to help people being served access telehealth 

services.64, 65, 66 Telehealth is also not a solution when provider capacity within organizations is severely 

limited. There are still only so many slots available for a psychiatrist to see clients whether they are 

providing services via telehealth or in-person. 

Providers face considerable uncertainty as it is not clear whether regulatory flexibilities enabling current 

telehealth practices will extend past the pandemic. As people return to more in-person services, 

providers and consumers will need to figure out what is the best use of telehealth, for which individuals 

it is most effective, and if there are interventions that are more effective in-person. Providers in rural 

areas may need to make trade-offs in some of these areas. For instance, it may be that group 

interventions are more effective in person, but this is outweighed by the convenience for providers and 

participants, who may have to drive for hours to participate in these sessions. Taking all of this into 

account, it is clear that telehealth has an important role in mental health systems moving forward. It 

provided safe access to services during the pandemic and created a sustainable business model for 

many providers through the pandemic. In general, and in rural areas specifically, it offers a more 

convenient way for people to access many mental health services. In addition to direct service delivery, 

telehealth may be used to support consultation with other providers, such as primary care providers or 

less specialized behavioral health care providers, so may be a way of bolstering the capacity of the 

existing workforce in rural and remote areas. 

Program Spotlight – Telehealth Expansion in a Remote Area 

Lindsey McCarthy, MSW, Executive Director, Southern Plains Behavioral Health Services 

Southern Plains Behavioral Health Services (Southern Plains) serves Gregory, Todd, Tripp, and 

Mellette Counties in South Dakota. Their service area includes the Rosebud reservation and land 

trust, the home of the Rosebud Sioux Tribe, a branch of the Lakota people. The area of the state that 

they serve is extremely remote, with a population under 25,000 people across the four counties as of 

the 2010 census. Southern Plains provides services to over 700 people, a majority of whom have 

Medicaid coverage or receive services funded by the state. 

Southern Plains has provided some telehealth services since 2006 but was working to expand their 

telehealth capacity before the COVID-19 pandemic. They had hosted on-site telehealth training for all 

of their staff in the year before the pandemic with the intention of expanding these services, but the 

pandemic greatly accelerated their schedule for telehealth adoption. In the second quarter of 2020, 

they found themselves moving almost all services to delivery through telehealth. 

The shift to telehealth has been largely advantageous for Southern Plains, greatly reducing staff 

transportation time and improving access for clients. At the beginning of the pandemic, their 

psychiatric no shows decreased significantly. Some clients expressed interest in going back to inperson and stopped engaging after the first few months of remote services, but most clients have 

been happy with continued telehealth services. Southern Plains has been able to provide a variety of 

services remotely. For some clients, participation in groups required a two hour drive each way 

before the shift to telehealth, so remote groups have been a major improvement. In their work with 

clients who have more complex or serious conditions, the telehealth hasn’t been a major barrier. In 

some cases it has enabled staff to have multiple shorter remote contacts with clients in a week 

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instead of one in-person visit. Southern plains moved to providing crisis assessments remotely using 

telehealth, offering the service remotely to local hospitals and the jail, which has worked well. 

Internet access has been a barrier for many clients. Some clients also do not have the cell phone 

minutes or data available in their phone plans to consistently participate in telehealth. There are also 

issues of mobile network coverage and there are some areas across the four-county area where 

mobile phone service is spotty or unavailable. 

Moving to telehealth has also resulted in organizational benefits for Southern Plains. Having clinicians 

on the road throughout the day made it difficult to schedule meetings and coordinate. With most 

people working remotely and providing services via telehealth, there are more regular meetings with 

more staff present. Remote work has also forced staff to use online systems, which has also improved 

coordination. 

The Southern Plains experience with telehealth over the past year was captured in something Ms. 

McCarthy said as we wrapped up our interview, “We spend less in gas, our utility bills are lower, and 

we’re able to reach more people. We need to learn from COVID to make sure we are reaching as 

many people as we can.” After adapting to conditions under the pandemic, Southern Plains faces 

additional uncertainty as COVID-19 transmission rates decrease. Much of the telehealth expansion 

that has been possible has been a result of temporary regulatory flexibility in response to COVID-19, 

so the continuation of current expanded telehealth practices will depend on future state and federal 

policies. 

Building the Array of Effective Practices in Rural and Remote Settings 

There is an array of evidence-based practices that have been shown to improve outcomes for people 

with mental disorders, but there are challenges in implementing these in rural or remote areas. 

Especially for individuals with more intensive or complex needs, these interventions, such as assertive 

community treatment (ACT), supported employment, permanent supportive housing, or high-fidelity 

wraparound, are not only focused on providing psychosocial interventions or psychotropic medication, 

but more broadly connecting people with a variety of community supports and addressing social 

determinants of health. As a result, these are practices that, while telehealth may support them or be 

incorporated into them,67, 68 rely on face-to-face contact and services delivered in community settings. 

Many of these were developed in urban and suburban settings and are built on assumptions around 

service infrastructure, population density, and workforce that may not hold true in rural settings. There 

has been some work to systematically adapt and evaluate evidence-based practices in rural and remote 

settings, but it is limited.69 

The challenges involved in implementing these evidence-based practices in rural areas varies by 

practice. For practices like ACT that rely on a robust interdisciplinary team and intensive community 

contact, staffing, transportation, and economies of scale may be challenging.

70 Some practice models 

face focus-specific challenges in rural and remote areas, such as the general lack of job opportunities, 

which may impact supported employment programs,71 or the lack of available affordable rental housing, 

which may impact permanent supportive housing and other housing supports.

72 

Adaptation of evidence-based supports in order to successfully deliver them in rural and remote areas 

may mean adapting established models or identifying core components of EBPs, and finding effective 

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ways to deliver these components or achieve the same goals through staffing and service delivery 

models that are possible in rural and remote areas. EBPs must also be responsive to cultural issues and 

should be adapted to the culture of the individuals receiving them.73 This should especially be a priority 

in the delivery of services to tribal populations.74 Given the great variation in populations, capacity, and 

challenges in rural and remote areas, it is likely that there won’t be a one-size-fits-all adaptation of EBPs 

that will enable their use across the United States, but that a range of approaches will need to be 

developed and deployed. 

Program Spotlight – Incorporating Telehealth into Program for Assertive Community Treatment 

(PACT) Team Operations 

Dr. Charlie Swanson – Medical Director, Piedmont Community Services Board 

Piedmont Community Services Board (CSB) in southern Virginia was scheduled to undertake an 

independent fidelity review for their PACT team in March 2020 when the pandemic began. PACT, also 

known just as ACT in many places, is a multidisciplinary team approach with assertive outreach for 

people with SMI who require an intensive level of support to remain stable while living in a 

community setting. Instead of going through the fidelity review process, Piedmont CSB found itself in 

the position of adapting all of its operations, including the PACT team, to operate as safely as possible 

during the pandemic. The PACT team serves 84 people in Henry County and the city of Martinsville in 

southern Virginia. The team includes a psychiatrist, four nurses, a pharmacy technician, a peer, two 

counselors and several case managers. 

In the operations of the ACT team, transportation challenges are a major consideration given the 

distances that need to be traveled to see clients. For several years the team has been using telehealth 

to facilitate visits with the psychiatrist, Dr. Charlie Swanson. This proved advantageous when the 

COVID-19 pandemic began because clients were already used to telehealth services. The team was 

able to shift some contact to telehealth, for instance, checking in with clients, but many ACT team 

functions still required in-person visits. Shortages of personal protective equipment (PPE) were a 

problem, especially in the early stages of the pandemic. Dr. Swanson reported purchasing ponchos for 

ACT team members providing in-person services from the Tractor Supply Company at one point 

because of shortages in PPE. 

Dr. Swanson reported that clients did fairly well through the first few months of the pandemic, 

summoning internal resources to remain stable. Over time though, the stress of the pandemic has 

impacted the PACT clients. Clients showed great concern for the wellbeing and safety of ACT team 

members and many embraced social distancing measures to protect the staff. Despite shifting 

services to telephonic contact when possible and taking precautions, some members of the ACT team 

contracted COVID-19. 

While most services offered by Piedmont CSB shifted to telehealth, there were limitations with how 

many PACT functions could be done over the phone. Some PACT clients met with team members via 

Zoom but delivering services via telehealth had several limitations. Given the seriousness of the 

mental illnesses experienced by the people served by the PACT team, they were not always able to 

communicate their needs or receive support over the telephone. As Dr. Swanson put it, “Telephonic is 

helpful, but it’s not like seeing folks face to face.” Also, while mobile service was generally available in 

Henry County, many clients had a limited broadband access and a number of phone minutes or 

broadband access through their phone plans, so were limited in how much they could participate in 

telehealth. Delivering in-person services also enabled team members to provide other supports, such 

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as taking groceries to the people they worked with, which became more important given the 

disconnection and isolation that people experienced during the pandemic. Some services were 

particularly difficult to deliver during the pandemic, such as groups that focus on SUD, social support, 

and wellness, which didn’t work over Zoom for people receiving ACT. Although Dr. Swanson felt that 

the use of telehealth in other Piedmont CSB services would continue past the pandemic, he 

anticipated that the PACT team would revert to more in-person contact for the majority of the team, 

as they had operated before the pandemic, but continuing to offer psychiatric visits remotely. 

Developing Rural Crisis Systems 

The United States is currently undergoing an intensive period in the development of behavioral health 

crisis services. With the rollout of a national “988” crisis hotline, the creation of a crisis set aside within 

the Community Mental Health Services Block Grant, enhanced Medicaid coverage of mobile crisis 

services and a public dialogue of the appropriate role of law enforcement in the response to behavioral 

health crises,

75 attention within states to crisis services has never been greater. 

Rural and remote communities confront several major challenges that impact the development and 

delivery of crisis systems and services. Large geographic areas to cover, combined with limited available 

resources, often leads to long wait times to access services when an individual experiences a behavioral 

health crisis in these communities. Long distances to travel to services that are located primarily in 

urban areas, such as inpatient care, and the availability of transportation itself to services may be 

difficult.76 Workforce shortages and challenges related to recruitment and retention of qualified 

professional staff to ensure quality crisis services delivery also persist in rural and remote 

communities.77 

Strategies recommended in SAMHSA’s National Guidelines for Crisis Care: A Best Practice Toolkit to 

address these challenges largely center on leveraging partnerships with area first responders to 

strengthen crisis response abilities and incorporating technologies like telehealth to make the best use 

of available resources in developing and delivering crisis care.78 Regional partnerships are sometimes 

formed to share resources and make services like mobile crisis available in rural and remote 

communities. However, relatively low demand for these services can still make funding and staffing 

teams for 24/7 availability a challenge.79 Capitalizing on available human resources like volunteer or oncall clinicians can assist in making crisis services available when needed. Alaska, for example, trains 

citizens as Behavioral Health Aides (BHAs) employed by their regional tribal health organizations to 

provide on-call responses to individuals who are experiencing a behavioral health crisis.80 Collaboration 

with area first responders like EMS may be leveraged to assist with transportation to care, which is also 

difficult to fund and provide. 

Pre-COVID-19, some rural and remote communities were able to both offer access to limited licensed 

and/or credentialed clinicians and other professional staff (e.g., psychiatry), and equip existing first 

responders with resources to connect individuals in crisis with proper screening and next step crisis care 

by incorporating technology like telehealth. For example, in some rural Colorado communities, 

paramedics are trained to do an initial screening and then connect individuals via telehealth to a 

qualified mental health professional who can further guide needed follow-up care.81 Colorado was also 

exploring training volunteers who are bachelor’s-level providers or peers in rural communities preCOVID to use tablets to virtually connect individuals in crisis to care using telehealth.82 

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The COVID-19 pandemic may have shifted priorities and/or resources away from the piloting of new 

crisis care strategies like these, and also necessitated decreasing some crisis services capacity due to 

social distancing requirements (e.g., in crisis stabilization units).83 It also highlighted major challenges 

related to mental health and access to care during crises in rural and remote areas, while accelerating 

the use of new and emerging models of delivering crisis care. COVID-19 presented an opportunity to 

rapidly expand the use of virtual care using telehealth. This has been effective in addressing some 

services access issues in rural and remote communities by allowing for modified payment mechanisms 

and new provider types to bill for services delivered via telehealth. The increased availability of 

telehealth may have also helped to overcome some of the stigma associated with seeking mental health 

care in rural communities by offering alternatives to office-based treatment. However, the surge in the 

use of telehealth has also highlighted the ongoing challenges in rural and remote communities related 

to limited broadband connectivity, as well as limits on affordability of and access to devices like tablets 

in order for individuals in these communities to take advantage of virtual behavioral health services and 

supports, including crisis care.84 

Conclusion 

It will be years before more complete data is available that shows the short- and long-term impacts of 

COVID-19 on the prevalence of mental disorders and service delivery in rural and remote areas. The 

United States mental health system embarked in an experiment, shifting overwhelmingly to telehealth 

delivery of mental health services during the COVID-19 pandemic. While this has broad implications for 

the mental health system, the impact is even larger for rural and remote mental health systems, where 

telehealth has long been seen as a possible solution to access problems. The field will need to do 

extensive work to understand where telehealth has worked and where it has not. 

People in rural areas may access mental health services at similar rates to other areas of the United 

States, but they do not have equivalent access to intensive or specialty services. There is considerable 

work to be done to develop rural and remote mental health systems, building a workforce that draws on 

a wider variety of mental health professionals, leveraging advances in telehealth, identifying people in 

need of more intensive and specialized services, and adapting EBPs to ensure that people get the 

services they need. This is also true for tribal communities in rural and remote areas. As tribal mental 

health systems develop and adapt services to better meet the needs of AI/AN people, there is great 

potential meet the significant needs that exist in these communities. 

As COVID-19 restrictions lift and more data becomes available, policymakers and practitioners will get a 

better sense of the extent to which people in rural and remote areas received the mental health services 

they needed during 2020 and 2021. Meeting the needs of people in rural and remote areas will require 

work at the federal, state and local levels. Federal and state policymakers must assess the proper role of 

telehealth, informed by clinical experience, and adjust laws and regulations accordingly. They must also 

work with providers, researchers, and the communities and populations being served to identify 

strategies that will contribute to a robust, interconnected, and evidence-based system of mental health 

care in rural and remote areas. 

Thank you to Jessica Black from the University of Alaska Fairbanks, Chris Fore, Tamara James, Marcy 

Ronyak, and Glorinda Segay from the Indian Health Service, Heather Gotham, Dennis Mohatt, Ann 

Skinstad, and Teresa Brewington from the Mental Health Technology Transfer Center Network, Charlie 

Swanson from the Piedmont Community Services Board, and Lindsey McCarthy from Southern Plains 

Behavioral Health Services, who all participated in interviews to inform the content of this brief. 

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22Bhalla IP, Stefanovics EA, Rosenheck RA: Social determinants of mental health care systems: Intensive community based care 

in the Veterans Health Administration. BMC Public Health 2020; 20(1): 1-13 23Dotson JAW, Roll JM, Packer RR, et al: Urban and rural utilization of evidence-based practices for substance use and mental 

health disorders. The Journal of Rural Health 2014; 30(3):292-299 

158
 

 

 

 

 

 

 

 

 

 

 

 

24Pinals DA, Fuller DA: Beyond beds: The vital role of a full continuum of psychiatric care. Washington, DC, National Association 

of State Mental Health Program Directors, 2017. https://www.nasmhpd.org/sites/default/files/TAC.Paper_.1Beyond_Beds.pdf 25 Designated Health Professional Shortage Areas Statistics Second Quarter of Fiscal Year 2021 Designated HPSA Quarterly 

Summary. Washington, DC, Health Resources and Services Administration, 2021. 

https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport 

26Andrilla CHA, Patterson DG, Garberson LA, et al: Geographic variation in the supply of selected behavioral health 

providers. American journal of preventive medicine 2018; 54(6): S199-S207 27 Ibid. 

28 Estimating the Distribution of the U.S. Psychiatric Subspecialist Workforce. Ann Arbor, MI, University of Michigan Behavioral 

Health Workforce Research Center, 2018. https://www.behavioralhealthworkforce.org/wp-content/uploads/2019/02/Y3-FA2-

P2-Psych-Sub_Full-Report-FINAL2.19.2019.pdf 29 Schwartz MR, Patterson DG, McCarty RL: State Incentive Programs that Encourage Allied Health Professionals to Provide Care 

for Rural and Underserved Populations. Seattle, WA, Center for Health Workforce Studies, University of Washington, Dec 2019. 

https://depts.washington.edu/fammed/chws/wp-content/uploads/sites/5/2019/12/State-Incentive-Programs-Allied-Health-FR2019.pdf 

30Watanabe-Galloway S, Madison L, Watkins KL, et al: Recruitment and retention of mental health care providers in rural 

Nebraska: perceptions of providers and administrators. Rural and remote health 2015; 15(4): 97 31 Recruitment and Retention for Rural Health Facilities. Washington, DC, Rural Health Information Hub, US Department of 

Health and Human Services, 2021. https://www.ruralhealthinfo.org/topics/rural-health-recruitment-retention 32Hoeft T J, Fortney JC, Patel V, et al: Task-sharing approaches to improve mental health care in rural and other low-resource 

settings: a systematic review. The Journal of rural health 2018; 34(1):48-62 33 Behavioral Health Service Provision by Primary Care Physicians. Ann Arbor, MI, University of Michigan Behavioral Health 

Workforce Research Center, 2019. https://www.behavioralhealthworkforce.org/wp-content/uploads/2019/12/Y4-P10-BHCapacityof-PC-Phys_Full.pdf 34Fish JN, Mittal M: Mental Health Providers during COVID-19: Essential to the US Public Health Workforce and in Need of 

Support. Public Health Reports 2021; 136(1):14-17 35Druss BG, Cohen AN, Brister T, et al: Supporting the Mental Health Workforce During and After COVID-19. Psychiatric Services 

2021 (Epub ahead of print April 22, 2021) 36 Office of Minority Health Profile: American Indian/Alaska Native. Washington, DC, US Department of Health and Human 

Services, 2021. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62 37 Tribal Nations and the United States: An Introduction. Washington, D.C. National Congress of American Indians, February 

2020. https://www.ncai.org/tribalnations/introduction/Indian_Country_101_Updated_February_2019.pdf 38 National Center for Health Statistics (NCHS) provisional death counts (https://data.cdc.gov/NCHS/Provisional-Death-Countsfor-Coronavirus-Disease-C/pj7m-y5uh, data through April 3, 2021). Numbers are ratios of age-adjusted rates standardized to 

the 2019 US intercensal population estimate. 

39 Hostetter M, Klein S: Learning from Pandemic Responses Across Indian Country. New York, NY, Commonwealth Fund, 2020. 

https://www.commonwealthfund.org/publications/2020/sep/learning-pandemic-responses-across-indian-country 40 Hill L., Artiga S: COVID-19 Vaccination among American Indian and Alaska Native People. San Francisco, CA, Kaiser Family 

Foundation, 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/covid-19-vaccination-american-indianalaska-native-people/ 41Results from the 2019 National Survey on Drug Use and Health: Detailed tables. Rockville, MD, Center for Behavioral Health 

Statistics and Quality, Substance Abuse and Mental Health Services Administration, 2020. https://www.samhsa.gov/data/ 42Stone DM, Jones CM, Mack KA: Changes in Suicide Rates—United States, 2018–2019. MMWR. Morbidity and Mortality 

Weekly Report 2020, 70. https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7008a1-H.pdf 43 Indian Health Service 2020 Profile. Rockville, MD, Indian Health Service, 2021. 

https://www.ihs.gov/newsroom/index.cfm/factsheets/ihsprofile/ 

44 Ibid. 

45 The national Tribal behavioral health agenda. Rockville, MD, Tribal Behavioral Health Agenda Collaborative, Substance Abuse 

and Mental Health Service Administration, 2016. https://store.samhsa.gov/product/The-National-Tribal-Behavioral-HealthAgenda/PEP16-NTBH-AGENDA 46 Behavioral Health Services for American Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series 61. HHS 

Publication No. (SMA) 18- 5070EXSUMM. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2018. 

https://store.samhsa.gov/sites/default/files/d7/priv/tip_61_aian_full_document_020419_0.pdf 

47O'Keefe VM, Cwik MF, Haroz EE: Increasing culturally responsive care and mental health equity with indigenous community 

mental health workers. Psychological services 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824928/#R5 48 Neylon KA: Strategies for the Delivery of Behavioral Health Crisis Services in Rural and Frontier Areas of the US. Alexandria, 

VA: National Association of State Mental Health Program Directors, 2020. http://nri-inc.org/media/1679/2020paper10.pdf 

159
 

 

 

 

 

 

 

 

 

49 The national Tribal behavioral health agenda. Rockville, MD, Tribal Behavioral Health Agenda Collaborative, Substance Abuse 

and Mental Health Service Administration, 2016. https://store.samhsa.gov/product/The-National-Tribal-Behavioral-HealthAgenda/PEP16-NTBH-AGENDA 50 Inpatient Mental Health Assessment. Rockville, MD, Indian Health Service, 2011. 

https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/FINAL_IHCIA_InpatientMH_Assess 

ment_Final.pdf 

51 Culture Card: A Guide to Build Awareness: American Indian and Alaska Native. HHS Publication No. (SMA) 08-4354. Rockville, 

MD, Substance Abuse and Mental Health Services Administration, 2009. 

https://store.samhsa.gov/sites/default/files/d7/priv/sma08-4354.pdf 52Spivak S, Spivak A, Cullen B, et al: Telepsychiatry use in US mental health facilities, 2010–2017. Psychiatric services 

2020; 71(2):121–127 53Creedon TB, Schrader KE, O'Brien PL, et al: Rural-nonrural differences in telemedicine use for mental and substance use 

disorders among Medicaid beneficiaries. Psychiatric services 2020; 71(8):756–764 54 Telehealth: Delivering Care Safely During COVID-19. Washington, DC, US Department of Health and Human Services, 2021. 

https://www.hhs.gov/coronavirus/telehealth/index.html 

55 Telehealth guidance by state during COVID-19. Washington, DC, American Psychological Association, 2021. 

https://www.apaservices.org/practice/clinic/covid-19-telehealth-state-summary 56 Telehealth Impact: Claims Data Analysis. Mclean, VA, The COVID-19 Healthcare Coalition Telehealth Impact Study Work 

Group, Mitre Corporation, 2021. https://c19hcc.org/telehealth/claims-analysis/ 57 Medicaid & CHIP and the COVID-19 Public Health Emergency. Washington, DC, Centers for Medicare & Medicaid Services, 

2021. https://www.medicaid.gov/state-resource-center/downloads/covid-19-medicaid-data-snapshot.pdf 58 Patel SY, Mehrotra A, Huskamp HA, et al: Variation in Telemedicine Use and Outpatient Care During The COVID-19 Pandemic 

in The United States. Health Affairs 2021; 40(2): 349–358 59 Busch AB, Sugarman DE, Horvitz LE, et al: Telemedicine for treating mental health and substance use disorders: Reflections 

since the pandemic. Neuropsychopharmacology 2021; 46(6):1068–1070 60Medalia A, Lynch DA, Herlands T: Telehealth conversion of serious mental illness recovery services during the COVID-19 

crisis. Psychiatric Services 2020; 71(8): 872–872 61 D. Mohatt, personal communication, May 4, 2021 

62Anderson M, Perrin A: Disabled Americans are less likely to use technology. Washington, DC, Pew Research Center FactTank: 

News in the Numbers, 2017. https://www.pewresearch.org/fact-tank/2017/04/07/disabled-americans-are-less-likely-to-usetechnology/ 

63Anderson M, Kumar M: Digital divide persists even as lower-income Americans make gains in tech adoption. Washington, DC, 

Pew research center 2017. https://www.pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-even-as-lower-incomeamericans-make-gains-in-tech-adoption/ 64 Oklahoma to provide iPads for telehealth during pandemic. Mental Health Weekly 2020. 

https://onlinelibrary.wiley.com/doi/epdf/10.1002/mhw.32321 

65 Parker R: Smartphones Distributed for Telehealth. Inside Indiana Business 2020. 

https://www.insideindianabusiness.com/story/42930355/smartphones-distributed-for-telehealth 66 Get a free smartphone today. Indianapolis, IN, Anthem, 2021. Available at: https://blog.anthem.com/communityresources/get-a-free-smartphone-today 67Henwood BF, Madden DR, Lahey J, et al: Testing the feasibility of telemental health services in permanent supportive 

housing. Journal of Social Distress and the Homeless 2019; 1–5 68Swanson CL, Trestman RL: Rural assertive community treatment and telepsychiatry. Journal of Psychiatric Practice 

2018; 24(4):269–273 69Weaver A, Capobianco J, Ruffolo M: Systematic review of EBPs for SMI in rural America. Journal of evidence-informed social 

work 2015; 12(2):155–165 70 Koch H, Bastian K: Assertive Community Treatment Fidelity and Rural Consideration. Mountain Plains MHTTC, n.d. 

https://mhttcnetwork.org/sites/default/files/2019-06/rural-assertive-community-treatment-slide-deck.pptx 71Al-Abdulmunem M, Drake RE, Carpenter-Song E: Evidence-Based Supported Employment in the Rural United States: 

Challenges and Adaptations. Psychiatric Services (Epub ahead of print March 18, 2021) 72 Rural America’s Rental Housing Crisis. Washington, DC, National Rural Housing Coalition, 2014. 

http://ruralhousingcoalition.org/wp-content/uploads/2014/07/NRHC-Rural-America-Rental-HousingCrisis_FINALV3.compressed.pdf 73Bernal G, Jiménez-Chafey MI, Domenech Rodríguez MM: Cultural adaptation of treatments: A resource for considering culture 

in evidence-based practice. Professional Psychology: Research and Practice 2009; 40(4):361 74The national Tribal behavioral health agenda. Rockville, MD, Tribal Behavioral Health Agenda Collaborative, Substance Abuse 

and Mental Health Service Administration, 2016. https://store.samhsa.gov/product/The-National-Tribal-Behavioral-HealthAgenda/PEP16-NTBH-AGENDA 

160
 

 

 

 

 

 

 

75 Pinals D: Ready to respond: Mental health beyond crisis and COVID-19. Alexandria, VA, National Association of State Mental 

Health Program Directors, 2021. 76 Neylon KA: Strategies for the Delivery of Behavioral Health Crisis Services in Rural and Frontier Areas of the US. Alexandria, 

VA, National Association of State Mental Health Program Directors, 2020. http://nri-inc.org/media/1679/2020paper10.pdf 77 Ibid. 

78 National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit. Rockville, MD, Substance Abuse and 

Mental Health Services Administration, 2020. https://www.samhsa.gov/sites/default/files/national-guidelines-forbehavioral-health-crisis-care-02242020.pdf 79 Shaw R: Financing Mental Health Crisis Services. Alexandria, VA, National Association of State Mental Health Program 

Directors, 2020 80 Neylon KA: Strategies for the Delivery of Behavioral Health Crisis Services in Rural and Frontier Areas of the US. Alexandria, 

VA, National Association of State Mental Health Program Directors, 2020. http://nri-inc.org/media/1679/2020paper10.pdf 81 Ibid. 

82 Ibid. 

83 Ibid. 

84 Ibid. 

161
Funding Opportunities 

for Expanding Crisis 

Stabilization Systems 

and Services 

No. 8 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

162
 

 

 

 

Funding Opportunities for Expanding Crisis 

Stabilization Systems and Services 

Kirsten K. Beronio, J.D. 

Director of Policy and Regulatory Affairs 

National Association for Behavioral Healthcare 

(Previously) Senior Policy Advisor for Behavioral Healthcare 

Center for Medicaid and CHIP Services 

Centers for Medicare and Medicaid Services 

U.S. Department of Health and Human Services. 

Cover Art by Malkah Pinals 

Eighth in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

163
 

 

 

Disclaimer 

The views, opinions, content, and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, 

or other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation 

Beronio, K.K. (2021). Funding Opportunities for Expanding Crisis Stabilization Systems and Services. 

Technical Assistance Collaborative Paper No. 8. Alexandria, VA: National Association of State Mental 

Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

164
 

 

 

 

 

 

Abstract: 

Recent dramatic increases in federal funding for mental health care and addiction treatment have 

created significant new opportunities to expand access to behavioral healthcare. At the same time, 

designation of a three-digit nationwide crisis hotline (988) has highlighted the need for increased 

crisis call center capacity and crisis stabilization services in most communities. Development of 

statewide crisis stabilization systems that provide support through call centers, mobile crisis teams, 

and crisis stabilization centers can provide an essential framework for improving connections to 

needed services and supports while simultaneously decreasing reliance on emergency departments 

and law enforcement. Unprecedented increases in federal block grants and increased Medicaid 

support for mobile crisis and home and community-based services offer states a multi-faceted 

opportunity to significantly improve care for individuals experiencing mental health or addiction 

crises. This paper discusses the following recent developments and implications for improving access 

to crisis stabilization services. 

Highlights: 

• Supplemental mental health and substance use disorder block grant funding can support the 

leadership, planning, coordination, and implementation steps needed to develop 

comprehensive statewide crisis stabilization systems. This increased federal funding along 

with substantial new grant opportunities can incentivize and support providers to expand 

crisis stabilization programs and services. 

• Existing and newly enacted Medicaid authorities can bolster expanded crisis stabilization 

programs and provide reliable funding for these programs going forward. This paper details 

various opportunities in Medicaid to finance crisis stabilization programs and services 

including a recently enacted enhanced federal Medicaid match for mobile crisis teams and 

increased federal Medicaid funding for home and community-based services; 

• Expanded coverage of telehealth is critical for on-going improvements to crisis stabilization 

systems. This paper discusses the importance of continued coverage of telehealth after the 

Covid-19 public health emergency ends, including services via audio-only technology. It also 

describes some recent improvements to Medicare coverage of tele-behavioral health; 

• This paper also outlines some promising opportunities to support crisis stabilization systems 

through alternative payment models and demonstrations. 

Recommendations for the Post-COVID-19 Future: 

1. Invest in statewide crisis stabilization systems; 

2. Improve coverage of crisis services and reimbursement rates to increase availability of crisis 

stabilization programs; and 

3. Support providers to expand access to crisis stabilization services. 

The paper concludes with recommendations for additional federal policies to support state crisis 

stabilization systems and programs. 

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S

everal developments over the past year, driven in part by COVID-19, have created a unique 

opportunity to increase access to mental health and substance use disorder services, in particular 

crisis intervention and stabilization services. These developments include the enactment of a 

federal law designating 988 as a behavioral health crisis hotline that will be easy to remember and 

available nationwide by July 2022.

1 In addition, the significant impact of COVID-19 on behavioral health 

and the spike in overdose deaths during the pandemic have led Congress to dramatically increase 

funding for mental health and substance use disorder federal block grants and create significant new 

opportunities to support behavioral healthcare in Medicaid. Furthermore, several high-profile, tragic 

incidents have led to growing recognition of the need for alternatives to law enforcement responses to 

behavioral health emergencies, particularly among people from racial minority or disadvantaged 

communities. This paper will focus on how new federal funding opportunities can support development 

of crisis stabilization systems that can serve as alternatives to unnecessary use of emergency 

departments and law enforcement to assist individuals experiencing behavioral health crises. 

Behavioral Health Before, During, and After the COVID-19 Pandemic 

Before the pandemic, the United States was already experiencing multiple behavioral health crises. 

Although overall overdose deaths had declined slightly in 2018, the number of people dying from 

overdoses of synthetic opioids, cocaine, and psychostimulants was increasing at an alarming pace.2 

Rates of suicide had also been rising steadily, up 35% between 1999 and 2018.3 Serious behavioral 

health conditions had become so prevalent and elevated, they had driven down overall life expectancy 

in the United States.4,5 

During the COVID-19 pandemic, national surveys have repeatedly shown dramatic increases in the 

incidence of anxiety and depression.6 Suicidal ideation increased,7 and drug overdoses increased almost 

30% with more than 93,000 deaths in 2020.8 Although suicide rates seemed to level off and even 

decreased last year,

9 these overall findings are preliminary and differ by demographic subgroups. 

As concerns about COVID-19 infection subside, mental health and substance use disorders may remain 

elevated for many people. Experiences with epidemics in the past indicate that the impact on behavioral 

health may continue for years to come.10,11,12 Children and adolescents are at risk of depression and 

anxiety during and after the pandemic ends according to a review of more than 80 studies on the impact 

of social isolation.

13 Therefore special attention should be paid to them and other vulnerable 

populations, including minorities and underserved communities at greater risk of on-going challenges. 

Designation of 988 Sparks Increased Support for Crisis Stabilization Services 

The National Suicide Hotline Designation Act (Pub. L. 116-172), establishing 988 as a nationwide toll-free 

mental health crisis and suicide prevention hotline, presents a significant new opportunity to address 

increased behavioral health needs. An easy to remember three-digit number will be an important new 

resource for people struggling with behavioral health crises as well as their family and friends. The Act 

requires that all calls to 988 be directed to the pre-existing National Suicide Prevention Lifeline funded 

and overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA) or the 

Veterans Crisis Line overseen by the U.S. Department of Veterans Affairs. An order by the Federal 

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Recent State Laws 

Funding Crisis 

Stabilization Services 

Communications Commission has set the deadline for 

telecommunications providers to implement this change as July 16, 

2022.14 

In recognition of the expected increase in call volume and the need for 

additional capacity to answer these calls, Congress included a provision 

in the 988 Designation Act clarifying that states may enact fees on 

telephone services including mobile phone services.15 In particular, the Colorado (SB21-154) 

Act specifies that nothing in the legislation or the Communications Act -with a telecommunications 

of 1934 or otherwise prohibits states from imposing fees on telephone user fee 

services including mobile phones for 988 related services. These fees are 

Nevada (SB 390) to be used for routing calls made to 988 to a crisis center and providing - with a telecommunications crisis outreach and stabilization services in response to these calls. user fee Several states have enacted legislation authorizing such fees. 

Virginia (SB1302) In addition, Congress increased funding for the Lifeline network that will -with a telecommunications underpin 988 by $5 million in the SAMHSA FY 2021 appropriations 

user fee included in the Consolidated Appropriations Act (Pub. L. 116-260) (for a 

total of $24 million for FY 2021). The President’s Budget for FY 2022 calls 

Washington (HB 1477) for $102 million for the National Suicide Prevention Lifeline. -with a telecommunications Furthermore, the House of Representatives, Labor, Health and Human 

user fee Services, and Education FY 2022 funding bill reported out of the full 

Appropriations Committee on July 15, 2021 includes over $113 million 

Utah (SB155) for the Lifeline. -appropriates funding 

Improvements to the Lifeline call center network as well as expansions -no telecommunications user 

of mobile crisis teams and crisis receiving and stabilization centers are fee 

needed to improve services and supports for individuals struggling with 

behavioral health crises. Furthermore, these crisis stabilization systems 

and services can help decrease over-reliance on emergency rooms and 

law enforcement responses to behavioral health crises.16,17 

SAMHSA has issued National Guidelines for Behavioral Health Crisis Care that focus on several levels of 

crisis intervention and stabilization including regional crisis call centers, mobile crisis teams, and crisis 

receiving and stabilization centers.18 These guidelines envision regional call centers that are available 

24/7 and clinically staffed to provide telephonic crisis intervention services. These centers should triage 

calls to facilitate assessments and coordinate additional support as needed including ideally with the 

capacity to dispatch mobile crisis teams if necessary.

19 

Mobile crisis teams can help resolve and de-escalate situations when an individual is experiencing a 

crisis in the community or at the person’s home. In addition, back-up by psychiatrists or other clinicians 

should be available. Furthermore, mobile crisis response providers should have good relationships with 

mental health and addiction treatment providers in their communities including crisis stabilization 

residential beds and inpatient settings. 

167
 

 

 

 

 

 

 

 

 

 

 

 

 

-

For those who require more assistance than a mobile crisis team can provide, the SAMHSA National 

Guidelines call for crisis receiving and stabilization centers and sub-acute crisis residential facilities. 

Crisis receiving and stabilization facilities are open 24 hours a day, seven days a week and are staffed 

with multidisciplinary teams that include prescribers, nurses, clinicians, and peers. The Guidelines call 

for these centers to accept walk-ins, ambulance, fire, and police drop-offs. 

Leadership is Key for Developing and Supporting Crisis Stabilization Systems 

The advent of 988 has drawn attention to the need for collaboration and investment in expanding crisis 

stabilization programs and services into coordinated 

systems. However, leadership and concerted efforts 

are needed to direct various substantial new funding 

streams as well as to coordinate many critical 

stakeholders into developing coordinated crisis 

stabilization systems that include at least the core 

components described in the SAMHSA National 

Guidelines. 

State mental health and substance use disorder 

agencies have the expertise in behavioral health 

treatment and crisis stabilization as well as 

relationships with many of the various stakeholders 

that are required for leading this effort. Moreover, 

these agencies oversee use of mental health and 

substance use disorder block grant funds that 

Congress has dramatically increased over the past year 

to facilitate and encourage bold action by the states in 

addressing new and on-going behavioral health crises. 

Substantially Increased Block Grant Funding 

Creates New Opportunities 

At the end of 2020 and again this spring, Congress 

infused significant new funding into the MHBG and 

SAPTBG as part of the Consolidated Appropriations 

Act, 2021 (CAA)20 and through the American Rescue 

Plan Act (ARPA). 21 

Overview of SAMHSA Block Grants 

Annual appropriations for formula based block 

grants administered by SAMHSA provide 

important federal funding to support state mental 

health and SUD services and systems. Most 

recently, these block grants, the Community 

Mental Health Services Block Grant (MHBG) and 

the Substance Abuse Prevention and Treatment 

Block Grant (SAPTBG), were funded at over $757 

million and $1.858 billion respectively for FY 

2021.1 Congress and SAMHSA set general 

parameters on the use of these funds while 

leaving distributions and additional refinements to 

the state mental health and SUD agencies. 

Although other funding sources, e.g., Medicaid, 

cover a much higher percentage of overall 

spending on mental health and SUD services, the 

block grants represent a partnership between the 

federal and state governments specifically aimed 

at addressing mental health and SUD issues. In 

addition, these block grant funds provide a safety 

net for those who need mental health and SUD 

services. 

In the CAA, in addition to the regular appropriations for the block grants and other programs 

administered by SAMHSA, supplemental appropriations provided an additional $825 million for the 

MHBG and $1.65 billion for the SAPTBG for FY 2021. SAMHSA announced award of these funds March 

11, 2021,22 and states have until March of 2023 to expend these supplemental funds. 

168
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In this legislation, Congress also set aside $35 million of the regular FY 2021 MHBG appropriation 

specifically to fund crisis stabilization programs. The House Appropriations Committee report included 

the following description of this set-aside: 

“Furthermore, the Committee directs a new five percent set-aside of the total for evidencebased crisis care programs addressing the needs of individuals with serious mental illnesses 

and children with serious mental and emotional disturbances. The Committee directs 

SAMHSA to use the set-aside to fund, at the discretion of eligible States and Territories, 

some or all of a set of core crisis care elements including: centrally deployed 24/7 mobile 

crisis units, short-term residential crisis stabilization beds, evidence-based protocols for 

delivering services to individuals with suicide risk, and regional or State-wide crisis call 

centers coordinating in real time.”23 

In the notices of awards sent to states regarding 

their FY 2021 MHBG funding awards, SAMHSA List of Abbreviations 

included several pages of guidance regarding the 

new set-aside for crisis services [See Appendix A]. ARPA American Rescue Plan Act 

SAMHSA specified that these set-aside funds must 

be used to finance “core crisis care elements 

CAA Consolidated Appropriations Act, 2021 

including centrally deployed 24/7 mobile crisis units, MHBG Community Mental Health Services Block 

short-term residential crisis stabilization beds, Grant 

evidence-based protocols for delivering services to 

individuals with suicide risk, and regional or statewide crisis call centers coordinating in real time.”24 

SAPTBG Substance Abuse Prevention &Treatment 

Block Grant 

States were required to submit revisions to their 

MHBG plans with detailed descriptions of the status of the state’s crisis system including access to local 

crisis call centers, availability of mobile crisis units, and the availability and/or utilization of short-term 

crisis receiving and stabilization centers. States were also required to describe proposed or planned 

activities for this 5% set-aside funding. In addition, SAMHSA stated that “states may need to dedicate 

the rest of the current fiscal year to planning, training, and/or infrastructure development while 

targeting program implementation for the following year.”25 

With the ARPA, enacted just a few months later in March of 2021, the federal government provided an 

additional $1.5 billion for the MHBG and $1.5 billion for the SAPTBG. States have until September 30, 

2025 to use these funds. SAMHSA announced these state allocations of these funds on May 18, 2021.26 

Although the specific set-aside provision for crisis stabilization was not included in the ARPA legislation, 

SAMHSA sent guidance to state mental health commissioners and substance use disorder directors 

encouraging states to focus some of the ARPA block grant funding to develop a behavioral health crisis 

stabilization continuum [in Appendix B]. SAMHSA urged states to ensure crisis services are available to 

various populations including people living in remote areas and underserved communities as well as 

children with serious emotional disturbances. 

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Table 1: Recent Increases in Mental Health and Substance Abuse Block Grants (Dollars in Millions) 

FY 2020 

Appropriations 

Enacted 12/2019 

FY 2021 

Appropriations 

Enacted 12/2020 

FY 2021 CAA 

Supplemental 

Appropriations 

Enacted 12/2020 

ARPA 

Enacted 3/2021 

MHBG $722.571 $757.571 

(including $35 

million for crisis 

set-aside) 

$825.000 $1,500.000 

SAPTBG $1,858.079 $1,858.079 $1,650.000 $1,500.000 

More recently, the President’s Budget for FY 2022 proposed “a set-aside of $75 million of MHBG funds 

to support state efforts to build much needed crisis systems.”27 This proposed increase more than 

doubles the amount provided for FY 2021 and is another step toward a 10% set-aside that many 

advocates are urging Congress to enact. Furthermore, the House Labor, Health and Human Services, and 

Education FY 2022 Appropriations bill proposes to increase the MHBG to $1.58 billion and includes a 

10% crisis set-aside.28 This bill would also provide $100 million for a Mental Health Crisis Response Pilot 

Program to establish or expand mobile crisis teams. In addition, the bill would also increase the SAPTBG 

by $1 billion to $2.8 billion and increase the State Opioid Response Grants by $500 million to $2 billion 

with a 10% set-aside for recovery services. Although the federal FY 2022 appropriation legislation is not 

yet final, these developments indicate that increased block grant funding levels and the set-aside for 

crisis services may be maintained at least in some fashion in the near term. 

Supplemental Block Grants Can Support Development of Statewide Crisis 

Stabilization System 

In guidance regarding the ARPA supplemental MHBG funding [in Appendix B], SAMHSA specifically 

recommends that states use these funds to develop partnerships among crisis continuum stakeholders 

including--

• Operators of Lifeline/988 call centers, 

• Law enforcement, 

• Providers of crisis stabilization services 

• Hospitals and health systems, 

• Housing authorities, 

• Peer recovery services providers, and 

• Substance use treatment providers 

Development of crisis stabilization programs and services into coordinated behavioral health crisis 

systems will require collaboration with a number of additional entities including --

• State Medicaid agency leaders, 

• Insurance commission officials, 

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• Emergency transportation providers, 

• 911 operators, 

• Other hotline operators in the state, 

• People with lived experiences of behavioral health conditions and their families, 

• Representatives of underserved communities, and 

• Other state and local regulatory agencies that oversee emergency services (if applicable). 

The SAMHSA ARPA guidance also recommends use of the 

additional MHBG funds to--

• Support implementation of information technology 

including increasing availability of broadband, 

• Fund implementation of electronic health records by 

behavioral healthcare providers, 

• Support use of Global Positioning System (GPS) technology 

to improve crisis response times, 

• Finance implementation of texting capabilities among 

providers, 

• Support the use of telehealth including for medication 

assisted treatment, and 

• Fund implementation of electronic bed registries. 

These activities and resources highlighted by SAMHSA comprise 

fundamental ways the federal block grants can be invested to 

support development of comprehensive coordinated crisis 

response systems. Flexible funding like the MHBG and SAPTBG can 

more readily support these types of investments than programs 

like Medicaid, Medicare, or private insurance programs which 

nonetheless should cover the services provided through crisis 

systems and programs. 

State agencies should consider using the supplemental block grant 

funds to support a number of additional activities aimed at 

developing statewide crisis stabilization systems. An initial step 

could be an assessment of existing providers of crisis stabilization 

services including any existing hotlines and call centers. This 

planning should also include an assessment of which call centers in 

the state already participate in the Lifeline/988 network, what their 

capacity will be to accept increased calls coming in through 988, 

and whether additional capacity to answer 988 calls will be 

needed. Planning for coordination among existing crisis hotlines 

within the state would be helpful. In addition, protocols for how 

988 will interface with 911 must be developed. 

Block grant funding could also support an environmental scan of 

the existing mobile crisis units and crisis stabilization centers 

Summary of Steps for Building 

Crisis Stabilization Systems 

-Assess availability of existing crisis 

hotlines, call centers, mobile crisis, 

and crisis stabilization centers and 

address barriers in regulations and 

reimbursement 

-Determine which call centers 

participate in the SAMHSA Lifeline 

and assess their capacity to respond 

to 988 calls 

-Develop protocols for responding to 

988 calls and other hotlines including 

911 and for coordinating with other 

call centers and crisis responders in 

the region and/or state 

-Provide training to crisis services 

personnel on how to provide 

equitable responses to 

disadvantaged communities 

-Implement electronic systems for 

tracking availability of mobile crisis 

teams and openings in crisis 

stabilization facilities in real time 

- Amend state laws that block use of 

alternative emergency response 

systems and create other barriers to 

-Expand use of peers for crisis 

stabilization and expand scopes of 

practice for other behavioral health 

practitioners as well 

- Collect data to assess impact and 

ensure quality 

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throughout the state to determine where additional services and programs exist and where there are 

gaps or improvements are needed. An assessment of Medicaid reimbursement rates for crisis 

stabilization services could help identify barriers to broader 

availability of services. In addition, block grant funding could support 

implementation of best practices for staffing mobile crisis units and 

other crisis stabilization programs. Crisis system development should 

support training for crisis services personnel to ensure equitable 

responses to disadvantaged communities. Furthermore, states 

should examine whether existing laws or regulations may impede 

development of alternatives to existing emergency response systems 

including rules against transporting individuals to alternative settings 

that are not emergency departments. 

In addition, state agencies should collaborate on improving 

technological support for crisis response. Block grant funding could 

be used to improve the capacity of crisis response providers to 

provide services via telehealth. States should also consider using 

block grant funds to develop or improve existing electronic systems 

for tracking openings in crisis stabilization facilities and programs in 

real time.29 In addition, these activities should include planning and 

funding data collection improvements and quality assurance 

programs for crisis stabilization services. 

In light of widespread shortages of behavioral health providers, it is 

important that state behavioral health leaders reassess the limits on 

the types of providers permitted to offer behavioral healthcare 

especially crisis stabilization services. In this regard, states should 

assess whether existing scope of practice laws are unreasonably 

limiting practitioners’ authority to assess and support those 

experiencing behavioral health crises. 

State efforts to plan and fund increased availability of crisis 

stabilization services and systems should include support for 

coverage of peer support specialists as part of crisis stabilization 

teams. Peers can provide a knowledgeable and calming presence that 

can greatly help to deescalate a behavioral health crisis. There is 

growing evidence on the effectiveness of peer support services at 

improving outcomes for individuals struggling with mental illness or 

addiction while reducing costs.

30,31 Some 39 states cover peer 

Medicaid Coverage of 

Peer Supports 

States may cite the 

following Medicaid 

authorities to support 

coverage of peer support 

services: 

- Rehabilitative services 

optional authority; 

- Medicaid managed care 

plans under section 1915(b) 

authority; 

- as a home and 

community-based services 

Medicaid state plan benefit 

under section 1915(i) or 

through a HCBS waiver 

under 1915(c). 

- as part of section 1115 

demonstrations; 

- included in the benefits 

that Certified Community 

Behavioral Health Clinics 

must provide as part of the 

on-going Medicaid 

demonstration and 

expansion grant program. 

support services in their Medicaid programs with 23 states covering them for mental health and 

addiction, 12 states only covering their services for mental health, and four for addiction only.32 Block 

grant funding could be used to assess barriers to increased use of peers for behavioral health crisis 

response and to develop strategies for securing on-going support for peer support services, e.g., through 

expanding Medicaid coverage. 

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Crisis system planning should also include an assessment of how crisis stabilization services are currently 

funded in the state as well as in other states including with fee-for-service Medicaid coverage, any 

managed care arrangements as well as whether providers are billing Medicare or commercial insurance 

for any of the services they provide. As 988 may significantly increase calls to behavioral health hotlines 

and demand for crisis stabilization services, support for these services should be increased with 

sustained funding sources. A discussion of how Medicaid can support these services follows. Moreover, 

coverage of crisis intervention and stabilization services provided to individuals covered by Medicare 

and private insurance should not fall solely on state and local governments as is now often the case. 

States should encourage and support crisis stabilization providers to bill Medicare for covered services 

provided to Medicare beneficiaries. Medicare covers crisis psychotherapy (CPT Codes 90839 and 

90840),

33 and according to CMS, 90839 is one of the most commonly used codes for billing Medicare for 

mental health services.

34 Although only certain provider types are eligible to bill these codes including 

psychiatrists, psychologists, and clinical social workers, and crisis stabilization providers likely will not 

have many higher-level credentialed providers on staff or at least not available 24/7, they may be able 

to take advantage of telehealth psychotherapy and “incident to” billing policies for higher credentialed 

providers. The “incident to” policy allows Medicare-enrolled providers to bill for services technically 

provided by an employee whom they supervise thereby allowing Medicare to reimburse for services 

provided by a broader array of practitioners. 35 Furthermore, Medicare covers crisis psychotherapy 

when provided via telehealth including audio-only telehealth.36 Therefore, a crisis stabilization services 

provider may be able to leverage the capacity of a small number of higher credentialed staff to provide 

services that can be covered by Medicare, particularly since CMS recently clarified that supervision for 

“incident to” services may be provided via two-way audio-visual technology.37 

State governments should also use their regulatory leverage to ensure commercial insurers contribute 

to covering the cost of crisis stabilization services either through fees or by including crisis services 

providers in their provider networks. It would also be important to ensure that the benefits for crisis 

stabilization services in state regulated plans are comprehensive. 

Several states have acted upon the provision in the 988 Designation Act encouraging implementation of 

fees on telephone services to fund development of crisis stabilization services.

38 However, it is not clear 

how many states will enact similar fees, and additional sources of on-going support for crisis 

stabilization services will be critical. As discussed below, new and existing opportunities in Medicaid 

offer promising new options for supporting crisis stabilization systems in a more predictable way. 

Funding for Provider Implementation and Construction Costs is Needed to Expand 

Crisis Stabilization Programs 

As gaps in availability of crisis stabilization services are identified, block grant funds could also 

potentially be used to help cover implementation, start-up, and improvement costs for new crisis 

stabilization services and programs in different regions or counties of the state as well as provider costs 

for standing up these services. These kinds of costs are not generally covered by insurers or healthcare 

coverage programs like Medicaid and Medicare. Start-up and improvement costs for providers of crisis 

stabilization services include hiring staff and developing billing capabilities so that providers can bill 

insurance and coverage programs like Medicaid and Medicare. The guidance issued by SAMHSA 

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regarding recent increases in the block grant funds encourages use of these funds to cover some of 

these implementation and improvement costs including coordination at the local level, adoption of 

health information technology including availability of broadband and cellular technology for providers, 

improving telehealth capabilities, and implementing electronic health record systems. 

However, there are certain significant limitations on the use of block grant funding, including a 

prohibition on the use of Block Grant funds for construction costs. This limitation applies to both MH 

and SAPTBGs. Federal laws regarding the use of MHBG and SAPTBG specify that states may not use 

these funds “to purchase or improve land, purchase, construct, or permanently improve (other than 

minor remodeling) any building or other facility”.

39 However, a waiver of the prohibition on use of funds 

for construction, although not land acquisition, is authorized in the SAPTBG.40 To qualify for this waiver, 

states must demonstrate that adequate treatment cannot be provided in existing buildings. In addition, 

a state must have a plan that minimizes costs of construction, and the state must agree to provide a 

one-to-one match in cash for the federal funding used for construction. Nonetheless, in light of the 

substantial recent increases in funding for the SAPTBG, states may have more of an incentive and 

opportunity to apply for a waiver of the construction cost prohibition and utilize SAPTBG dollars to 

significantly support expansion of SUD treatment services. 

Other recently enacted Covid-19 relief funding for states and localities can also help support 

development of crisis stabilization programs. The Coronavirus State and Local Fiscal Recovery Funding 

included in the ARPA is potentially an even more flexible source of funding than the SAMHSA block 

grants. The U.S. Department of Treasury awarded the $350 billion in emergency funding to state, local, 

territorial, and Tribal governments on May 10, 2021. This funding can be used to cover costs incurred 

through December 31, 2024. The Department of Treasury announcement4142 and interim final rule 

specifically refer to behavioral health services including “crisis intervention” and “hotlines or warmlines” 

as allowable uses of these funds.43 There does not appear to be any prohibition on the use of these 

funds to cover construction costs. The allocations to the states and localities are posted on the 

Department of Treasure website.44 

Furthermore, the House of Representatives recently revived the practice of earmarking federal funding 

for local community projects and Members of Congress were invited to recommend specific local 

projects to the House Appropriations Committee for FY 2022 funding. The House Appropriations 

Committee included funding for a long list of these community projects in the FY 2022 appropriations 

bill reported out of the full Committee on July 15, 2021. Although funding for these projects is not final, 

many projects on the list (at least 135) focus on mental health and substance abuse. Moreover, at least 

fourteen projects are focused on funding crisis services, and some of these projects would specifically 

fund facilities and equipment costs related to providing behavioral health crisis services. The full list of 

projects is posted on the House Appropriations Committee website.45 

Grants for Community Mental Health Centers and Certified Behavioral Health Clinics 

Can Support Development of Crisis Stabilization Programs and Services 

The CAA included significant new funding for discretionary grant programs that can help support 

implementation of crisis stabilization services, including $825 million in grants for community mental 

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health centers (CMHCs). Applications were due on May 21, 2021 for these grants that may be used for 

the following purposes: 

• Enhancing the capacity of CMHC staff to address crisis and emergency response; 

• Supporting increased capacity for and availability of crisis beds; 

• Expanding mobile crisis mental health services; 

• Coordinating with crisis centers/hotlines to ensure that strong referral pathways are 

established and/or restored; 

• Developing and implementing outreach strategies and referral pathways for vulnerable 

populations, such as minority populations and individuals residing in economically 

disadvantaged communities; 

• Training and supporting peer staff to serve as integral members of the team to address 

mental health needs; and 

• Providing diversion services to promote alternatives to hospitalization and incarceration, 

e.g., multiple intercept model.46 

This funding may not be used for major construction or renovations, but up to 20 percent of the total 

grant award for each budget period may be used for infrastructure development and up to $75,000 may 

be used for renovations. A set of frequently asked questions posted by SAMHSA clarifies that: 

“[I]nfrastructure development does not relate to construction or alteration/renovations of brick 

and mortar structures. Infrastructure in this context is systemic infrastructure activities that 

support services, for which there are no individual services delivered. Examples include the 

development and maintenance of a crisis-response capacity, including hotlines, mobile crisis 

teams, web-based check-in groups (for medication, treatment, and re-entry follow-up), drop-in 

centers, respite services, etc. Please note that on page 49 of the FOA, applicants may request up 

to $75,000 for renovations and alterations of existing facilities, if necessary and appropriate to 

the project.”47 

Recent federal Covid-19 relief legislation also greatly increased funding for Certified Community 

Behavioral Health Clinic (CCBHC) expansion grants. These grants support provision of comprehensive 

behavioral health supports and care coordination by clinics that are also required to provide, among 

other services, 24/7 crisis stabilization services. The CAA allocated an additional $250 million specifically 

for CCBHC expansion grants. In addition, ARPA provided an additional $420 million for CCBHC expansion 

grants. The general prohibition on use of funds for construction also applies to CCBHC grants along with 

the allowance for up to $75,000 for renovations. Nonetheless, these grants can be used to improve 

access to crisis intervention services including mobile crisis teams and peer supports.48 

Medicaid Can Cover Some State Agency Costs for Improving Crisis Stabilization 

Systems 

In addition to covering crisis stabilization services, Medicaid can also support state development and 

implementation activities to improve access to crisis stabilization services for Medicaid beneficiaries. A 

2018 CMS letter to State Medicaid Directors regarding “Opportunities to Design Innovative Service 

Delivery Systems” for individuals with serious mental health conditions points out that states “may be 

able to access administrative match for crisis call centers.”49 This “administrative match” provides 

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federal Medicaid reimbursement for 50% of the proportion of the costs attributable to serving Medicaid 

beneficiaries. This administrative match is different from the federal medical assistance percentage 

(FMAP) that states receive for Medicaid covered services and therapies provided to Medicaid enrollees. 

For example, Georgia accesses federal Medicaid funding to help cover administrative costs associated 

with operating a modern statewide crisis system that includes a hotline with the capability for 

dispatching mobile crisis teams. The state demonstrates the proportion of costs attributable to Medicaid 

beneficiaries by estimating the percent of residents with serious mental illness, addiction, and 

intellectual disabilities/developmental disabilities who are enrolled in Medicaid since these populations 

are most likely to need crisis stabilization services. 

In addition, some administrative costs can be reimbursed at a higher federal matching rate, under 

federal authorities that comprise the Medicaid Information Technology Architecture (MITA) according to 

the 2018 CMS guidance on Opportunities to Design Innovative Delivery Systems.

50 Under the MITA 

authorities, information technology costs can qualify for 90% federal match for implementation costs 

and 75% match for operating costs. The 2018 guidance specifically refers to this enhanced federal match 

under MITA as available “to help states establish crisis call centers to connect beneficiaries with mental 

health treatment as well as to develop technologies to link mobile crisis units to beneficiaries coping 

with serious mental health conditions.”51 In addition, according to this CMS guidance, “development by 

the state of data-sharing capabilities between hospitals and community-based mental health 

providers”52 regarding admissions and discharge for acute care may qualify for the enhanced MITA 

federal matching rates. 

The 2018 CMS guidance also refers to the enhanced match under MITA being available for state 

development of telehealth-enabling technology. Furthermore, this guidance refers to state costs for 

developing electronic bed registries as qualifying for enhanced federal reimbursement of “90% for 

development costs and 75% for operational costs”.53 Other examples of costs that may qualify for this 

higher match include providing cell phones or iPads to mobile crisis teams to facilitate telehealth 

services with a clinician at another location during a crisis intervention, developing and implementing 

software applications to facilitate communication between crisis call centers and supervisory clinicians 

with mobile crisis team staff, and implementing text and chat technologies that many beneficiaries, 

including younger people, may be more comfortable using as part of the services offered by crisis call 

centers. 

States may also be able to use untapped Children’s Health Insurance Program (CHIP) funds for Health 

Services Initiatives (HSIs) focused on crisis stabilization services tailored to children and adolescents. HSI 

options allow states to use a limited amount of their annual CHIP allotments and receive the higher 

federal CHIP matching rate (generally about 15% percentage points higher than Medicaid for a state) for 

projects aimed at improving children’s health.54 This spending is subject to the overall 10% cap on the 

use of CHIP funds for administrative purposes which must also account for spending to administer the 

CHIP funds.55 A number of states use this source of flexible funding for projects related to behavioral 

health services, including suicide and violence prevention for lesbian, gay, bisexual, and transgender 

youth.56 In addition, some states have used this funding to support development of poison control 

centers that provide emergency advice and referral assistance.

57,58 

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Existing Medicaid Authorities Support Coverage of Crisis Intervention and 

Stabilization Services 

Medicaid is one of the largest sources of funding for mental health and substance use disorder services 

in the United States,

59 and many of the individuals who require crisis services are Medicaid beneficiaries. 

Therefore, Medicaid has a large role in determining access to behavioral health services including 

mental health and addiction crisis stabilization services. Practically, all state Medicaid programs do cover 

crisis intervention or stabilization services based on a variety of federal Medicaid authorities.

60 

CMS directly addressed this topic in the guidance regarding “Opportunities to Design Innovative Services 

Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional 

Disturbance.” That guidance pointed out that the following state plan benefits can authorize coverage of 

behavioral health crisis services: clinic services, diagnostic services, rehabilitative services, physicians’ 

services, other licensed practitioner services, as well as the health home benefit, and primary care case 

management.

61 CMS specified that the services directly coverable with these authorities include 

screening, assessment, diagnosis, mental health and addiction treatment services, targeted case 

management, psychiatric rehabilitation services, peer supports, and family supports. 

The 2018 Medicaid guidance further explained that some activities and costs that are key components 

of providing crisis stabilization services are not directly coverable. For example, provider costs for 

outreach and team supervision cannot be directly covered by regular Medicaid authorities. However, 

CMS explained that costs related to delivery of covered services may be incorporated into the 

reimbursement rates for the covered services. 

Thus, in addition to providing comprehensive coverage of crisis intervention and stabilization services in 

their Medicaid programs, states should also ensure that their Medicaid reimbursement rate 

methodologies for crisis services incorporate the ancillary costs CMS pointed out as not directly 

coverable in the 2018 Medicaid guidance. These ancillary costs or activities include outreach and 

engagement with individuals in crisis and with other health care and public service providers as well as 

team coordination and supervision that are critical to crisis intervention and stabilization. 

Furthermore, as the SAMHSA National Guidelines for Behavioral Health Crisis Care advised, 

reimbursement rates for crisis intervention and stabilization should take into account the need for these 

programs to be available at all times for unscheduled, emergency care similar to the rate structure for 

emergency department care and ambulance transports.62 The exigencies of providing crisis services that 

require providers to be available and on-call twenty-four hours a day seven days a week makes these 

types of programs difficult to finance using traditional fee-for-service or encounter-based methods. 

Moreover, crisis stabilization reimbursement methodologies should allow for professional fees to be 

billed separately from the more inclusive team-based capacity rates for crisis stabilization. These 

professional fees can generally be billed to Medicare as discussed above; however, the team-based crisis 

stabilization rates most likely cannot. Therefore, separating out the professional fees can facilitate 

seeking Medicare reimbursement for those services. State agencies should ensure that services and 

consultations by higher credentialed providers via telehealth can be reimbursed as part of or as an 

adjunct to any team-based care payment methodology. 

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CMS has previously approved Medicaid payment methodologies and team-based capacity 

reimbursement rates sometimes pared with separately billed professional fees in a number of states. 

Below are examples of states that have implemented comprehensive team-based capacity 

reimbursement rates in their Medicaid programs: 

• The New Jersey Medicaid program covers Psychiatric Emergency Rehabilitation Services (PERS) 

including mobile services for all Medicaid eligible consumers. Services include assessment, 

immediate crisis resolution and de-escalation, counseling, referral to appropriate services 

including arranging for transport or admission, consultation with physicians or other qualified 

providers, and follow-up as necessary with the individual and/or caretaker/family member 

within 14 days of an episode of PERS care. Reimbursements include an “episode of care” 

payment for mental health services provided by PERS certified assessors and PERS specialists. An 

episode of care must include at a minimum a comprehensive face-to-face assessment and a 

disposition with either a transfer or discharge. There are rates for the first 23.99 hours (including 

a higher rate for mobile crisis intervention) and an additional hourly rate for care that extends 

beyond 24 hours in a crisis intervention facility. Psychiatrists and other licensed professionals bill 

separately for time spent on direct therapy using the appropriate CPT codes. In addition, followup services are reimbursed per one-hour unit of service.63 

• Delaware covers mobile and facility-based crisis intervention services available 24 hours a day 

seven days a week to provide assessment, crisis stabilization and de-briefing with the 

beneficiary, crisis counseling, consultation with other qualified providers, psycho-education and 

supportive services for families and consumers, recovery/discharge planning, follow-up as 

necessary with the beneficiary and the beneficiary’s caretaker or family member, linkages to 

other services, and arranging for transfers, transport and admissions as necessary. 

Reimbursement for facility services is at a per diem rate, and mobile crisis services 

reimbursement rates are paid per 15-minute intervals.

64 

• New York provides coverage of comprehensive crisis intervention services through its Medicaid 

managed care program as part of statewide effort to provide “a coordinated behavioral health 

crisis response system available to all New Yorkers”. The state has a comprehensive set of 

reimbursement rates that includes telephonic crisis response for 15-minute intervals and per 

diem rates for telephonic crisis responses that extend beyond 90 minutes. New York also has set 

rates for mobile crisis response in 15-minute intervals, per diem rates for mobile crisis 

interventions that last 90 to 180 minutes, and a different per diem rate for mobile crisis 

interventions that last for at least three hours. In addition, the state has set higher rates for 

teams of two with licensed professionals and unlicensed/certified peer support specialists. New 

York has also established reimbursement rates for crisis follow-up services in 15-minute 

intervals with different rates for single licensed providers and single peer providers and higher 

rates for two person teams comprised of a licensed provider and peer. New York is covering 

adult and child crisis residential services as part of this crisis intervention and stabilization 

program. The state has established suggested rates for crisis residential services for individuals 

over 21 and mandated rates for crisis residential services for individuals under 21.65 New York’s 

benefit and bill guidance includes the following description of this benefit: 

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“The Crisis Residence component of the Crisis Intervention benefit is designed to 

reimburse providers to integrate Crisis Residence services into existing behavioral health 

crisis response systems. Crisis Residence programs are an important part of the 

statewide comprehensive crisis service continuum. These programs differ regionally 

according to local needs and resources. Crisis Residence programs work with 

community-based organizations, hospitals, schools, law enforcement, and other entities 

to address the needs of individuals experiencing a mental health crisis.”66 

The 2018 CMS guidance also pointed out that managed care authorities can support crisis stabilization 

services. Managed care arrangements can offer more flexibility regarding some restrictions in Medicaid 

and can include coverage of additional services not as directly covered by regular Medicaid authorities. 

Moreover, managed care organizations can facilitate use of multiple 

funding streams for crisis stabilization services including Medicaid 

reimbursement for services, MHBG and SAPTBG block grant funds and 

other federal grant funding, as well as state and local funds.67 Requirements for Mobile 

Crisis Teams to Qualify for Importantly, state agencies should ensure that reimbursement rates for Increased Federal mobile crisis units are sufficient to support two person teams. The new 

mobile crisis intervention benefit in Medicaid discussed below requires Medicaid Match 

at least two person teams for a mobile crisis service to qualify for an 

85% federal match. -Include at least two members 

New Opportunities are Available in Medicaid to Support - Include one professional 

Crisis Stabilization Services and Systems authorized to conduct an 

assessment (additional team 

Medicaid programs in every state cover some form of crisis stabilization member may be a peer) services using a variety of authorities and reimbursement approaches.

68 

However, in a number of states there are still significant gaps in services - Be available 24/7 every day 

covered (e.g., some states do not provide Medicaid reimbursement for - Be trained in trauma- mobile crisis services) and certain providers are excluded or limited in informed care, de-escalation, the types of services they can provide; for example, a number of states and harm reduction 

do not allow peers to participate in their Medicaid programs.69 

Furthermore, there are long-standing restrictions on the availability of - Provide services outside 

Medicaid reimbursement for residential treatment settings with over 16 hospitals or other facilities 

beds referred to as the Institutions for Mental Diseases (IMD - Be able to provide exclusion).70 

screening/assessment, 

The ARPA established two important new opportunities for states to stabilization, and coordination 

increase support for crisis stabilization services in their Medicaid with health and social services 

programs: an increased federal matching rate for qualifying mobile crisis and supports 

intervention services and an increased federal match for home and -Have relationships with local community-based services (HCBS) including benefits covered under the 

medical and behavioral health Medicaid rehabilitative services, case management, and 1915(i) providers authorities.71 

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Increased Federal Medicaid Match for Mobile Crisis Stabilization Teams 

Section 9813 in the ARPA incentivizes states to establish or expand Medicaid coverage for mobile crisis 

services with an 85% federal matching rate for covered services provided by qualifying mobile crisis 

units. This enhanced federal match is available for 12 quarters during the five-year period starting April 

of 2022. Qualifying mobile crisis services are defined as covered items and services that are furnished to 

a beneficiary outside a hospital or facility who is experiencing a mental health or substance use disorder 

crisis. These services must be provided by a multidisciplinary team that includes at least one behavioral 

health professional authorized to conduct an assessment of the individual under state law and other 

professionals or paraprofessionals with appropriate expertise in crisis response including peer support 

specialists. Members of these teams must be trained in trauma-informed care, de-escalation strategies, 

and harm reduction. These teams must be available 24 hours a day every day to provide screening and 

assessment, stabilization and de-escalation, and coordination and referrals to health, social, and other 

services and supports in a timely manner. To qualify for the enhanced match, states must provide 

assurances that they will use the additional federal funds to supplement and not supplant state funding 

for mobile crisis services based on the level of state funding during the prior fiscal year. 

The ARP Act also appropriated $15 million in planning grants to support development of state plan 

amendments, section 1115 demonstrations, or section 1915(b) or 1915(c) waivers to provide qualifying 

community-based mobile crisis intervention services. CMS issued the notice of funding opportunity for 

these planning grants on July 13, 2021.72 CMS included the following actions among the examples of 

activities for which planning grants could be used: 

• “Technical assistance on planning emergent intervention and crisis services and the 

integration with crisis call centers, crisis intervention centers, and longer-term post-crisis 

care coordination programs and resources such as community-based recovery supports; 

• Conducting a statewide needs assessment for community-based mobile crisis intervention 

services, including such factors as provider capacity, provider qualifications, scope of 

services furnished, equity strategies, and privacy protections; 

• Enrolling prospective Medicaid providers and making technical assistance available for 

meeting Medicaid claiming requirements for furnishing community-based mobile crisis 

intervention services; 

• Building linkages and developing collaborations of community-based mobile crisis 

intervention services with National Suicide Prevention Lifeline crisis call centers and first 

responders; 

• Building and strengthening partnerships with relevant state and local partners (e.g., Single 

State Agencies for substance abuse and mental health); and 

• Assessment of state information systems to identify options for improving interagency 

communication and data sharing for facilitating individuals’ access to on-going treatment 

and to prevent recurring crises”.73 

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Ideally, these planning grants can support and encourage participation by state Medicaid agencies in 

statewide crisis services planning along with other crisis intervention stakeholders. These planning funds 

could encourage collaboration among these stakeholders on how Medicaid coverage policies can 

support broader availability of crisis stabilization services and how the MHBG and SAPTBG and other 

grant funding can be used to complement (instead of overlap) Medicaid coverage of crisis services 

including by covering fixed costs for establishing and operating mobile crisis teams. These collaborations 

could also explore other mechanisms for supporting crisis stabilization services including incorporating 

these services into coverage provided by Medicaid managed care plans as well as reimbursement rate 

methodologies for crisis stabilization services that take into account that these services must be 

available all the time and are accessed unpredictably on an emergency basis. In addition, this planning 

could include discussion of opportunities for expanded coverage and availability of crisis services 

presented by section 9817 of ARPA provision offering enhanced Medicaid funding for HCBS (discussed 

below). 

Enhanced Federal Medicaid Funding for Home and Community-Based Services and 

Infrastructure 

The ARPA includes another opportunity to increase Medicaid support for crisis stabilization services with 

section 9817 offering states a ten-percentage point increase in their federal matching rate for HCBS. This 

increased federal matching rate applies to state spending on HCBS from April 1, 2021 through March of 

2022. State spending eligible for the enhanced federal match includes spending on benefits covered 

under a number of federal Medicaid authorities including the rehabilitative services benefit, the case 

management benefit, 1915(i) state plan option, and section 1115 demonstrations all of which often 

serve as the authorizing provisions for Medicaid coverage of crisis stabilization and other behavioral 

health services. 

In recently issued guidance74, CMS specifies that the additional federal funding amounting to 10% of a 

state’s spending on HCBS from April 1, 2021 through March 31, 2022 must be used by the state on 

improvements or expansions of HCBS. These improvements or expansions can take place over a threeyear period from April 2021 through March 31, 2024. The guidance further explains that this increased 

federal funding can be reinvested one time between April 1, 2021 and March 31, 2022 to cover the state 

share of additional HCBS services (the authorities for which are listed in Appendix B of the guidance). 

There are two fundamental requirements for states to qualify for the additional federal funding for 

HCBS: 1) states must use the federal funds to supplement and not supplant state funding for HCBS; and 

2) states must implement or supplement one or more activities to enhance, expand, or strengthen HCBS 

in their Medicaid program. 

Regarding the first requirement, CMS guidance specifies that states may not impose stricter eligibility 

standards for HCBS than those in effect on April 1, 2021. In addition, states must maintain coverage of 

HCBS in effect as of that date including the services and amount, duration, and scope of that coverage. 

Finally, states must maintain provider payment rates for HCBS in effect as of April 1, 2021. These 

maintenance of effort requirements apply until the additional federal funds are fully expended. 

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Regarding the second requirement, CMS guidance advises that states must spend state funding 

equivalent to the increased federal matching funds to implement or supplement activities to enhance, 

expand, or strengthen HCBS. These activities must expand, enhance, or strengthen HCBS beyond what is 

available under the state Medicaid program as of April 1, 2021. State activities and spending to 

strengthen or expand HCBS can extend through March 31, 2024. 

Several of the HCBS authorities listed in Appendix B of this guidance and eligible for the enhanced match 

and reinvestment are used by states to authorize Medicaid coverage of crisis stabilization services. 

Therefore, states could use this opportunity to significantly expand Medicaid coverage of crisis 

stabilization services authorized under the rehabilitative services option or case management authority 

or other HCBS authority in Appendix B with the additional federal funding provided by this provision of 

the ARPA. The guidance specifies that states may reinvest additional federal funding provided under 

this provision to cover the state matching funds for additional HCBS services and be eligible for the 

higher federal matching rates one time between April 2021 and March 2022. 

In addition, many of the activities listed in Appendices C and D including those related to capacity 

building, infrastructure development, and improvements to reimbursement that states are encouraged 

to use these additional federal HCBS Medicaid funds on could be used by states to improve their crisis 

stabilization services and systems. 

The CMS guidance explicitly recommends use of these federal HCBS funds for certain activities to 

improve mental health and substance use disorder services. This section specifically refers to skill 

rehabilitation to “assist eligible individuals in receiving mental health services, substance use treatment 

and recovery services, and necessary rehabilitative services” and expanding capacity including 

“recruiting additional behavioral health providers, increasing payment rates for providers, expanding 

access to telehealth.” Furthermore, although many of the other activities in Appendices C and D are 

framed as ways to expand and improve HCBS for people with physical or intellectual disabilities, these 

same types of activities could also help improve behavioral health crisis stabilization services. These 

other activities include --

• Increasing payment rates for care providers; 

• Activities to recruit and retain care providers and professionals; 

• Workforce training, technology costs (referring specifically to assistive technology, but could 

also include technology used to provide crisis services including iPads for law enforcement 

and/or mobile crisis teams and internet costs for new and/or expanded crisis stabilization 

centers); 

• Educational materials (focused on COVID-19 but could also include 988 and telehealth); 

• Language assistance including sign language (could also be implemented in crisis service 

systems to improve care for minority and underserved communities); 

• Establishing toll free phone lines and marketing and outreach campaigns that could support 988 

implementation; 

• Providing person-centered planning and training (also critical for people experiencing a 

behavioral health crisis); 

• Improvements to quality measurement; 

• Developing cross-system partnerships among managed care plans, providers, and social support 

agencies including housing and employment supports; 

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• Caregiver training and respite, expanding the use of telehealth including investments in 

infrastructure including start-up costs, e.g., equipment, internet connectivity and activation 

costs, providing smartphones, and computers; 

• Covering costs of implementing health information technology; 

• Care coordination enhancements such as notification systems for hospital admission, discharge, 

and transfer notifications; and 

• Implementing integrated care models. 

All of these activities to enhance HCBS could be implemented by states specifically to improve and 

expand mental health and substance use disorder crisis stabilization services. 

The guidance specifies that participating states are required to submit an initial spending plan 

estimating the total amount of federal funding the state plans to claim as the 10% federal match 

increase for HCBS. In addition, this plan must include a description of activities that the state will 

implement with these additional federal matching funds between April 1, 2021 and March 31, 2024. The 

guidance also points out that this plan should also explain how the state plans to sustain these activities 

beyond March of 2024. States also have to submit quarterly reports updating the estimates of the 

amount of federal funds the state expects to draw down due to the increased federal matching funds, 

any spending on the planned activities, and progress reports on those activities. 

Moreover, the guidance also states that the initial and quarterly reports should include “any additional 

federal funds attributable to the increased federal match that the state expects to receive by 

reinvesting” the additional federal funds to cover the state share for additional HCBS services. As 

mentioned above, CMS did specify that the state must explain in their initial and quarterly reports how 

activities funded in this way will be sustained. As a result, use of some of this federal funding to cover 

fixed-cost infrastructure and capacity building activities may help lessen difficulty later on of maintaining 

expanded coverage of services. 

A number of states have posted their plans for the use of this additional federal funding to expand and 

enhance HCBS. Some of these plans are fairly general and could support a variety of activities including 

activities to expand and improve crisis stabilization services. Moreover, some states indicate they plan 

to refine their plans in subsequent reports to CMS. 

Massachusetts proposed to access an additional $500 million in federal funding for HCBS under section 

9817 of the ARPA.75 The state has proposed to focus this funding on HCBS workforce, access, and 

technology/infrastructure improvements. In addition, the state’s plan indicates the additional federal 

funding will be used to support implementation of its “Roadmap for Behavioral Health Reform” issued in 

early 2021.76 This Roadmap calls for a more centralized service enabling people to call or text to access 

mental health and addiction treatment and expanded availability of treatment including at night and on 

weekends, more community-based alternatives to emergency department crisis services, and more 

culturally relevant care. In addition, the state proposes an across-the-board payment increase and 

enhancements including hiring bonuses and internship and training opportunities for direct care 

workers. Furthermore, the state will invest in expanding access to HCBS services including Community 

Behavioral Health Centers and navigation supports in emergency departments and inpatient settings, as 

well as increased use of technology to improve communication, case management, coordination among 

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providers, data sharing, and caregiver directories. The state indicates it plans to further refine these 

plans going forward. 

California’s plan77 proposes to draw down an additional $4.6 billion in federal funding for HCBS. The 

state proposes to focus these funds on increasing and supporting HCBS direct care workers through 

training, stipends, bonuses, and career pathways. In addition, the state proposes use of these funds for 

improvements to transitions and navigation with HCBS including navigators in emergency rooms to 

screen and refer to mental health or SUD programs and services to assist individuals leaving criminal 

justice settings. The state proposes to use these funds to incentivize managed care plans to address 

homelessness. In addition, California proposes to use these funds for rehabilitation and construction of 

residential facilities for senior citizens. The state proposes to fund a contingency management pilot 

program for individuals with stimulant use disorder. In addition, the state proposes to fund several 

technology infrastructure projects focused on improving care for individuals with disabilities and senior 

citizens. 

The Indiana plan proposes to use more than $877 million in additional federal funding on HCBS 

workforce development, enhancing HCBS with specialized programs for different groups, building 

provider capacity, and caregiver training and support.78 These proposed activities include investment in 

expanding the capability and capacity of the Indiana Crisis System based on the SAMHSA National 

Guidelines for Behavioral Health Crisis Care. These efforts will include support for one or more call 

centers with 24/7 call coverage. In addition, the state proposes to provide funding to behavioral health 

providers to expand mobile crisis support and crisis stabilization services. 

Additional Avenues to Support Crisis Stabilization through Medicaid 

In the 2018 Letter to State Medicaid Directors on “Opportunities to Design Innovative Service Delivery 

Systems for Adults with Serious Mental Illness or Children with Serious Emotional Disturbance”, CMS 

highlighted increasing availability of crisis stabilization services as a key strategy for improving care for 

Medicaid beneficiaries with SMI or SED. This CMS guidance specifies that “[c]ore elements of crisis 

stabilization programs include development of regional or statewide crisis call centers coordinating 

access to care in real time, centrally deployed mobile crisis units available 24 hours a day seven days a 

week, and short-term, sub-acute residential crisis stabilization programs.” 79 The letter also points out 

that these services can help divert Medicaid beneficiaries with these conditions from unnecessary stays 

in emergency departments and involvement with law enforcement. 

Furthermore, this CMS guidance highlights that a long-standing prohibition on Medicaid reimbursement 

for services provided to beneficiaries residing in IMDs may apply to a core component of crisis 

stabilization systems, sub-acute crisis residential crisis stabilization programs, if those facilities have 

more than 16 beds. However, the letter describes how states may be able to cover these services for no 

more than 15 days under a Medicaid managed care rule that applies to comprehensive risk-based 

managed care organizations or prepaid inpatient hospital plans.80 

This State Medicaid Director letter also established a section 1115 demonstration initiative that waives 

the IMD exclusion to allow Medicaid coverage for crisis residential settings with over 16 beds in states 

that agree to take a number of steps to improve community-based behavioral health care in the state. 

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These additional actions referred to as “Milestones” in the guidance include committing to increased 

funding for community-based services including crisis call centers, mobile crisis units, and 

observation/assessment centers. As a result, this demonstration initiative frees up local and state 

funding previously dedicated to covering services in IMDs, so these funds can be used to support 

improvements in crisis intervention and stabilization programs. 

States with these section 1115 demonstrations are also required to conduct in-depth annual 

assessments of the availability of mental healthcare throughout the state including the availability of the 

crisis stabilization services (including call centers, mobile crisis, and crisis stabilization centers). States 

are also required to provide updates on actions taken to increase availability of these services. 

In addition, participating states are expected to report quarterly or annually on specific performance 

measures including emergency department utilization, inpatient utilization, and readmission following 

hospitalization in an inpatient psychiatric facility, follow-up after hospitalization for mental illness, 

access to preventive/ambulatory care, total costs, and per capita costs for mental health among 

beneficiaries in inpatient or residential setting compared to all other beneficiaries.

81 

As of July 2021, CMS has approved applications from the following states for these demonstrations: 

District of Columbia, Idaho, Indiana, Oklahoma, Utah, Vermont, and Washington. In addition, 

Massachusetts, Alabama, and New Mexico have submitted formal applications. 

CMS previously established a similar section 1115 demonstration program in 2015 that was revised in 

2017. This initiative likewise allows coverage of services for beneficiaries in IMDs including crisis 

residential settings primarily to receive SUD treatment. These demonstrations also require states to take 

a number of steps to improve the SUD treatment continuum of care in their state. In addition, states are 

required to report on a set of performance measures and metrics on a wide range of issues including the 

following topics: initiation and engagement in treatment, use of opioids, continuity of medication to 

treat opioid use disorder, treatment offered at discharge and follow-up after discharge, emergency 

department utilization, inpatient stays, and readmissions among beneficiaries with SUD. CMS has 

approved 32 states for these 1115 demonstrations and an additional three states have formally 

submitted applications. 

These demonstrations incentivize states to enhance their crisis stabilization systems in order to meet 

the requirements or milestones to improve access to community-based care. In addition, statewide 

implementation of crisis stabilization services and the crisis system improvement activities discussed 

above should help states perform well on the milestones and performance measures for these 

demonstrations. 

Telehealth is a Key Component of Enhanced Crisis Stabilization Services and Systems 

Use of telehealth to provide mental health and addiction treatment services grew exponentially during 

the COVID-19 public health emergency. Almost 40% of Medicare beneficiaries accessed office visits via 

telehealth and 60% accessed mental health services via telehealth.82 Services delivered to Medicaid and 

CHIP beneficiaries via telehealth also increased dramatically particularly in the use of telehealth for 

mental health services.

83 In addition, commercial insurers greatly expanded coverage of telehealth, with 

private insurance claims data consistently showing mental health conditions to be among the most 

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frequent reason for telehealth visits. As utilization of telehealth overall has begun to decline, utilization 

of telehealth for mental health treatment has remained strong, far outpacing the level of continued use 

of telehealth for other conditions.84 

The availability of telehealth undoubtedly preserved access to behavioral healthcare to a significant 

degree. However, for many disadvantaged individuals, this alternative avenue was not sufficient to 

maintain access. Data recently released by CMS indicate that Medicaid enrollees’ access to mental 

health and SUD services decreased dramatically during the pandemic and did not fully recover despite 

greater use of telehealth.

85 This decrease in utilization of behavioral healthcare was pronounced among 

children and youth during the pandemic perhaps due to the lack of access to behavioral healthcare 

through schools.86 

Crisis call centers, mobile crisis service providers, and crisis stabilization centers often provide services 

via telehealth. Continued expanded coverage of telehealth with reimbursement rates on par with inperson services will help support broader availability of crisis services that can hopefully address some 

of the behavioral health impact and expected increased need for mental health and SUD treatment 

services resulting from the Covid-19 pandemic. 

The significance of expanded Medicare coverage of telehealth services for improving access to crisis 

stabilization services should not be overlooked since Medicare coverage policies often influence 

Medicaid and commercial insurance. Moreover, continued coverage of audio-only telehealth services 

will be critical since telehealth crisis services are often provided via telephone calls. Among Medicare 

beneficiaries who had a telehealth visit last summer and fall, over half of them accessed care using a 

telephone only.87 Furthermore, coverage of audio-only telehealth services enables access to behavioral 

healthcare in areas where broadband service is often not available to support video interactions. Lowincome populations and homeless individuals are also less likely to have access to telehealth services via 

video-conference technology. 

In addition, availability of care through audio-only telehealth is even more important in rural areas due 

to the common shortage of behavioral healthcare providers in those areas. According to the Health 

Resources and Services Administration (HRSA), there are more than 5,700 mental health provider 

shortage areas across the United States, with more than one-third of Americans (119 million people) 

living in these shortage areas.88 Telehealth services can help extend the capacity of behavioral health 

services to reach individuals in need of behavioral healthcare including crisis services in those shortage 

areas. 

Recent legislation has significantly improved Medicare coverage of telehealth for beneficiaries in need 

of mental health or substance use disorder treatment. The Substance Use-Disorder Prevention that 

Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT Act)

89 improved 

Medicare coverage of telehealth for SUD treatment by eliminating the limitation on coverage to services 

provided in certain rural geographic areas and the requirement that beneficiaries travel to originating 

site facilities to access telehealth services. (Currently, CMS has waived these limits on telehealth during 

the pandemic.) Due to this change in the law, even after the public health emergency is over, Medicare 

beneficiaries will be able to access SUD services via telehealth from their homes or communities and 

regardless of the geographic area they are in. Furthermore, these changes also require that 

reimbursement for providers be at the same rate as if these services were provided in-person, although 

facility fees would not be provided.90 

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Similar improvements to Medicare coverage of mental health services via telehealth to beneficiaries at 

home and regardless of geographic locations were enacted as part of the CAA.

91 In addition, in a recent 

rulemaking implementing this provision, CMS has also proposed to maintain Medicare coverage of 

audio-only technology for telehealth services for mental health and certain SUD treatment.92 These 

changes could help support Medicare coverage of telehealth services provided by crisis stabilization 

services providers, but a requirement that the beneficiary must have seen the provider in-person within 

the prior six months is a significant barrier to the utility of these provisions for improving access to crisis 

stabilization services. Exceptions to this preexisting treatment relationship requirement should be 

allowed for behavioral health crisis situations. 

Opportunities to Support Crisis Stabilization through Alternative Payment Models 

and Demonstrations 

As discussed above, reimbursement for crisis stabilization services must be structured differently than 

payment for other mental health or substance use disorder services. Payment methodologies and rates 

must take into account the need to have crisis stabilization services available around the clock and 

accessible without appointments or even notice. These services also generally require a team-based 

approach to care that is sometimes provided in the community by a mobile crisis unit, sometimes in a 

crisis receiving/observation center, and sometimes an emergency room or other setting, including jails. 

These types of services demand a flexible funding approach that factors in the variety of resources 

needed to provide this type of care. 

Certified Community Behavioral Health Clinic Model 

The Medicaid CCBHC demonstration is one example of how a comprehensive flexible payment 

methodology can be developed that includes mobile crisis services in the community as well as crisis 

stabilization services in a clinic setting. This demonstration supports provision of a comprehensive array 

of services by community mental health centers with a cost-based daily or monthly Medicaid payment 

rate. The Medicaid demonstration was the basis for the CCBHC expansion grants described above that 

were increased substantially in the CAA and ARPA. There are also quality improvement features 

included in the demonstration. States have the option to provide bonus payments to CCBHCs that meet 

certain quality metrics. In addition, CCBHCs and states are required to report on performance measures 

aimed at assessing the impact of this demonstration. The demonstration includes 10 states.

93 It started 

in 2016 and has been extended many times most recently until September 30, 2023. 

Several of the Medicaid CCBHC demonstration states have added their CCBHC payment rates to their 

Medicaid state plans. In Missouri, for example, the state plan amendment adding this payment rate for 

clinics that qualify as CCBHCs refers to the Rehabilitative Services Option for authority. This payment 

methodology incorporates all the costs of providing 24/7 crisis stabilization services including mobile 

crisis services and also including the costs of activities that go into providing these services that are not 

as directly covered by existing Medicaid authorities including outreach and engagement costs, care 

coordination, and team-based consultation costs. 

In addition to this Medicaid demonstration, the CCBHC expansion grant program has funded 

development of CCBHCs in all but about ten states.

94 These grants do not include the Medicaid 

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reimbursement model incorporated into the demonstration. However, availability of CCBHCs in a state, 

even those that are funded by SAMHSA discretionary grants, could facilitate development of a Medicaid 

payment rate modeled after the payment rates in the CCBHC demonstration that could cover all the 

costs that go into providing 24/7 crisis stabilization services. 

Emergency Triage, Treat, and Transport (ET3) Model 

The Center for Medicare and Medicaid Innovation (CMMI) within CMS recently kicked off a new 

payment model for emergency services for Medicare beneficiaries that is closely aligned with the 

objectives of increasing crisis stabilization services.

95 This model, the Emergency Triage, Treat and 

Transport (ET3) model, pays for transportation of Medicare beneficiaries to alternative locations instead 

of the settings to which beneficiaries are generally required to be brought, usually hospital emergency 

departments. Participants in the five-year program that started in January of 2021 are 184 public and 

private Medicare-enrolled ambulance providers in 36 states. The model will test two new Medicare 

payments: 1) for ambulance transport to alternative destinations not currently covered by Medicare; 

and 2) for treatment in place when appropriate by a qualified health care practitioner at the scene of an 

emergency response or via telehealth. The alternative settings where participating ambulance providers 

may bring beneficiaries include primary care offices, urgent care clinics, and community mental health 

centers or other destinations approved by CMS. Crisis stabilization centers should also qualify as 

alternative settings where Medicare beneficiaries could be brought. Payments to participants will be 

tied to performance on key quality measures in the third year of the demonstration. 

This nationwide demonstration highlights the need for alternatives to emergency departments for those 

who do not really need to be there, and the need for greater flexibility in state and federal regulations 

regarding emergency response and where individuals experiencing a behavioral health crisis may be 

brought for stabilization services. In addition, this demonstration points out the need for improvements 

to Medicare coverage of crisis stabilization services. As described above, Medicare coverage for crisis 

stabilization services is generally limited to crisis psychotherapy (CPT codes 90839 and 90840), but many 

crisis stabilization centers do not bill for these codes because they do not have the staff with the right 

credentials. 

CMMI also announced a complementary opportunity for local governments where emergency transport 

providers participating in the ET3 model are located. This additional opportunity will provide funding to 

expand emergency and non-emergency medical triage services in these locations. As currently 

structured, access to triage services funded with these grants would have to be provided in response to 

calls to 911. However, there may be an opportunity to coordinate these improved triage capacities with 

broader state and local efforts to increase the availability of triage services for callers to 988. State 

mental health and substance use disorder agencies should identify whether any of the providers in their 

state are participating in this program96 and incorporate those activities into their planning for 

coordinated and comprehensive crisis stabilization systems. 

CMMI in collaboration with the Center for Medicaid and CHIP Services at CMS issued guidance on how 

states could implement similar payment and care delivery models in their Medicaid programs.97 This 

guidance describes various Medicaid authorities and payment policies that states could implement in 

order to support emergency transport for Medicaid beneficiaries to alternative destinations instead of 

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emergency departments and to cover practitioners including EMTs providing services to Medicaid 

beneficiaries on the scene of a 911 response. 

This joint guidance points out that under federal law Medicaid may cover emergency response services 

provided on the scene without transport by EMTs who are under the supervision of a physician or other 

licensed practitioners including licensed paramedics. In addition, Medicaid may cover services provided 

on the scene by unlicensed practitioners under the preventive services Medicaid authority although 

these services must be recommended by and under the supervision of a licensed provider. This guidance 

could be useful in considering how to structure Medicaid coverage of mobile crisis teams. 

In addition, the joint guidance points out some issues for states to consider in implementing Medicaid 

coverage of crisis stabilization services including whether state policies and regulations prohibit 

emergency response personnel from transporting individuals to alternative destinations or prohibit 

providing treatment on the scene of the emergency without providing transportation. In addition, the 

guidance encourages states to consider whether the state Medicaid program covers the relevant HCPCS 

codes for emergency response services. 

In this guidance, CMS points out that federal Medicaid law and regulations do not specify that 

emergency transportation must be to a hospital and indicates that these issues are determined in state 

law and regulation. CMS also specifies that a number of state Medicaid agencies have implemented 

Medicaid coverage of transportation to alternative destinations and CMS lists crisis stabilization centers 

as examples of alternative destinations that state Medicaid agencies may include in their initiatives. CMS 

also highlights that Medicaid managed care plans may have flexibility to cover alternative destinations 

and transportation services. 

Partnerships with Hospitals and Health Systems: The Maryland Example 

Maryland has a unique approach to healthcare financing that may be instructive for how to 

encourage greater collaboration between hospitals and community-based providers on 

development of crisis stabilization programs and services. The Health Services Cost Review 

Commission (HSCRC) sets the reimbursement rates that all payers (e.g., Medicare, Medicaid, 

commercial) must pay hospitals in the state. This program required a waiver from the Centers for 

Medicare and Medicaid Services so that Medicare could be included in this all-payer initiative.98 

The most recent renewal of this waiver agreement between Maryland and CMS requires the state 

to meet certain benchmarks regarding care for Medicare beneficiaries in the state in terms of 

spending and performance measures. To keep control over spending for Medicare beneficiaries in 

the state, the HSCRC has offered grant funding for regions and localities in the state to support 

development of collaborations between hospitals and community-based providers to help drive 

down spending while increasing quality of care. A recent round of grants focused on supporting 

development of crisis stabilization systems in different regions within the state with the hope that 

these efforts will result in establishment of programs that offer individuals experiencing behavioral 

health crises alternatives to going to the hospital emergency departments.

99 Hospitals are key 

stakeholders in efforts to develop crisis stabilization facilities and programs as alternatives to 

emergency departments, and states are encouraged to coordinate with them in efforts to improve 

crisis stabilization systems and increase availability of crisis stabilization programs and services. 

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Conclusion 

The dual national crises of increased drug overdoses and high rates of suicide demand a new approach 

to addressing behavioral health crises. Designation of 988 as a nationwide toll-free hotline is a 

galvanizing event that should spur renewed focus on developing comprehensive coordinated crisis 

stabilization systems that can respond to the needs of 988 callers with local resources and support. 

Fortunately, several game-changing opportunities have arisen to help support state and local efforts 

including tremendous increases in federal block grant funding, a number of opportunities to enhance 

Medicaid funding for these programs, and greatly expanded coverage of telehealth services. 

Recommendations for State Policy Makers Regarding Increased Block Grant and 

Medicaid Funding 

I. Invest in Statewide Crisis Stabilization Systems 

• Develop and coordinate statewide improvements to crisis stabilization programs by convening 

stakeholders with vested interests in increasing access to these services in addition to state mental 

health and substance use disorder agencies including state Medicaid agency leaders, law 

enforcement, hospital/health system emergency departments, crisis stabilization services providers, 

insurance commissioners, emergency transportation providers, 911 operators, other hotline and 

public service number operators, housing authorities, people with lived experiences of having 

serious behavioral health conditions, peer support specialists, families of adults or children with 

serious behavioral health conditions, representatives of underserved communities and populations, 

as well as possibly other state and local regulatory agencies that regulate providers of emergency 

services; 

• Conduct a gap analysis regarding capacity of existing crisis stabilization centers, mobile crisis teams, 

and call centers and assess the need for increased capacity and coordination among these 

programs; 

• Enhance health information technology including by expanding broadband, providing technology for 

telehealth, and improving or establishing electronic systems for tracking which providers have 

capacity to care for individuals in crisis; 

• Pursue Medicaid funding for state administrative costs, including enhanced match for health 

information technology, for improving crisis stabilization systems and services including 

development and operation of call centers and electronic systems for tracking crisis stabilization 

programs’ capacity to accept individuals in crisis, as well as support for improvements to providers’ 

telehealth capabilities (in proportion to the degree to which Medicaid enrollees benefit from these 

improvements); 

• Consider funding call center operations through contracts to support rapid responses regardless of 

coverage; 

• Develop protocols for when responses to hotline calls should come through 911 or 988 as well as 

policies for when and how law enforcement should be involved in crisis response activities; 

• Remove state limitations on coverage of interventions provided outside of hospitals; 

• Eliminate restrictions on emergency transportation only to hospital emergency departments to 

allow reimbursement for transportation to crisis centers, clinics, and other settings; 

• Explore whether CHIP funding for HSIs is available to support development of specialized crisis 

stabilization services for children and adolescents; and 

• Develop data collection and quality assurance programs for crisis stabilization programs; 

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II. Improve Coverage of Crisis Services and Provider Reimbursement to Increase Availability of 

Stabilization Programs 

• Reconsider how crisis stabilization services are financed to determine whether additional Medicaid 

authorities are available for covering crisis services; 

• Access additional federal Medicaid funding through the 10% increased federal match rate for HCBS 

to improve and expand crisis stabilization programs; 

• Revise Medicaid reimbursement rates for crisis stabilization programs to address the need for 

team-based capacity that is available around the clock and allow professional fees to be billed 

separately from the team-based payment in part to facilitate reimbursement by other payors 

including Medicare; 

• Ensure Medicaid reimbursement rates for mobile crisis stabilization services are sufficient to 

support two-person teams; 

• Add coverage of peer supports to the state Medicaid program, if not already covered, and 

authorize peers support providers to support clinicians in providing crisis stabilization services; 

• Develop and submit a state plan amendment or other authorization to access the 85% federal 

Medicaid match to expand mobile crisis services beginning April of 2022; 

• Ensure coverage of telehealth for behavioral health services including audio-only telehealth with 

comparable reimbursement rates to in-person treatment in Medicaid and state-regulated 

insurance; 

• Authorize and support billing by call center staff for telehealth services provided to callers; 

• Require health insurers offering coverage plans in the state, including Medicaid managed care 

plans, to cover crisis stabilization services and include crisis stabilization providers in their 

networks; and 

• Apply for section 1115 demonstrations for innovative service delivery systems for individuals with 

SUD, SMI, or SED to expand coverage of crisis residential settings that qualify as IMDs; 

III. Support Providers to Expand Access to Crisis Stabilization Services 

• Cover providers’ start-up costs for establishing new crisis stabilization programs including hiring 

staff and developing capacity to bill Medicaid, commercial insurance, and Medicare; 

• Work with crisis services providers to improve their capacity to bill Medicare and commercial 

insurance, as well as Medicaid, for covered crisis services; 

• Encourage hiring of peer support specialists particularly by crisis stabilization programs, and 

incentivize development of stepped up career opportunities for peers; 

• Reexamine limits on scope of services for providers of crisis stabilization services to ensure they are 

not unnecessarily restrictive; 

• Support provider establishment of crisis stabilization programs to address the needs of special 

populations with flexible funding for start-up costs and training; and 

• Provide training for providers and other crisis stakeholders regarding crisis responses for special 

populations including children with serious behavioral health conditions, underserved and minority 

communities, and individuals with IDD. 

Recommendations for Additional Federal Policies to Support Crisis Stabilization Systems and Programs 

• Establish a permanent ten percent set-aside in the MHBG to support on-going crisis stabilization 

system expansions and improvements; 

• Provide infrastructure funding to states and counties to cover construction of new crisis stabilization 

facilities; 

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• Clarify that the IMD exclusion does not apply to crisis stabilization centers because they are focused 

on providing short-term de-escalation and stabilization and connections to treatment as opposed to 

being “primarily engaged in providing diagnosis, treatment, or care for persons with mental 

diseases”;

100 

• Require Medicare Advantage, Qualified Health Plans, and Federal Employee Health Benefit Program 

plans to cover crisis stabilization services; 

• Maintain Medicare coverage of telehealth, including audio-only services, with reimbursement on 

par with rates for in-person services; 

• Recognize an exception for behavioral health crises to the Medicare telehealth requirement that the 

beneficiary must have seen by the provider in-person within the prior six months for Medicare to 

cover mental health or substance use disorder telehealth services to beneficiaries who are home or 

in their communities; 

• Issue federal guidance on application of parity to crisis stabilization services; and 

• Encourage and enable CMMI ET3 model participants to coordinate emergency response activities 

covered by Medicare through that demonstration with efforts to improve responses to 988 in those 

communities. 

SIGNIFICANT DATES 

April 2022: Medicaid 85% federal Match for mobile crisis services goes into effect for twelve quarters 

JULY 2022: Three-digit behavioral health crisis and suicide prevention hotline, 988, available nationwide 

via all telecommunications providers 

MARCH 2023: Deadline for states to expend additional MHBG and SAPTBG funding provided in the CAA 

MARCH 2024: Deadline for states to spend 10% increase in federal Medicaid match for HCBS 

SEPTEMBER 2025: Deadline for states to expend additional MHBG and SAPTBG funding provided in the 

ARPA 

192
List of Abbreviations 

ARPA American Rescue Plan Act 

CCBHC Certified Community Behavioral Health Clinic 

CHIP Children’s Health Insurance Program 

CMS Centers for Medicare and Medicaid Services 

CAA Consolidated Appropriations Act, 2021 

ET3 Emergency Triage, Treat, and Transport 

IDD Intellectual or Developmental Disabilities 

IMD Institution for Mental Diseases 

MHBG Community Mental Health Services Block Grant 

SAMHSA Substance Abuse and Mental Health Services Administration 

SAPTBG Substance Abuse Prevention and Treatment Block Grant 

SMI Serious Mental Illness 

SUD Substance Use Disorder 

NB: The author would like to thank Brenda Jackson for her detailed input and expert guidance. 

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194

Appendix A: SAMHSA Guidance on Mental Health Block Grant Set-Aside for Crisis 

Services

Substance Abuse and Mental Health Services Administration (SAMHSA) is directed by 

Congress through the Consolidated Appropriations Act, 2021 and the Coronavirus Response 

and Relief Supplement Appropriations Act, 2021 [P.L. 116-260], to set aside 5 percent of the 

Mental Health Block Grant (MHBG) allocation for each state to support evidence-based crisis

systems. Congress specifically provided an increase to federal fiscal year (FY) 2021 MHBG

appropriation over the FY 2020 level to help states meet this new requirement without losing 

funds for existing services. The appropriation bill has the following requirement for the 

new 5 percent set-aside.

Furthermore, the Committee directs a new five percent set- aside of the total for evidencebased crisis care programs addressing the needs of individuals with serious mental illnesses

and children with serious mental and emotional disturbances. The Committee directs

SAMHSA to use the set-aside to fund, at the discretion of eligible States and Territories, some

or all of a set of core crisis care elements including: centrally deployed 24/7 mobile crisis

units, short-term residential crisis stabilization beds, evidence-based protocols for delivering

services to individuals with suicide risk, and regional or State-wide crisis call centers

coordinating in real time.

A fully developed crisis response system is responsive any time and any place. What does a 

person in crisis need? Someone to talk to, or someone to respond, or a safe place to go for

evaluation, stabilization and follow up. SAMHSA expects that states will build on the 

emerging and growing body of evidence for effective community-based crisis- intervention 

and response systems. SAMHSA recognizes that the development of fully accessible and

responsive crises services involves complex problem solving with multiple entities and

systems. We also recognize that strategic crisis services implementation can result in better

care and cost savings through the reduction in avoidable emergency department visits,

psychiatric admissions, police engagement, arrests, incarcerations and 911 calls.

SAMHSA recently developed Crisis Services: Meeting Needs, Saving Lives, which includes 

“National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit” as well as

other related National Association of State Mental Health Programs Directors (NASMHPD)

papers on crisis services. Please note that this set aside funding is dedicated for the core set

of crisis services as directed by Congress. Nothing precludes states from utilizing more than

5 percent of its MHBG funds for crisis services for individuals with serious mental illness or 

children with serious emotional disturbances. If states have other investments for crisis

services, they are encouraged to coordinate those programs with programs supported by this

new 5 percent set aside. This coordination will help ensure services for individuals are

Guidance for the revision of the FY 2020-2021 Mental Health

Block Grant Application for the new Crisis Services 5% setaside
195

swiftly identified and are engaged in the core crisis care elements.

SAMHSA is requesting states to implement this 5 percent set-aside through a “request for

revision of the 2020-21 MHBG plan” within the Environmental Factors, Section 15. 

Crisis Services. States are encouraged to fund programs to meet the needs of persons with

crisis services, specifically utilizing the SAMHSA’s National Guidelines for Behavioral

Health Crisis Care, tool kit. States may address the three core services either through 

enhancing existing program activities or through developing a set of new activities based on 

the tool kit.

It is expected that the states’ capacity to implement crisis services will vary based on the

actual funding from the 5% allocation. It is also recognized that with the timing of the

allocation distribution, states may need to dedicate the rest of the current fiscal year to

planning, training, and/or infrastructure development while targeting program implementation

to the following year. Additionally, many states have begun implementing such models or 

similar approaches and can build on these existing efforts through their proposed MHBG plan

revision. States must submit their plan revision request proposal into the FY 2020-2021 

MHBG Behavioral Health Assessment and Plan in Section C. Environmental Factors and Plan,

15. Crisis Services. This section initially requested to report how states and local communities

identify and effectively respond to, prevent, manage and help individuals, families, and

communities recover from crises.

States should also complete line 10, Crisis Services (5%) in Table 2 State Agency Planned

Expenditures [MH] under Section B: MHBG.

SAMHSA requests states to submit the following with the proposal. 

• Update the checkboxes and add any comments in the comment boxes in Section C.

Environmental Factors and Plan, 15. Crisis Services

• Update Table 2 to reflect the 5% set-aside funds

Include a description of the current status of your states crisis program as well as

proposed plan for expenditure of the 5% set aside. We recommend the following

information when submitting the proposals. 

• Description of the status of the state’s current crisis system. Please describe in terms of

the following three elements: current access to local crisis call centers, the availability of

mobile crisis behavioral health first responder services and the availability and or

utilization of short-term crisis receiving and stabilization centers. The suggested

framework for describing your states current system capacity is below. Receipt of this

data will enable us to track national development and utilization of each of the crisis

components over time.

• Stages of Implementation terms:

a) The Exploration-Planning stage: is the stage when states identify their communities’

needs, assess organizational capacity, identify how crisis services meet community

needs, and understand program requirements and adaptation.
196 

b) The Installation stage: occurs once the state has proposed a plan and begins making the

changes necessary to implement the service based on the SAMHSA guidance.

This includes coordination, training and community outreach and education activities.

c) Early Implementation: occurs when the state has the core crisis service implemented in

some parts of the state, about 25% or less persons have access to that service.

d) Middle Implementation stage: occurs when the state has the core crisis service

implemented such that about half of the people in your state have access to that service.

e) Majority Implementation: occurs when the state has the core crisis service implemented

in most parts of the state so that most people have access.

f) Program Sustainment stage: occurs when implementation is statewide and has a clear

funding plan.

We request that you indicate what stage each of the three elements is in your state and

submit this back to us in your application. 

Exploration

Planning

Installation Early

implementation

Less than 25% 

of people in

state

Middle

Implementation

About 50% of 

people in state

Majority

Implementation

At least 75% of 

people in state

Program

Sustainment

Someone

to talk to

Someone

to

respond

Place to

go

Other program implementation data that might be useful to characterize crisis services system

development. These are included for your consideration only and we recognize that some of 

these are not readily available. These are based on data components that some states and

localities have found useful in measuring impact and outcome of crisis services.

1. Someone to talk to: Call Center Capacity

a. Number of locally based crisis call Centers in state

i. In the Suicide lifeline network

ii. Not in the suicide lifeline network

b. Number of Crisis Call Centers with follow up Protocols in place

c. Total number of calls statewide and by local crisis call center

d. Percent of 911 calls that are identified as MH related
197

2. Someone to respond: mobile behavioral health crisis capacity

a. Number of mobile responders that are independent of first responder structures

(police, paramedic, fire)

b. Number of mobile responders that are integrated with first responder structures (police,

paramedic, fire)

c. Number of mobile responders that employ peers

d. Number of police responses to mental health crises

3. Place to Go: Available resources in the state

a. Number of Emergency Departments

b. Number of Emergency Departments that operate a specialized behavior health

component.

c. Number of Crisis Receiving and Stabilization Centers (short term, 23 hr units that can

diagnose and stabilize individuals in crisis)

d. Number of hours of overtime by law enforcement related to accompaniment of persons

with MH conditions in ED or other settings.

e. Number of persons boarded in ED (In ED longer than 24 hours and waiting for

psychiatric admission.)

• Clearly describe the proposed/planned activities utilizing the 5% set aside for FY 21,

including an estimated budget. States may be at different stages for different geographic

locations. States will be required to report on what activities have been completed

throughout the grant with this set-aside funding.

• Via the revision request, upload the document (word or pdf) using the upload tab into

Section C. Environmental Factors and Plan, 15. Crisis Services. Please title this

document “Crisis Services in FY 21”. Upon submission, SAMHSA will review the

revision proposals to ensure they are complete and responsive. Once the revision

proposal is approved by SAMHSA, the allotment for the 5 percent set aside will be

awarded to the state.
198

Appendix B: SAMHSA Guidance on American Rescue Plan Act Funding

May 18, 2021 

Dear Single State Authority Director and State Mental Health Commissioner:

Public Law 117-2, the American Rescue Plan Act of 2021 (ARPA), signed by President Biden

on March 11, 2021, directed the Substance Abuse and Mental Health Services Administration

(SAMHSA) to provide additional funds to support states through Block Grants to address the 

effects of the COVID -19 pandemic for Americans with mental illness and substance use 

disorders. The COVID-19 pandemic has exposed and exacerbated severe and pervasive health and

social inequities in America, including the critical importance of supporting people with mental

illness and substance use disorders. As the pandemic swept through the states, societal stress and

distress over this newly emerging disaster created the need for nimble and evolving policy and

planning in addressing mental and substance use disorder services. SAMHSA, through this

guidance, is asking states to improve and enhance the mental health and substance use service

array that serves the community. 

ARPA allocated $1.5 billion each for Mental Health Block Grant (MHBG) and Substance Abuse 

Prevention and Treatment Block (SABG) grants to the states. States have until September 30, 

2025, to expend these funds. Federal block grant monies are provided to support state priorities

and SAMHSA asks that states consider the following in developing an ARPA Funding Plan.

A. MHBG Guidance

States must spend the MHBG funds based on 42 U.S.C. Chapter 6A, Subchapter XVII, Part B,

Subpart I: Block Grants for Community Mental Health Services for adults with serious mental

illness (SMI) and children with serious emotional disturbance (SED). () Consistent with HHS

Disaster Relief Flexibilities, SAMHSA may waive requirements with respect to allowable

activities, timelines, or reporting requirements for the MHBG, as deemed necessary to facilitate a 

grantee’s response to coronavirus.

The MHBG allocation requires states to set aside ten percent (10%) of their total allocation for

first-episode psychosis or early SMI programs. 

SAMHSA encourages states to consider a focus on support of a behavioral health crisis

continuum. An effective statewide crisis system affords equal access to crisis supports that meet

needs anytime, anyplace, and for anyone. This includes those living in remote areas and

underserved communities as well as youth, older adults, persons of diverse backgrounds, and

other marginalized populations; the crisis service continuum will need to be able to equally and

adeptly serve everyone. SAMHSA recommends states consider use of the ARPA MHBG funds

to develop, enhance, or improve the following:

5600 Fishers Lane • Rockville, MD 20857

www.samhsa.gov • 1-877-SAMHSA-7 (1-877-726-4727)
200

• Develop partnerships with the emerging Suicide Lifeline (9-8-8) systems, Law

Enforcement, EMS, health care providers, housing authorities, Housing and Urban

Development (HUD) Continuum of Care, hospital systems, peer-based recovery

organizations, and substance use specific treatment providers, all of whom have a critical

role in the crisis continuum. 

• Utilize five percent of funds for crisis services, as described in the FY 2021 

appropriations language.

• A comprehensive 24/7 crisis continuum for children including screening and assessment;

mobile crisis response and stabilization; residential crisis services; psychiatric 

consultation; referrals and warm hand-offs to home- and community-based services; and

ongoing care coordination. 

• Provide increased outpatient access, including same-day or next-day appointments, for

those in crisis.

• Improve information technology infrastructure, including the availability of broadband 

and cellular technology for providers, especially in rural and frontier areas; use of GPS,

to expedite response times, and to remotely meet with the individual in crisis.

• The adoption and use of health information technology, such as electronic health records,

to improve access to and coordination of behavioral health services and care delivery. 

• Consider digital platforms, such as Network of Care, which facilitate access to behavioral 

health services for persons with SMI-SED.

• Advance telehealth opportunities to expand crisis services for hard to reach locations,

especially rural and frontier areas. Expand technology options for callers, including the 

use of texting, telephone, and telehealth. Note: States cannot use the funds to purchase 

any items for consumers/clients. 

• Implement an electronic bed registry that coordinates with existing HHS provider 

directory efforts and treatment locator system that will help people access information on 

crisis bed facilities, including their locations, available services, and contact information. 

• Support for crisis and school-based services that promote access to care for children with

SED.

• Develop medication-assisted treatment (MAT) protocols to assist children and adults who

are in crisis, which may leverage telehealth when possible. 

• Expand Assisted Outpatient Treatment (AOT) services.

• Develop outpatient intensive Crisis Stabilization Teams to avert and address crisis.

• Technical Assistance for the development of enhanced treatment and recovery support

services including planning for Certified Community Behavioral Health Clinics

(CCBHC).

SAMHSA requests that the following information is included when submitting the proposals: 

1. Identify the needs and gaps of your state’s mental health services continuum including 

prevention, intervention, access to crisis services, treatment, and recovery support 

services.
200

2. Identify the needs and gaps of your state’s mental health services related to developing a 

comprehensive crisis continuum. Focus on access to your states services through crisis

call centers with local knowledge of available services, availability of mobile crisis

response teams and crisis receiving and stabilization services.

3. Describe your state’s spending plan proposal, including a budget that addresses the needs 

and gaps related to crisis and services continuum. 

4. Describe how the state will advance the development of crisis and other needed

prevention, intervention, treatment and recovery support services so that your state’s 

system is responsive to the needs of your residents with SMI and SED. Refer to the 

Guidebook on crisis services.

5. Explain how your state plans to collaborate with other departments or agencies to address

crisis, treatment, and recovery support services.

6. Describe how the state plans to spend the ten percent set aside for first-episode 

psychosis/early SMI and, if applicable, the five percent set aside for crisis services.

7. Describe other state priorities or activities that the state plans to fund during the 

performance period using ARPA funds, with consideration given to disproportionately 

high rates of MH/SUD in certain communities and disparities in COVID-19 BH-related

outcomes by race, ethnicity, and other factors.

8. Describe how the state will use, or consider, health IT standards if using funds for health

IT infrastructure or advancement. This includes a description of standards and, as

applicable, conformance to Office of the National Coordinator certification criteria in

health IT products used or that will be used to support behavioral health clinical priorities

and interoperable data exchange. States must use standards identified by the Office of 

the National Coordinator for Health IT in 45 C.F.R. 170 where applicable and also should 

consider standards identified in the Interoperability Standards Advisory 

(https://www.healthit.gov/isa/), including but not limited to those standards described in

the, the “Allows for the Exchange of State Prescription Drug Monitoring Program 

(PDMP) Data” section and the “Social Determinants of Health” section.

Using the WebBGAS Revision Request for the FFY 2021 Block Grant Application, upload the 

document (Microsoft Word or pdf) using the tab into the State Information Section, Chief

Executive Officer’s Funding Agreement – Certifications and Assurances/Letter Designating

Signatory Authority [MH]. Please title this document “ARPA Funding Plan 2021 (MH).”

B. SABG Guidance

States are required to plan for, expend, and report on the FY 21 SABG ARPA Supplemental

Funding based on 42 U.S.C. Chapter 6A, Subchapter XVII, Part B, Subpart II: Block Grants for

Prevention and Treatment of Substance Abuse, and 45 CFR, Part 96, Subpart L.

Consistent with HHS Disaster Relief Flexibilities, SAMHSA may waive requirements with

respect to allowable activities, timelines, or reporting requirements for the SABG as deemed

necessary to facilitate a grantee’s response to coronavirus. 

Accordingly, all regular provisions of the statute and regulations pertaining to the SABG are

fully applicable to the planning and expenditure of the SABG ARPA Supplemental Funding. 
200

This includes, but is not limited to, the definitions, assurances, requirements, and restrictions of 

the SABG standard funding. 

The SABG allocation requires states to expend not less than twenty percent (20%) of their total

allocation for substance use disorder (SUD) primary prevention services for individuals who do

not require treatment for substance abuse, in accordance with 42 USC 300x-22 and 45 CFR

96.124 and 96.125. The SABG allocation also requires “designated states” to expend five percent

(5%) of their total allocation for EIS/HIV Services, in accordance with 42 USC 300x-24(b) and

45 CFR 96.128. 

The SUD prevention, intervention, treatment, and recovery support services continuum includes 

various evidence-based services and supports for individuals, families, and communities. Integral

to the SABG are its efforts to support health equity through its priority focus on the provision of 

SUD prevention, treatment, and recovery support services to identified underserved populations. 

These underserved and marginalized populations include, but are not limited to, pregnant women

and women with dependent children; persons who inject drugs; persons using opioids and/or

stimulant drugs associated with drug overdoses; persons at risk for HIV, TB, and Hepatitis;

persons experiencing homelessness; persons involved in the justice system; persons involved in

the child welfare system; Black, Indigenous, and People of Color (BIPOC); LGBTQ individuals; 

rural populations; and other underserved groups. 

SAMHSA recommends states develop, enhance or improve the following through the SABG

ARPA funds: 

• Develop and expand the use of FDA-approved medications and digital therapeutics as a 

part of addiction treatment that can provide interactive, evidence-based behavioral

therapies for the treatment of opioid use disorders, alcohol use disorders, and tobacco use 

disorders, along with the implementation of other evidence-based treatments and

practices.

• Provide increased access, including same-day or next-day appointments, and low barrier

approaches, for those in need of SUD treatment services.

• Direct critical resources in expanding broad-based state and local community strategies

and approaches in addressing the drug overdose epidemic, involving SUD prevention, 

intervention, treatment, and recovery support services.

• Improve information technology infrastructure, including the availability of broadband 

and cellular technology for providers, especially in rural and frontier areas, and use of 

GPS to expedite response times and to remotely meet with the individual in need of 

services.

• The adoption and use of health information technology to improve access to and

coordination of SUD prevention, intervention, treatment, and recovery support services

and care delivery, consistent with the provisions of HIPAA and 42 CFR, Part 2.

• Advance telehealth opportunities to expand services for hard-to-reach locations, 

especially rural and frontier areas. Expand technology options for callers, including the 

use of texting, telephone, and telehealth. Note: States may not use the funds to purchase 

any items for consumers/clients. 
200

• Enhance the primary prevention infrastructure within your state and communities using 

the Strategic Prevention Framework planning model and implementing evidence-based

practices, the six CSAP prevention strategies with an emphasis on environmental 

approaches. 

• Consider incorporating strategies around adverse childhood experiences to improve 

substance misuse outcomes among all populations, but especially young adults 18-25 and

those over 26 years of age; preventing and reducing marijuana use by youth below the 

state’s legal age of use; and mitigating the impact of increased alcohol access by youth as

identified during the COVID-19 pandemic. It is important to identify and address

disparities and describe how you are incorporating equitable approaches. 

• Support expansion of peer-based recovery support services (e.g. recovery community 

organizations, recovery community centers, recovery high schools, collegiate recovery

programs, recovery residences, alternative peer group programs) to ensure a recovery

orientation which expands support networks and recovery services. These programs are

helping people sustain their recovery, engaging families and significant others, bridging

the gap between treatment and long-term recovery, and supporting people reentering the 

community from incarceration.

SAMHSA requests that the following information is included when submitting the proposals: 

1. Identify the needs and gaps of your state’s SUD services continuum, related to

developing a comprehensive prevention, intervention, treatment, and recovery support 

services continuum. 

2. Describe how your state’s spending plan proposal will address the state’s substance use

disorder services continuum, including a budget that addresses the needs and gaps related

to this continuum. 

3. Describe your state’s progress in addressing the rising drug overdose rate in many parts

of the country, and what steps the state will be taking to improve access to SUD

treatment, by improving identification of persons in need, reducing barriers to admission

to treatment, and strengthening mechanisms to promote client engagement and retention

in SUD treatment and recovery support services.

4. Describe your state’s progress in implementing the increased and widespread use of FDA

approved medications for the treatment of opioid use disorder, alcohol use disorder, and

tobacco use disorder, in combination with other substance use disorder evidence-based

treatments and practices.

5. Explain how your state plans to collaborate with other departments or agencies to address

the SUD services continuum. 

6. Describe how the state plans to use SABG ARPA funding to promote health equity

among identified underserved populations, and how it plans to address heath disparities

in the planning, delivery, and evaluation of SUD prevention, intervention, treatment, and

recovery support services.

7. Describe the state’s efforts and plans to promote an increased emphasis on the

development, delivery, and support of widespread SUD recovery support services,

systems, and mechanisms across the state.
200

8. Describe other state priorities or activities that the state plans to fund during the 

performance period of September 1, 2021 through September 30, 2025 using ARPA 

funds. 

9. Describe your state plans for enhancing your state’s prevention infrastructure which may

include incorporating work around ACEs and improving substance misuse outcomes 

among young adults and older adults. (Primary Prevention set-aside)

a. The impact of increased access to marijuana and the state’s strategies to prevent

misuse by the underage population. 

b. Strategies to reduce the COVID-19 impact of increased alcohol accessibility and

misuse.

c. How the state is using equitable strategies to reduce disparities in the state’s

prevention planning and approaches. Using the WebBGAS Revision Request for

the FFY 2021 Block Grant Application, upload the document (Microsoft Word or 

pdf) using the tab into the State Information Section, Chief Executive Officer’s

Funding Agreement – Certifications and Assurances/Letter Designating Signatory

Authority [SA]. Please title this document “ARPA Funding Plan 2021 (SA).” 

10. Describe how the state will use, or considered, health IT standards if using funds for 

health IT infrastructure or advancement. This includes a description of standards and, as

applicable, conformance to Office of the National Coordinator certification criteria in

health IT products used or that will be used to support SUD clinical priorities and

interoperable data exchange. States must use standards identified by the Office of the 

National Coordinator for Health IT in 45 C.F.R. 170 where applicable and also should 

consider standards identified in the Interoperability Standards Advisory

(https://www.healthit.gov/isa/), including but not limited to those standards described in

the “Allows for the Exchange of State Prescription Drug Monitoring Program (PDMP)

Data” section and the “Social Determinants of Health” section.

States must upload separate proposals based on MHBG and SABG guidance into the 

WebBGAS system. Upon submission, SAMHSA will review the proposal to ensure it is

complete and responsive. Proposals must be submitted to WebBGAS by Friday, July 2, 

2021,11:59 EST. 

SAMHSA is ready and willing to assist you in addressing the needs of individuals with

mental illness and substance use disorders. Please feel free to contact your SAMHSA state

project officers and grants management specialists with any questions that you may have.

Sincerely,

Tom Coderre

Acting Assistant Secretary for

Mental Health and Substance Use
 

 

 

 

 

 

 

 

 

References 

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8 Ahmad FB, Rossen LM, Sutton P: Provisional drug overdose death counts. Centers for Disease Control and 

Prevention, National Center for Health Statistics Data Brief, 2021. https://www.cdc.gov/nchs/nvss/vsrr/drugoverdose-data.htm 9 Ahmad FB, Anderson RN: The Leading Causes of Death in the US for 2020. JAMA 2021; 325(18):1829-1830, 2021 10 Hawryluck L, Gold WL, Susan, S: SARS Control and Psychological Effects of Quarantine, Toronto, Canada. Emerg 

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2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed 

13 Loades M, Chatburn E, Higson-Sweeney N., et al: Rapid Systematic Review: the Impact of Social Isolation and 

Loneliness on the Mental Health of Children and Adolescents in the Context of Covid-19. J Am Acad Child Adolesc 

Psychiatry 2020; 59(11):1218-1239 14 Federal Communications Commission: Designating 988 for the National Suicide Prevention Lifeline. Report and 

Order, FCC-20-100, 35 FCC Rcd 7373(9), Jul 2020. https://www.fcc.gov/document/designating-988-nationalsuicide-prevention-lifeline-0 15 The National Suicide Hotline Designation Act of 2020, Pub. L 116-172 (2020). 16 Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies. Rockville, MD, Substance Abuse and 

Mental Health Services Administration,2014. https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4848.pdf 17 Wachino V, Camhi N: Building Blocks: How Medicaid Can Advance Mental Health and Substance Use Crisis 

Response. Well Being Trust, May 2021. https://wellbeingtrust.org/news/how-medicaid-can-advance-mentalhealth-and-substance-use-crisis-response/ 18 National Guidelines for Behavioral Health Crisis Care, Best Practice Toolkit. Rockville, MD, Substance Abuse and 

Mental Health Services Administration, 2020. https://www.samhsa.gov/sites/default/files/national-guidelines-forbehavioral-health-crisis-care-02242020.pdf 19 Ibid. 20 Consolidated Appropriations Act, 2021 (Pub. L. 116-260), enacted December 27, 2020. 

https://www.congress.gov/bill/116th-congress/house-bill/133/text 21 American Rescue Plan Act (Pub. L. 117-2), enacted March 11, 2021. https://www.congress.gov/bill/117thcongress/house-bill/1319/text 

204
 

 

 

 

 

 

 

 

 

 

 

 

 

22 “With Pandemic Worsening the Mental Illness and Addiction Crisis, Biden Administration to Provide Nearly $2.5 

billion to States, Territories for Treatment, Prevention Aid.” Rockville, MD, Substance Abuse and Mental Health 

Services Administration, press release, March 11, 2021. https://www.samhsa.gov/newsroom/pressannouncements/202103110230 

23 Labor, HHS, Education Subcommittee, Appropriations Committee, U.S. House of Representatives, Report on FY 

2021 Appropriations, Rpt. No. 116-450, p. 149-150 (July 15, 2020). 24 Notices of Awards of Community Mental Health Block Grant Funding. Rockville, MD, Substance Abuse and 

Mental Health Services Administration, Feb. 3, 2021. 

25 Ibid. 26 “HHS Announces $3 Billion in American Rescue Plan Funding for SAMHSA Block Grants to Address Addiction, 

Mental Health Crisis.” Rockville, MD, Substance Abuse and Mental Health Services Administration, press release, 

May 18, 2021. https://www.samhsa.gov/newsroom/press-announcements/202105181200 27 FY 2021 Justification of Estimates for Appropriations Committees. Rockville, MD, Substance Abuse and Mental 

Health Services Administration, Department of Health and Human Services, 2021. 

https://www.samhsa.gov/sites/default/files/about_us/budget/fy-2021-samhsa-cj.pdf 28 House of Representatives, Labor, Health and Human Services, and Education Appropriations Subcommittee: FY 

2022 Appropriations Report. Available at https://docs.house.gov/meetings/AP/AP00/20210715/113908/HMKP117-AP00-20210715-SD003.pdf 29 Improving Access to Behavioral Health Crisis Services with Electronic Bed Registries. Alexandria, VA, National 

Association for Mental Health Program Directors, April 2021. Available at 

https://www.nasmhpd.org/sites/default/files/Bed_Registry_Full_Report.pdf 

30 Repper J, Carter T: A Review of the Literature on Peer Support in Mental Health Services. Journal of Mental 

Health 2011; 20:392-411. 31 Value of peers. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2017. 

https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/value-of-peers-2017.pdf 32 Open Minds: State Medicaid Reimbursement for Peer Support Services. March 2018. 33 Medicare Mental Health. Medicare Learning Network Booklet, Baltimore, MD, Centers for Medicare and 

Medicaid Services (CMS), Center for Medicare Services, April 2021. 

https://www.cms.gov/files/document/medicare-mental-health.pdf 34 Ibid. 35 “Incident To” Guidance. Medicare Learning Network Matters, Baltimore, MD, Centers for Medicare and 

Medicaid Services (CMS), Center for Medicare Services. https://www.cms.gov/outreach-and-education/medicarelearning-network-mln/mlnmattersarticles/downloads/se0441.pdf 36 List of Telehealth Services for Calendar Year 2021. Washington, DC, Centers for Medicare and Medicaid Services 

(CMS), Center for Medicare Services. https://www.cms.gov/Medicare/Medicare-GeneralInformation/Telehealth/Telehealth-Codes 37 Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to part B 

Payment Policies; Final Rule. Washington, DC, Centers for Medicare and Medicaid Services (CMS), Center for 

Medicare Services, December 28, 2020. https://www.federalregister.gov/documents/2020/12/28/2020-

26815/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part 38 See Nevada SB 390, Utah SB 155, Virginia SB 1302, and Washington HB 1477. 39 See 42 U.S.C. § 300x-5(a)(3) and 42 U.S.C. §300x-31(a)(1)(C). 40 See 42 U.S.C. § 300x-31(c). 41 U.S. Department of Treasury, Press Release, Treasury Launches Coronavirus State and Local Fiscal Recovery 

Funds to Deliver $350 billion, May 10, 2021. https://home.treasury.gov/news/press-releases/jy0169 42 Allocations for states and localities is available on the agency website: https://home.treasury.gov/policyissues/coronavirus/assistance-for-state-local-and-tribal-governments/state-and-local-fiscal-recovery-funds 43 U.S. Department of Treasury, Coronavirus State and Local Fiscal Recovery Funds, Interim Final Rule, 86 Fed. Reg. 

26786 (2021). 

44 U.S. Department of Treasury, Coronavirus State and Local Fiscal Recovery Fund Allocations. 

https://home.treasury.gov/policy-issues/coronavirus/assistance-for-state-local-and-tribal-governments/state-andlocal-fiscal-recovery-funds 

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45 House of Representatives, Appropriations Committee, Labor, Health and Human Services, and Education 

Subcommittee: List of Community Projects Funded. 

https://appropriations.house.gov/sites/democrats.appropriations.house.gov/files/documents/FY%2022%20LHHS 

%20Funded%20CPF.pdf 

46 Community Mental Health Centers Grant Funding Opportunity Announcement. Rockville, MD, Substance Abuse 

and Mental Health Services Administration. https://www.samhsa.gov/sites/default/files/grants/pdf/fy-2021-cmhcfoa.pdf 

47 Frequently Asked Questions on FY 2021 Community Mental Health Center Grant Program Funding Opportunity 

Announcement. Rockville, MD, Substance Abuse and Mental Health Services Administration. 

https://www.samhsa.gov/sites/default/files/grants/pdf/faq/fy-2021-cmhc-foa.pdf 48 FY 2021 Certified Community Behavioral Health Clinic Expansion Grants Funding Opportunity Announcement. 

Rockville, MD, Substance Abuse and Mental Health Services Administration. 

https://www.samhsa.gov/sites/default/files/grants/pdf/fy-2021-ccbhc-foa.pdf 49 Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children 

with a Serious Emotional Disturbance. State Medicaid Directors Letter # 18-011. Washington, DC, Centers for 

Medicare and Medicaid Services (CMS), Center for Medicaid and CHIP Services, 2018. 

https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf 50 Ibid. 51 Ibid. 52 Ibid. 53 Ibid. 54 Frequently Asked Questions (FAQs) Health Services Initiatives. Washington, DC, Centers for Medicare and 

Medicaid Services, 2017. https://www.medicaid.gov/federal-policy-guidance/downloads/faq11217.pdf 55 Ibid. 56 Leveraging CHIP to Improve Children’s Health: An Overview of State Health Services Initiatives. Washington, DC, 

National Academy for State Health Policy. https://www.nashp.org/leveraging-chip-to-improve-childrens-health-anoverview-of-state-health-services-initiatives/ 57 CHIP Health Services Initiatives: What They Are and How States Use Them. Washington, DC, Medicaid and CHIP 

Payment and Access Commission (MACPAC), July 2019. Available at https://www.macpac.gov/wpcontent/uploads/2019/07/CHIP-Health-Services-Initiatives.pdf 58 Leveraging CHIP to Improve Children’s Health: An Overview of State Health Services Initiatives. Washington, DC, 

National Academy for State Health Policy. https://www.nashp.org/leveraging-chip-to-improve-childrens-health-anoverview-of-state-health-services-initiatives/ 59 Behavioral Health Spending & Use Accounts 2006-2015. Rockville, MD, Substance Abuse and Mental Health 

Services Administration, 2019. https://store.samhsa.gov/sites/default/files/d7/priv/bhsua-2006-2015-508.pdf 60 Wachino V, Camhi N: Building Blocks: How Medicaid Can Advance Mental Health and Substance Use Crisis 

Response. Well Being Trust, May 2021. https://wellbeingtrust.org/news/how-medicaid-can-advance-mentalhealth-and-substance-use-crisis-response/ 61 Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children 

with a Serious Emotional Disturbance. State Medicaid Directors Letter # 18-011. Washington, DC, Centers for 

Medicare and Medicaid Services (CMS), Center for Medicaid and CHIP Services, 2018. 

https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf 62 National Guidelines for Behavioral Health Crisis Care, Best Practice Toolkit. Rockville, MD, Substance Abuse and 

Mental Health Services Administration, 2020. https://www.samhsa.gov/sites/default/files/national-guidelines-forbehavioral-health-crisis-care-02242020.pdf 63 New Jersey Department of Human Services, Division of Medical Assistance & Health Services Newsletter, Vol. 24 

No. 10, October 2015. Available at the following website - search for Vol. 24 No. 10: 

https://www.njmmis.com/documentDownload.aspx?fileType=076B9D7D-96DC-4C8A-B9CE-BA46F47DDE1F 64 Delaware Adult Behavioral Health DHSS Service Certification and Reimbursement Manual, 2016. 

https://dhss.delaware.gov/dhss/dsamh/files/ReimbursementManual.pdf 

65 New York, Medicaid Reimbursement Rates. https://omh.ny.gov/omhweb/medicaid_reimbursement/ 

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66 Crisis Intervention Benefit: Adult Crisis Residence Benefit and Billing Guidance. Albany, NY, New York 

Department of Health Office of Mental Health: October 2020. https://omh.ny.gov/omhweb/bho/docs/adult-crisisresidence-benefit-and-billing-guidance.pdf 67 Balfour ME, Stephenson AH, Winsky J, et al: Cops, clinicians, or both? Collaborative approaches to responding to 

behavioral health emergencies. Alexandria, VA, National Association of State Mental Health Program Directors, 

August 2020. https://www.nasmhpd.org/sites/default/files/2020paper11.pdf 68 Wachino V, Camhi N: Building Blocks: How Medicaid Can Advance Mental Health and Substance Use Crisis 

Response. Well Being Trust, May 2021. https://wellbeingtrust.org/news/how-medicaid-can-advance-mentalhealth-and-substance-use-crisis-response/ 69 State Health Facts, Medicaid Behavioral Health Services as of 2018. Kaiser Family Foundation. 

https://www.kff.org/statedata/collection/medicaid-behavioral-health-services/ 70 See Clause (B) following section 1905(a)(29) of the Social Security Act. 71 American Rescue Plan Act, Pub. L. 117-2, Section 9813, State Option to Provide Qualifying Community-based 

Mobile Crisis Intervention Services and Section 9817, Additional Support for Medicaid Home and Communitybased Services During the Covid-19 Emergency. https://www.congress.gov/bill/117th-congress/housebill/1319/text 

72 “$15 Million Funding Opportunity for State Planning Grants to Bolster Mobile Crisis Intervention Services”. News 

alert, Centers for Medicare and Medicaid Services, Center for Medicaid and CHIP Services, July 13, 2021. 

https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/2e7f201 

73 American Rescue Plan Act of 2021: Section 9813 State Planning Grants for Qualifying Community-Based Mobile 

Crisis Intervention Services. Notice of Funding Opportunity. Washington, DC, Centers for Medicare and Medicaid 

Services, Center for Medicaid and CHIP Services, July 13, 2021. https://www.grants.gov/web/grants/searchgrants.html?keywords=93.639 74 Implementation of American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid Home and 

Community-based Services during the Covid-19 Emergency. State Medicaid Director Letter #21-003. Washington, 

DC, Centers for Medicare and Medicaid Services, Center for Medicaid and CHIP Services, May 13, 2021. 

https://www.medicaid.gov/federal-policy-guidance/downloads/smd21003.pdf 75 Massachusetts Home and Community-based Services (HCBS) Services Plan. Boston, MA, Massachusetts Office of 

Health and Human Services Office of Medicaid, June 17, 2021. https://www.mass.gov/doc/massachusetts-arpahcbs-initial-spending-plan-june-2021-0/download 76 Roadmap for Behavioral Health Reform: Ensuring the Right Treatment When and Where People Need It, A MultiYear Plan Summary. Boston, MA, Massachusetts Executive Office of Health and Human Services, February 2021. 

https://www.mass.gov/doc/roadmap-for-behavioral-health-reform-ensuring-the-right-treatment-when-andwhere-people-need-it/download?_ga=2.150074418.543999700.1626644303-538278098.1626644303 77 American Rescue Plan Act Increased Federal Medical Assistance Percentage for Home and Community-based 

Services, Initial HCBS Spending Plan Projection. Sacramento, CA, California Department of Health Care Services, 

July 12, 2021. https://www.dhcs.ca.gov/Documents/DHCS-HCBS-Spending-Plan-Web-Package-7-12-21.pdf 78 Spending Plan for Implementation of the American Rescue Plan Act of 2021, Section 9817. Indianapolis, IN, 

Indiana Family and Social Services Administration: Proposed July 9, 2021. 

https://www.in.gov/fssa/ompp/files/Indiana-HCBS-Enhanced-FMAP-Spending-Plan.pdf 79 State Medicaid Director Letter #18-011, “Opportunities to Design Innovative Service Delivery Systems for Adults 

with a Serious Mental Illness or Children with a Serious Emotional Disturbance”, Nov. 13, 2018. Washington, DC, 

Center for Medicaid and CHIP Services, Center for Medicaid and CHIP Services. https://www.medicaid.gov/federalpolicy-guidance/downloads/smd18011.pdf 80 42 CFR § 438.6(e). 81 1115 Demonstration State Monitoring & Evaluation Resources, (includes resources on mental healthcare 

availability assessment and performance measures). Washington, DC, Centers for Medicare and Medicaid, Center 

for Medicaid and CHIP Services. https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-

demonstration-monitoring-evaluation/1115-demonstration-state-monitoring-evaluation-resources/index.html 82 Medicare and Medicaid: Covid-19 Program Flexibilities and Considerations for their Continuation. Washington, 

DC, U.S. Government Accountability Office (GAO), May 2021. https://www.gao.gov/assets/gao-21-575t.pdf 

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83 Medicaid & CHIP and the Covid-19 Public Health Emergency: Preliminary Medicaid and CHIP Data Snapshot: 

Services through July 31, 2020. Washington, DC, Centers for Medicare and Medicaid Services (CMS), May 2021. 

https://www.medicaid.gov/state-resource-center/downloads/covid19-data-snapshot.pdf 84 FAIRHealth Monthly Telehealth Regional Tracker (Accessed May 2021) https://www.fairhealth.org/states-bythe-numbers/telehealth 85 Medicaid & CHIP and the Covid-19 Public Health Emergency: Preliminary Medicaid & CHIP Data Snapshot, 

Services through October 31, 2020. Washington, DC, Centers for Medicare and Medicaid Services, May 2021. 

https://www.medicaid.gov/state-resource-center/downloads/covid-19-medicaid-data-snapshot.pdf 86 Panchal N, Kamal R, Cox C: Mental Health and Substance Use Considerations Among Children During the Covid19 Pandemic. Kaiser Family Foundation, May 26, 2021. https://www.kff.org/coronavirus-covid-19/issuebrief/mental-health-and-substance-use-considerations-among-children-during-the-covid-19-pandemic/ 87 Koma W, Cubanski J, Neuman T: Medicare and Telehealth: Coverage and Use During the Covid-19 Pandemic and 

Options for the Future. Kaiser Family Foundation, May 2021. https://www.kff.org/medicare/issue-brief/medicareand-telehealth-coverage-and-use-during-the-covid-19-pandemic-and-options-for-the-future/ 88 National Projections of Supply and Demand for Selected Behavioral Health Practitioners: 2013-2025. Rockville, 

M.D, Health Resources and Services Administration, National Center for Health Workforce Analysis, November 

2016. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/behavioral-health-2013-

2025.pdf 

89 The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and 

Communities (SUPPORT) Act (Pub. L 115-271) Sec. 2001, Expanding the Use of Telehealth Services for the 

Treatment of Opioid Use Disorder and Other Substance Use Disorders. 

https://www.congress.gov/115/plaws/publ271/PLAW-115publ271.pdf 90 Dunham CC, Sprankle, M: The SUPPORT for Patients and Communities Act: Expanding Medicare Coverage of 

Telehealth Services to Combat the Opioid Crisis. The National Law Review 2018. 

https://www.natlawreview.com/article/support-patients-and-communities-act-expanding-medicare-coveragetelehealth-services 91 Consolidated Appropriations Act (Pub. L. 116-260) Division CC, Section 123, Expanding Access to Mental Health 

Services Furnished Through Telehealth, Dec. 2020. https://www.govinfo.gov/content/pkg/BILLS116hr133enr/pdf/BILLS-116hr133enr.pdf 92 CY 2022 Medicare Physician Fee Schedule Proposed Rule Fact Sheet. Washington, DC, Centers for Medicare and 

Medicaid Services (CMS), Center for Medicare Services, July 13, 2021. https://www.cms.gov/newsroom/factsheets/calendar-year-cy-2022-medicare-physician-fee-schedule-proposed-rule 93 The ten states participating in the CCBHC Demonstration are Minnesota, Missouri, New York, New Jersey, 

Nevada, Oklahoma, Oregon, Pennsylvania, Michigan, and Kentucky. 

94 FY 2021 Justification of Estimates for Appropriations Committees. Rockville, MD, Substance Abuse and Mental 

Health Services Administration, Department of Health and Human Services, 2021. 

https://www.samhsa.gov/sites/default/files/about_us/budget/fy-2021-samhsa-cj.pdf 95 Emergency Triage, Treat, and Transport (ET3) Model. Washington, DC, Center for Medicare and Medicaid 

Services, Center for Medicare and Medicaid Innovation. https://innovation.cms.gov/innovation-models/et3 96 List of selected ET3 participants here: https://innovation.cms.gov/media/document/et3-participants 97 Center for Medicare and Medicaid Innovation and Center for Medicaid and CHIP Services Joint Informational 

Bulletin: Medicaid Opportunities in the Emergency Triage, Treat, and Transport (ET3) Model. Washington, DC, 

Centers for Medicare and Medicaid Services, August 2019. https://www.medicaid.gov/federal-policyguidance/downloads/cib080819-3.pdf 98 See description of Maryland All-Payer Model on the CMS website. https://innovation.cms.gov/innovationmodels/maryland-all-payer-model 99 See description of the Health Services Cost Review Commission Regional Partnership Catalyst Grant Program. 

https://hscrc.maryland.gov/Pages/regional-partnerships.aspx 100 See section 1905(i) of the Social Security Act, 42 U.S.C. 1396d 

208
Technology’s 

Acceleration in 

Behavioral Health: 

COVID, 988, Social 

Media, Treatment 

and More No. 9 

NASMHPD Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

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Technology’s Acceleration in Behavioral 

Health: COVID, 988, Social Media, Treatment 

and More 

Stephen Phillippi, PhD, LCSW, CCFC 

Brian Bumbarger, PhD, Med 

Cover Art by Malkah Pinals 

Ninth in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

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Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, or 

other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Phillippi, S., Bumbarger, B. (2021). Technology’s Acceleration in Behavioral Health: COVID-19, 988, Social 

Media, Treatment and More. Technical Assistance Collaborative Paper No. 9. Alexandria, VA: National 

Association of State Mental Health Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

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Abstract: 

Advances in technology offer options for the millions of Americans who experience mental health 

conditions, since most lack access to care or are not receiving the care they need. The permeating 

presence of technology in our lives offers a previously unimaginable window on both population and 

individual level data to inform models of epidemiology and etiology of mental health and mental 

illness, and the potential to provide behavioral health care in drastically different ways. While much of 

the advances have focused on access, growing attention is being given to quality. This quality includes 

issues of confidentiality, ease of use, reimagining therapeutic relationships, and improving mental 

health outcomes. This change has been accelerated by the COVID pandemic, particularly when the 

need arose to rely on technology vs. traditional in person treatment. This paper explores telehealth, 

artificial intelligence (AI) in social media, 988, apps, software and more related to behavioral health. 

As the evidence of effectiveness grows, behavioral health technologies have the potential to reach 

more clients and help engage and retain them in services in a cost-effective manner. It will also be 

critical to ensure that the use of technology is done with a sense of fairness and equity so that any 

individual, in any setting, can have access to equivalent care. Thus, it is imperative that there be 

intentionality surrounding the advances in the use of technology to avoid a second tier “behavioral 

healthcare-lite” system for marginalized populations that in fact have the highest needs but are 

hardest to reach. 

Highlights: 

• Technology can increase options for the nearly 1 in 5 Americans who experience a mental health 

condition, since most lack access to care, and over half are not receiving the care they need. 

• Tele-mental health potentially addresses two significant problems in behavioral health: the 

critical shortage of behavioral health professionals and the logistical and financial challenges of 

providing services to rural populations. 

• There are intentional efforts by software developers to encourage the public to engage 

technology for behavioral health, self-help. 

• Social media platforms are using artificial intelligence to detect and communicate regarding 

mental health concerns, particularly related to suicide. 

• It is critical to ensure that the use of technology is done with a sense of fairness and equity so 

that any individual, in any setting, can have access to equivalent care. 

Recommendations for the post-COVID-19 future: 

1. Much more empirical evidence is needed to determine the effectiveness of behavioral health 

technologies in relation to populations and specific mental health conditions. As that evidence 

grows it is also critical that translation of that science into practice happens in order to reach more 

consumers and help engage and retain them in needed services in a cost-effective manner. 

2. Technology, particularly the increased capacity to capture and analyze large data sets, will allow 

new examinations of individual and population behavioral health and subsequently strengthen 

our etiologic models and the potential design of new interventions. 

3. The drastic changes in the delivery of behavioral healthcare, brought on by technology, demand 

a re-examination of the supporting infrastructure and workforce to ensure that high quality is 

maintained as access increases. 

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As of 2021, 97% of Americans owned a cell phone, and over 85% owned a smart phone, compared 

to just 35% owning a smarty phone just a decade ago.

1 Furthermore, 72% of U.S. adults say they 

use at least one social media site (up from 43% just a 

Digital and mobile technologies hold decade ago).

2 Among 18- to 29-year-olds, approximately 84% 

enormous potential for increasing access are social media users, followed by 81% of persons between to services, facilitating self-help, ages 30 to 49, 73% of those 50 to 64, and 45% of 65 and older monitoring and assessing variations in individuals.

3 These technologies offer options as more than 43 symptoms and wellness-promoting million Americans, nearly 1 in 5, experience a mental health activities, and increasing health literacy. condition, most lack access to care, and over half are not This potential will be fulfilled only if 

receiving the care they need.

4 In addition to opportunities for behavioral health service providers are 

general use, the ubiquitous presence of technology in our lives willing to adopt effective new 

offers a previously unimaginable window on both population technologies, to develop the adequate 

and individual level data, which can inform models of skills to use them, and to fully support 

service users. epidemiology and etiology of mental health and mental illness. 

As such, technology has the potential to transform behavioral –Nemec and Chan, 2017. p341 health care delivery in drastically different ways. 

Technology in behavioral health care is evolving at a rapid pace. Nevertheless, there are three 

cornerstones of effective behavioral healthcare that need to be considered regardless of the 

technological advancement. These cornerstones include access to care, timeliness of service delivery, 

and high-quality services. Although much of the technological 

Three cornerstones of effective advances have focused on access, growing attention is being behavioral healthcare: given to the quality of services. This includes issues of 

1. Access to care confidentiality, ease of use, reimagining therapeutic 2. Timeliness of service delivery relationships, and effects of technology used to provide services 3. High-quality services with positive mental health outcomes. 

COVID-19 fueled the rapid growth of technology implementation in mental health care delivery due to 

the need to transition away from traditional in-person treatment given the public health measures to 

control coronavirus spread.

5 Technology will undoubtedly be a part of the future of mental health care 

systems, but not without growing pains and issues. This paper, Technology’s Acceleration in Behavioral 

Health: COVID, 988, Social Media, Treatment and More, examines recent advances in mental healthcare 

technology and discusses relevant issues to their implementation Topics addressed include: 

• telehealth technology 

• 988 tech & mobile crisis response 

• artificial intelligence in social media 

• mobile-mental health apps 

• emerging technology 

The paper concludes with a discussion of workforce development around technology, infrastructure 

needs, and recommendations for the field. 

Telehealth Technology 

One of the most apparent uses of technology in behavioral health has been the advent of remotely 

delivered treatment services, often referred to as telehealth. Telehealth for mental healthcare, or tele213
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mental health saw a dramatic increase in utilization during the COVID-19 pandemic. Tele-mental health 

potentially addresses two significant problems in behavioral health: the critical shortage of behavioral 

health professionals and the logistical and financial challenges of providing services to rural populations. 

The relationship between the recent dramatic increase in tele-mental health and the COVID-19 

pandemic is complicated. Like previous natural disasters, the COVID-19 pandemic led to increased 

mental health stressors across the population, restricted movement, and drastic disruption to the 

traditional health care system, including mental and behavioral health care. Prior to the pandemic, a 

loose national agenda had already been underway to increase the use of tele-mental health in order to 

expand access to behavioral health services in rural and underserved communities, but the quarantine 

orders that came to most states early in the pandemic forced an urgent shift to remote behavioral 

health services. The pandemic revealed the critical limitations of conventional in-person behavioral 

health treatment, as well as the fragility of the traditional referral networks patients and practitioners 

have come to rely upon to connect people to needed services. Policymakers recognized this fragility and 

need for adaptations by offering regulatory flexibility, and providers and practitioners developed 

innovative strategies to quickly pivot to a variety of remote delivery models, potentially reaching new 

patient populations. 

As a state-level intermediary supporting the improvement of behavioral health services for Medicaideligible children, the Center for Evidence-to-Practice at Louisiana State University both assisted and 

studied practitioners’ transition to tele-mental health during the early months of the pandemic and 

quarantine order. Most practitioners, whether implementing evidence-based treatment models or 

otherwise, reported they were able to effectively transition to some hybrid variation of tele-mental 

health to continue providing services.

6 This transition to tele-mental health was facilitated by temporary 

regulatory flexibility in Medicaid and HIPAA regulations, support from national model purveyors (such as 

Multisystemic Therapy and Functional Family Therapy), intermediaries (such as the Center for Evidenceto-Practice) and professional support networks, and practitioners’ own innovation (e.g., developing 

hybrid models that combined video teleconferencing, chat and text messages).7 Although most 

providers were able to successfully shift to tele-mental health in this setting, they reported, and 

separate Medicaid claims data confirmed, a significant decrease in the number of referrals received and 

clients served in the first six months of the pandemic (a time when one would expect both referrals and 

clients to increase significantly). This not only challenges the tele-mental health goal of expanded access 

to behavioral health services, but also raises concerns about the potential of increasing disparities in 

already underserved populations such as those living below the poverty line, of minority 

races/ethnicities, or living in rural areas. 

Similar to Louisiana’s experience, the National Association of State Mental Health Program Directors 

(NASMHPD) Research Institute found that nearly 88% of state mental health systems reported their 

community providers experienced a significant decrease in clients since the beginning of COVID-19.

8 Of 

these providers, 71% reported that decreases have been significantly, but not totally, offset by the use 

of tele-mental health, and 15% reported that tele-mental health has not significantly offset the loss in 

clients, indicating an overall net reduction in clients served in both cases.

9 Likewise, respondents to the 

NRI survey reported that the added regulatory flexibility with Medicaid and HIPAA was invaluable in 

transitioning to tele-mental health during COVID-19. This emergency transition to tele-mental health has 

important implications for the financial stability of community behavioral health providers as well, with 

NRI reporting that 29 states have had to provide supplemental funds to community providers to keep 

them solvent, at a time when those providers should be investing in technology and training to 

effectively use it. 

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Another important consideration for the field’s rapid shift to tele-mental health delivery of behavioral 

health services is the potential impact on treatment quality and effectiveness. One of the factors 

slowing the expansion of tele-mental health prior to the COVID-19 pandemic was the seemingly 

conflicting agenda to scale up evidence-based models. The fundamental argument for prioritizing 

evidence-based treatment models over standard behavioral health practice was the strong empirical 

support from randomized trials of these interventions, imparting a much stronger confidence in 

effectiveness and offering standardized treatment protocols (validated in the same trials) to promote 

better treatment adherence. Many evidence-based behavioral health treatment models have developed 

tele-mental health adaptations but have not rigorously tested them in clinical trials. These tele-mental 

health adaptations are grounded in the same behavior change theories and etiologic frameworks as the 

original evidence-based versions, so it is unlikely they would be totally ineffective. However, there is 

evidence that important characteristics of the curative process, such as the therapeutic alliance 

between patient and clinician, may be negatively impacted by a tele-mental health environment and 

thus may weaken key outcomes.

10,11 

988 Tech & Mobile Crisis Response 

In conjunction with telehealth, states are finding use of this technology with the rollout of 988 and crisis 

mobile services. Increasing the ease of calling for help in a crisis, requires increased need for effective 

response. Technology is allowing interconnectedness between call centers, as well as GPS tracking for 

emergency response and locations of available services. 

For example, states are actively engaged in discussions of how to transfer behavioral health crisis calls 

from 911 (and back if needed). Ruiz (2021) reported that Austin, Texas became one of the first cities in 

the country to add a fourth options for 911 callers. Operators now ask if the caller needs emergency 

medical, police, fire, or mental health services. Those in need of mental health services are transferred 

to a mental health provider. This interconnectedness of services has reported that 86% of mental health 

calls are now being resolved without the need for police. However, if and when law enforcement is 

needed for public safety reasons, they remain connected for that request from mental health providers. 

Austin is not alone, in Phoenix, Arizona an interconnected consortium of nonprofit agencies has built a 

crisis line and mobile response system, that is handling about 20,000 calls per month, dispatching 

mental health providers, rather than police, in about 2,200 instances a month, again with the vast 

majority of calls resolved on the phone.

12 As the new 988 suicide hotline is implemented nationwide, it 

is anticipated that this will also be further integrated with these system of response. 

Colorado has blended its response technologies with telehealth. According to Neylon (2020), writing on 

behalf of the National Association of Mental Health Program Directors, Colorado is implementing a 

model that uses trained bachelor’s level or peer specialists, who bring tablets into the field when 

responding to people in crisis. These devices are used to connect the individual to a masters-level 

clinician via telehealth services to offer a formal triage and recommendations for the level of immediate 

care assessed.

13 Similarly, in Charleston County, South Carolina EMS is equipped with telehealth 

technology for mobile crisis teams to triage crises virtually and make recommendations on next steps.14 

This service is structured in a way that quickly places ambulance services back into rotation, reduces 

mobile crisis drives to longer distance locations if not warranted, and limits over utilization of transport 

to emergency departments for similar mental health assessment.

15 

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Using GPS tracking for emergency location of people and available services can also improve crisis 

response. GPS location of the nearest mobile crisis response team helps link teams to those in need with 

the shortest response time options. Having caller id functioning and implementing GPS-enabled 

technology to more efficiently dispatch care to those in need is also listed in the best practices noted by 

SAMHSA.

16 According to these guidelines, “GPS-enabled Mobile Crisis Dispatch Mobile crisis teams 

should use GPS-enabled tablets or smart phones to support quick and efficient call hub determination of 

the closest available teams, track response times, and ensure clinician safety (e.g., time at site, real-time 

communication, safe driving, etc.).”17 

According to SAMHSA, best practices to operate regional crisis call centers should include utilizing realtime bed registry technology to support efficient connection to needed crisis resources.

18 Bed registries, 

like those implemented in Georgia, show the availability of beds for crisis stabilization, with interactive 

exchanges between hospitals and crisis teams. According to TTI Bed Registry Project (2019), Georgia’s 

call-center clinicians, walk-in crisis centers, emergency departments, jail staff, and mobile crisis teams 

can refer individuals requiring a bed for crisis stabilization to a receiving facility. The system monitors 

bed occupancy as facilities enter bed availability in real time as admissions and discharges occur. System 

data show occupancy in crisis stabilization beds at 90% or better, denials at 10% or less, and an average 

length of stay of seven days or less.

19 

Artificial Intelligence in Social Media 

Much of technology is being encountered by consumers and communities without individuals 

necessarily realizing the impact on population mental health, by using artificial intelligence (AI) 

technologies. AI is defined as intelligence demonstrated by machines as "intelligent agents" that 

perceive an environment (e.g., social media platforms) and takes actions to achieve a goal, take action, 

or problem solve.

20 With suicide the second leading cause of death for 15– to 29-year-olds,21 and US 

military veterans committing suicide at rates 1.5 times that of the non-veteran population,

22 social 

media is in a unique position to intervene and attempt to connect those in distress with support.

23,24 

Facebook has been using its artificial intelligence to detect and send alerts regarding suicide concerns 

since 2017.

25 The goal was to get timely help to those posting things that might indicate suicidal ideation 

and/or send resources to those posting concern about friends or family members suicidality. In practice, 

Facebook automatically sends messages of concern and links to resources when suicidality is suspected 

with no human interface. Although this may be better than nothing, it also leaves all of the next steps to 

the receiver of the message. The effectiveness of these non-human interactions with Facebook artificial 

intelligence AI remains to be further explored as no data are being shared on outcomes.

26 One study did 

examine the importance of artificial intelligence interaction with some Facebook users at increased risk 

for suicide. Specifically, a study of Facebook users with high rates of use, described as addictive, are also 

known to have higher risk of suicide.

27 

Mobile Mental Health Apps 

There are also intentional efforts by software developers to promote the public to engage technology 

for self-help. This is evidenced by simply picking up your smartphone and typing mental health in your 

app store. Almost a third of the health-related apps focus specifically on mental health.

28 One will find a 

myriad of apps that use techniques borrowed from evidence based practices such as Cognitive 

Behavioral Therapy to address issues like depression, anxiety, post-traumatic stress disorder (PTSD), 

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obsessive-compulsive disorder (OCD), and more without the presence of a trained provider or physical 

psychotherapy room/clinic. During COVID-19 several states, like New York, promoted accessible apps to 

help individuals manage anxiety and social isolation.

29 More data will be needed over time to 

understand how these tools fit into the array of available supports. Nevertheless, some are quite 

popular. The top self-help mental health apps of 2021 are listed in Table 1. 

Table 1: “Top mental health apps of 2021”30 

Behavioral Health Focus Area App Examples Basic Information 

Suicide Prevention 

MY3 Customize to user warning signs, offers 

coping strategies, and links to resources. 

notOK Designed for adolescents as a means to 

let identified friends, family and support 

networks know help is needed 

General Mental Health 

What’s app CBT and ACT methods 

MoodKit CBT based with activities to improve 

mood 

Addiction 

Twenty-Four Hours 

a Day 

meditations to focus on sobriety 

Quit That! a recovery tool to track habits to help 

quit alcohol, smoking, drugs 

Anxiety 

Mindshift changing how users think about anxiety 

through encouragement, assisting riding 

out intense emotions, etc.) 

SAM- Self-help for 

Anxiety 

Management 

users build their own 24-hour anxiety 

toolkit from 25 different techniques 

CBT Thought 

Record Diary 

helps identifying negative and distorted 

thinking patterns 

Bipolar Disorder 

IMoodJournal personal journal and mood tracker to 

record mood, symptoms, sleep 

mediations and energy cycles 

eMoods track depressive and psychotic 

symptoms, elevated mood, and 

irritability to indicate severity of 

symptoms 

Depression 

Happify mood-training program 

MoodTools CBT approach using videos to improve 

mood and behavior & log 

thoughts 

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Behavioral Health Focus Area App Examples Basic Information 

Eating Disorder 

Recovery Record record meals, feelings, and complete 

questionnaires to track progress 

Rise Up and 

Recover 

track meals and associated feelings, 

urges, coping strategies 

Obsessive-Compulsive Disorder 

nOCD mindfulness and exposure response 

prevention treatment, assessments, and 

motivation support 

Worry Watch identify trigger points for anxiety, trends, 

reflection on harmless outcomes, change 

of thinking patterns 

GG OCD games and techniques to increases 

awareness of negative thoughts and 

training to push these aside for more 

positive outcomes 

PTSD 

PTSD Coach self-assessment, support opportunities, 

positive self-talk, and anger management 

tools 

Breathe2Relax stress management tool teaching 

diaphragmatic breathing to decrease 

fight or flight response 

Schizophrenia 

UCSF PRIME connects to peers to decrease social 

isolation and options to track goals 

Schizophrenia 

HealthStorylines 

tools to monitor condition, symptoms, 

medication, and moods 

Mindfulness and Mediation 

Headspace teaching tools to develop skills of 

mindfulness and meditation targeting 

stress, anxiety, sleep, and focus 

Calm guided meditations, sleep stories, 

breathing programs, and relaxing music 

for countering stress and anxiety 

Ten Percent 

Happier 

guided meditations, videos, stories, and 

inspirational pieces to address anxiety, 

stress, parenting, sleep, etc. 

As noted by Psycom, these apps are not necessarily a replacement for therapy, but they are anywhere 

from free to very reasonably priced as compared to the cost of traditional mental health therapy. 

Besides cost-efficiency, they also make help more accessible, with response times in the minutes, and 

portable.

31 Of course, mental health care apps do not promote equity in access for those that may not 

be able to afford a smartphone, have access to affordable or free broadband networks, or lack skills to 

use smartphone technology. 

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Behavioral health experts in the field are also paying close attention to the benefits and risks of these 

rapidly emerging apps. According to the National Institute of Mental Health (NIMH), the pros of mental 

health apps include convenience, anonymity, introduction to care (i.e., first step for those that might 

avoid care), lower cost, service to a wider population of people, interest (i.e., appeal), round-the-clock 

access, consistency, support (including for those in therapy), and data collection (e.g. location, 

movement use, etc.).

32 These advances also come with concern. Currently these include questions about 

effectiveness, appropriate target populations for their use, as well as appropriate target conditions that 

they aim to ameliorate, privacy (from IP addresses to who stores what data), industry-wide standards, 

regulation, and overselling (i.e., promising more than the app delivers).

33 Regarding standards and 

regulation, NIMH created the National Advisory Mental Health Council Workgroup on Opportunities and 

Challenges of Developing Information Technologies on Behavioral and Social Science Research in order 

to offer guidance and monitor rapidly changing use of technologies. In 2017, the NIMH advisory council 

noted that digital health is no longer limited to the technologically savvy.

34 With more than 2.2 billion 

people in the world with a smartphone, including almost two-thirds of minority and low-income 

populations, these mental health technologies are more accessible than ever.

35 Researches have also 

noted this, as internet-based and mobile device-based data collection for studies has increased with 

tools for sample population recruitment, retention, and information collection.

36 

The BRIGHTEN study, a randomized controlled study examining the use of technology to deliver mental 

health treatment serves as an opening to learn about utility and outcomes of these technological tools 

as augmentations to traditional therapies.

37,38 According to the research findings currently released, the 

three apps tested to treat depression had a significant impact on mood and level of functioning over 

time, though one of the limitations turned out to be the challenge in keeping participants engaged in the 

research itself. The research team is still analyzing data to determine how well the apps treated 

depression and if one app was better than the others.

39,40 

Still, the largely untested and unregulated mobile behavioral health application market leaves it 

vulnerable to unscrupulous, unethical, or simply well-meaning but untrained app developers, making it 

difficult for consumers or even professionals to navigate to mobile apps that are safe, secure, and 

effective. Although some have argued the breakneck pace of the evolving technology makes it 

impractical to hold these apps to the same rigorous standards of randomized trials, others have 

suggested that basing apps on evidence-based treatment models might be a rational compromise.

41,42 

Several entities offer emerging guidance pertaining to these SAMHSA’s Using Technology-Based technologies. One advisory board for mental health Therapeutic Tools in Behavioral Health information technology points out that the many systems of Services is an available resource for healthcare for serving those struggling with mental health 

treatment providers at conditions (mental care, physical care, hospitals, etc.) need to https://store.samhsa.gov/sites/default/ treat patients holistically, communicate, and coordinate care. files/d7/priv/sma15-4924.pdf The increase reliance on pay for performance also suggests 

considerations for integrating technologies. A few highlights 

are that technology still needs to prove itself; patient engagement is critical to success; and, product 

quality controls are needed.

43 To this latter point, the group suggest practitioners examine if the product 

has been tested for use with an intended audience (including RCTs), and if behavioral health 

professionals (e.g., psychologists, social workers, or other licensed mental health providers) contributed 

to the development of the technology.

44 

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Emerging Technology 

In addition to the commonly used app and social media platforms for the general public, behavioral 

health providers are increasingly using technology approaches to support their work with consumers. 

Therapists are capitalizing on these tools to improve care for their clients. They are recommending app 

use for homework and self-care (see the apps listed above as an example), using them to provide direct 

care, and supplementing conventional care using ecological momentary assessment to collect frequent 

real-time passive self-reports and to provide intensive outpatient monitoring.

45,46 

One example of software to assist therapist and clients is Talkspace Online Therapy. Marketed to 

consumers who “can’t afford to visit a therapist but still needing someone to talk to,” Talkspace starts at 

$65 per week and includes text messaging with a trained professional as often as the person needs for 

support through depression and more for couples and individuals.

47 With benefits listed such as 24/7 

access, no commute/transportation and scheduling hassles, seamlessly switching therapists for 

continuity of care, they are certainly addressing several of the barriers to treatment. For too long, it has 

been recognized that the top barriers to behavioral health treatment are cost, awareness, stigma, and 

accessing a provider.

48 However, there are currently no data available to show the effectiveness of this 

online therapy approach. Funding to support research on the effectiveness of these types of strategies 

to help populations with diverse needs, could help determine the utility of this approach. 

As therapists and therapies become more tech savvy, approaches are emerging to enhance the therapy 

environment itself. Once such approach is the use of avatars (digital self-representations) to facilitate 

online communication between therapists, clients, and peers. According to Rhem et al. (2016), there are 

four key ways that avatars are being used in therapy. These include: 

• online peer support communities; 

• using avatars to communicate and interact in a therapeutic environment; 

• to participate in skills building games; and, 

• to communicate with an autonomous virtual therapist. 

The research suggest that the use of avatars helps clients engage, form therapeutic alliances, seek 

treatment due to anonymity, express and explore their identity, and reduces communication barriers 

while the therapists can control and manipulate treatment stimuli.

49 However, as noted like all these 

new technologies further research on feasibility, effectiveness, and ethical use is needed. 

More research in this area may be coming. Between 2009 and 2015, NIMH awarded over 400 grants and 

almost $4.5 million dollars to research technology-enhanced interventions designed to prevent or treat 

mental health disorders.

50 These interventions are trending away from computer use and more to 

mobile devices and include interactive formats and game-like approaches. They also include both active 

(engaged treatment) and passive (data collection, artificial intelligence, machine learning and 

automated responses) for assessment and monitoring. 

Technology and Workforce Development 

For decades, the United States child and adolescent mental health workforce has suffered from a severe 

shortage and poor children and rural communities have consistently borne the brunt of that unmet 

need.

51,52 The COVID-19 pandemic amplified both the workforce shortage and service disparities by 

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simultaneously reducing the workforce and further isolating children in need. Technology has the 

potential to address the workforce shortage in three ways: 

• technology can potentially be used to reduce the overall prevalence of behavioral health 

problems by detecting relatively minor problems when they are easier to treat and may be 

treated through self-help strategies such as the apps described previously. 

• technology can potentially be used to increase access to effective treatment models through 

TMH. As described previously, the use of technology and the dramatic increase of TMH has been 

a critical strategy to increase access. 

• technology can be used to increase the reach, cost-effectiveness and quality of training and 

professional development for the behavioral health workforce. 

Simultaneously however, such dramatic shifts in practice are fundamentally redefining the delivery of 

children’s behavioral health care, and thus will require a significant re-tooling of the workforce. 

Dissemination and implementation science makes clear that the high-quality, widespread adoption of 

any significant new technology in a given field requires the use of intentional and adequately funded 

adoption strategies, including developing and maintaining the required competencies for providers to 

use the new technologies and the protections of the rights of people who will access the technologysupported services.

53 With subsequent future innovations, it will be important to remember that the 

technology itself is not self-actualizing, and to adequately plan for, fund, and take the time to develop 

the workforce capacity necessary to make optimal use of the technology. 

Several exemplars have emerged in recent years to demonstrate the innovative technology strategies 

being employed to build and strengthen the behavioral health workforce. These include: 

• The Behavioral Health Education Center of Nebraska’s Virtual Mentor Network has created a 

state pipeline program for future behavioral health professionals using online virtual sessions 

for rural college and high school students.54 

• The University of Hawaii has partnered with the Mayo Clinic in a model program to develop an 

expert children’s mental health workforce to serve geographically isolated and culturally diverse 

communities using interactive video teleconferencing (IVTC) and tele-mental health, 

strengthening collaboration with local primary and behavioral health providers.

55 

• In Project ECHO (Extension for Community Healthcare Outcomes) a hub-and-spoke virtual 

training and coaching model originally developed at the University of New Mexico for Hepatitis 

C care, the Addiction Training and Technical Assistance Center (ATTC) utilized the model to 

facilitate an IVTC knowledge-sharing network conducting virtual mentoring with locally based 

substance use treatment supervisors, to enhance workforce capacity to provide clinical 

supervision.

56 The ATTC chose clinical supervision to test this virtual training and coaching model 

based on its centrality as a workforce development amplifier. 

• Putney et al. (2019) describe an online interactive technology used in advanced level Master of 

Social Work programs to offer virtual client simulations (PeopleSim) as a tool to train screening 

and brief intervention and motivational interviewing. The virtual and asynchronous nature of 

the “patient” offers tremendous cost, convenience, and consistency over traditional live patient 

training, and students demonstrated significant pre- to post gains in screening and brief 

intervention skills, motivational interviewing skills, and change planning skills. Though no 

comparison group was included in the evaluation, this study demonstrates the potential efficacy 

of this innovative workforce development strategy.57 

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These are just a sampling of some of the innovate technology approaches being used to increase the size 

and the skills of the behavioral health workforce, offering an exciting glimpse of the future of training 

and professional development. 

Infrastructure Needs 

To understand the magnitude of the infrastructure and capacity challenge that comes with the adoption 

of these multiple technological innovations, it is instructive to look at the adoption of electronic health 

records (EHR) which began in earnest with the passage of the Health Information Technology for 

Economic and Clinical Health Act of 2009 (more information available at 

https://www.hipaajournal.com/what-is-the-hitech-act/) and the associated government stimulus. 

Although this combination of enabling legislation and financial incentives created rapid expansion of 

electronic health records over the past decade, the development of the technology and the necessary 

workforce capacity has been a story of uneven progress of fits and starts, and psychiatry and related 

fields have had the lowest adoption rate of all subspecialties.

58 Although well-designed EHR systems can 

increase efficiency and streamline services, it is equally common to see poorly designed or implemented 

systems with poor user interfaces that increase inefficiencies and errors, risk security breaches, and 

compromise the quality of health care and patient safety. 

For the behavioral health and addiction fields, a new national infrastructure is in place and poised to 

make good use of technology platforms to provide training and professional development. To address 

the national opioid epidemic in the years immediately prior to the COVID-19 pandemic, Congress 

appropriated over $3 billion to the Substance Abuse and Mental Health Services Administration 

(SAMHSA) to establish a national infrastructure of Technology Transfer Centers (TTCs), including the 

Addiction TTCs (ATTC Network), Prevention TTCs (PTTC Network), and Mental Health TTCs (MHTTC 

Network). These TTCs are tasked with building the capacity of the local behavioral health workforce to 

provide evidence-based interventions.

59 In response to stay-at-home orders in early Spring 2020, the 

entire TTC infrastructure rapidly shifted its full continuum of training and technical assistance to a multitiered virtual platform to offer uninterrupted remote service delivery. The TTCs have reported increased 

convenience and decreased costs in connecting local service providers with trainers and technical 

assistance providers, but have also noted inequitable access, especially for rural practitioners and 

communities, based on bandwidth limitations and some discomfort with technology. Overall, the TTC 

network represents a great potential national infrastructure for continuing to use technology to 

strengthen and support the mental health workforce. 

Questions Remain 

With the advances, questions and concerns have arisen that remain to be addressed. For example, it is 

not clear how service providers will need to respond when individuals just stop coming to virtual spaces. 

Another question is what happens when crises emerge, like suicidality, and the provider is only available 

via text or the client disconnects from a smartphone telehealth session. Some apps use a members IP 

address to determine exact location to send first responders, but it is often more difficult to determine 

the client’s level of risk in messages. Thus, it is unclear whether crisis response will be over utilized or 

underutilized. The American Psychological Association points out several other critical issues 

practitioners must attend to such as HIPAA compliance and patient privacy protections of technology 

based communications, state licensing laws for practitioners treating patients when their location may 

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be beyond their legal or ethical treatment allowance (e.g., talking to someone in a state where the 

provider is not licensed), as well as the ethics and practice parameters with the use of the many apps 

and platforms that allow users to remain anonymous.

60,61 

Another area of exploration needed regarding the increased infusion of technology is the potential 

disparities in care between large health care systems versus small providers and individual mental 

health practitioners. The significant investment in the technology, associated training and maintenance, 

and necessary cybersecurity may be financially out of reach for small organizations and sole proprietors. 

Many of these issues were not dealt with at the height of the pandemic when the major driver was to 

decrease any disruption in services, but as technology is integrated more into the work of behavioral 

health, these questions will need answers. 

Conclusion 

As the evidence of effectiveness grows, behavioral health technologies have the potential to reach more 

clients and help engage and retain them in services in a cost-effective manner.

62 Although technology 

can drastically increase access to behavioral health care for otherwise marginalized populations, there 

are many nuanced aspects of it that require further study, and thus it cannot be seen as a panacea. 

Similarly, although some would argue that the shift to more technological approaches to behavioral 

health have the unintended potential to disconnect behavioral health professionals from their clients on 

a personal, human level, there has been a great deal of experience with technology as a result of COVID19 that has been positive. Consistent throughout the literature is the theme that technology is not 

intended to replace in-person client contact. The current focus is almost always on how technology, 

when incorporated into treatment and prevention efforts, can supplement existing methods and 

provide services to clients who might not otherwise receive treatment. This may change as artificial 

intelligence and machine learning technology improves, but for now, it appears that technology will be a 

supplement to other forms of psychiatric care. As the behavioral health field evolves, it will be critical to 

ensure that the use of technology is done with a sense of fairness and equity so that any individual, in 

any setting, can have access to equivalent care. Thus, it is imperative that there be intentionality 

surrounding the advances in the use of technology to avoid a second tier “behavioral healthcare-lite” 

system for marginalized populations that in fact have the highest needs but are hardest to reach. Aware 

of the growth and potential, but also recognizing all the unknowns, the American Psychological 

Association cautions to tread carefully. They urge practitioners to consider the fit of technology with 

different clients and the seriousness of their level of risk and need.

63 

Tele-mental health, mobile care apps, artificial intelligence, and infrastructure technology have 

undeniably revolutionized every aspect of behavioral health and will continue to do so as further 

innovations are developed. As described throughout this article, this suite of technologies has the 

potential to: 

• Dramatically increase access to quality behavioral health care, 

• Connect consumers to behavioral health care where and when it is most convenient, potentially 

reducing barriers of geography and stigma, 

• Promote wide scale and unobtrusive assessment and screening to promote early identification 

of mental illness and substance use issues, 

• Empower individuals to self-manage their own emotional wellness, potentially reducing the 

overall prevalence of serious mental, emotional and behavioral problems, 

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• Increase the pace, scale, efficiency and accuracy of behavioral health research in order to 

improve the effectiveness of behavioral health care and reduce morbidity and mortality, and 

• Improve the coordination of care. 

The United States is in an uncomfortable era in behavioral health care, with one foot in the old way and 

one foot in the new. The mental health system is seeing the promise of technology but have not yet 

worked through all the important challenges of the transition. But the promise of technology is 

undeniable. For technology to demonstrably, collectively impact population-level behavioral health, it 

will require a coordinated and optimized effort that adequately addresses all three key variables: need, 

access and quality. Individually, there is ample proof of concept that technology can address each 

individually. Through low-cost self-help apps and artificial intelligence that passively identifies the 

earliest signs of dysfunction or dysregulation, the overall prevalence of behavioral health problems 

could potentially be reduced. Through tele-mental health adaptations of evidence-based treatment 

models and policy initiatives to ensure adequate broadband access to every home, there is the also the 

potential to ensure that all who need behavioral health services will have access to them. 

Technologically innovative training, workforce development, infrastructure advances and quality 

assurance strategies will help to ensure that behavioral health services are delivered by highly trained 

professionals ensuring adherence to strict treatment protocols in a coordinated system of care. 

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Using Data to 

Manage State 

and Local-level 

Mental Health 

Crisis Services 

No. 10 

 Ready to Respond: 

Mental Health Beyond Crisis and COVID-19 

September 2021 

228
 

 

 

 

Using Data to Manage State and LocalLevel Mental Health Crisis Services 

Robert Shaw, MA 

Senior Research Associate 

National Association of State Mental Health Program Directors Research Institute, Inc. 

rshaw@nri-inc.org 

703-738-8171 

Cover Art by Malkah Pinals 

Tenth in the 2021 Ready to Respond Series of Ten Technical Assistance Briefs 

focused on Beyond Beds, Reimagining a Sustainable and Robust Continuum of 

Psychiatric Care 

National Association of State Mental Health Program Directors 

www.nasmhpd.org/content/tac-assessment-papers 

September 2021 

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Acknowledgements: 

The author would like to thank the following individuals for sharing invaluable insight and providing 

guidance about this important topic: Megan Lee, M.A., L.P.C. and Tim Gruzeski, M.A., with the Colorado 

Office of Behavioral Health’s Crisis Services; Devin Teicher and Jenn Conrad, M.S.W., L.C.S.W, C.C.M., 

with Signal Behavioral Health in Colorado; Claire Wang and Glenn Owens from Delaware Division of 

Substance Abuse and Mental Health; Debbie Atkins, Anna Bouque, and Terri Timberlake, with the 

Georgia Department of Behavioral Health and Developmental Disabilities, Dawn Peel and Jennifer Dunn, 

with the Georgia’s Southwest and East-Central Regional Field Offices; Josh Cantwell, with Grand Lake 

Mental Health Center in Oklahoma; Nicole Cunha and LeAnne Huff, with Utah’s Division of Substance 

Abuse and Mental Health Treatment Services; David Reed, with Washington State’s Health Care 

Authority; Joe Avalos, Chris Foster, and Valerie House, with Olympic Health and Recovery Services 

(Thurston and Mason Counties Behavioral Health Services); Ted Lutterman, and Kristin Neylon, M.A., 

with the NASMHPD Research Institute, and Debra A. Pinals, MD Chair, Medical Directors Division 

National Association of State Mental Health Program Directors Medical Director, Behavioral Health and 

Forensic Programs Michigan Department of Health and Human Services Clinical Professor of Psychiatry 

Director, Program in Psychiatry, Law and Ethics, University of Michigan. 

Disclaimer: 

The views, opinions, content and positions expressed in this paper are those of the author and do not 

necessarily represent or reflect the official views, opinions, or policies of any governmental, academic, 

or other institution with whom the author is affiliated; nor does mention of trade names, commercial 

practices, or organizations imply endorsement by the U.S. government, any state government, academic 

or other institution. 

Recommended Citation: 

Shaw R. (2021). Using Data to Manage State and Local-Level Mental Health Crisis Services. Technical 

Assistance Collaborative Paper No. 10. Alexandria, VA: National Association of State Mental Health 

Program Directors. 

This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition contract/task order, 

HHSS283201200021I/HHS28342003T and funded by the Center for Mental Health Services/Substance Abuse and 

Mental Health Services Administration of the Department of Health and Human Services through the National 

Association of State Mental Health Program Directors. 

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Abstract: 

Managing crisis services will require the collection and use of data to make decisions about how, 

when, and where crisis services are provided. Also, registries of available crisis services and other 

services in the psychiatric care continuum will help inform policymakers about access to behavioral 

health services and any barriers to such access. Operating crisis services will include the provision of 

services based more on past activities and determining specific strategies for implementation of 

activities. Managing crisis services is an iterative process that requires the constant collection of data 

or knowledge that can be used to assess all aspects of a provider’s or a state’s activities to continually 

adjust to achieve better services. Great efforts are expended to collect data that document the 

activities of providers, often also with the goal of demonstrating that funding has been well spent. 

States and their providers do not always operate in an environment where they have all the data 

they could use, and often the data they collect are not fully accurate or timely. Nevertheless, even 

suboptimal data are valuable and can provide insight albeit broad rather than minute. Management 

decisions can still be made, even with data limitations, and the direction taken can later shift if 

subsequent data indicate that a wrong turn has been taken. States and providers will do well to 

continually examine data and operational practices for ongoing quality improvement for the most 

effective crisis services possible. 

Highlights: 

• States and local providers interviewed are using data to manage the provision of crisis services. 

• There are always more and better data that can be collected, however the lack of ideal data 

should be a reminder for caution but should not completely inhibit decision making. Using data 

to manage crisis services is an approach to solving problems and addressing needs 

Recommendations for the post-COVID-19 future: 

1. Data should be collected and used to understand the ways in which the COVID-19 pandemic has 

altered society, including where people live, how they are accustomed and comfortable 

interacting with the world, and their jobs and how that impacts crisis service utilization. 

2. Crisis services should be managed in a way that adeptly meets needs both within and 

subsequent to the pandemic. 

3. Technology can be used to enhance registries and locator tools to inform data collection 

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T

he Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Practice Guidelines: 

Core Elements for Responding to Mental Health Crises suggests that crisis service systems include 

data-driven "quality-control and performance-improvement mechanisms that operate within an 

organization,” that demonstrate what populations experience mental health crises. Data should be used 

for “identifying gaps, developing remedies, and monitoring the impact of these remedies.” ∗ . In the next 

few years, states will be implementing 988 suicide call lines. Because much of the work is still in the 

planning phases, it is not yet known how this will be integrated into existing crisis systems. 

This current paper, Using Data to Manage State and Local Level Mental Health Services, explores the 

extent to which crisis services in states and local mental health agencies collect and use data to inform 

their crisis service systems. Systems can either be operated or managed. The distinctions between 

these types of services are as follows and further delineated below: 

Operated systems: The provision of services is based more on past activities and practices and 

less on data. 

Managed systems: Data are collected and used to make decisions about how, when, and where 

crisis services are provided. 

Data are often collected with one specific purpose being a way to document activities at the local level 

and to inform leadership at the state level and at the state level to the executive and legislative 

branches of government. State governments have an interest in documenting that expenditures are 

spent according to legislation, executive priorities, effectively, and efficiently. However, this use of data 

lends itself more to oversight than management. 

This paper will first discuss management models to understand how states could be managing their 

crisis service systems from the perspective of data systems. Next, it will look at the data collected by 

existing and proposed service registries and discuss how those data collection elements relate to 

management goals the states may have. Service registries are tools states use to connect individuals to 

services. This paper will provide an overview the types of service registries that currently exist and then 

review how some states are using data to manage their crisis service systems. The ambition, depth, 

functionality, and use of registries vary by state, so state level examples of the use of data to manage 

crisis services will be presented.1 Crisis services are often managed at the local level, so this paper will 

also describe at how local crisis service providers in several states are using data to manage their 

systems. 

*Where specific state and local examples are described, program leaders within those regions whose services are included in 

this paper had the opportunity to review and provide edits to the description of their activities and the paper as a whole. 

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Management of Systems and the Relationship to Data 

Management is the process of dealing with or controlling things or people. Harold Koontz, an influential 

management theorist, classified management models into six schools in 1961: 

• Management Process - Management is a process of getting things done through people 

organized into groups. 

• Empirical - Good management is based upon the experience of what did and did not work. 

• Human Behavior – Good management is based on good relationships. 

• Social System - Good management is based on establishing a cooperative environment. 

• Decision Theory – Good management is based upon using a rational approach to making 

decisions. 

• Mathematical – Good management is a logical process that is based on quantifiable variables.

1 

Each of these types of management depends on turning information into decisions and actions. A goal 

must be decided upon and relevant data should be collected that allows managers to determine success 

in attaining their goals. In this paper, highlights of data collection across the crisis service behavioral 

health continuum to inform these various aspects of management will be reviewed. 

Service Registries 

Crisis Service Registries are tools that provide information about where there are open services for 

people in crisis who are determined to need a particular type of service, whether in-patient or in the 

community. These registries, however, require operations and management to ensure their 

effectiveness. 

A well regulated Service Registry, being necessary for the optimization of the use of mental health crisis 

service capacity, especially inpatient capacity, and the treatment of individuals with mental illness in the 

least restrictive setting, is an evolving practice that is being supported as a promising practice for 

ensuring timely access to a complete continuum of care, in line with recommendations noted in Beyond 

Beds (The Vital Role of a Full Continuum of Psychiatric Care).

2 A service registry, however narrow or 

broad its focus, is a tool whose success is dependent on its usefulness. Usefulness can be defined in 

many ways, such as operating without glitches and downtime, providing timely information, and 

reducing the wait time for access to services. 

In 2020, 24 states had operating or were building behavioral health service registries. There were also 

regional service registries. Arizona had at least two systems, one for the northern part of the state, 

based in Phoenix, that was very sophisticated and successful, and one in the southern part of the state, 

based in Tucson, that was paper-based, and has also been successful in guiding access issues. 

The existing service registries have various degrees of success with success defined as being a useful tool 

that allows individuals in need of behavioral health services to be placed in an appropriate care setting 

with minimal wait times. Registries require front-end staff entering information about service availability 

in their own system, as well as end-users seeking information to access services in real time. Both user 

experiences are critical important determinant of a registry’s usefulness. It is important to note that 

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registries are most often used by case managers, clinicians, emergency departments, and first 

responders trying to place an individual in need with an appropriate service. If a user can accurately see 

that the services being sought are not available, then the system is successful. If the service availability 

information is more often wrong or not current than current and accurate, the system is not successful. 

Many registries do not have real-time information. Real-time information is ideal because system users 

can rely upon the information in the system to be accurate at the time of their placement search. Realtime information is not absolutely necessary for a system to be successful. If a system's information is 

not updated in real-time but the information in the system is current enough to be relied upon by users, 

then the system can be successful. Even when a system has real-time information, if vacancies are 

scarce the system will be unsuccessful because the lack of available services will overwhelm the enduser’s experience and they will eventually not rely on the system to identify proper placements of 

individuals being served. Thus, registry information requires balance between sufficiency of information 

as well as availability and accessibility of services in the first place. 

Based upon site visits to states and interviews with states about their service registries, Dr. David 

Morrissette created a typology for these systems (Figure 1):

3 

Figure 1. Typology or Registry Systems 

• Search Engines: “Users visit the website to view information on crisis bed facilities, 

their locations, services, availability, and contact information.” 

• Referral Systems: “In addition to providing regularly updated information on bed 

availability, the websites support authorized users to submit HIPAA-compliant electronic 

referrals to secure a bed using preset forms and protocols.” 

•Referrals Networks: "The bed registry site provides regularly updated information on 

bed availability supports users to submit HIPAA-compliant electronic referrals to secure a 

bed and supports referrals for behavioral health crisis and outpatient services to and 

from service providers who are members of the referral network." 

Search engines are the least sophisticated of the system types. They intend only to make it easier for a 

bed to be found and a patient to be placed in care. Users of search engines have to contact facilities 

showing a vacancy to fill that vacancy with a patient. In most cases, currently used search engines are 

generally focused on psychiatric inpatient and/or crisis beds. Accessing the rest of the continuum of 

services is not addressed. For example, one would have to look elsewhere to schedule an appointment 

for an outpatient service. Referral systems are more sophisticated versions of search engines. Referral 

systems not only identify vacancies but allow users to send documents necessary to initiate placements 

to fill vacancies. Referral Networks are the most sophisticated and comprehensive version. They not 

only allow identify vacancies but allow users to schedule outpatient services. 

Morrissette’s typology is very useful in understanding the intent of the various registry systems. Getting 

facilities to participate by keeping their vacancy information current is the biggest barrier to success. If 

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the information is sufficiently accurate and the system is easy enough to operate that users come to it 

first when trying to identify available services for individuals, then the system will be more successful. 

State Level Crisis Service Registry Data Collection 

Crisis Service Registry Data Collection 

Forty-three states with existing, developing, or planned crisis service registries were asked by NRI to 

report what data they expected their service registries to collect. Data collected by service registries can 

be used to document activities and to manage systems. The extent to which a state collects accurate 

and timely data determines its ability to use data to make management decisions. Based on the types of 

data reported collected by the 23 states with existing and developing registries at the end of 2020, and 

reported to be collected by the 20 states developing new service registries states have some or all of the 

following goals: 

• Making services easier to access; 

• Making services more available; 

• Improving outcomes for people accessing services; and 

• Improving the operation of the registry and service provision system. 

As states are developing service registries, NRI gathered information on their effectiveness is measured. 

Several metrics were identified including service accessibility, service availability; improved outcomes 

for individuals served, and improved operations of the registry itself. Below are results of the 

information gathered from the forty-three states with existing or planned registries in terms of the 

percentage of states using particular metrics. Among the forty-three states with existing, developing, or 

planned registries, the following responses were provided (percentages are based on 43 states 

reporting: 

Service accessibility will be measured by: 

• Referral wait times (the time a caller waits to be referred to any type of treatment) (35%) 

• Connection to treatment (19%) 

• Denials of service (13%) 

• Discharge wait time (the time a patient waits to be discharged from care) (2%) 

Service availability will be measured by: 

• The volume of service usage (47%) 

• The geography of need (7%) 

Improving outcomes for people in need of access to services will be measured by: 

• Diversion from either hospitals or criminal justice (33%) 

• Better treatment outcomes (14%) 

• Contact with law enforcement (2%) 

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Improving the operation of the registry and the service provision system will be measured by: 

• Provider compliance with service vacancy updates (14%) 

• Training on the registry system or training of providers on the provision of services (14%) 

• User satisfaction and the public perception of the system (7%) 

• The performance of the registry system as a web tool (2%) 

Mental Health Block Grant Reporting on Crisis Services 

In 2020, Congress added a new 5% set-aside to the Mental Health Block Grant to assist states in 

establishing a comprehensive behavioral health services continuum (and Congress appropriated an 

additional $42.25 million to the MHBG to fund this set-aside). SAMHSA’s guidance to states 

accompanying the new funds, emphasized the CrisisNow model of a comprehensive crisis continuum 

described in the 2020 National Guidelines report released by SAMHSA and the National Association of 

State Mental Health Program Directors (NASMHPD).4 

In 2021, states as part of their submission to SAMHSA about the use of the new Crisis set-aside were 

asked to report what elements of a crisis service system they were planning on implementing broken 

out by prevention and early intervention, intervention, stabilization, and post-crisis interventions and 

supports. 

Thirty-eight states responded to a SAMHSA request to report on the implementation of a crisis service 

system. Of these states, 55% had reached program sustainability for providing someone to talk to, while 

45% were in the process of implementing this service. Of these states, 26% had reached program 

sustainability for providing someone to respond to a crisis, while 71% were in the process of 

implementing this service. Of these states, 21% had reached program sustainability for providing 

someone in crisis a place to go for treatment, while 74% were in the process of implementing this 

service.5 

States were asked to report which of the listed crisis prevention and early intervention, crisis 

intervention and stabilization, and post-crisis intervention and support programs they were or would 

including as part of their crisis service system. 

Elements within Mental Health Crisis Service Systems 

In the NRI's 2020 State Profiles data collection, states were asked to report on the types of crisis 

intervention services provided by the SMHA and the number of persons receiving these services during 

the fiscal year 2019. This information was augmented by data collected by NASMHPD in 2021 on crisis 

services provided by the states. The number of persons receiving a service within a year is not a 

measure with any depth. It is not clear from the data how much of the states are covered by the 

particular crisis services asked about. In many states, crisis services are organized locally and the state 

may not have a great role in their provision. What is clear is that only a small number of states with 

particular crisis services had easy or ready access to this service data. It is difficult to make evidencebased decisions without evidence. Management without information is difficult. 

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Crisis Prevention and Early Intervention 

Suicide prevention was reported to be an element in the crisis service systems, planned or operational, 

in 90% of states. With the implementation of 988 hotlines, this is likely to change to all states. Safety 

Planning, a tool that results in a list of warning signs, coping strategies, and resources a person in crisis 

can use when experiencing future crises, is a system element in 80% of states. 

Data reported by states via NRI’s State Profiles for 2020 and data collected by NASMHPD in 2021 show 

that at least 78% percent of states currently have 24-hour crisis hotlines, with one state not reporting. 

NRI Profiles data show that the rate of use of crisis lines ranged from 82 to 2,684 per 100,000 of the 

population with an average of 789. 

As planning continues with the build out of a 988 response, “988 systems” will need to connect suicidal 

people in crisis with appropriate services. States with successful referral systems will be well placed to 

provide 988 system operators with information that will allow them to connect callers with appropriate 

services at all levels of intensity. Not all callers will require mobile crisis intervention, yet a search engine 

that only reports psychiatric bed vacancies will be inadequate for the needs of a 988 system. 

Crisis Intervention/Stabilization 

Crisis Intervention Team (CIT)/Law Enforcement was reported to be an element in the crisis service 

systems, planned or operational, in 94% of states via NRI’s State Profiles for 2020. CIT provides law 

enforcement with training that allows officers to more effectively interact with individuals experiencing 

a behavioral health crisis and thereby reduces stigma and helps divert people from jails to treatment.

6 

Mobile Crisis Outreach, which is community-based mobile interventions for people experiencing a 

mental health crisis,

7 was reported to be in an element in 92% of states. Data reported by states via 

NRI’s State Profiles for 2020 and data collected by NASMHPD in 2021 show that at least 73% percent of 

states currently have mobile crisis programs with six states unknown. Profiles data show that the rate of 

use in FY 2019 ranged from 9 to 1,317 per 100,000 of the population with an average of 394. 

Crisis Residential/Respite services, always available, no-wrong-door facilities that access and treat 

people experiencing a mental health crisis,

8 were reported to be an element in 88% of states. Profiles 

data and data collected by NASMHPD in 2021 show that at least 57% percent of states currently have 

less than 24-hour crisis stabilization units, with five state unknown, and at least 69% have more than 24-

hour crisis residential units, with seven states unknown. An expansion of crisis stabilization and crisis 

residential programs should occur in the next couple of years. Profiles data show that the use of less 

than 24-hour units ranged from 1 to 1,070 per 100,000 of the population with an average of 270. 

Profiles data show that the use of more than 24-hour units ranged from 2 to 197 per 100,000 of the 

population with an average of 67. 

Hospital Emergency Departments and Urgent Care were reported via NRI’s State Profiles for 2020 to be 

an element in 86% of states. In areas following the Crisis Now model of mobile crisis teams transporting 

people to crisis stabilization facilities, thereby diverting away from hospital emergency departments, 

there would be a limited role for hospitals in addressing mental health crises.

9 

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The Living Room Model (Assessment/Triage), 24-hour community crisis centers that offer people in crisis 

a calm and welcoming space where they receive treatment, support, rest, relaxation, and referrals to 

other services,

10 was an element in 47% of states. 

Of the states responding to the NRI survey, 27%, reported including Open Dialogue as an element in 

their service array. Open Dialogue is a practice developed in Finland that takes a social perspective to 

helping people with mental illness by including family members, friends, and co-workers in the 

treatment and wellness discussions.

11 

Post Crisis Intervention/Support 

Connection to care coordination, follow-up clinical care, follow-up outreach, and follow-up support were 

reported to be elements in the crisis service systems planned or operational in 86% of states. Care 

coordination refers to the coordination of care across behavioral health and general healthcare.

12 

Peer Support/Peer Bridgers are reported to be elements in 84% of states. Peer Support is the process of 

giving and receiving support, knowledge, assistance, and skills between people with unique lived 

experience with mental health conditions.

13 

Peer Bridgers are peer support specialists who assist individuals hospitalized for a psychiatric illness 

return to their community.

14 Recovery community coaches/peer recovery coaches will elements in 69% 

of states. 

Family-to-Family Engagement and Follow-up crisis engagement with families and the community are 

elements in 67% of states. Recovery-oriented community organizations are elements in 59% of states. 

Using 911 Call Information for Service Prediction 

Implementing 988 suicide hotlines means that states will have the opportunity, if 988 systems collect 

and share data, to use data to manage their crisis service systems in ways that were previously 

unavailable. A lot depends on how the 988 hotlines are implemented and how data elements are 

conceived and implemented. 

For at least a decade, researchers have been using 911 call data to attempt to predict hotspots using 

spatial analysis to better inform policymakers.

15,16,17 Researchers have also used 911 data to attempt to 

predict frequent users of emergency medical services.

18 Successful data analysis is based upon accurate 

data. 911 call centers are typically organized locally and often have used different technologies and 

methodologies, which hampers the collection and analysis of 911 call data. 

Beginning in 2003, the United States Department of Transportation, National Highway Traffic Safety 

Administration (NHTSA) has worked to define and help states implement Next Generation 911 (NG911) 

services that allow for the interoperability of data and call center hardware and software.

19 As of 2019, 

33 states have adopted a statewide NG911 plan that includes data uniformity and automated data 

handling.

20 The National Emergency Number Association (NENA) has standards related to answering and 

routing calls that include the number of answered calls, attempted calls, disconnected calls, diverted 

calls, abandoned calls, misrouted calls, call duration, and call hold time.

21 

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Call centers for 911 are not necessarily service providers, rather they are trained to respond to a variety 

of emergencies and route the calls to the appropriate first responders,

22 whereas hotline call center 

staff should be clinicians who are an integral part of the clinical response to a call.

23 

The National Suicide Prevention Lifeline, collects information on hours of operation, speed of answer, 

contact handling time, on-hold time, cost per call, service level, etc.24 These metrics are related to the 

availability and accessibility of hotline services rather than the location of the person in crisis, type of 

crisis, demographic information on the callers, percent seen by a mobile crisis team, percent forwarded 

to crisis respite or residential facilities. 

A comparison of 911 call centers and suicide hotline data analytics to those of a commercial business 

such as Domino’s Pizza may be instructive. Domino’s considers itself to be a technology company that 

delivers pizza. Domino’s tracks customer data across its franchises to determine buying patterns, 

including location.

25 Domino’s has a financial incentive to optimize its resources in pursuit of increased 

sales. Ideally, a behavioral health crisis service system would reduce the need for its services by reducing 

the incidence of crises among the population it serves. They are similar in that location, type of 

service/pizza sold, use of materials, use of staffing, frequency of use, customer satisfaction, etc. are 

metrics that should be tracked and analyzed to optimize performance and efficiency. These data can 

answer questions such as where to place service locations, appropriate staffing levels based on historic 

usage data, and types of services to be provided. 

Use of Data to Manage State and Regional Crisis Service Systems 

Interviews were conducted with six state mental health authorities (SMHAs) and four regional providers 

of mental health crisis services. The states were selected based upon information that was gathered 

about them through previous interviews conducted with them for previous papers on crisis services and 

service registries. The regional crisis service systems were selected based on suggestions made by the 

states interviewed and, in the case of Grand Lake in Oklahoma, based upon an interview about the 

coordination and cooperation established between the mental health system and law enforcement. 

These examples are presented in alphabetical order, by state, and not hierarchically. States differ in how 

they organize the provision of public mental health services, they have unique geographies, political 

histories, funding structures, and goals beyond optimizing the provision of services to people in need. 

Nonetheless, the following case studies are illustrative how crisis services data and registries are coming 

together as a crisis continuum of services is realized in particular regions. 

Colorado Office of Behavioral Health 

Colorado’s crisis service continuum is split between Rocky Mountain Crisis Partners, which is the crisis 

hotline and text provider, and four Administrative Service Organizations (ASOs) that are responsible for 

seven regions. Colorado Office of Behavioral Health (OBH) directly manages the provision of crisis 

services at the state level, including the statewide crisis hotline, which has been contracted out to Rocky 

Mountain Crisis Partners. The OBH also manages the ASO contracts. The ASOs manage the provision of 

services and the contracts with the service providers in the seven regions. Colorado Crisis Services began 

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operating in 2014. Previously, and currently, the state's Community Mental Health Centers (CMHCs) 

provide emergency services. The services provided by the CMHCs significantly overlap the services 

provided through Colorado Crisis Services. The CMHCs are not all the same, often because of regional 

differences in funding and staffing. Colorado has one large urban and suburban area stretching from 

Fort Collins in the north, through Denver and its suburbs, and south to Colorado Springs. Every part of 

the system is expected to work seamlessly with every other part. Services are intended to be boundaryless in the sense that the closest, available mobile crisis team is supposed to take a call, even if the 

service location is outside of their region. 

The state uses a broad definition of a mental health crisis, one defined by the caller. However, there is a 

narrower crisis definition used by the providers (a non-life-threatening situation in which a person 

experiences an intensive behavioral, emotional, or psychiatric response triggered by a precipitating 

event. The person may be at risk of harm to self or others, disoriented or out of touch with reality, 

functionally compromised, or otherwise agitated and unable to be calmed. If this crisis is left untreated, 

it could result in a behavioral health emergency). Individuals who believe they are in crisis are 

encouraged to call for help. The provider then assesses the situation and responds appropriately, to 

serve individuals in the least restrictive setting possible. 

The SMHA data and analytical focus are often on collecting and summarizing information to provide to 

the legislature and less on using this data for managing the performance of providers. This is partly a 

result of the indirect contractual relationship with providers. 

The SMHA has been collecting crisis system data at an aggregate level to look at trends and changes. 

They track call center service utilization by client demographics, call abandonment rates, call response 

times, time on call, etc. Since the ASOs have a contractual relationship with the providers, the 

performance of the providers is managed by the ASOs and not at the state-level. The state does set 

some of the terms of the ASOs contracts with providers and uses data to amend contracts to improve 

service provision. The SMHA does not have an existing crisis service registry though they are developing 

one that will collect client-level data. With client-level data, they will have a greater ability to measure 

performance. 

The crisis line is currently and has previously been monitored through performance metrics such as 

incoming volume, abandonment rate, and activity duration. Currently, there is an expectation that at 

least 80% of calls are answered within the first minute and the abandonment rate remains 10% or 

lower. When, due to COVID-19 pandemic-related issues such as staff turnover and switching to working 

from home, the performance began to lag, the SMHA increased the resources available to the crisis line 

contractor. 

The SMHA tracks the utilization of mobile crisis services by client demographics, frequency of use by 

individuals, and location of where the services were provided, and analyzes for trends. One of their goals 

is for mobile services to reach clients where they are and not serve people in places where there are 

already available mental health services, such as at schools. 

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Colorado tracks the performance of less than 24-hour crisis walk-in centers and the more than 24-hour 

crisis residential facilities, including looking at length of stay and tying length of stay to diagnoses. They 

have also looked at the availability to accept law enforcement drop-offs and whether the centers are 

pre-screening individuals to rule them wrongly out of services. It is expected that walk-in centers be able 

to receive and process anyone. 

The SMHA has used data to update its follow-up requirements to keep people served at an outpatient 

level with more wraparound services. The requirement changed from follow-up with individuals at oneand five-days post-discharge to one, three, and ten days post-discharge. They are tracking the success of 

this update, but it was too early at the time of the interview to determine its success. 

For states just starting to build crisis data systems, Colorado suggests that robust relationships are 

between all community partners, including setting performance and outcome standards. Without 

defining performance expectations and defining success, a program cannot determine success just 

through aggregate data reporting. It is also important to clearly define the data you are expecting your 

providers to collect otherwise they may default to lumping much of their data into the “Other” category. 

Colorado – Signal Behavioral Health 

Signal Behavioral Health Network (Signal) is contracted by the state of Colorado to provide crisis services 

in three regions covering the Boulder-Denver metro area along with outlying areas that are either in the 

mountains or on the plains. Their region’s mental health crisis care continuum includes a statewide call 

center, managed by an entity independent of Signal Behavioral Health, mobile crisis teams, crisis 

stabilization units, and in-home and facility-based crisis respite services. In the past year, crisis services 

for children and youth have begun to get more attention with consideration for how to better serve the 

unique needs of this population. 

The call center is responsible for dispatching mobile crisis teams and they provide telephonic crisis and 

peer support to callers across the state of Colorado. The agency contracted to administer the call center 

also operates the national suicide prevention hotline in Colorado. Signal manages but does not operate 

the providers of crisis services, including the mobile crisis teams, the walk-in center, crisis stabilization 

units, and the respite service providers. Of the calls received for their regions by the statewide call 

center, only about one percent result in the dispatch of a mobile crisis team or a referral to a walk-in 

center. There are between 500 and 600 calls per month statewide to the call center. 

As the contracted administrator of the crisis services in Denver region, Signal Behavioral Health operates 

as a representative of the state, and is responsible for crisis services statewide. Signal collects data from 

the providers that document their activities, such as the number of people served, types of episodes, 

etc. That data is forwarded to the SMHA. 

Signal uses data to look at service trends by provider, such as changes in use patterns. For example, 

when children started to go back to school following the outbreak of the COVID-19 pandemic, the call 

center experienced an influx of calls from and related to adolescents. Signal is required by contract to 

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develop performance plans for the providers in their region and seeks to understand what providers are 

doing and experiencing to help the provider better manage their activities, such as suggesting staffing or 

programmatic changes. Signal receives episodic and aggregate data from their providers but not claims 

data. When collecting data from their various providers, Signal is at the mercy of the providers’ data 

systems, which vary in what and how data are collected. 

Signal is not in a position to manage the overall mental health service system in their regions since those 

operate largely independently from the contracts that Signal oversees. It is often the case that the 

providers Signal oversees are also providers of non-crisis mental health services but it often happens 

that a person in crisis receives services from providers who are not their normal service providers and 

therefore may have access to little information about the individual whose crisis they are trying to 

resolve. 

To reduce the use of 911, emergency rooms, and law enforcement when addressing individuals in crisis, 

Signal contracts with a private ambulance company to transport the small number of individuals seen by 

mobile crisis teams who need higher intensity services. Without the ambulance, the mobile crisis team 

would have to involve either law enforcement or emergency rooms, dispatched by 911 to transport the 

individual to facility-based care such as a crisis stabilization unit, respite facility, psychiatric inpatient 

care, or withdrawal management. 

The crisis stabilization facilities in the regions that Signal manages do not operate as walk-in centers, as 

these are currently distinctly separate services in Colorado. Some of the facilities require medical 

screens and often not the same medical screen by all facilities before they admit individuals. The 

requirement for medical screening, which can include glucose, COVID-19, and pregnancy testing, has 

been adopted by facilities out of an abundance of caution. The caution is in part a result of the 

architecture of the facilities, which do not have sally ports for Law Enforcement to drop off individuals. 

The facilities try to avoid what otherwise would be a mix of all ages, from children to adults, and levels 

of intensity of behavioral needs. 

Delaware Division of Substance Abuse and Mental Health 

Delaware's adult crisis service system within the Division of Substance Abuse and Mental Health, 

includes crisis call centers, mobile crisis teams, 23-hour receiving centers, and two crisis respite centers 

(for supports over 24 hours in duration), was established more than forty years ago. The system is 

operated and staffed by state employees and is connected to their electronic bidirectional referral 

system, Delaware Treatment & Referral Network (DTRN), powered by OpenBeds. There is a separate, 

parallel crisis service system that services youth because, in Delaware, youth in need of mental health 

services are served by a separate state agency. 

Adult crisis services are divided regionally into two crisis service teams. The call center staff are 

integrated with the mobile crisis teams, meaning that the crisis team members who respond to calls at 

the call center are also the ones who would travel to any person in crisis, if that is deemed necessary. 

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That means that a person in crisis who receives mobile crisis services will be visited by the person who 

took their call. Crisis services are staffed by trained mental health professionals and peers. 

Delaware uses a broad, person-centered definition of a mental health crisis. An individual is in crisis if 

that individual feels that they are in crisis. Whether or not a caller is visited in person is dependent on 

the presented level of dangerousness. If the crisis is not dangerous, a mobile response would depend on 

whether the situation warrants such a response and the availability of the team members to travel. The 

crisis teams use OpenBeds to arrange appointments for people in crisis. The crisis teams can also 

connect callers with the mental health professionals who are most familiar with the person, assuming 

that they are available, and the caller is previously connected to care. 

Delaware currently collects call center data through paper-based call logs. The information in the logs is 

aggregated into a spreadsheet then reported to the Division’s headquarters that use that information to 

track whether the call centers are meeting their goals. The state is in the process of digitizing this data 

collection. Using a centralized database, the state can look up whether those individuals are already in 

care and whether or not they are attending their appointments. 

Delaware uses a data dashboard to track the operations of its crisis service system. Included in their 

dashboard is the ratio of calls into the crisis service system versus calls out, such as calls to providers, 

the hospital diversion rate, and the types of services provided, including case management, counseling, 

medication checks/medication monitoring, psychiatric evaluations, screening, transportation, and 

wellbeing checks. Targets have been set for the measures and the SMHA tracks how well their system 

achieves those goals. Currently, Delaware has been meeting their goals. Of all the items tracked, 

Delaware considers response time the most important measure. 

At the call center/mobile crisis team level, the state tracks incoming and outgoing calls, including the 

number of such calls, the response times, and the interval between the initial call and the arrival of a 

mobile team. Outgoing calls are calls made by the crisis team staff including to the police or the service 

provider who typically cares for the individual in crisis. The SMHA tracks the number of responses, the 

resolution of the crisis, the number of types of responses, calls by senior citizens age 62 years and older, 

detentions/no detention, and voluntary admission/no admission. 

Crisis team members must have mental health screener certification, which requires a 40-hour training 

course to complete a 24-hour detention, meaning that the team members will have detained someone 

for no more than 24 hours. The state does not have specific hiring goals that address cultural 

competency and diversity, but they do convene culturally diverse hiring panels. Spanish is the 

predominant second language in Delaware and, as of this writing, there are no crisis team members who 

are fluent in Spanish. Workforce recruitment challenges are not unique to but exist in Delaware, 

especially challenges hiring staff who are fluent in languages other than English. To bridge language 

gaps, crisis team members use the computerized Language Line service. 

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The Delaware Division of Substance Abuse and Mental Health also have a partnership with the Delaware 

State Police. As a result of this partnership, several police stations furthest from a call center are staffed 

with a mental health professional, who goes out on calls during the evening shifts. The pilot locations 

will soon launch a pre-arrest diversion program, collaboration between the SMHA, the State Police, and 

the Delaware Department of Justice. This pilot program was more a result of an interest in collaboration 

between the State Police and SMHA and the amenability of the particular police station than a result of 

using data to determine unmet need. 

Currently, two 23-hour crisis stabilization centers are contracted but not operated by the state. 

Delaware is currently renewing the contract. The new contract will add a third such center to one of the 

three total counties, which currently does not have such a center. The success of these centers is, in 

part, determined by looking at the number of people admitted to a crisis stabilization center who do not 

end up requiring hospitalization. 

There are two, greater than 24-hour crisis respite centers each with three to four beds. These beds are 

largely used by people who were previously at one of the two 23-hour centers. As with the 23-hour 

centers, Delaware look at the number of people admitted who do not end up requiring hospitalization 

to determine their success. 

In addition to the previously mentioned crisis services and the separate and parallel youth crisis service 

system, there is also Lifeline, the suicide prevention hotline. 

Crisis services in Delaware are not currently billed but are provided regardless of insurance or ability to 

pay. They can track how much the services are costing the state and what the cost per client is. 

Figure 2: Utilization by Type of Service 

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For states just starting to build a crisis data system, Delaware, whose system has been in place for more 

than forty years suggests that states should track response time, the total volume of calls, and the ratio 

of mobile crisis responses to the total number of calls. 

Georgia Department of Behavioral Health and Developmental Disabilities helped develop the Crisis Now 

model of mental health crisis services and has continually worked on this endeavor for many years. 

Accordingly, they use a broad definition of a mental health crisis, meaning they allow the individual to 

define their crisis. The state runs a central crisis call center that coordinates access to care for all 

individuals, not just those in crisis. The call center is connected to a service registry which allows for 

individuals to be connected to treatment at a variety of levels, including mobile crisis services, but also 

for non-crisis services. In addition to mobile crisis teams, the call center can connect individuals with 

their Assertive Community Treatment (ACT) team, assuming they are receiving ACT services, and even 

dispatch ACT team staff to the individual in crisis. The crisis call line is available 24 hours a day, seven 

days a week. Additionally, there is a peer-run warm line that is available from 8:00 a.m. to 8:00 p.m. The 

goals of the system are to connect people to treatment in such a way that the incidence of crises is 

minimized and the individuals are served in the most helpful way possible. 

To achieve their goals, Georgia's SMHA has a robust service registry that not only connects people to 

treatment at all levels, from community services to inpatient services, but the registry also helps Georgia 

collect data at a state level to manage its crisis service system. 

The SMHA receives daily, weekly, and monthly reports that help them actively manage their system. For 

example, they receive daily reports of the volume of calls, weekly reports on items such as the call 

abandonment rate, the average speed to answer, which is broken out by types of callers. Since their call 

center is used for non-crisis purposes and not just to respond to crises, they have known callers, such as 

clinicians, who use the system to place individuals in care at a variety of levels of intensity. Monthly, 

they get reports on the average speed to answer a call, the abandonment rate, and the hold-time. The 

hold time or time a caller is placed on hold is an important metric for them because their goal is to be as 

responsive as possible. 

These data reports are used by Georgia to manage their system. For example, when they found that 

they had a high hold time, they used their data to figure out what factors were causing callers to be put 

in on hold and then made changes to their system to improve their efficiency and the caller experience. 

They implemented a voice recorder that would break into the hold music and provide information to 

callers. To address hold times on calls, they changed the way that the staff handed calls off to clinicians, 

so the staff remains with the caller as they are waiting to hand them off to a clinician. Additional staff 

was required to better handle the volume of calls more rapidly. The system is experiencing a staffing 

shortage. To inform their staffing decisions, Georgia has analyzed when their call centers are the busiest 

(Mondays) and least busy (Sundays except for Mother's Day). 

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To manage their mobile crisis teams, Georgia looks at the response times, specifically whether teams 

respond to calls in a reasonable time, crisis response cancellation rates, linkages to treatment, referrals 

types, service denial types, and repeat crisis interactions with the same individuals. Their goal is a 

diversion to less intensive levels of treatment for 85% of mobile crisis responses. They also look at the 

staffing of the mobile crisis teams, including whether not unfilled positions are open for longer than 12 

weeks. The data they collect has helped provide them with an understanding of service trends, such as 

areas with high incidence rates, trends for service requests by time of day and day of the week. They use 

the data and their analyses to work with their providers to better inform staffing decisions. 

In most cases, Georgia’s less than 24 hour and greater than 24 crisis facilities are the same facilities. To 

manage this level of care, they collect a lot of data and use a variety of regular and ad hoc reports. Their 

goal is for their facilities to improve how they serve their communities. They look at care denial rates, 

occupancy rates, diversion to lower levels of care, and length of stay, among other measures. Before 

they propose opening a new facility, they seek to make sure that their existing facilities are used most 

effectively. 

Overall, Georgia uses their data to create forecasting models to identify what parts of its system should 

change to better meet the needs of its constituents. Their robust service registry allows them to 

understand service usage at all levels of care provision, including their capacity and the utilization of that 

capacity. 

For states starting out in creating a more robust crisis service system, Georgia recommends that they 

focus on knowing what problems they are trying to fix. For Georgia, the most fundamental issue for 

them was to optimize the use of their existing services. The overall integration of their services in a 

service registry that can connect people to treatment and tracks the use of treatment service capacity 

allows them to continually work to improve their system and not just address possibly momentary 

crises. To create the analyses used to inform the management of the system, they have found it very 

beneficial to have data analysts. Their data can inform decision making. Making changes necessitates 

analyzing the consequences as part of a continuous process of improvement. 

As robust and extensive as Georgia’s data collection system is, there are still areas where they would like 

more information. Their system was not built overnight and is the result of additions and subtractions 

based upon their experience. They would like to have more information on how involuntary 

commitments, are made and the appropriateness of these commitments. They would also like to track 

recidivism more closely to determine what is driving recidivism rates and how they could change their 

system to improve these rates. 

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Figure 3: Georgia Mobile Crisis Response Services Dashboard 

Figure 4: Georgia: “What If” Gap Analysis for Crisis Services 

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Georgia –Southwest and East-Central Regions 

NRI spoke with representatives of the Southwest and East-Central regions. Southwest serves a largely 

rural population while East-Central serves a mix of rural and urban populations. The regions are 

overseen by state personnel who work in coordination with the agency’s central administration as equal 

partners. 

Georgia's approach to management, including at the regional level, is that they focus on the goal of 

providing services at all levels of intensity to their constituents most efficiently and appropriately 

possible. They work with providers to understand their needs and concerns and help providers from the 

various parts of the crisis service continuum collaborate to better accomplish their goals. Providers are 

encouraged to share what is working and what is not work so that all can benefit from the experience. 

The regions use data to look at trends and to solve glitches. There are regular meetings, temporarily 

interrupted due to the COVID-19 pandemic. These meetings are still occurring but have shifted from inperson to virtual meetings. 

Though the call center is a statewide entity, rather than regional, the call center interacts with local 

providers. If that interaction is not running as smoothly as desired, for example, if there are long wait 

times, that information is relayed to the central administration for them to address with the call center. 

The regional managers have monthly meetings with the mobile crisis teams to review their activities, 

such as response time and number of calls. They help the crisis teams better manage their activities by 

identifying cyclical trends or any other issues that have arisen either within the teams or in the 

interaction of the teams with other providers, such as hospitals. If a particular hospital is determined to 

be overcalling the mobile crisis team, which causes stress to that part of the system, they will work with 

the hospital to retrain them on the appropriate and intended use of crisis teams. 

In Georgia, the less than 24-hour and more than 24-hour crisis respite facilities are generally the same 

facility. The regional managers meet with these facilities with the mobile crisis teams to foster a better 

understanding of the system and thereby improve the relationship between these different service 

providers. For example, in the past, there has been a misunderstanding by the centers that they were 

shouldering more of the burden of providing crisis services than they were. Using data, a regional 

manager was able to show that 90% of mobile crisis calls result in the individual staying in the 

community rather than coming to a respite center. 

The mobile crisis providers, who are not state employers rather contractors, meet quarterly with law 

enforcement in their region, providing the Law Enforcement with continuing education credits to inform 

them about how the crisis system operates. They begin the meetings with a presentation that shows 

what is being done, where people are being served, what needs to be done, and how law enforcement 

fits into the crisis service continuum. These meetings have been temporarily suspended due to the 

pandemic. 

The regional managers work to make sure that their stakeholders understand the workings of their 

system so that the stakeholders can use it as intended. However, the system is designed to be flexible 

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and its design is informed by information and experience. They are always open to change if that change 

better achieves the overall goal of the system. For example, it became apparent that there were 

differing, non-standardized understandings of the definition of autism. When that issue was identified, 

the state better defined that data element. The providers are encouraged to feel that they are partners 

with the state agency and with other providers. The state uses any feedback provided to them to make 

changes to their system. 

Oklahoma – Grand Lake Mental Health Center 

Grand Lake Mental Health Center (GLMHC) serves twelve counties in northeast and northcentral 

Oklahoma with a population of 480,000 and covering 10,000 square miles. The region is rural, but they 

have 22 clinics in the twelve counties. 

Grand Lake is very good at collecting and using data. They believe everything they do should have an 

attached data point, and that their data should be used. As a result of their rethinking of the provision of 

all services, not just crisis services, they have reduced hospitalization by 80-98%, depending on how the 

reduction is estimated. The implementation of their reimagined service system was more than paid for 

by the cost savings that their new system realized. They have also saved time and money for local law 

enforcement by drastically reducing their travel and wait times as they bring people in crisis in for 

services. They have also reduced jailings by making it easier for law enforcement to transport people in 

crisis to treatment than to jail them. 

Grand Lake has been able to achieve these successes by creating a service system that can provide 

treatment to individuals, whether they are in crisis, whenever they want it and wherever they are. 

The basis of Grand Lake’s system is their crisis service centers which can individuals in voluntary services 

as well as those under an emergency detention order. Their goal is for there to be a crisis service center 

no more than 45 minutes from any individual in their 10,000 square mile region. While they have not yet 

met this goal, they are on the way to meeting it. Since many people in crisis are transported by law 

enforcement, they try to locate their crisis centers close to sheriff’s offices, which reduces transport 

time for law enforcement. Grand Lakes tries to transport people voluntarily because they have found 

that if you eliminate a person’s resistance, you can immediately start their recovery. More than 95% of 

the people they transport volunteer to be transported. Grand Lake also works very closely with law 

enforcement to encourage their willing participation in the Grand Lake’s treatment delivery processes. 

Individuals in crisis begin their treatment as they are being transported to a crisis center. This is possible 

because Grand Lake sponsored the development of the MyCare App, when loaded onto an iPad it puts 

the iPad into a single app Mode, making it, in their opinion, the “perfect Mental Health machine.” This 

app connects an individual with a clinician the moment they encounter a peace officer and can be used 

as they are being transported as there is a GLMHC iPad in every law enforcement vehicle in the 12 

counties they serve. A GLMHC iPad is given to individuals when they are discharged from the Urgent 

Care facilities for their future use, reducing crisis transports and instances of relapse. Grand Lake pays 

for the data fees and quality for a reduced rate as first responders. The distribution of the iPads with the 

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MyCare App began with the individuals who have the most need because they reasoned that the 

greatest benefit, and therefore cost savings, could be realized by better serving the individuals most 

frequently in need. The savings realized from this group funded the more widespread distribution of 

iPads to people less in need. Currently, more than 5,000 iPads have been distributed. They have found 

that it was easier to get buy-in from stakeholders once they were able to demonstrate their initial 

successes. 

Individuals with IPads can access services, or arrange for appointments, whenever they want to, even if 

they are out of the region on vacation. Their no-show rate for appointments has declined. They have 

reduced hospitalization. There is no on-hold with the app. The app connects individuals with staff at the 

crisis centers. Since the crisis center staff are already at work, there are no extra personnel needed to 

staff the telehealth available with the app. If an individual in crisis does not already have an iPad with 

the app and is in crisis, they can contact a 24-hour crisis line and a mobile team can go out and meet the 

individual. After the COVID-19 pandemic began, Grand Lake was well prepared to provide contactless 

mental health treatment. For example, to reduce potential COVID-19 exposures they even delivered 

iPads to people at their home. 

Grand Lake has been successful at achieving its goals of reducing hospitalizations and improving the 

cooperation of law enforcement because they have approached achieving their goals with an open mind 

and with data. Data serves the purpose of quantifying their situation and documenting the success or 

failure of the systemic changes they try. For example, they began with more than 1,100 inpatient 

hospitalizations per year. To reduce hospitalizations, they created new levels of care, the crisis service 

centers. They measured the inpatient hospitalizations and the use of the crisis centers. They found that, 

within five years, hospitalizations were reduced by 80-98%. The reduction of hospitalizations did not 

result in increased use of the crisis centers. The use of the crisis centers also decreased. They were also 

able to document the mileage and hours saved by law enforcement. Since the state was paying for the 

law enforcement's mileage used to transfer individuals to treatment, Grand Lake was also able to 

calculate those cost savings. There are likely other cost savings in addition that were not calculated, such 

as the time saved from long waits in emergency departments by law enforcement. 

Grand Lake has not only used data to reduce hospitalizations but also has focused on improving the 

overall health of the individuals they serve... When clients are at the crisis centers, full laboratory studies 

are available to examine appropriate levels for psychotropics as appropriate, but also do examine 

medical issues. For example, providers are able to take basic lab tests to look at cholesterol levels and 

assess for urinary tract infections. When the COVID-19 pandemic began, they started tracking the 

impact of the pandemic on their clients. 

Leadership at Grand Lake are invested in ever improving outcomes. For example, there has been 

discussion regarding examining data around suicides. Another consideration is in ensuring that they 

provide a comprehensive Mental Health System that treats people in the least restrictive environment, 

which in turn will prove to be the least expensive. By bringing technology and agencies providing 

services together, it is also hoped that people in need of mental health services will receive them, rather 

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than be routed to the criminal system. Mobile technology has been an innovation at Grand Lake that is 

helping services tip toward solutions. 

Utah Division of Substance Abuse and Mental Health Treatment Services 

The Division of Substance Abuse and Mental Health Treatment Services has been transitioning its crisis 

service continuum towards the Crisis Now model and is expanding the availability of crisis services in the 

areas served by their 13 local mental health authorities that contract with the state. Crisis services are 

mandated to be available statewide 24 hours a day, seven days a week. There is one crisis hotline and a 

warmline that cover the entire state. Mobile crisis teams are covering all of Utah's regions and the crisis 

walk-in facilities adhere to the Crisis Now model that includes policies of no refusal. Individuals decide 

whether or not they are in crisis and the system responds to their specific needs. Their goal is for 

services to be available statewide with response times of half an hour for law enforcement and one hour 

for the mobile teams in the more densely populated areas of the state and within two hours in the rural 

areas. 

Utah uses the data collected by their system to track how people move through the continuum of crisis 

and what happens to them and how responsive the crisis system is to the needs of their users. Among 

the data elements they use to track the use of their system is the duration of calls to the crisis line, as 

well as the time it takes for a call to be answered. 

Staffing the call center with only clinical staff has proven financially challenging, and impractical given 

general workforce challenges in recruiting and retaining clinicians across the state. Thus, leaders from 

Utah are considering other models that might be equally effective. For example, they were able to 

determine that clinicians tended to spend longer with users on the phone and engaged with callers as 

they might in therapy. Review or processes and practices indicated that for crisis call responders, it may 

be more prudent to identify the current, and future, services needs of that user. Call center staff will 

continue to be required to be appropriately trained, but they will not need to also be clinicians. The 

mobile crisis teams consist of a peer and a clinician in the denser populated areas and at least a peer 

and a case manager in the rural areas. 

In monitoring the success of the different parts of their crisis service continuum, Utah is primarily 

concerned with referral rates. For example, how many mobile crisis team visits did calls to the crisis call 

center generate, and how many users were either stabilized as a result of the services provided on the 

call or if they were connected to community services. Their goal is to treat people in the least restrictive 

manner possible and preferably at home. 

The state uses data to track where mobile crisis teams were referred by the call centers but were not 

available to make the call, either because of staffing or resource issues. In some cases, the team that is 

referred is not always the closest to the person in crisis. 

When monitoring the work of the crisis receiving centers, Utah looks at the time it took for law 

enforcement to drop off a person in crisis because they do not want law enforcement to perceive their 

interactions with the centers to be burdensome. Utah tracks the rate of diversions from jails. They track 

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how long someone is at the center and if they are there for longer than 23 hours, why they remained, 

and then when they leave, they track whether they left, be it a hospital, detox facilities, residential 

treatment, or back home. Utah also collects data on what the perceived alternatives to the crisis centers 

are. Their goal is to help their system meet the needs of the people they serve by identifying service or 

resource gaps. 

Utah is also interested in knowing what other states are doing to address crises in their communities so 

that they might adopt or adapt the successes of others to better Utah’s system. 

Utah recommends that any state just starting to build a crisis data system collect data on the number of 

calls made to crisis call lines broken out by the number of callers who remained in the community, 

including at home, as compared to the number who needed a higher level of care. Utah’s goal is that 

70% of callers remain in place. 

While Utah uses data to manage its crisis service system, the state leaders in crisis services realize that 

not all data are useful. For example, they collect some data points that have few responses or data that 

do not appear to be accurate, for example, response time by mobile crisis teams to the destination. 

They continue to examine the reliability and accuracy of the data to engage in further refinements in 

data collection to help inform practice... 

Washington 

Washington’s crisis service system is organized regionally. The regional Administrative Service 

Organizations (ASOs) are either based in a single county or are based in a cluster of counties that have 

joined together to provide services. The State Mental Health Authority contracts with the ASOs for crisis 

and non-Medicaid paid services. Medicaid services are purchased through Medicaid are provided by five 

large Managed Care Plans. The MCOs purchase crisis services through the ASOs for managed care 

enrollees. 

Each region has a centralized call center; some regions also have warm lines. Multiple regions have crisis 

triage/stabilization facilities. These facilities are licensed to hold people for more than 24 hours but are 

also used for stays of less than 24 hours. Each facility has the capacity for police drop-offs. Typically 

police drop-offs are held for up to 12 hours for evaluation. 

The regions also have mobile crisis teams. Until this year, there was no state-level definition of a mobile 

crisis team. In one region, a team might be defined as two individuals who can go out on calls, and the 

region would report having multiple teams for 24/7 response. In another region, a team would consist 

of the entire crisis responder staff and could be 20 or more individuals. The SMHA is developing a 

statewide definition for crisis teams for accurate capacity tracking. 

Washington’s system includes involuntary treatment for people in crisis. The regions have designated 

crisis responders who evaluate people for involuntary treatment. In rural areas, those people may also 

be a member of the mobile crisis team responding to a call. In those cases, the mobile crisis team 

members announce to the individual that they will be assessing them for involuntary treatment and 

everything that they said to them previously will not count as part of the determination but everything 

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said subsequently will be. The assessments are a quasi-legal procedure rather than a clinical 

intervention. These crisis responders have the authority to put people on five-day, involuntary holds. 

Later, individuals placed in involuntary treatment can be held for up to 90 days through hearings 

convened by local Superior Courts. 

The SMHA has for decades collected a substantial amount of data on the involuntary treatments, which 

comes to them in a timely manner. The data include the date and time of the encounter, the outcomes 

of the investigations, and the legal criteria used for detention determinations. They track this by region, 

including looking at outliers related to the number of investigations and the outcomes. A separate 

dataset tracks the hearings, including how many people make it to court within 48 hours, how many 

cases are dismissed, how many are sent to less-restrictive alternatives, and how many are committed 

for 14 or 90 days. 

Washington’s crisis service system is undergoing change and expansion due to factors which include the 

Trueblood Decision, legislative action expanding crisis services, the future roll-out of 988 services, and 

the creation of a broad service registry to link people to care at all levels of intensity. The Trueblood 

lawsuit challenged the delays in competency evaluation and restoration services for people in jail. The 

court ordered the state to provide such evaluations within 14 days and competency restoration within 

seven days of court orders.

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To determine the cost of expanding the availability of crisis services, including expanding the number of 

crisis teams, the SMHA needed to create a standard definition of a crisis team, which they then costed 

out. In the new definition, a crisis team consists of 11 people, including a supervisor. The new definition 

allows for two people to be in the field, including one peer and one behavioral health professional) with 

service available year-round and 24 hours per day. They are also able to calculate per person service 

costs. Previously, the regions were reluctant to provide the state with information about their workforce 

because they were afraid that their workers would be recruited by other regions. The promise of 

expanding capacity allayed those fears. As a result of calculating the costs of providing crisis services, the 

SMHA determined that Medicaid billing will not cover the cost of providing crisis services. The legislature 

understands that the expansion of crisis services purchases availability and coverage rather than 

individual services. 

In the past, they looked to the regions to monitor the success of the crisis services they provided. The 

regions had an incentive to provide effective services because they would be fiscally responsible for 

paying for any involuntary treatment. The state did track the number of crisis calls received by the 

regions but did not connect that data to outcomes data. In the future, the SMHA will be legislatively 

required to track the performance of the crisis service systems run by the ASOs. 

With the future rollout of 988 services, the call centers will be able to connect with the service registry 

that is under development. The recently passed 988 bill provides for call center staff to be able to find 

out if individuals have Advance Directives or under current involuntary treatment orders. 

Additional data that would help manage the crisis service system would include the disposition of calls 

to the crisis system, including the ability to link information that identifies callers with the involuntary 

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treatment investigations. It would also be helpful if the data collected in the future could allow for the 

assessing risk for each call. Data should constantly be analyzed to address the needs of their 

constituency, however; if data are not used then their collection should be discontinued. 

Washington Olympic Health and Recovery Services (Thurston and Mason Counties) 

Olympic Health and Recovery Services (OHRS) are a county-governed, publicly funded licensed 

Behavioral Health Agency (BHA) that provides crisis services to Thurston and Mason counties, 

Washington. Thurston has a population of 300,000 and has rural and urban areas while Mason is rural 

and has a population of about 65,000. Olympic Health and Recovery Services responds to about 400 

crisis outreaches per month, 80% of which are in Thurston County, and conducts about 250 involuntary 

assessments per month (see the section above for a discussion of Washington's involuntary assessment 

activities. 

They are not the sole crisis service provider in their region and the services are not always coordinated 

amongst the various providers. They have zero relationship with the regional National Suicide 

Prevention LifeLine (NSPL) call center located 100 miles away. Olympia, the state capitol, the county seat 

of Thurston County, operates their non-licensed crisis team using city funds in collaboration with OHRS, 

who co-locates a responder on their team 40 hours per week. The local ASO, contracts with Catholic 

Community Services to provide separate 24/7 youth mobile outreach services. 

In Washington, most regions use a contracted call center. In this case, Olympic operates its own 24/7 

call center. As in Delaware, clinical staff operate the call center and are part of the mobile crisis teams 

responding to those calls, when needed. Calls are triaged, however, if the call came from a hospital, they 

have to send out staff who can make involuntary commitment decisions, otherwise, normal staff can 

respond. Only 12% of the calls result in an involuntary commitment determination. Staff also reach out 

to individuals for up to 14 days after a mobile crisis visit. 

While they do not operate crisis stabilization centers, they do provide stabilization services, but in the 

individual’s home. The stabilization outreach program is peer staffed and responds to an average of 55 

clients per month. They go to the individual’s home, stay with them, talk with them, and try to connect 

the individual with resources to address their needs. Crisis stabilization outreach began in November 

2020 and so, at the time of the interview, they did were not able to determine if the program was 

successful in diverting individuals from hospitals. 

One of Olympic’s largest problems is staffing. Washington's involuntary commitment rules require a 

high-level staff but recruiting and retaining higher-level staff is difficult. Since the vast majority of crisis 

calls do not result in involuntary commitment, Olympic added lower-level staff, including certified peers, 

who are fully capable of taking care of the lower-intensity calls. 

Lack of information on the clients they serve is a problem that Olympic experiences. In 2020, as a result 

of a reorganization of Medicaid funding in Washington, Olympic no longer received information on 

Medicaid-funded clients, who are about 60% of the people they serve. Olympic does not have access to 

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the local emergency department information exchange and often does not have any information on the 

person they are responding to, including their medical history or family information. Many of the 

individuals they provide crisis services have crisis plans but they no longer have access to those plans. 

Though access to crisis plans is required by the state, no mechanism exists to make sure that the access 

happens. Since many of the crisis calls happen in the middle of the night, they are not able to contact 

the individual's normal providers to find out information about the individual's medical history. 

Olympic collects their data to track and manage their operations. They are interested in knowing what 

the overall service needs in their communities are and how they are meeting that need and so collect 

response time, referral source, demographic information, law enforcement calls by law enforcement 

agency, etc. Each of the law enforcement entities in their region has different protocols and responds 

differently to crises so knowing which law enforcement entity their will encounter on a crisis call is 

important to know to resolve the situation most effectively. They use time of day to track trends and use 

that data to influence staffing decisions. They have used response time to referrals to expand the 

staffing of their crisis teams. During the COVID-19 pandemic, they experienced an increase in crisis calls. 

Increasing their crisis service staff did not result in a decrease in involuntary commitments, which, to 

them, means that even with the increase in service capacity; they are still not meeting the service needs 

of their community. 

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Figure 5: Olympic Health and Recovery Services Crisis Service Report Template 

BH-ASO

 Crisis System Metrics Report 

BH-ASO 

Contact Person 

Phone Number 

Email 

Reporting Period (quarter/year) 

Metric Number Metric Month 1 Month 2 Month 3 Quarter Total 

Crisis Calls 

1a Total number of calls to crisis line 0 

1b Total number of calls to crisis line answered 0 

1c Average answer time of calls to crisis line (seconds) #DIV/0! 

1d Total number of calls to crisis line answered live within 30 seconds 0 

1e Percentage of calls to crisis line answered live within 30 seconds #DIV/0! #DIV/0! #DIV/0! #DIV/0! 

1f Total number of calls to crisis line abandoned 0 

1g Percentage of calls to crisis line abandoned #DIV/0! #DIV/0! #DIV/0! #DIV/0! 

Mobile Crisis Outreach Services 

2a Total number of mobile crisis outreach services 0 

2b Percentage of EMERGENT mobile crisis outreach service 

requests/referrals that were responded to within two (2) hours #DIV/0! 

2c Percentage of URGENT mobile crisis outreach service requests/referrals 

that were responded to within twenty-four (24) hours #DIV/0! 

Involuntary Treatment Act (ITA) Investigations 

3a Total number of ITA investigations 0 

3b Total number of ITA investigations conducted via telehealth 0 

3c Total number of ITA investigations not meeting detention criteria, 

resulting in a referral to outpatient treatment 0 

3d Total number of ITA investigations not meeting detention criteria, 

resulting in a referral to voluntary inpatient treatment 0 

3e Total number of ITA investigations resulting in detention or revocation 0 

3f Total number of ITA investigations resulting in detentions or revocations 

filed as SUD 0 

3g Total number of ITA investigations resulting in detentions or revocations 

filed as MH 0 

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Figure 6: Olympic Health and Recovery Services Crisis Service Data Definitions 

1a 

Crisis Calls 

Total number of calls to crisis line. 

Definition: All Calls received by regional crisis line regardless of caller intention or if sufficient information is 

gathered to generate an H0030 encounter. 

1b Total number of calls to crisis line answered. 

Definition: Number of calls answered by a live person. 

1c Average answer time of calls to crisis line (seconds). 

Definition: Average answer speed for calls that are answered by a live person (1b). This does not include wait 

times for abandoned calls. 

1d Total number of calls to crisis line answered live within 30 seconds. 

Definition: Total number of calls answered by a live person (1b) <30 seconds 

1e Percentage of calls to crisis line answered live within 30 seconds. 

Definition: (Total calls answered by a live person <30 seconds) / (Total calls answered). (1d / 1b). Note: use 

two decimal places e.g. 98.75% 

1f Total number of calls to crisis line abandoned 

Definition: Number of calls that result in hang up after 30 seconds (including those who hang up during an 

automated attendant script) 

1g Percentage of calls to crisis line abandoned 

Definition: (Calls abandoned) / (Total number of calls to crisis line) (1f / 1a) Note: use two decimal places e.g. 

4.75% 

2a 

Mobile Crisis Outreach Services 

Total number of mobile crisis outreach services. 

Definition: Crisis services provided by eligible provider type (H2011-SERI) in response to a crisis outreach 

referral. Referrals can originate from any source, including but not limited to, crisis call lines, community 

members, health care professionals, law enforcement, family members, or by individuals in crisis (selfreferral). This excludes Involuntary Treatment Investigations. 

2b Percentage of EMERGENT mobile crisis outreach service requests/referrals that were responded 

to within two (2) hours. 

Emergent Definition: Mobile Crisis Outreach Services provided for a person that, if not provided, would likely 

result in the need for crisis intervention, or hospital evaluation due to concerns of potential danger to self, 

others, property, or grave disability. 

Definition: (EMERGENT requests/referrals responded to in two (2) hours or less) / (Total number of 

EMERGENT requests/referrals). Note: use two decimal places e.g. 98.75% 

2c Percentage of URGENT mobile crisis outreach service requests/referrals that were responded to 

within twenty-four (24) hours. 

Urgent Crisis Definition: Mobile Crisis Outreach Services to be provided to persons approaching a behavioral 

health crisis. If services are not received within 24 hours of the request, the persons situation is likely to 

deteriorate to the point that emergency care is necessary. 

(URGENT requests/referrals responded to in twenty-four (24) hours or less) / (Total number of URGENT 

requests/referrals) Note: use two decimal places e.g. 98.75% 

3a 

Involuntary Treatment Act (ITA) Investigations 

Total number of ITA investigations. 

Definition: All crisis encounters where a Designated Crisis Responder conducts an ITA investigation whether or 

not the outcome is a detention. All encounters coded as H2011HW. 

3b Total number of ITA investigations conducted via telehealth. 

Definition: The total number of ITA Investigation (3a) conducted via telehealth 

3c Total number of ITA investigations not meeting detention criteria, resulting in a referral to 

outpatient treatment. 

Definition: The total number of ITA Investigation (3a) not meeting detention criteria, resulting in a referral to 

outpatient treatment. 

3d Total number of ITA Investigations not meeting detention criteria, resulting in a referral to 

voluntary inpatient treatment 

Definition: The total number of ITA Investigation (3a) not meeting detention criteria, resulting in a 

referral to voluntary inpatient treatment. 

3e Total number of ITA investigations resulting in detention or revocation. 

Definition: The total number of ITA Investigation (3a) resulting in detention or revocation. 

3f Total number of ITA investigations resulting in detentions or revocations filed as SUD. 

Definition: The total number of ITA Investigation resulting in detention or revocation (3e), filed as SUD. 

3g Total number of ITA investigations resulting in detentions or revocations filed as MH. 

Definition: The total number of ITA Investigation resulting in detention or revocation (3e), filed as MH. 

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Conclusion 

Management is the process of dealing with or controlling things or people. Management decisions can 

be informed by evidence, necessity, feelings, whim, accident, and even changes in the political 

environment. Decisions can have intended and unintended consequences, improve things, make things 

worse, or have no impact. This paper argues that the most successful management decisions are a) 

intended to improve something, b) based upon evidence that informs the decision, c) part of a 

continuing management process of improvements, and d) undertaken with the understanding that 

actions have consequences that also should be studied and understood. Information used to inform 

decisions should be relevant to the management decisions they will be used for and collected as 

accurately as possible. Data about state mental health programs are often collected as documentation, 

reported by local providers to the SMHA and by SMHAs to the Federal Government, as part of the block 

grant reporting, to legislatures. 

As this report shows, local providers and SMHAs are using data to manage the provision of mental 

health crisis services. The extent to which data are used, and the provision of services is managed, varies 

by state. Some local providers and SMHAs use an ad hoc approach while some use a continual 

improvement approach.

27 In some states, the SMHA has a very indirect relationship with service 

providers where the services providers are contracted by a local entity which, itself, has a direct 

relationship with the SMHA. In such a case, the SMHA manages the provision of services by 

documenting the fulfillment of the guidelines and procedures that the SMHA establishes and 

occasionally, often at the beginning of a new contract, alters. In some states, the local entities also have 

indirect relationships with service providers and the management of services is similar to that of SMHAs 

with indirect service provider relationships. 

When a local agency or state manage and provide services directly, there are many opportunities to use 

data to inform management decisions. Grand Lake in Oklahoma, for example, directly operates services. 

Using a continual improvement approach, they have reimagined service provision, documented their 

successes and failures, and used data to further alter their activities. Similarly, Georgia’s SMHA runs the 

state’s crisis service system and has direct relationships with the service providers. Georgia also uses a 

continuous improvement approach to alter their activities. Any individual change that is made using a 

continuous quality improvement approach may or may not be a success, and may or may not have a 

large impact. Still, the accumulation of improvements over the years, even small improvements, can add 

up vast improvement and broad systemic change that can result in better services for the people who 

need them, when they need them. 

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