I 118th CONGRESS 1st Session H. R. 6415 IN THE HOUSE OF REPRESENTATIVES November 14, 2023 Ms. Tokuda (for herself, Mr. Fitzpatrick , Ms. Balint , Mr. LaMalfa , Mr. Tonko , Mrs. Watson Coleman , Mr. Neguse , Ms. Norton , Ms. Salinas , and Mrs. Torres of California ) introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committee on Transportation and Infrastructure , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To increase access to mental health, substance use, and counseling services for first responders, and for other purposes.

1. Short title This Act may be cited as the Crisis Assistance and Resources in Emergencies for First Responders Act or the CARE for First Responders Act . 2. Findings Congress finds the following: (1) According to the Department of Homeland Security, there are an estimated 4.6 million people serving as career and volunteer professionals in the United States within 5 primary response disciplines: law enforcement, fire and rescue services, emergency management, and public works. (2) First responders are usually the first on the scene to face challenging, dangerous, and draining situations. (3) First responders are also the first to reach out to disaster survivors and provide emotional and physical support to them. These duties, although essential to the entire community, are strenuous to first responders and with time put them at an increased risk of experiencing some mental health and substance use issues and conditions. (4) The combination of exposure to trauma, demanding schedules, and physically challenging roles puts first responders at an increased risk for mental health issues such as depression, post-traumatic dress disorder, stress, and suicidal behaviors. (5) According to a 2018 study by the Substance Abuse and Mental Health Services Administration, 30 percent of first responders develop behavioral health conditions including depression and post-traumatic stress disorder, as compared with 20 percent in the general population. (6) The Substance Abuse and Mental Health Services Administration finds that an estimated between 125 and 300 police officers die by suicide annually. (7) Data from the National Violent Death Reporting System indicates that first responders made up 1 percent of all suicides from 2015 to 2017. When broken down by response discipline, these first responder suicides occurred among law enforcement officers (58 percent), firefighters (21 percent), emergency medical services providers (18 percent) and public safety telecommunicators (2 percent). (8) According to the Firefighter Behavioral Health Alliance, more firefighters died of suicide than in the line of duty between 2014 and 2020, and nearly 58 percent of firefighters were exposed to traumatic events like mass shootings, violence car crashes, or child abuse. (9) For many first responders, it can be difficult to transition from being a provider to client or patient is not an easy one so when a first responder finally seeks treatment, it can be devastating to encounter an ill-prepared provider and may result in reluctance to seek further help. (10) Many first responders may consider stress to be part of the job and feel that they cannot or should not talk about traumatic events and other occupational stressors. Perceived stigma around mental health problems or concerns over impact on employment, including but not limited to being labeled as unfit for duty, may lead first responders to not report trauma, mental health issues, or suicidal thoughts. (11) There are limited resources available to specifically address the mental health needs of first responders. Often, first responders are directed to general mental health practitioners who may not understand the unique demands faced by first responders or the cultures in which they operate. While these services may meet the needs of many patients, general practitioners may not understand what first responders experience on the job or be able to relate to them in a culturally competent manner. (12) Providing first responders with mental health and substance use resources and services that are readily available and occupationally relevant can help them deal with excess stress, attain timely and clinically appropriate care, and feel better prepared to respond to an emergency. (13) Public safety telecommunicators, including 9–1–1 operators and fire dispatchers, are the backbone of our national emergency response system. They provide round-the-clock coverage in more than 6,000 emergency communication centers around the country. (14) Public safety telecommunicators are responsible for answering emergency and nonemergency calls and directing police, fire and rescue, and other emergency response personnel to assist those in need. They are required to multitask, conduct on-the-spot problem solving, and maintain composure and compassion, while coaching callers through often difficult and disturbing situations like home invasions, incidents of domestic violence, burning homes, automobile accidents and fatalities, and homicides. (15) The work of public safety telecommunicators is often high-stress, fast-paced, and emotionally demanding. Every day, they are faced with challenges and trauma that places them at increased risk for developing mental health challenges. (16) According to studies conducted by National Institute for Occupational Safety and Health, between 17 percent and 24 percent of public safety telecommunicators have symptoms of post-traumatic stress disorder and 24 percent have symptoms of depression. While telecommunicators are often the very first responders engaged with those on scene, research on their suicide risk and mental health has lagged. (17) Despite playing a critical role in protecting and saving lives in emergency situations, public safety telecommunicators are classified by most States and by the Federal Government as office and administrative support personnel and not as first responders, leaving them without access to important mental health resources available to other emergency response professionals. 3. Crisis counseling assistance and training (a) In general Section 416(a) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act ( 42 U.S.C. 5183(a) ) is amended by inserting and to qualified emergency response providers responding to major disasters after victims of major disasters . (b) Definitions Section 102 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act ( 42 U.S.C. 5122 ) is amended by adding at the end the following: (13) Public safety telecommunicator The term public safety telecommunicator means a public safety telecommunicator as designated in detailed occupation 43–5031 in the Standard Occupational Classification Manual of the Office of Management and Budget issued in 2018, or any successor designation. (14) Qualified emergency response providers The term qualified emergency response providers means— (A) emergency response providers (as defined in section 2 of the Homeland Security Act of 2002 ( 6 U.S.C. 101 )); and (B) public safety telecommunicators. . 4. Specialized services for first responders Subpart 3 of part B of title V of the Public Health Service Act ( 42 U.S.C. 290bb–31 ) is amended by adding at the end the following: 520O. Specialized services for first responders (a) Establishment Not later than 2 years after the date of enactment of this Act, the Secretary of Health and Human Services, acting through the Assistant Secretary of the Substance Abuse and Mental Health Administration, shall develop and carry out a comprehensive program designed to provide mental health services specifically tailored to qualified emergency response providers. Such program shall— (1) provide for mental health care availability to qualified emergency response providers on a 24-hour basis; (2) provide for a qualified emergency response providers hotline operated through the 988 Suicide and Crisis Lifeline under section 520E–3 of the Public Health Service Act ( 42 U.S.C. 290bb–36c ) that is confidential and toll-free, sufficiently staffed by appropriately trained mental health personnel and available at all times; and (3) provide for outreach to, and education programs for, qualified emergency response providers and their families, with priority given to qualified emergency response providers of major disasters. (b) Best practices research (1) In general The Secretary shall, in consultation with the heads of the agencies specified in paragraph (2), conduct or support research on best practices for providing mental health services to, and prevent suicide among, qualified emergency response providers. (2) Agencies specified The agencies specified in this paragraph are the following: (A) The Department of Homeland Security. (B) The Federal Emergency Management Agency. (C) The United States Fire Administration. (D) The National Institute of Mental Health. (E) The Centers for Disease Control and Prevention. (F) The Department of Justice. (c) Information addressed in education programs Education provided under subsection (a)(3) shall include information designed to— (1) remove the stigma associated with mental illness; (2) encourage qualified emergency response providers to seek treatment and assistance for mental illness; (3) promote skills for coping with mental illness; and (4) help families of qualified emergency response providers with— (A) understanding issues arising from the transition of qualified emergency response providers back into family life and regular work, following the end of a disaster assignment; (B) identifying signs and symptoms of mental illness; and (C) encouraging qualified emergency response providers to seek assistance for mental illness. (d) Peer support counseling program (1) In general The Secretary shall, as part of the comprehensive program under this section, establish and carry out a peer support counseling program, under which active and retired qualified emergency response providers may volunteer as peer counselors— (A) to assist other qualified emergency response providers with issues related to mental health, readiness, and readjustment; and (B) to conduct outreach to qualified emergency response providers and their families. (2) Administration In carrying out the peer support counseling program under this section, the Secretary shall— (A) provide for adequate training of individuals who volunteer to serve as peer counselors, including training carried out under section 416(a) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act; and (B) coordinate with such community organizations, State and local governments, institutions of higher education, chambers of commerce, local business organizations, organizations that provide mental health services, and other organizations as the Secretary considers appropriate. (e) Other components The Secretary may take such other actions to carry out the comprehensive program under this section as the Secretary determines appropriate for purposes of reducing the incidence of mental illness and suicide among qualified emergency response providers. (f) Definitions In this section: (1) Public safety telecommunicators The term “public safety telecommunicator” means a public safety telecommunicator as designated in detailed occupation 43–5031 in the Standard Occupational Classification Manual of the Office of Management and Budget issued in 2018, or any successor designation. (2) Qualified emergency response providers The term qualified emergency response providers means— (A) emergency response providers (as defined in section 2 of the Homeland Security Act of 2002 ( 6 U.S.C. 101 )); and (B) public safety telecommunicators. (3) Major disaster The term major disaster has the meaning given such term in section 102 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act ( 42 U.S.C. 5122 ). 520P. On-site mental health services grants (a) In general The Secretary, acting through the Assistant Secretary for Mental Health and Substance Use, shall award competitive grants to eligible entities to establish a new health care delivery site that is a mobile unit to provide integrated, short-term crisis services to qualified emergency response providers of a major disaster . Such services shall be— (1) linguistically and culturally appropriate; (2) trauma-informed; and (3) incorporate disaster behavioral interventions. (b) Use of funds An eligible entity that receives a grant under this subsection may use funds received through the grant to provide mobile crisis response, stabilization, and intervention services, including— (1) initial support and triage via mobile crisis team visits; (2) on-site screening and evaluation of mental and behavioral health issues; (3) assessment of current supports and resources; (4) short-term crisis management throughout a major disaster; (5) referral for appropriate follow-up services, including sub-acute or acute hospital care; (6) supportive, collaborative crisis planning; (7) consultation with existing supports and services; and (8) self-care techniques and resilience training. (c) Authorized purchase or lease The Secretary may purchase or lease equipment for purposes of carrying out this section, which may include data and information systems (including the costs of repaying the principal of, and paying the interest on, loans for equipment). (d) Grant terms (1) Maximum amount The amount of a grant awarded under subsection (a) may not exceed $150,000. (2) Duration The term of a grant awarded under subsection (a) shall be for a period of not less than 6 months. Such term is renewable for a single, additional term so that the total term of the grant does not exceed 2 years. (e) Evaluations and Technical Assistance The Secretary shall— (1) evaluate the activities supported by grants awarded under subsection (a), and disseminate, as appropriate, the findings from the evaluation; (2) provide appropriate information, training, and technical assistance, as appropriate, to eligible entities that receive a grant under this section , to help such entities to meet the requirements of this section, including assistance with selection and implementation of evidence-based interventions and frameworks to protect the mental health of qualified emergency response providers; and (3) identify best practices, as applicable, to improve the identification, assessment, treatment, and timely transition, as appropriate, to additional or follow-up care for qualified emergency response providers who are at risk for mental illness, suicide, and substance abuse, and enhance the coordination of care for such individuals during and after a major disaster, in support of activities supported by grants awarded under subsection (a). (f) Definitions (1) Eligible entity The term eligible entity means a State, local, territorial, or Tribal health department, community health center, rural health clinic, or nonprofit organization that— (A) is located in or around a major disaster area; and (B) has experience working with qualified mental health professionals in providing mental health, substance use, or counseling services. (2) Major disaster The term major disaster has the meaning given such term in section 102 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act ( 42 U.S.C. 5122 ). (3) Major disaster area The term major disaster area has the meaning given such term in section 625.2 of title 20, Code of Federal Regulations (or successor regulations). (4) Public safety telecommunicators The term “public safety telecommunicator” means a public safety telecommunicator as designated in detailed occupation 43–5031 in the Standard Occupational Classification Manual of the Office of Management and Budget issued in 2018, or any successor designation. (5) Qualified emergency response providers The term qualified emergency response providers means— (A) emergency response providers (as defined in section 2 of the Homeland Security Act of 2002 ( 6 U.S.C. 101 )); and (B) public safety telecommunicators. (6) Qualified mental health professional The term qualified mental health professional means a health care practitioner or social and human services provider who— (A) is licensed or certified under State law in the State involved; and (B) offers services for the purpose of improving an individual’s mental health or to treat mental health or substance use disorders, including— (i) a physician, allopathic physicians, osteopathic physician, nurse practitioner, or physician assistant with a specialty in mental and psychiatry; (ii) a health service psychologist; (iii) a licensed clinical social worker; (iv) a psychiatric nurse specialist; (v) a marriage and family therapist; (vi) a licensed professional counselor; (vii) a substance use disorder counselor; (viii) an occupational therapist; or (ix) any other individual who— (I) has not yet been licensed or certified to serve as a professional listed in any of clauses (i) through (viii); and (II) will serve at a Federally qualified health center (as defined in section 1861(aa)(4) of the Social Security Act) under the supervision of a licensed individual or certified professional so listed. (g) Authorization of appropriations There is authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2024 through 2028. .