Transcript
Welcome and Introductions
Dayna Riddle, Patagonia Health
Hello everyone. Welcome to today’s Health Solutions webinar hosted by Patagonia Health. The topic of today’s session is 988 and National Trends in Behavioral Health Crisis Care. I'm Dayna Riddle, your moderator.
Our presenter is Dr. Margie Balfour, Chief of Quality and Clinical Innovations at Connections Health Solutions and Associate Professor of Psychiatry at the University of Arizona. Dr. Balfour has received national recognition for her work in crisis response, including being named Doctor of the Year by the National Council for Behavioral Health and receiving the Tucson Police Department's Medal of Honor.
The Current State of Behavioral Health Crisis Response
Dr. Margie Balfour
Historically, people in mental health crises were met by law enforcement. While this may have seemed logical in the past, we now understand how harmful this approach can be.
In medical emergencies, trained professionals respond and provide treatment. In mental health crises, however, police often respond first, which can lead to an increased risk of injury or death. There are also significant racial disparities, as Black Americans are disproportionately affected. Often, these individuals end up incarcerated instead of receiving appropriate treatment. Jails are not equipped for mental health care, and this can result in longer incarceration times, higher costs, increased likelihood of recidivism, and the loss of employment and housing.
Emergency rooms also struggle to address psychiatric emergencies. They often lack psychiatric services, which leads to long wait times for transfers and poor experiences for both patients and staff.
The Sequential Intercept Model
The Sequential Intercept Model maps out how people move through the justice system and identifies points where intervention can occur. One key intercept is at the moment of law enforcement contact. However, with a robust crisis care system, these interactions can be prevented entirely.
The Rise of 988: A Turning Point
The launch of 988 marks a transformative moment for behavioral health crisis care. It's similar to the early days of 911 in the 1960s and is supported by bipartisan legislation and COVID-era funding. This change reflects a broad consensus that law enforcement should not be the default first responders for mental health crises.
The National Council for Mental Wellbeing released the "Roadmap to the Ideal Crisis System," which defines what an effective behavioral health crisis system should look like. The core principles of the roadmap emphasize that crisis systems should be considered essential community services, much like EMS or fire departments. Importantly, a true system requires multiple interconnected services rather than standalone programs.
Designing a True Crisis System
When thinking about system design, most people jump straight to the services such as call centers and mobile units. However, design begins with structure.
The roadmap identifies three critical design elements: accountability and governance, a continuum of services, and clinical best practices. The roadmap goes beyond merely outlining services by detailing how communities must organize and integrate systems. It's a system that, like a complex rocket, only works when all parts function together.
Arizona: A National Model for Crisis Care
Arizona's behavioral health crisis system is often cited as a national model. What makes it work is a clear sense of accountability, with established goals and metrics. There is also strong collaboration among mental health providers, law enforcement, EMS, and schools. The system uses real-time data to guide quality improvement.
Arizona's crisis system has its roots in Medicaid innovation. It was the first state to implement a statewide managed care waiver, also known as the 1115 waiver. Services are funded through braided funding streams that combine Medicaid, federal, state, and local grants. As a result, crisis care is accessible regardless of the individual's payer source.
Crisis System Services in Southern Arizona
The continuum of services begins with crisis call centers that respond to over 7,000 calls per month. About 80% of these calls are resolved through phone counseling alone. These centers are integrated with scheduling software that allows them to arrange next-day appointments.
The next level involves mobile crisis teams. Pima County has 16 such teams, and dispatch is coordinated via GPS and specialized software. These teams are staffed by clinicians or peer specialists. About 70% of field interventions by mobile teams are resolved without requiring further escalation.
For individuals who need a higher level of care, crisis stabilization facilities offer an alternative to emergency rooms. These facilities provide walk-in urgent care and 23-hour observation. Most clients are stabilized and discharged within 24 hours.
Following stabilization, post-crisis wraparound services provide continued care. Transition programs and peer support agencies ensure that individuals receive the follow-up they need. There are also step-down services available for less acute cases.
Law Enforcement Integration
To prevent unnecessary incarceration, Arizona's system integrates law enforcement as a key stakeholder. Mobile teams are given preferred access and respond more quickly to law enforcement requests. Crisis staff are co-located with 911 centers, enabling them to resolve calls without involving police when possible. Police can drop off individuals at crisis centers in under 10 minutes, streamlining the process and making clinical care the easiest option.
Arizona's model demonstrates how crisis systems can be structured for success through governance, integrated services, and financial alignment. The ultimate goal is to provide community-based, least-restrictive, and cost-effective care for individuals in behavioral health crises.
Introduction to 988
988 is a relatively new, national three-digit number for behavioral health emergencies. It replaced the older 800 number used for the National Suicide Prevention Lifeline. Unlike 911, which is managed locally, 988 connects to a network of over 200 call centers across the country. When you dial 988, your call is routed to the appropriate center, and if that center is overwhelmed, the call rolls over to another one so someone is always available to respond.
988 supports phone, text, and chat communication. The system is overseen by SAMHSA, with the main administrative organization being Vibrant Emotional Health. They have set national standards for how the system operates.
However, 988 is only the beginning. Many other crisis calls happen through other hotlines or through 911. Some communities use 211 or 311 for crisis services. It’s estimated that about 10% of all 911 calls could be handled by behavioral health services. So while 988 may have started with 3 million calls in a year, the need could exceed 40 million annually.
This is a step toward building a behavioral health emergency response system comparable to 911—one designed specifically for mental health and substance use crises.
Public Concerns and Local Variations
When 988 first launched in July, it faced some backlash on social media. People warned others not to call 988, fearing that police would be sent, which caused concern in communities where law enforcement involvement is seen as a threat.
In response, Vibrant Emotional Health released data showing that only about 2% of 988 calls result in an active rescue via 911—and about half of those are with the caller's consent. However, responses vary depending on local infrastructure. Communities with mobile crisis teams and alternatives to law enforcement can avoid police involvement, but those without such resources may still rely on police.
This variation underscores the importance of building out comprehensive crisis services across the country.
Integration with 911 Systems
There are around 9,000 public safety answering points (911 call centers) across the country, and they differ greatly depending on whether they’re urban, rural, or have other unique characteristics. In recent years, these centers have been exploring how to integrate with 988 systems and local crisis lines.
Some models involve simple coordination, such as a direct line between 911 and behavioral health services. Others are co-located, with behavioral health staff embedded in 911 centers. Tucson, for example, uses a fully integrated model where crisis line staff work inside the 911 center and have access to both emergency and mobile team dispatching systems.
The goal is a “health first” response: clinical staff should respond to mental health emergencies instead of law enforcement whenever possible.
Mobile Crisis Response Teams
There are many different models for mobile crisis teams, and the field is still evolving. Community needs vary widely—urban vs. rural, tribal populations, and more—so different configurations work better in different settings.
A national survey by Matt Goldman and Preston Looper showed wide variation in team composition. Common models include:
- Clinician-only teams, which may include licensed or unlicensed clinicians or a clinician with a peer support specialist.
- Co-responder teams, which pair clinicians with first responders like police, EMS, or fire.
- Multidisciplinary teams, with all three roles: clinicians, EMS, and law enforcement.
Which model is best depends on the community. Clinician-only teams have been shown to reduce emergency room visits and hospitalizations and are cost-effective. Outcomes for co-responder teams are mixed. What’s clear is that people, especially in BIPOC communities, tend to prefer clinician-involved responses over police-only approaches.
Including peers—people with lived experience of mental illness—is one way to build more trust and represent the communities served.
Crisis Stabilization Facilities
A crucial piece of crisis care is having a safe place for people to go. However, the term “crisis stabilization unit” (CSU) means different things in different places. Margie Balfour and colleagues recently published a paper to begin categorizing these facilities.
All crisis centers should provide treatment, not just act as holding areas. They should be trauma-informed, safe, and therapeutic, with peer support, care coordination, and the ability to handle both mental health and substance use issues.
Facilities vary based on patient acuity and the intensity of services. On one end of the spectrum are high-acuity centers that handle involuntary patients, agitated or intoxicated individuals, and those in withdrawal. These centers are staffed 24/7 by psychiatrists, nurses, and other medical professionals. On the other end are low-acuity centers with minimal medical involvement—these might provide peer support and a safe place to stay overnight.
The challenge lies in the middle, where there’s wide variation and potential for mismatches in care. Communities need clear understanding of what each facility can and cannot do.
Example: Tucson Crisis Response Center
Tucson’s facility fits the high-acuity model and was built in 2011 using Pima County bond funds. The county owns the building and leases it to the regional behavioral health authority (RBHA) for $1 per year. Services are funded through the Medicaid system and other braided funding streams, making it sustainable.
The center serves 12,000 adults and 2,400 children annually. It includes:
- 24/7 urgent care for walk-ins needing medication refills or care connection.
- A 23-hour observation unit.
- A sub-acute inpatient unit for longer stays.
- An adjacent crisis line and hospital, with connections to an inpatient psychiatric facility and mental health court.
Communities don’t need this exact setup, but the key is to make the system easy to use and easier than jail.
Key to Success: Community Integration
Crisis Intervention Training (CIT) for law enforcement is a 40-hour program that teaches officers how to recognize and de-escalate mental health situations. But CIT is more than just training—it's a framework for a whole-community response.
A successful system must have a receiving center that accepts all patients without clinical barriers and offers fast drop-off times—ideally under 10 minutes. This makes it more appealing and practical for police to divert individuals in crisis to treatment rather than jail.
Tucson’s facility follows this model. It has a secure entrance and dedicated space for officers, reducing wait times and removing logistical barriers. A study by the Vera Institute of Justice found that officers in Tucson were less likely to arrest individuals during mental health calls, attributing this change to the availability of the crisis facility.
Observation Units and Therapeutic Design
The youth observation unit at Tucson's facility is an open area with chairs instead of individual rooms. This design allows for constant observation and social interaction, which is therapeutic. In contrast, emergency rooms often isolate mental health patients in bare rooms, which is not conducive to recovery.
In Tucson, patients participate in group activities, talk with staff and peers, and receive early treatment. Flexibility is built into the system so police are never turned away—even during volume surges.
Interdisciplinary Crisis Response Team
And as far as what happens. So we have an interdisciplinary team. We have 24/7 coverage with our psychiatric providers, peers, nurses, techs, and case managers, and we start with this assumption. We don't go, "Oh, you're really sick. We need to look for an inpatient bed for you." We go, "Oh, you need to be in the office. Observation unit. Now we're going to try to resolve your crisis," and then we'll start treatment early. We can start meds. We can, like I said, we can do a detox. We can start Suboxone, we do groups and peer support.
Within that 24 hours, we reassess them, and if they're getting better, then we continue on with getting them connected to the services they need in the community. Only if they're not better, then we start looking for them an inpatient bed, and so we're able to discharge most to community-based care. We also look at what percent start off involuntarily, that we're able to engage in voluntary services too, because that's the least restrictive thing.
We have a lot of substance use as well. If you look at our data, about 15% come in saying, "I'm here for a substance use issue," but about two-thirds actually have a substance use diagnosis or tox results, and it's mostly meth followed by alcohol. And it's just really important—mental health and substance use services should be integrated. This kind of illustrates how you should expect that people have a co-occurring substance use issue and have the ability to deal with that as well.
Law Enforcement as a Collaborative Partner
Law enforcement, they're a huge partner of ours, and we're very fortunate, especially down here in Tucson, because we have a very progressive police department. But all around the country, officers and police departments are recognizing that there needs to be a better way. They need to collaborate with the mental health system to get people into care, because you can't arrest your way out of this problem.
Tucson Police follows the recommendations by the National Council and CIT, where CIT is more effective when it's voluntary, where officers who want to take it, versus being voluntold. But all officers get basic Mental Health First Aid training, which is eight hours. And then most of their officers have the 40-hour CIT training. Then they have some specialized units that get more advanced training, like motivational interviewing and trauma-informed care.
Collaborative Crisis Response System
This is what you hear a lot about—co-responders. In our system, we've moved towards talking about a collaborative response, because the more options you have, the better. It's not necessarily a co-response; it's collaboration.
If you look at the crisis cycle, there's acute crisis—a discrete event where there needs to be de-escalation, intervention, and it's high urgency. But after the crisis resolves, you need to make sure that people are getting connected. As the crisis develops, there's an opportunity for outreach to get people connected to care early, maybe preventing escalation.
Health-First Response Approach
In the acute phase, we want to do a health-first response. We don't want to send the police unless absolutely necessary. If there's no safety risk, then it should be the responsibility of the mental health system. That's where the crisis line, mobile teams, and facilities come into play.
If there is a safety risk, then there are multiple options to collaborate based on the needs of that situation. Sometimes, the fastest thing is to recognize at the 911 call point that this is mental health and they need to go to the CRC and just send a CIT-trained officer. Other times, if someone is suicidal and won’t come out of their house, the mobile team assists the police.
Outreach and Follow-up Services
When you look at outreach and follow-up, this is less urgent and usually involves multiple touches. If there's no safety or criminal risk, it should be completely the responsibility of the mental health system. Our REBA here in Tucson has what they call second responders to do follow-up like peer wraparound services.
If there is some kind of safety or criminal component, then that’s where co-responders or peer co-responders come in. We use those a lot in our system, where they follow up after overdoses or threats of violence. They also have a homeless outreach team—all of those teams have an officer and a peer.
Their specialty teams are plainclothes officers in unmarked cars, which helps de-escalate people. Their detectives look for individuals falling through the cracks to connect them to the mental health system before criminal involvement escalates.
Our law enforcement drop-offs show that most people are dropped off voluntarily, especially adults. That’s unusual and shows how well Tucson Police engage individuals. Common reasons for arrest—nuisance calls or lifestyle crimes like public drinking or vagrancy—have gone down.
Reducing Crisis Escalations and Costs
Previously, when police had an involuntary pickup order and someone was barricaded in their house, the default response might have been to call SWAT. But we now use mobile and specialty teams to de-escalate and talk people out. It’s more effective and cost-efficient.
We also have a deflection program where an officer and peer engage someone with substance use and avoid arrest, connecting them to care. Up to 70% of people accept deflection, and officers prefer it—it’s faster than making an arrest.
Return on Investment for Crisis Services
Phoenix system data shows a strong return on investment from crisis services—savings in inpatient care, ER costs, and psychiatric boarding. There are also savings in police time, calculated as FTEs back on the street.
Arizona Medicaid shows a $370 million return on crisis system investment. But it’s important to note—Medicare and commercial insurance do not contribute. Crisis services often get paid from indigent care because private insurance doesn’t reimburse. There are bills in Congress to change that—reach out to your representatives.
Measuring Crisis System Quality
The group that wrote the roadmap to the ideal crisis system also published a five-page brief on quality measurement in crisis services. Rather than a prescriptive list of measures, they suggest approaches.
One is a conventional framework—map the person’s path through the system and create measures around each step. Another is a person-centered approach that spells out "ACCESS TO HELP." For example, measure how many people get resolved at the lowest level of care.
Tucson’s system didn’t happen overnight. It took 20 years to build, starting with one mental health court and CIT program. Growth has been exponential, but you have to start somewhere.
Q&A Session
Getting Started and Local Resources
There is a self-assessment tool in the roadmap report for communities to evaluate where they are. It helps spark discussion and mapping of existing services. That’s a great first step and doesn’t cost anything—just start talking.
Staffing Shortages and Peer Certification
Like everyone else, we face staffing issues. We created our own state-approved peer certification program. This allows us to train people ourselves and recruit uncertified individuals. We’re also working on career ladders so staff can grow without leaving.
Using Data for Accountability and Improvement
We defined a set of metrics and our regional behavioral health authority adopted them. We collaborate closely with them and send them daily data feeds, which they use to identify outliers and gaps.
For example, they can see which clinics have high rates of crisis cases or which schools are making 911 calls. They’ve been able to target in-school services as a result. This is how you can use data to identify gaps and improve services.
Funding Crisis Services for the Uninsured
Every state receives a Mental Health and Substance Use Block Grant from SAMHSA. These are not applied-for grants; states have discretion on how to use them. In Arizona, those funds help cover crisis services for people who aren’t Medicaid eligible.
