The Whole Continuum of Behavioral Health Care: Reintroduction of the 988 Implementation Act

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Q&A

On July 25, 2023, Congressman Jamie Raskin and Congressman Tony Cárdenas reintroduced the 988 Implementation Act with Congressmembers Brian Fitzpatrick, Lisa Blunt Rochester, Doris Matsui, Seth Moulton, Grace Napolitano, and Don Beyer. Psychiatric Times sat down with the VP of Government Affairs for Connections Health Solutions, Chris Santarsiero, MBA, to learn more.

PT: Can you tell us a bit about the reintroduction of the 988 Implementation Act?

Santarsiero: It is an exciting time. A year has gone by since the transition to 988, and there is a lot more work to do to build out the infrastructure, response times, and staffing.

For 988 to be truly effective, crisis services must operate in a comprehensive continuum. The 988 Implementation Act provides federal support and funding for states to enact 988 and crisis services, and to broaden awareness of available resources. This will ensure that it’s not just a number to call but a line to connect to services in every community, including trained first responders and crisis centers.

Specifically, the 988 Implementation Act:

-Solidifies funding for 988 regional and local call centers to ensure a timely 24/7 response to callers anywhere in the country

-Provides funding for community-based crisis response, including mobile crisis teams and crisis receiving and stabilization centers

-Supports crisis workforce development with increased funding for training and scholarship opportunities

-Increases access to care by requiring that all health insurance plans cover crisis services

-Implements a national suicide prevention awareness campaign in partnership with a wide array of stakeholders

988 has been a great catalyst to talk about mental health. The mission is a number to call, someone to respond, and a place to go. The 988 Implementation Act really charged that—we are investing in and perfecting it. The launch overall has been very successful, and now we are building out the necessary continuum, which is contingent on what each community’s needs are, what infrastructures are in place, and what needs to be improved upon. What an amazing time to be in the behavioral health arena, because people are finally willing to talk about it openly and acknowledge that more needs to be done.

Figure. Disparities in the Response to Medical vs Behavioral Health Emergencies

Used with permission from Connections Health Solutions.

PT: How will this legislation impact patients utilizing Medicare and Medicaid programs?

Santarsiero: The Act calls for Medicaid and Medicare coverage. Today, Medicaid is the largest payer of behavioral health services. Even still, there are gaps in care. Our organization is headquartered in Arizona, though we have expanded to and are continuing to expand to other states, and we are fortunate to have structures in place that allow for a continuum like this to take place, but most other parts of the country do not. It also expands upon certified community behavioral health clinics (CCBHCs), the great success of the bipartisan Safer Communities Act. Since the inception of the CCBHC program, in the 10 demonstration states, CCBHCs saw a 60% reduction in emergency room visits; 60% reduction in police visits, jail visits, and police holdings; 33% reduction in homelessness; and 74% reduction in overall hospitalization. It is a wonderful program and a great start.

On the Medicaid side, it kind of wraps around the continuum that is needed. On the Medicare side, there is a gap. Medicare does not cover crisis services today. Once Medicare coverage and quality standards are established, then commercial insurance will follow suit—that is typically how it works. The Act also calls for commercial insurers to cover the services as well, which is long overdue.

PT: What do you see as the future of 988 and crisis care? Will there be further challenges with sustaining funding?

Santarsiero: I feel great about the future of 988. Recently, a couple more states established sustainable funding through a 988 cell phone surcharge. I think that is a good step. Right now, there is a lot of federal funding for 988 to draw down from, but there are a handful of states that are looking at 988 cell phone surcharges similar to 911. NAMI just came out with some polling data that is very positive: over 80% of those polled approved of a 988 surcharge. There is clearly recognition across the continuum of voters that it is necessary to have parity there. In that regard, I am very optimistic.

CMS’ Certified Community Behavioral Health Clinic Demonstration provides a path towards sustainability. Its goal is to improve access to high-quality, integrated behavioral health care for individuals with mental health and substance use disorders. There are 10 states that are already in the CCBHC program, and there are 10 more that will be announced by the middle of next year. That means there will be 20 states with a sustainable funding model directed by Medicaid, but in collaboration with the community-based providers. The Bipartisan Safer Communities Act pretty much ensures that within 8 years, any state that wants to be part of this CCBHC program will be allowed in. It is 10 states every 2 years for the next 8 years. But I also know, in talking with other state leaders and Medicaid agencies and associations, some states are going straight the state plan amendment route, regardless of if they get approved for the next demonstration round. States like Texas and Kansas have already done so. Moves like this leverage the existing structure of Medicaid. I feel good about it in terms of long-term sustainability.

PT: Can you talk about the importance of specialized units for individuals experiencing behavioral health emergencies? 

Santarsiero: It is not easy to talk about folks that are presenting with violent behaviors or suicidal threat to self or others, aggressive behaviors, public intoxication. The system as a whole in most parts of the country has not been equipped to deal with that type of person in crisis. Individuals who are violent, threatening, and in a crisis usually end up in an emergency room or jail. What our model proves is you can have a co-responder model—a partnership with first responders and law enforcement—individuals can get the care they need when they need it most.

Our Crisis Response Center (CRC) in Tucson is part of the Tucson Police Department’s Department of Justice Law Enforcement-Mental Health Learning Site Program. Usually, the first people in a community that come to visit are law enforcement, along with county commissioners and sometimes even legislators. To get buy in from first responders first like that… they see there is a better way.

At Connections Health Solutions, roughly 50% to 60% of our involuntary patients convert to voluntary status. We get them engaged in their care, and I find that remarkable. Unfortunately, involuntary patients are seen as a population, when the state hospitals are dealing with them, that are just there and constantly in flux. One of the amazing things we are showing with our model is that we can get them engaged and back with their families, which helps solve the homelessness problem. If you are not engaged in your care, families sometimes may no longer want you around. Getting individuals in crisis treated, agreeing to their care, and in a better place—sometimes that is the first step for housing. Then they might agree to a plan of care postcrisis with help from ties to the community. As to maintaining care, some individuals look at readmissions like they are a terrible thing. If they must come back to us, okay—they come back, they get what they need. It is important to talk about this patient population to achieve equity in mental health and establish trust in 988. If we lose those who need us most—those with severe mental illness—we are doing a great disservice.

It is important to have that continuum built out in collaboration with all community stakeholders and leaders. Our walk-in centers can treat all acuities up to LOCUS Level 6, but somebody with a LOCUS Level 1, 2, or 3 can still walk in and get behavioral health care. It is important for a community to have a space where they say, “Oh, this is where you can go if you need help,” especially for commercially insured folks who cannot otherwise be seen by a psychiatrist or therapist, and we hope to provide that.

PT: What other legislation should mental health clinicians be aware of?

Santarsiero: There are a lot of great proposals out there, but the 2 we really focus on are the 988 Implementation Act and the Behavior Health Crisis Services Expansion Act. The latter is going to be reintroduced to Congress by Congresswoman Blunt Rochester from Delaware and Congressman Fitzpatrick from Pennsylvania in the House, and Senator Cortez Masto from Nevada and Senator Cornyn from Texas in the Senate. Clinicians should look at those bills because there are workforce provisions in there, which is great.

We are also really excited about is the Biden Administration’s proposed rule on the Mental Health Parity and Addiction Equity Act (MHPAEA). It proposes to significantly improve health plan compliance and strengthen parity enforcement to ensure that people with mental health and substance use disorders do not face arbitrary barriers from insurance providers and receive the care that they need. Connections is currently drafting a written response to address current gaps in access to and provision of a full continuum of behavioral health crisis services. It is 395 pages, but there are 2 pages that have questions and requests for information on crisis. You will have 60 days to comment. It might be good for clinicians to know about this. This is a great opportunity to engage in a rulemaking and to weigh in on a provision. We are excited about the crisis provisions, obviously, but I think overall, it really illustrates the gap in coverage and parity between physical and mental health. Kudos to the administration for doing that.

PT: Any final thoughts anything you want to share?

Santarsiero: Regarding 988, a few weeks ago I had a conversation with an editor who has been covering Congress since 1995 and he told me, “I think this is the best thing Congress has ever done.” But the irony of that story, is 988 did not happen easily. The legislative process is based on friction, and it took 5 years to pass. I think it's a wonderful catalyst. It is so simple to remember and promote.

Now the mission is to ensure a complete continuum for each community in the nation and make it incumbent upon communities to build upon. So many communities are doing such great work now, right down to the state and local level. Communities, stakeholders, law enforcement, first responders, the medical community, the mental health community, and the continuum—as a whole—are working to realize this mission. In 5, 10, or 15 years, we may have an equivalent to 911. I think everybody by and large has confidence in the 911 system. The charge is to be as good, if not better, on the mental health or behavioral health side. There is so much to do, but we are here now, so let's capitalize on it.

PT: Thank you!

Mr Santarsiero is the VP of Government Affairs for Connections Health Solutions.