Washington passes law establishing 9-8-8 call line for behavioral health crises and plans redesign of crisis behavioral health system

September 9, 2021

Purpose
This bulletin provides hospitals information on E2SHB 1477, which will redesign Washington State’s crisis behavioral health services system and tie service delivery to 9-8-8, a universal three-digit telephone number for people to call when they or a loved one experiences a behavioral health crisis. The new law implements recent federal legislation that will activate 9-8-8, beginning July 16, 2022.

E2SHB 1477 is a broad and complex law that implicates all parts of the overall behavioral healthcare system, including hospitals, once the various pieces in the bill are operational. During the 2021 legislative session, WSHA advocated and requested several significant changes to the legislation, which were ultimately adopted. The overview section of this bulletin describes these results. The new law starts with significant planning and system design work, which WSHA will continue to be involved with at the agency levels.

Applicability/Scope
E2SHB 1477 contains no current changes that directly impact hospital operations, but they are expected in the future.  A major component of the new law is the development of technological platforms that link people in crisis to services. These platforms will include a real-time registry or “tracker” for inpatient beds, crisis behavioral health services, and next-day appointments.

E2SHB 1477 is chiefly a foundation setting bill to support crisis call centers that take 9-8-8 calls when the number goes live on July 16, 2022. It initiates several system reform efforts to create a coordinated and centralized crisis behavioral health care delivery system. This new system is also expected to play a role in reducing pressure on law enforcement to respond to crises that would benefit from behavioral health expertise. This includes:

  • Tasking state agencies to prepare for increased call volume when 9-8-8 goes live, including developing new crisis call center “hubs” to triage callers;
  • Establishing a large planning committee with several responsibilities, which WSHA is a part of, to evaluate the existing crisis behavioral health system landscape in Washington and plan for its evolution to a more centralized and coordinated model of crisis care delivery statewide; and
  • Creating a graduated tax on all phone lines starting October 2021, to help fund the operation of the future 988 Behavioral Health Crisis Response and Suicide Prevention Line.

Recommendations
There are no steps for hospitals to take currently. WSHA will be actively engaged in the planning and implementation of 988 in Washington and will communicate with members about opportunities to participate as they arise.

Overview
E2SHB 1477 builds on federal legislation aimed at creating greater access to suicide prevention and behavioral health support when people need it most, and to divert individuals from settings and services that are less equipped to manage their needs (such as calling 9-1-1 or seeking help from law enforcement).

In October 2020, Congress passed the National Suicide Hotline Designation Act of 2020, designating the number 9-8-8 as the universal telephone number within the United States to access the National Suicide Prevention and Mental Health Crisis Hotline System. Currently, this hotline, which is maintained and supported by a large network of crisis centers known as the National Suicide Prevention Lifeline (Lifeline), is accessed as a toll-free, ten-digit number. Lifeline also connects veterans to a Veterans Crisis Line for veteran-specific behavioral health support. The 2020 federal law replaces that ten-digit number with 9-8-8 and authorizes states to collect a fee on certain phone lines, like the 9-1-1 system, to help fund the operation of expanded crisis call services.

This past legislative session in Olympia, Washington lawmakers in both the House and Senate took the opportunity presented by the federal law to reimagine the way crisis behavioral health services are delivered in the state.  E2SHB 1477 implements and goes beyond the federal legislation in several meaningful ways.

E2SHB 1477’s first component is to prepare for how 9-8-8 will change crisis call services in Washington, including:

  • Preparing for 9-8-8 callers. The Washington State Department of Health (DOH) must plan for increased crisis call center volume and response rates of at least 90% by July 22, 2022. There is also a tax imposed on all radio access lines, interconnected voice over internet protocol (VoIP) services lines, and switched access lines (as defined in the law) to support the new call services. The 9-8-8 tax is phased-in, starting with 24 cents per line per month between October 1, 2021 and December 21, 2022, and increases to 40 cents per line per month, beginning January 1, 2023. Taxes may be used to route calls from the 988-crisis hotline to an appropriate call center, and for personnel and provision of acute behavioral health, crisis outreach, stabilization services, and follow-up case management. The legislature also provided significant funding for the development of crisis response services, including nearly $40M to expand mobile crisis rapid response teams.
  • Creating standards for and designating “Crisis Call Center Hubs.” DOH must also develop standards that existing Lifeline crisis call centers should meet to become specially designated “crisis call center hubs” and designate such hubs by July 1, 2024. Hubs will be responsible for meeting operational, clinical, and reporting standards and collaborating with DOH, the Health Care Authority (HCA), Lifeline, and the Veterans Crisis Line to ensure consistent messaging. These hubs must employ highly qualified, skilled, and trained clinical staff to de-escalate crisis situations, assess behavioral health disorders, triage to system partners, and provide case management and documentation.

E2SHB 1477’s second component is to task DOH and HCA to develop technology pieces that will facilitate and support the crisis call centers hubs connecting people with crisis services, including:

  • new technologically advanced behavioral health and suicide prevention crisis call center system platform for use in crisis call center hubs that use technology that is interoperable with other crisis and emergency response systems statewide; and
  • behavioral health integrated client referral system that coordinates system information with the crisis call center hubs and behavioral health entities.

The two technology pieces must have several capabilities including, among other things, access to real-time information relevant to the coordination of behavioral health crisis response and suicide prevention services, including real-time bed availability for all behavioral health bed types. HCA and DOH will be required to develop a technical and operations plan for the development of this technology with initial reports to the legislature and relevant state agencies by January 1, 2022.

E2SHB 1477’s third component is to establish a Crisis Response Improvement Strategy Committee (CRIS) to develop an integrated behavioral health crisis response and suicide prevention system. The CRIS committee has a broad membership, including WSHA, and multiple sub-committees to help achieve its tasks. Tasks include conducting a needs assessment of the state’s behavioral health crisis response and suicide prevention system, identifying goals for provision of statewide and regional behavioral health crisis services, improvement targets, and 13 other specific topics related to creating a centralized, coordinated crisis behavioral health system.

The CRIS committee and its sub-committees will meet regularly. Sub-committees will focus on discrete topics including technology, cross-system crisis response collaboration, and confidential information and coordination.

The CRIS committee is comprised of a variety of behavioral health stakeholders, and many of them, including WSHA, are already participating in a separate but related workgroup run by DOH and funded by Lifeline to support implementation of 988.

WSHA’s advocacy and involvement with E2SHB 1477. WSHA was heavily engaged in the development of the policy components of the bill. We worked closely with the bill’s key proponents and other stakeholders to help articulate its grand vision for system reform while also assuring it contained sufficient building blocks to help Washington move from its current fragmented and challenged structure to the one imagined by the bill.

We are very pleased to see WSHA’s requested changes incorporated into the final bill, which was repeatedly rewritten throughout the session—up to and including the last day of session. We were especially pleased our final changes were advanced as a floor amendment by the bill’s chief sponsor in the Senate and adopted by the full Senate. Among the key changes WSHA strongly advocated for were: 

  • Removing a mandate on hospitals and other behavioral health providers to report real-time bed information ahead of development of the system and technology needed to receive it. WSHA understands the relevance and opportunity with tracking bed capacity as a way of managing limited behavioral health resources, but believes it is important for the state to first evaluate how they plan to employ this technology and provide an implementation strategy ahead of a potential mandate, to the extent one is required at all;
  • Removing “single bed certification” beds from the bed registry language since these are not actually licensed behavioral health beds. WSHA understands the intention to capture all behavioral health services in an integrated, coordinated monitoring system. However, a bed used for involuntary treatment on a single bed certification represents a lack of a bed and to have included them would have meant counting a negative as a positive; and
  • Adding a hospital and provider-focused topic to the list of topics the CRIS committee must provide recommendations on regarding “the systems and capabilities needed to report, maintain, and update real-time information regarding the availability of behavioral health beds and outpatient appointments.” One concern WSHA repeatedly expressed during the development of E2SHB 1477 was that it concentrates on state agencies and call centers using technology to track system capacity but did not contemplate the other side of the equation, such as hospitals. To develop a fully interoperable, coordinated system as the bill imagines, policymakers and state agencies will need to be mindful of what it means to implement and operate the technology-driven tools at the point of care. We believe this language provides an important opportunity to begin thinking about how that will be achieved.

Overall, WSHA was pleased to see E2SHB 1477 become law, making Washington the 3rd state in the nation to implement the federal 988 law. WSHA looks forward to contributing to the important foundation-setting work ahead. WSHA advocated for a seat on the CRIS committee and understands that the opportunity to redesign Washington’s crisis behavioral health system in the way imagined in the bill will mean greater access to crisis care and fewer emergency department visits for people who need more specialized care and attention.

References
E2SHB 1477
National Suicide Hotline Designation Act of 2020
Department of Health – News Release – 988 State Planning Grant

WSHA’s 2021 New Law Implementation Guide
Please visit WSHA’s new law implementation guide online. The Government Affairs team is hard at work preparing resources and information on the high priority bills that passed in 2021 to help members implement the new laws, as well as links to resources such as this bulletin. In addition, you will find the Government Affairs team’s schedule for release of upcoming resources on other laws and additional resources for implementation.

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