Is Tennessee ready for 988?

Some expect big jump in calls for mental health help. State doesn’t

Friday, July 8, 2022, Vol. 46, No. 27
By Cara Baker Davis

Tennesseans have a new resource for emergency mental health crises beginning July 16. Like 911, 988 is a new three-digit crisis number that connects to the existing National Suicide Prevention Lifeline.

“It’s 911 for your body, and it’s 988 for your brain,” explains Becky Stoll, vice president of Crisis and Disaster Management in Tennessee. Stoll oversees the continuum of Centerstone’s crisis services, including the 24-hour crisis call center in MetroCenter, which will field 988 calls in Nashville.

There are more than a dozen crisis/suicide prevention lines in Tennessee, ranging from the National Suicide Prevention Lifeline and Tennessee Statewide Crisis Line to several community-based crisis providers. In 2021, more than 158,907 calls were received to those lines.

And the severity of those calls is increasing, Stoll says.

“What my staff will tell me is, some of the acuity of the calls has increased,” Stoll says. “What I think we’re starting to see as the pandemic has shifted and changed is, mental health issues starting to rear their heads, probably in folks who have never traditionally had mental health issues.

“I don’t even think we know at this point what the negative effects are going to have been of the pandemic,” Stoll continues. “I think we’re starting to see them, especially in youth and young adults. And we’ve got to have a system that’s ready to handle that. 988 is just the genesis of all of it.”

In anticipation, the state has been building capacity for the National Suicide Prevention Lifeline with grant funding since October 2019, before the federal mandate of 988 passed in October 2020. Since then, additional grants have allowed the state to bulk up its infrastructure based on current capacities – not projections.

While some, like Veterans Affairs officials, expect call volume to increase as much as 150% when the three-digit line launches, Marie Williams, commissioner of the Tennessee Department of Mental Health and Substance Abuse Services says “there’s nothing to really base that on” and did not request additional funding.

“We didn’t ask for additional money in that because I work for a state that wants to see the data and the facts,” Williams says. “And we don’t have data or facts to say how many more people are going to call.”

Stoll concurs. “I can’t imagine on the 16th that all of a sudden our phones are going to blow up,” Stoll says. “What I think we’ll see is a nice, steady progression of the calls being increased.

“And we can really do some good data analysis about: What are the resources in terms of human capital to answer the phones? What are we going to need outside of what we already have?”

Real-time, web-based data systems will track the call load, Williams says. “So, for example, if we get into this and within the first three months we see a spike in calls, which means more demand on our systems, I’ll be the first person to go to the governor (and) the legislature to say, ‘Hey, we’re going to need to put funding in here.

“But right now, given what we’ve seen that happened with 911, it takes a while for people to say, ‘Oh, I can call 988?’” Williams says. “So we’re going to track that. But as far as being prepared, we are prepared.”

Following the federal mandate from the Federal Communications Commission in 2020 to order phone companies to direct all 988 calls to the suicide lifeline by July 16, Congress authorized state governments to add fees through local wireless carriers. Tennessee did not opt to do this in preparation for the launch. It could still do so if the need arises.

“The legislation did allow for if a state chose to levy a fee on phones to the state,” Stoll says, explaining Tennesseans pay a fee for 911 service. “Do you have any idea what you pay for 911? I didn’t until I went and looked at my Verizon bill. It’s a $1.50. You pay a $1.50 a month. And most people don’t know that they’re paying for that service. So there is the opportunity if it ever arises that a state could do that.”

Approximately 96% of the United States is covered by 911 service today, the National Emergency Number Association reports, but it took a decade to accomplish legislation covering nine states and 26% of the population by 1979.

“It’s our understanding that when 911 went live, it took a while for the general public to know, recognize and call the number,” Williams says. “Therefore, we believe a similar rate of rollout will occur with 988. The discussion nationally among SAMHSA [The Substance Abuse and Mental Health Services Administration], Vibrant Health, and others who are leading this initiative aligns with our impression.”

Williams added that many states and SAMHSA, which has provided grant funding for 988 to the state, have asked for a slow rollout of the promotion of 988 due to a lack of infrastructure and funding. “We are going to market and do that in accordance with our work with SAMHSA in our contract with them.”

However, Williams says Tennessee is better positioned than many other states in terms of infrastructure.

“Many states don’t have crisis stabilization units or mobile crisis teams in their state,” Williams says. “We’re already fully funded for both of those items. So when this goes live, we’re not going to be the state saying, ‘Wow, we’re not prepared for where these people go.’”

Stoll says the lack of promotion is intentional.

“There’s not a massive marketing campaign going on about this,” she says. “And that’s from the federal level, I think it’s been pretty intentional that we didn’t want to turn a fire hose on a system that really wasn’t ready for that. And so now we’re inching up to the 16th, which really nothing magical is going to happen on the 16th.

“I think the messaging around this, they’re trying to be pretty cautious. You don’t want to overcommit and underperform,” Stoll says. “I think we’ll see a slow, not slow, but ... I don’t know that it’s going to be the floodgates opening just on the 16th.”

The biggest challenge facing the 988 rollout is a shortage of workers across the behavioral health industry. “We have a vacancy rate of staff across the whole country,” Williams says.

What happens after someone navigates a crisis that precipitated a call to 988? That’s where things get complicated.

“It’s hard to get appointments to be seen,” Stoll says about access to care after a crisis. “The bandwidth is definitely not meeting the need. It’s just not.

“I get calls all the time from family and friends. I mean all, weekly. ‘Hey, can you help me find a therapist for my fill-in-the-blank, uncle, daughter, cousin, kid, whatever.’ And it’s hard. And if you don’t go to community mental health and you go see a private practitioner, I would say none of them take insurance.

“They all got out of the insurance business a long time ago because it was so costly to them,” Stoll continues. “And they had to jump through so many hoops, then I think on the community mental health side where you see a lot of Medicaid recipients, it’s bandwidth, and you just have to shuffle deck chairs, like ‘who needs it the most?’”

Tennessee ranks 45th in access to mental health care (which includes workforce availability) in Mental Health America’s 2022 rankings. This means there is approximately 1 mental health provider for every 740 residents, or approximately 1 for every 150 Tennesseans with mental illness, according to a 2019 report by the Tennessee Association of Mental Health Organizations.

On average, three Tennesseans die by suicide every day. This is 29% higher than the national rate, data published by the Tennessee Department of Health reveals.

“There are many out there who are still reeling from the high stress and anxiety from the past few years without the ability to find therapists in their insurance network or to be able to afford one if they don’t have insurance,” says Julia Hoge, a therapist with East Nashville Counseling Group.

“Lower cost mental health care wait lists are long, as are those of private practice therapists like myself at this point,” she says. “I’m still hopeful that schools, crisis lines, and other community support will grow in their capacities to support community members in the aftermath, but we have a long way to go and not a lot of funding to get us there.”

Williams says she will continue to ask for increases in her total budget to address shortages across the board. “We have asked for increases,” she says. “TennCare has asked for increases. We have gotten funding to pass out to our providers to be able to pay better wages. And so I wish to continue to do that in my budget. Next year we’re going to ask for another 18 million because we had originally asked for 36 million.”

Despite vacancies in the workforce, Williams says, the state’s goal is to reach a 90% answer rate in the call centers (it’s currently at 87%), and when the call isn’t answered locally, it’s routed to a backup call center and then the national backup call center.

“There will be an answer to the call,” she says. “If we don’t answer a call, it goes to the D.C. office or federal office, and then they track it back to us.”

Stoll says the national benchmark for answering a crisis call is 30 seconds. In addition, individuals can text 988 to chat with a call center responder. Texts will be received and responded to by CONTACT Care Line in Oak Ridge.