On August 24, the Health Care Council of Chicago (HC3), in collaboration with the Illinois Association for Behavioral Health (IABH), hosted a virtual discussion to share how communities triage crisis calls and crisis lines to ensure that callers receive appropriate responses.
Mindy Kowden, Senior Director, Third Horizon Strategies
Maria Bruni, Senior Vice President, Family Guidance Centers
Kelsey DiPirro, Director of Community & Rapid Response Programs, C4
Laura Fine, Illinois State Senator, D-Glenview
Alisha Warren, Assistant Commissioner for Behavioral Health, Chicago Department of Public
Lee Ann Reinert, LCSW, Deputy Director, Policy, Planning, and Innovation, Illinois Department of
Human Services, Division of Mental Health
Watch the Recap
Moderator’s Remarks: Mindy Kowden (MK)
The behavioral health crisis in the United States has had broad implications. According to reports, there was a 103 percent increase in the number of children going to emergency rooms for mental health crises last year, increasing by another 23 percent this year.
It is vital that our communities put systems in place to address these trends. Still, most are relying on law enforcement and the 911 system, which are often poorly prepared to respond to behavioral health issues. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the ideal crisis continuum includes having someone to call, a mobile crisis response system, and somewhere to go (e.g., a walk-in crisis center).
Areas of Focus in Addressing the Behavioral Health Crisis
Senator Laura Fine (SLF): Senator Fine chairs the Behavioral Health and Mental Health Committee (BH and MH Committee) in the Illinois State Senate. When Senator Fine asked to form the committee, she was met with hesitancy, but the need for the committee became more apparent at the onset of the pandemic. Before the formation of the committee, any bill that dealt with mental health went to the Department of Human Services or other committees that did not necessarily have a strategic focus on this issue, so the BH and MH Committee has been influential in providing a central place to examine bills addressing behavioral and mental health needs.
Senator Fine has been working closely with Jud DeLoss, the CEO of the Illinois Association for Behavioral Health (IABH), to determine what is needed to support Illinois’ mental health landscape. One of their current priorities is very focused on supporting the mental health workforce in Illinois. They also co-developed the mental health omnibus, which removes barriers to mental health professionals who want to reenter the field, provides funding for internships that aims to promote a diverse mental health workforce, and gives tax breaks to employers who hire people recovering from substance use disorder (SUD) or mental health issues.
Lee Ann Reinert (LAR): Since 2020, Lee Ann has been leading the statewide planning of 988 with the Illinois Department of Human Services Division of Mental Health. She started with an implementation planning grant to prepare for 988, which offered opportunities to engage and learn from other states in the process and technical support to assist the state’s efforts to become compliant with SAMHSA’s crisis continuum pillars: someone to call, someone to respond to, and a place to go.
Illinois had contracts that were coming up for rebids. However, the department wanted to prioritize support for those that would be responding to the new crisis line. They knew there wasn’t enough staffing or infrastructure to respond to all of the calls; there were six Illinois-based centers, with the majority of calls being answered by national backup centers. Investing in changing this, they went from 18 percent to 70 percent of calls being answered by centers in Illinois. Today, they continue to work with call centers to expand capacity and become even more responsive.
Alisha Warren (AW): The Chicago Department of Public Health (CDPH) is working with some other panelists surrounding crises and behavioral health challenges. They have been focused on trauma-informed centers and creating a network of providers for city residents to prevent problems from happening. They are on track to serve 60,000 Chicago residents this year. CDPH is working on sending care teams to respond to 911 mental health crisis calls and having clinician support at 911 call centers to assist with a more coordinated response and opportunity for intervention without police.
Kelsey DiPirro (KP): C4 is also focused on SAMSHA’s continuum pillars, but goes one step further by adding “someone to follow up.” C4 aims to provide care with a 988 call center team working as the first point of entry of the C4 continuum. They are also involved with Screening Assessment Support Services (SASSS), one of the largest mobile crisis providers in the Chicagoland area, and one of the primary Chicago-based providers responding to crisis calls. C4 has a drop-in center as well as a place to access support services directly in person. The crisis treatment team works with people to address crisis events and the intervention specialist team helps people adjust to change and address social determinants of health. And the peer engagement team is composed of individuals with a shared experience to fully support clients' needs.
Maria Bruni (MB): Family Guidance Centers is a SUD provider that has partnered with CDPH and Substance Use Prevention & Recovery (SUPR) to help people connect via a phone-based helpline for those seeking SUD services and to connect them to medication-assisted recovery. Their medication-treatment options and counseling decrease opioid use, help to reduce withdrawal symptoms, keep people engaged in treatment longer, and reduce the risk of overdose. Generally, a small fraction of people who need medication assistance get access to it. With their programs, some are able to access an induction over the phone, which is particularly useful for those in rural areas who have trouble getting to brick-and-mortar treatment centers and others come in person.
MK: What is promising about the new 988 hotline? What is concerning?
KP: It is promising that the state has supported and invested in local providers. It is important for callers to speak with someone that reflects their culture and community, and can advise them on access to resources that are convenient and relevant to them. For example, if a patient calls from Chinatown and is referred to services in Roger Park, they are less likely to follow up with that referral. Thus, having local call centers that can address and understand the culture and geographic constraints for the caller to access support services is very important.
It is concerning that there are still parts of the Chicago area that are not covered. Additionally, the staffing shortages and hiring crisis in the space add more challenges. When agencies are making decisions about coverage areas, they must take into consideration the volume of calls for a certain area and the ability to hire people who live in, work in, and understand the neighborhood where the calls are coming from. This presents challenges to current hiring and therefore we continue to see gaps.
LAR: This is the first time we are seeing federal-level investment for parity amongst the compounding crises of mental and physical health which is very promising. There are many challenges, and the system is never going to be perfect in its ability to always respond to an individual at the right level. In looking at the contracts with the 988 system, it is a priority to make sure the person on the phone has all the resources at their fingertips to help the caller. There is a significant amount of work in coordinating and collaborating across 988 call centers and there are so many layers to make sure that we have a system that is responsive, safe, and meeting the needs of the individuals. Unfortunately, the system has been underfunded for a very long time and we are managing through.
SLF: It is very exciting, but we have to remember that it is a work in progress, that it is still new, and we are putting the pieces in place. The way that the system is set up now is going to be very different from what it will be five to 10 years down the line. The new hotlines will foster progress in how we help the people in our communities.
AW: There is no wrong door in regard to access and entry points to the system. CDPH and partners are building out new response mechanisms to the 911 system as well, so if people call 911 there will be options and resources available.
MK: How are community members being informed about which numbers to call? Is there confusion as people navigate?
MB: There is a lot of work being done to promote medication-assisted recovery, which is now a feature of Illinois’ Healthline. There is a campaign to make people aware of where to call for an opioid-related emergency. And if people don’t get connected to medication soon after an overdose, they are very likely to go back and reuse which puts them at high risk of another overdose with a higher fatality risk. When people leave the hospital after receiving overdose treatment, they will experience withdrawals and feel sick, and if they don’t have proper medication they will use again.
While it is not always clear whether someone is calling for mental health or SUD crisis, it is very rare that someone only has one problem. Usually, if someone is calling with a SUD issue there is a co-occurring mental health issue. The Illinois Healthline can provide integrated care for the person calling.
LAR: There is a lot of public campaign messaging in progress that is coming from the federal level. Federal officials have asked mental health authorities to follow their lead and not get out in front of the system so we can ensure that the system can handle the things promised in public messaging. We recognize that the number of calls coming in would increase now that there is a dedicated line tied to a three-digit number rather than the longer hotline number that has existed for years. As expected, each week the number of calls is increasing. Public messaging is very important, and there have been many focus groups to ensure the right messages will be delivered to the right people. IDHS has enlisted Vibrant, a marketing agency, to help ensure messaging is done properly. Vibrant is working on a unified platform that will make access to resource information available to call takers across the country. Even with our best resources at the table, there will still be calls that roll to backup centers across the nation. Whatever we build should recognize that sometimes Illinois calls will go to other centers, and they need to get the help they need. SAMHSA’s benchmark for the state to respond to local calls is 90 percent, and we are currently at a 78 percent response rate. No matter how well we build our system, the 988 system does not have GPS technology. However, it recognizes the caller's area code, so some calls could still be routed out of state even if the caller is in Illinois.
What needs to happen to strengthen the system outside of focusing on the crisis?
AW: At CDPH, there has been a focus on trauma-informed centers of care and increasing access to quality behavioral health programming, which has been crucial for crisis prevention. Because this network has been established, CDPH now has partners they can bring people to for follow-up. Clinicians are doing follow up for up to 30 days after a crisis because a crisis is not resolved at one encounter.
Due to the workforce shortage, many partners are in the same boat of not having g enough people to do all the work that needs to be done, so it is essential to support frontline staff and add more workforce. CDPH is working to open a sobering center and a housing unit that will have treatment embedded into the housing facility.
MB: On the SUD side, we have learned a lot about the barriers people face trying to access services. You can’t wait for people to show up for help; you must meet people where they are. FGC has a mobile unit to go out and do screenings, assessments, and inductions on medications. Last June, the Drug Enforcement Agency (DEA) changed the long-standing rules barring methadone and other medication-assisted recovery providers from using mobile units and storing the medicines on the units. Now, there are two units in the Chicago area.
KD: Community-based work is the heart of what C4 does, and there is a focus on how to remove barriers. To do that, hiring people with lived experience within communities is important, which requires equitable funding and hiring practices. The hiring process should consider paying fair market value to people doing this work. In order for people to do this work for a very long time and develop expert-level experience, they must also be able to have and sustain a personal life. There have been cracks throughout our wellness and care systems over the past couple of years. There is a national psychiatric bed shortage leaving people waiting weeks and even months for a bed. Building more crisis stabilization units and mobile units would be a good solution as they are valuable and cut down on wait time.
SLF: The state is focused on many of the issues being discussed. This year, they increased rates for the first time in a while, and although it is not enough, it is a step in the right direction. They created a new position in the governor’s office, similar to a mental health coordinator, that is responsible for looking at what is going on with children’s mental health and how to improve the system throughout the state. This summer, there was a joint subject matter hearing between mental health and SUD committees looking at where there are beds for children in crisis. We can keep sending children out of state, or we need to treat them here at home, so examining how to expand that access is essential.
MK: Are there discrepancies in public versus private coverage?
SLF: Illinois was one of the first states that passed mental health parity. We take this very seriously to ensure people get the coverage they need.
MB: We have much work to do as we try to integrate the SUD and crisis response with mental health. As we roll out 988 and it evolves over time, there will be an increased focus on connecting people to SUD care.
AW: For so long, mental health, SUD, and social services have been siloed. We have been diligently working together to identify gaps and how to fill those gaps. We are coordinating in a very different way than before, which is why we see positive changes.
KP: There are many opportunities to be creative in filling the gaps.
LAR: Mental health and SUD have been siloed for so many years, so when 988 was conceptualized, a decision was made to move away from the “National Suicide Hotline” to the “Suicide and Crises Line.” This is a step in the right direction.
SLF: This is an exciting time with so many positive changes taking place. With so many people putting their heads together to resolve these issues, I am hopeful that we will get it done together.