Elements of the continuum


In an ideal system, there is specific capacity for individuals in crisis to contact the crisis system for assistance at any time with ability to respond based on the level of intensity and urgency of need. This includes a variety of different types of services that can be connected or coordinated with each other as well as connected to the capacity to dispatch law enforcement, EMS or mobile crisis outreach or arrange for transportation to the appropriate crisis center. These services have various labels and functions, including helplines, warmlines, suicide prevention lifelines, 988 crisis lines and 911 dispatch coordination. Each type of service provides a useful function in an ideal system and all such functions should be provided for through the accountable entity and the community crisis collaboration. The rationale and description for each type of service are:

Call centers and crisis lines

A crisis call center is a 24/7 accessible phone number (e.g., 988) for people in behavioral health crisis and preferably incorporates phone, text, videoconferencing and web-based chat capability. In an ideal system, the crisis call center welcomes all types of calls and triages them appropriately to trained call responders who are well-trained in the resources of the community behavioral health crisis system. Remote call centers that are not connected with the community continuum are less than desirable. Having separate numbers for different types of calls can be confusing for those calling for help. Warmlines or helplines imply that the caller is not in an urgent situation and merely wants to access support. Crisis lines or hotlines imply that the caller needs more urgent help and are a direct access into the full continuum of crisis services.

One form of hotline is a suicide prevention lifeline. There are currently 161 certified in the United States and each adheres to a set of practice standards for certification. When all these types of service are accessible through a common number, it is easy for the call line staff to triage callers seamlessly to the appropriate response. In an ideal system, the helpline number is the go-to behavioral health crisis number that he whole community is educated to use, rather than calling the emergency room or 911. Recent federal legislation is directing planning for implementation of a 988 National Suicide Prevention Lifeline line, which will be a valuable approach to ideal crisis system development nationally.

The common goal of these helplines is to serve as an initial mode of engagement, triage and support to try to establish some connection with the caller, helping them feel comfortable to discuss their situation and assess the urgency and most appropriate next steps, which could include recommendations ranging from no follow-up to anything along the full continuum of crisis services. No matter what they are called, how they are staffed or what medium is used, these helplines should have the following features:

Widely known in the community: These helplines are only effective if people know about them. It is often necessary to invest resources in getting the word out and keeping the service in front of people’s minds, especially when the service is relatively new to a community. Just as everyone knows to dial 911 in an emergency, they should know the number to call (988) in a behavioral health crisis.

Easy access: People calling don’t have to go through a series of different operators or automated questions (e.g., “…press 1 if you are suicidal, press 2 if homicidal…” etc.) to get help. As engagement is critical, best practices in customer service should be prioritized and followed.

24/7/365 access: These services should be available at all times. If there is not local capacity to do so, arrangements should be made to have the calls forwarded to another entity during any locally uncovered hours in a manner that does not make it more difficult or complicated for the caller. In that case, a system of warm handoffs should be in place between the covering entity and the local crisis center.

Practice guidelines and core competencies: Helpline staff, regardless of professional background, should have training and demonstrated capacity in triage, engagement (e.g., motivational interviewing training) and intervention and risk assessment and intervention, preferably using National Suicide Prevention Lifeline guidelines Microsoft Word - NSPL Suicide Risk Assessment Standards and Prompt Questions _rev as of April 17, 2007_.doc (suicidepreventionlifeline.org) Processes that impede engagement, such as standardized or scripted questions, should be minimized.

Linguistically competent: These services should be able to respond directly, without need for translation, to at least the two most commonly spoken threshold languages in the service area and have capacity for translation services across a broad spectrum of languages.

911 call dispatch coordination

As part of the ideal crisis system, 911 calls are triaged If they are primarily behavioral health-oriented and there is no immediate life-threatening emergency requiring police or EMS, the call is triaged to the crisis call line center to initiate the behavioral health crisis response process, just as if the individual had called the “crisis call line” in the first place. If law enforcement response is indicated, the dispatchers are trained to connect the call to CIT-trained officers and/or mobile crisis/law enforcement response teams. Both these call response systems are necessary and complementary. Dispatchers for 911 are trained to identify critical information to direct calls to the appropriate responders and inform the nature of law enforcement response.

When 911 call-takers receive a request for service that they suspect involves a person with a mental illness, they gather descriptive information on the person’s behavior, if there is evidence that the person poses a danger to themselves or others, if the person possesses or has access to weapons and if the person has past or current involvement in mental health or substance abuse treatment. This helps to triage whether law enforcement involvement is needed, and if so, to provide law enforcement with information that is more likely to result in diversion from the criminal justice system.

Measurable Criteria for an Ideal System

The accountable entity ensures the design, implementation and continuing funding of a 988 call center for the crisis continuum that includes warmline and crisis line functions and meets Suicide Prevention Lifeline Center certification standards:

  • The call center number (988) is widely disseminated to the general public and human services providers through a public education campaign.
  • The call center operates 24/7, and staff are trained in appropriate triage and facilitating access to the full continuum of crisis response, including mobile outreach.
  • The call center is responsible for tracking data on type of calls, length of calls, outcomes of calls and other relevant metrics for the purpose of continuous improvement of response.
  • The accountable entity ensures development of the technology and competencies that support behavioral health crisis triage within the community’s 911 dispatch function.
    • There are clear protocols so 911 personnel know when and when not to dispatch law enforcement, as well as which officers and/or mental health co-responders are available to respond to calls that may involve a person with a behavioral health crisis.
    • The 911 computer-aided dispatch system has a unique code for mental health calls for service and is capable of flagging:
      - Repeat addresses associated with mental health calls for service.
      - People with mental illnesses who are repeatedly in contact with law enforcement.
      - People who pose a verifiable threat to officers.
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