Association of Access to Crisis Intervention Teams With County Sociodemographic Characteristics and State Medicaid Policies and Its Implications for a New Mental Health Crisis Lifeline

State Policies Associated with Availability of Mobile Crisis Teams

Mobile crisis teams are comprised of multidisciplinary mental health professionals that respond to mental health crisis calls in community settings. This study identified counties with mobile crisis teams and examined state policies associated with mobile crisis teams. Descriptive statistics and geographic information system software were used to quantify and map counties with mobile crisis teams in the United States. Relationships between state policies and mobile crisis teams were examined using an adjusted logistic regression model, controlling for county characteristics and accounting for clustering by state. Approximately 40% (n = 1,245) of all counties in the US have at least one mobile crisis team. Counties in states with legislation in place to fund the 988 Suicide and Crisis Lifeline were more likely to have a mobile crisis team (Adjusted Odds Ratio (AOR): 2.0; Confidence Interval (CI): 1.23-3.26), whereas counties in states with 1115 waivers restricting Medicaid benefits were less likely to have a mobile crisis team (AOR: 0.43; CI: 0.21-0.86). Additionally, counties with the largest population were more likely to have a mobile crisis team (AOR: 2.20; CI:1.43-3.38) than counties with the smallest population. Having a mobile crisis teams was positively associated with legislation to fund 988. Legislation that encourages expansion of existing crisis care services, specifically funding aimed at mobile crisis teams, may help increase availability of services for people who are experiencing a mental health crisis in the community.

Market Factors Associated with Comprehensive Behavioral Health Crisis Care Availability: A Resource Dependence Theory Study

Behavioral health crisis care (BHCC) is a care delivery model for individuals experiencing acute distress related to a mental health or substance use disorder. We examined market factors associated with comprehensive BHCC availability using 2022 data on mental health treatment facilities (n = 9385) obtained from the Substance Abuse and Mental Health Services Administration. We aggregated facility-level data by county (n = 3142) and merged with county-level market factors. Logistic regression models were used to examine the adjusted associations between market factors and BHCC availability. We found that 468 (14.9%) counties had at least one mental health treatment facility offering comprehensive BHCC services. Specifically, counties with more mental health providers (Adjusted Odds Ratio = 2.26, Confidence Interval = 1.32-3.86) and metropolitan counties (AOR = 3.26, CI = 1.95-5.43) had higher odds of having a comprehensive BHCC facility. Our findings highlight the importance of developing the mental health workforce to increase BHCC availability and a need to address disparities in rural counties.

Geographic variations in driving time to US mental health care, digital access to technology, and household crowdedness

Rural residents face significant barriers in accessing mental health care, particularly as the demand for such services grows. Telemedicine has been proposed as an answer to rural gaps, but this service requires both access to appropriate technology and private space in the home to be useful. Our study documented longer travel time to mental health facilities in rural areas and greater barriers to digital devices for telemedicine access in those same areas. However, urban areas demonstrated greater household crowdedness than rural noncore areas when looking at private space within the home. Across ZIP Code Tabulation Areas located more than an estimated 30 minutes from the nearest outpatient care, 675 950 (13.1%) rural households vs 329 950 (6.4%) urban households had no broadband internet. The current Affordable Connectivity Program should target mental health-underserved communities, especially in rural America, where the scarcity of digital access compounds travel burdens to mental health care.

Implementation of the 988 Suicide & Crisis Lifeline: Estimating State-Level Increases in Call Demand Costs and Financing

BACKGROUND

Per federal law, "988" became the new three-digit dialing code for the National Suicide & Crisis Lifeline on July 16, 2022 (previously reached by dialing "1-800-283-TALK").

AIMS OF THE STUDY

This study aimed to produce state-level estimates of: (i) annual increases in 988 Lifeline call volume following 988 implementation, (ii) the cost of these increases, and (iii) the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume are sufficient to meet call demand.

METHOD

A 50 state pre-post policy implementation design was used. State-level Lifeline call volume data were obtained. For each state, we calculated the absolute difference in number of Lifeline calls in the four-month periods between August-November 2021 (pre-988 implementation) and August-November 2022 (post-988 implementation), and also expressed this difference as percent change and rate per 100,000 population. The difference call volume was multiplied by a published estimate of the cost of a single 988 Lifeline call (USD 82), and then by multiplied by three to produce annual, 12-month state-level cost increase estimates. These figures were then divided by each state's population size to generate cost estimates per state resident. State-level information on the amount of state (FY 2023) and federal SAMHSA (FY 2022) funding earmarked for 988 Lifeline centers in response to 988 implementation were obtained from legal databases and government websites and expressed as dollars per state resident. State-level differences between per state resident estimates of increased cost and funding were calculated to assess the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume were sufficient to meet call demand.

RESULTS

988 Lifeline call volume increased in all states post-988 implementation (within-state mean percent change = +32.8%, SD = +20.5%). The total estimated cost needed annually to accommodate increases in 988 Lifeline call volume nationally was approximately USD 46 million. The within-state mean estimate of additional cost per state resident was +USD 0.16 (SD = +USD 0.11). The additional annual cost per state resident exceeded USD 0.40 in three states, was between USD 0.40- USD 0.30 in three states, and between USD 0.30 - USD 0.20 in seven states. Twenty-two states earmarked FY 2023 appropriations for 988 Lifeline centers in response to 988 (within-state mean per state resident = USD 1.51, SD = USD 1.52) and 49 states received SAMHSA 988 capacity building grants (within-state mean per state resident = USD 0.36, SD = USD 0.39). State funding increases exceeded the estimated cost increases in about half of states.

CONCLUSIONS

The Lifeline's transition to 988 increased 988 Lifeline call volume in all states, but the magnitude of the increase and associated cost was heterogenous across states. State funding earmarked for increases in 988 Lifeline center costs is sufficient in about half of states. Sustained federal funding, and/or increases in state funding, earmarked for 988 Lifeline centers is likely important to ensuring that 988 Lifeline centers have the capacity to meet call demand in the post-988 implementation environment.

What Explains Changes in Availability of Specialty Mental Health Services in Organized Settings?

Policy Points Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. Facilities were no more likely to offer six of seven services studied in 2019 compared with 2010 in both Medicaid expansion and nonexpansion states. For-profit facilities generally experienced the largest declines in service availability, while public facilities experienced the smallest declines with small increases in availability of select services. New payment models that incentivize the offer of specialty support services may be needed to encourage adoption of clinical and support services by specialty mental health organizations.

CONTEXT

Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. This creates equity issues, particularly when low-income and minority communities have access to fewer facilities. Medicaid expansion might encourage facilities to offer these services. However, this decision may also be affected by facility ownership type or mediated by service cost structure, particularly in the absence of innovative payment mechanisms. In this study, we determine whether and how Medicaid expansion and facility ownership are associated with changes in specialty mental health service availability in organized settings over time.

METHODS

We estimated two-way fixed effects models using six cross-sections of the National Mental Health Services Survey and compared changes in facility-reported offering of seven services from 2010 to 2019 (54,885 facility years): psychotropic medication, case management, family psychoeducation, psychiatric emergency walk-in services, supported employment, assertive community treatment, illness management, and recovery services. We tested whether Medicaid expansion and facility ownership (private for-profit, private not-for-profit, public) were associated with differential changes in service availability from 2010 to 2019.

FINDINGS

Overall, facilities were no more likely to offer nearly all services in 2019 than 2010. We found smaller declines for psychotropic medication and psychiatric emergency walk-in services among facilities in Medicaid expansion states compared to declines in non-Medicaid expansion states (6.3 (95% CI 95% CI = 1.8-10.7) and 5.5 (95% CI = 0.2-10.8) percentage points respectively). For-profit facilities experienced the largest declines in availability from 2010 to 2019, while public facilities experienced the smallest declines and some increases in availability of select services.

CONCLUSIONS

Specialty mental health services are still not widely offered in community outpatient settings despite significant investments in Medicaid, although Medicaid expansion was associated with slower declines in availability. New payment models that incentivize outpatient facilities to offer clinical and support services may be needed.