By Jeffrey A. Meyers, Veronica Ross-Cuevas, and Peter Joyce
With more than 125 deaths occurring each day, suicide has become the 10th leading cause of death in the U.S. In fact, suicide rates are at their highest levels since World War II.
Unfortunately, rural communities, which are often wrought with workforce and clinician shortages as well as hospital closures, face an increased risk of behavioral health and suicide rates when compared to non-urban areas. Additionally, suicide rates for veterans, the majority of whom live in rural areas, are 1.5 times greater than for other adults.
However, with new funding, state agencies and community providers can lead the implementation of a new hotline to prevent suicide.
The 9-8-8 hotline is set to be implemented nationally in July 2022.
Congress passed the National Suicide Hotline Designation Act in October 2020. Under the Act, the Federal Communications Commission established 9-8-8 as the new universal three-digit hotline number for the National Suicide Prevention Lifeline to increase public access to mental health and suicide prevention resources.
Leveraging new State and Local Recovery Funds (SLRF), as well as supplemental mental health block grants from the Substance Abuse and Mental Health Services Administration (SAMHSA), made possible through the American Rescue Plan Act (ARPA), many states passed legislation earlier this year with fresh appropriations for expanded mental health crisis services, anticipating steep increases in demand upon implementation of 9-8-8.
For rural areas, 9-8-8 implementation poses unique challenges.
Rural communities, especially, will need non-traditional strategies that allow them to effectively help prevent but still respond to requests for the behavioral health crisis services that 9-8-8 is anticipated to bring.
Lack of broadband access, populations spread over large geographic areas, and the closure of rural hospitals and health centers are just some of the barriers that rural states face in planning for 9-8-8 implementation and related mental health services.
Here are five strategies for states to meet the challenge of 9-8-8 implementation:
1. Target One-Time Funding for One-Time Expenditures
States need to carefully target the use of the ARPA’s new SLRF and SAMHSA one-time funds to non-reoccurring expenses, such as technology purchases, construction or renovation of space for providing crisis services, and electronic health record capacity. Additionally, workforce recruitment and retention incentives such as loan forgiveness and tuition reimbursement can help to attract and retain a new behavioral health workforce.
States should avoid creating a funding cliff when these ARPA funds expire – for example, hiring new staff, raising reimbursement rates, and expanding crisis programs and services with these one-time funds will not be sustainable in the absence of other funding to eventually replace the ARPA funds.
2. Deploy Community-Based Models of Care
Meeting citizens where they live and experience behavioral health crises is a national best practice. Rural states, however, face the challenges presented by geography – standing up statewide mobile crisis teams that meet fidelity standards to serve sparsely populated rural counties may not be feasible or cost effective.
Rather, rural states will need to explore alternate models of care which meet their unique needs. For example, several communities are launching paramedicine programs to respond locally to mental health crises and reduce reliance on hospital emergency departments as well as unnecessary police action. States can provide emergency medical technicians with specific training so that they can best respond to behavioral health calls.
Paramedics can be teamed with mental health or social workers to address the needs of behavioral health patients. Social workers and community health workers can also support behavioral health patients by reaching out to monitor their adherence to medications and other aspects of treatment plans when they are not in crisis.
3. Expand Telehealth
Telehealth has been increasingly used even before the COVID-19 pandemic to enhance access to mental healthcare in areas with limited resources. Several services can be delivered in virtual settings, including but not limited to evaluation and diagnosis, case consultation, treatment, medication management, and continuing care. Mobile health applications and on-demand direct services should be part of every state’s 9-8-8 toolkit.
Rural states especially should consider how best they can utilize SLRF funds to build out broadband and upgrade existing upload and download speeds. That strategy should involve braided funding and leverage SLRF funds that have been distributed across all levels of state and local government – the state, counties, metro areas, and non-entitlement units.
4. Enforce Mental Health Parity and Addiction Equity Act (MHPAEA) Compliance
The MHPAEA is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. While the federal criteria governing this requirement took effect in January 2014, several federal agencies amended the rules in April 2021 to ensure that commercial insurers and group health plans comply fully with “Non-Quantitative Treatment Limitations” (NQTLs). This includes the scope and duration of mental health benefits, provider network admission standards, and provider reimbursement methodologies – no less than they do with respect to co-pays and visit limits. These NQTLs can impact access to behavioral health treatment.
States, through their insurance regulatory authority, now have new reporting requirements to evaluate and confirm that commercial insurers are providing critical mental health and substance abuse benefits no more stringently than medical and surgical benefits.
5. Fund Social Determinants of Health (SDoH)
It has been long accepted that mental illness and substance misuse are influenced, in part, by social risk factors. Food insecurity, housing instability, social isolation, and lack of transportation can alone or in combination impact access to care and increase cumulative stress and the risk of behavioral health crises. Federal agencies, including the Centers for Disease Control and Prevention (CDC), are increasing their programmatic assistance and funding of social services that address SDoH.
For example, the CDC’s “Reaching People with Disabilities Through Healthy Communities” program addresses physical inactivity, poor nutrition, and tobacco use and exposure. Medicaid also offers several levers to address SDoH, including State Plan Optional Services to provide peer support and case management, waivers to help fund SDoH services through demonstration projects, and new managed care authorities in-lieu of value-added services that now can be factored into the cost of medical services for managed care providers.
The new 9-8-8 suicide prevention hotline holds the promise of bringing care to those in crisis.
Rapid access to suicide prevention and mental health crisis response has never been more needed in America. With suicide rates in rural counties nearly double those in urban counties, rural states particularly must carefully target funding in order to both implement the new hotline and be able to meet anticipated demand for crisis services.
While there is no single national crisis services solution, states should embrace nontraditional strategies to meet the challenges associated with 9-8-8 implementation.
Learn more about Guidehouse state government health services and how we can help evaluate and design funding options and crisis services for 9-8-8 implementation.