Nevada building behavioral health infrastructure, starting with new 988 hotline

Nevada, which continues to rank at the bottom of all states in access to care and high prevalence of mental illness, faces an uphill battle in creating a comprehensive crisis care system that will accompany the new 988 mental health line.

The deadline is in six weeks.

Congress passed the National Suicide Hotline Designation Act of 2020 mandating that 988 become a new, nationwide three-digit phone number for Americans to call when they or someone they love are in crisis and need to be connected with suicide prevention and mental health crisis counselors.

The act requires that phone service providers direct all new calls from the existing National Suicide Prevention Lifeline to the new number by July 16.

The transition to the three-digit number is part of a larger initiative that aims to build out crisis mobile outreach teams and a more robust system of treatment options, including a crisis stabilization center where behavioral and mental health care is coordinated.

“With physical health, we’ve had this coordination with 911 going on for 45 years, but behavioral health has been so stigmatized for so long that we never coordinated this,” said Rachelle Pellissier, executive director of Crisis Support Services of Nevada. “This [legislation] allows us to really start creating good coordination and starting giving parity to behavioral health.” 

The state will have to navigate challenges caring for locals and tourists, help one of the nation’s most diverse populations, build services in the state’s vast rural lands, and improve police training – all while building mobile crisis teams and crisis stabilization centers.

Crisis Support Services of Nevada, a National Suicide Prevention Lifeline partner that started to operate the state’s suicide hotline in 1966, will oversee the launch of the new number this summer.

“The convergence of the 10-digit number to the three-digit number is something I think Nevada is very well placed for,” Stephanie Woodard, senior advisory on behavioral health for the Nevada Department of Health and Human Services, said. “In a lot of other states they may not have had a state-wide call center, sometimes they had many, many different call centers that weren’t even connected to one another.” 

Crisis Support Services of Nevada’s unique position as a state-wide agency – and also as one of 12 backup call centers for the National Suicide Prevention Lifeline – allows it to more readily expand its team. It received funding to hire 25 additional staff in anticipation of increased call volume.

To date, it has hired 20 of that 25 staff and 10 have completed the crisis training for the call center, Pellissier said.

But there are still challenges with the rollout of the new number. The 988 system fields calls by area code, not by geographical location like 911, she said.

If a person keeps their Nevada area code, even if they move, their call will be transferred to the Nevada Crisis Support Services despite there being closer services. Or if a person is visiting Nevada and experiences a crisis, their 988 call would be fielded to where their area code is.

The national effort to address this is underway but may not be ready by July 16, Pellissier said.

Nevada also serves one of the nation’s most culturally and linguistically diverse populations. 

In Clark County, the state’s most populous, more than 10% of households have no one living there over the age of 14 who speak only English or who speak English “very well,” according to the Guinn Center’s 2020 Census in Nevada Snapshot.

Language barriers can present a challenge for crisis calls. While the state has a sizable Spanish speaking population, other notable languages include Tagalog, Korean, Arabic and Amharic, according to the report. 

Crisis Support Services of Nevada received a grant to hire two more bilingual staff members to answer calls, but the behavioral health care system has a long way to go before it can truly serve all the state’s residents, Pellissier said.

While the majority of the state’s population resides in its three metro areas, almost 10% of the population resides in rural and frontier areas, which account for 87% of Nevada’s land mass, according to the 2021 Nevada Rural and Frontier Health Data Book by the University of Nevada Reno’s School of Medicine.

About a quarter – 24.6% – of those in rural and frontier counties have struggled with binge alcohol use in the past month, and 20.3% have had a mental illness in the past year, according to data in the book.

“People in the rurals won’t use it or trust it until they see the kind of support they get,” Laura Yanez, executive director of NAMI Western Nevada, said. “I want them to understand that it is a part of an overall change in our mental health system in Nevada. It’s not just 988. It’s that crisis intervention now model.”

For most of the population, the first people to respond to mental health crises are law enforcement — something that is even more frequent in rural communities that Yanez oversees. But she said more law enforcement agencies in rural Nevada are being trained in crisis intervention.

Over 30% of people living with serious mental illness have their first interactions with the mental health care system through law enforcement agencies, but they are also 16 times more likely to be killed by law enforcement.

The state partnered with over 50 different local, state and national organizations, including Washoe County Sheriff, Reno Police Department, Carson City Sheriff’s Office, Las Vegas Metro Police Department, Lander County Sheriff’s Office and Douglas County 911 Emergency Services.

The 988 national implementation model hopes to create a separate mobile crisis response team to divert most crisis calls away from law enforcement. These teams often consist of two mental health specialists, like a clinician and a peer support advocate, who show up first to cases that can’t be de-escalated by the 988 call center.

“Just like EMTs, they would go out and help,” Pellissier said. “Do we have all those mobile teams together for July 16? Absolutely not, but we are creating them.”

Most of Nevada’s existing Crisis Mobile Teams are located in urban settings. Ensuring timely response to the rural and frontier counties with the current resources available is a challenge, Woodard said. 

The state currently has several different models of Crisis Mobile Teams in operation, according to Kendall Holcomb, a public information officer at the DHHS. Some operate through different law enforcement agencies. Others specifically serve children in Washoe and Clark counties. Nine are associated with different certified community-based behavioral health clinics across Nevada.

Each of the teams are operated individually, but there would be state-wide coordination under 988, she said. 

The final part of the 988 implementation plan is building crisis stabilization centers for those who need a dedicated environment that isn’t a hospital emergency room or a jail to get help and then more accessible resources in the community to support after-crisis care.

“The mobile teams may not be able to completely stabilize [a person], maybe they really need to be somewhere in a more clinical setting,” Pellissier said. “They don’t want to go to an emergency room and be stuck in a paper gown and strapped to a gurney for 8 to 10 hours… [They] don’t need to be treated like a criminal.”

But the state has yet to build those centers as it is waiting for a June 21 American Rescue Plan Act of 2021 (ARPA) request for $20 million and hopes to have these centers operational within a year, said Holcomb.

Even once those centers are built, insurance parity, access and cost are major barriers to those receiving mental health care — not just in the state, but nationally. Nevada is still figuring out how to navigate these issues, said Pellissier.

The 988 implementation model is a systemic shift in increasing access to behavioral and mental health care, but Nevada has had a little over a year to prepare for the deadline, said Woodard.

While federal funding has been allocated to the states to implement the new number, there have not been any evaluations on how prepared states are for the July 16 deadline, according to a report released this month by the Rand Corporation. 

But Nevada, along with Virginia, Colorado and Washington, are the only states that passed legislation to ensure state funding for 988. Nevada did it through 2021’s Senate Bill 390. The bill would allow at most a 35 cent charge per person, per month, per line to help support these services, said Holcomb. 

The fee amount is still being approved by the Nevada Legislative Commission and State Board of Health. Due to this, there is no set start date, she said. 

Additionally, Nevada received millions in federal funding to help implement 988. The state decided to use $3.5 million from ARPA for the 988 and was awarded another $1.06 million from the Substance Abuse and Mental Health Services Administration (SAMHSA).

That time constraint coupled with high prevalence for mental illness and limited access to care, a culturally and linguistically diverse population and the vast rural and frontier swaths of land in the state converges with Nevada’s long history of being one of the nation’s worst states in addressing mental health care.

“Will it be perfect come July 16? Absolutely not, but boy will it be a lot better and thank goodness we are all working on it,” Pellissier said. “It will in the next 10 years be a hundred times better than it is right now and really allow us to open up and talk about these issues and get people the help that they need.”