The Road to 988/911 Interoperability: Three Case Studies on Call Transfer, Colocation, and Community Response

Issue

The 988 Suicide and Crisis Lifeline—known more simply as 988—holds promise for significantly improving the mental health of Americans and has the potential to accelerate the decriminalization of mental illness. However, our previous research suggests that the rapid transition to 988 has left many gaps as communities scramble to prepare—not the least of which includes determining how 988 will interface with local 911 response systems and law enforcement (Cantor et al., 2022). Efforts to understand how jurisdictions are planning for the interface between 988 and 911, aligning program procedures, and creating staff buy-in are essential, as they could highlight effective solutions for jurisdictions that do not yet have a plan and reveal common challenges. In the project described in this study, we used a case study approach to understand the different ways in which jurisdictions have approached 988/911 interoperability—that is, the existence of formal protocols, procedures, or agreements that allow for the transfer of calls from 988 to 911 and vice versa. We also aimed to identify relevant facilitators, barriers, and equity-related considerations that shaped each jurisdiction's approach.

Methods

The three sites we worked with were the city of Sioux Falls and Minnehaha County, South Dakota; Orange County, New York; and Fairfax County, Virginia. These sites were selected to maximize variation with respect to a number of criteria, including population density and urbanicity, model of 988/911 interoperability, and recency of establishing 988/911 interoperability. For each site, we drew on three primary data sources: (1) a review of documents relevant to 988/911 interoperability (e.g., policy and procedure documents, interagency agreements), (2) qualitative interviews with staff of relevant agencies, and (3) two- to three-day site visits.

Our analysis had two stages. The first stage focused on the individual sites. A key goal of this work was to understand the nuances of the interface between 911 and 988 in each jurisdiction. Therefore, for each jurisdiction, we developed a detailed process map based on our document review, qualitative interviews, and site visits to demonstrate how behavioral health emergency calls were handled in that jurisdiction. We also used rapid qualitative analysis to formally code and analyze the qualitative interviews to understand barriers to and facilitators of 988/911 interoperability, lessons learned from implementation, efforts to serve diverse populations, and benefits of interoperability.

Key Findings

• In two of the three sites, the 988 call center was located separately from the 911 call center or public safety answering point. The third site had 988 and 911 call centers colocated in the same facility.
• Each site described the key decision points that governed the transfer of calls from 988 to 911 and vice versa. These decisions centered around the likelihood of risk of harm to the caller or other people, as defined by such factors as overdose, suicidal intent with access to means and opportunity, and presence of a physical injury.
• When behavioral health calls are handled by 988, the majority are able to be resolved on the phone; for example, one site reported that 97 percent of calls were resolved on the phone. However, some cases require an in-person response, and jurisdictions had a variety of in-person options, including mobile crisis units, traditional law enforcement officers, Crisis Intervention Team–trained law enforcement officers, co-response teams, and peer support teams.
• Although sites varied with respect to their specific resources and models of 988/911 interoperability, there were some cross-site findings related to effective planning and implementation. For example, planning and implementation should be collaborative, engaging a variety of contributors. Entities involved in planning should focus on developing shared language and mutual respect, even when their cultures differ.
• Having a local champion for 988/911 interoperability is an important facilitator for planning and implementation, though the specific background of the champion may vary across jurisdictions.
• 988/911 interoperability requires more than protocols for transferring calls between 988 and 911. It also must be considered within the larger continuum of crisis services available in the community.