Illinois 988 State Volume and Workload Estimates

Introduction

In July 2022, 988 will become the national three-digit dialing code for the National Suicide Prevention Lifeline, linked to the current phone number of 1-800-283-TALK (8255). As the administrator of the Lifeline since its inception in 2005, Vibrant Emotional Health knows that a national three-digit phone number can improve access to vital crisis services, extend the national reach of suicide prevention efforts, and reduce the stigma surrounding mental health and getting help. Most importantly, 988 will help to save lives every day.

To support states as they develop appropriate infrastructure and operations for 988, Vibrant Emotional Health has compiled models to measure the potential workload of contacts via phone, SMS, and online chat to individual states for the first five years of 988's service, as well as center-level cost estimates from a national best practices perspective. Vibrant has also included the user analysis and national demand model that informed the development of the workload and center-level cost estimates.

The scenarios described in this document do not represent an exhaustive range of all potential future system designs. These materials do not contain (and should not be interpreted as) medical, legal, accounting, tax, or other regulated advice.

Regarding public messaging of 988:

While a few carriers have been able to activate 988 at this time, the number will not be available across all carriers nationwide until July 2022. The Lifeline will continue to work with its network of over 180 centers and other stakeholders to prepare for the nationwide launch at that time.

Until July 2022, anyone in mental health crisis or emotional distress should continue to call the National Suicide Prevention Lifeline (1-800-273-8255).

Regarding public messaging of 988: While a few carriers have been able to activate 988 at this time, the number will not be available across all carriers nationwide until July 2022. The Lifeline will continue to work with its network of over 180 centers and other stakeholders to prepare for the nationwide launch at that time.

Until July 2022, anyone in mental health crisis or emotional distress should continue to call the National Suicide Prevention Lifeline (1-800-273-8255).

988 User Analysis

While 988 will be universally available to everyone in the United States, it has the potential to benefit about 39 million people annually-the estimated total number of individuals experiencing a suicidal or broader mental health and substance use crisis with means to contact 988. In comparison, about 12 million people currently call the Lifeline, its local/regional crisis centers (through their local number in addition to the Lifeline), and 911 for mental health or suicidal crises (i.e., subset serviced today) each year. This estimate does not account for potential changes to the prevalence of mental health or substance use disorders. This estimate is based on the results of a comprehensive market analysis conducted to determine the likely number of people whom 988 would most directly benefit: the addressable and serviceable populations.

Addressable Population:

  • 150 million people ages 12 or older (about 53% of U.S. population):
  • People with mental health and substance use disorders, and those with lifetime exposure to traumatic events. These populations are considered to be most vulnerable to suicide and mental health crises.
  • Includes 70 million with mental health/substance disorders (people with individual diagnoses + cooccurring disorders) + 80 million exposed to a traumatic event, with no mental health/substance disorder

Serviceable Population:

  • 39 million people, ages 12 or older (about 14% of U.S. population):
  • The subset of addressable population that 988 could support that includes:1) people in suicidal or broader mental health and substance use crises; 2) subset of callers to current hotlines (e.g., 911, Lifeline, network center hotlines); and 3) those not being currently served by any line.
  • Excludes 7 million who cannot access 988 due to various factors (e.g., overseas, in institutional settings, no phone access) + 104 million who may have a mental health/substance use issue but are not in crisis at a given time.
  • Being able to serve this many people will require significant investments in education and marketing to ensure every American knows what 988 is and when and how to contact 988; initiatives to change the public's attitudes about seeking help for mental health issues; and systems changes like standardized training for public safety professionals to ensure that contacts to 911 are diverted to 988, as appropriate.

National Demand for Services

After 988 goes live in July 2022, the national demand for Lifeline services is expected to increase. National demand is defined as the total volume of contacts (i.e., the combined number of calls, chats, and texts) initiated by callers/chatters/texters to 988. Depending on the growth model (i.e., low growth, moderate growth, high growth), 988 could serve 6-12 million contacts in year one, increasing to 13-41 million contacts by year five of implementation. The table below summarizes projected demand for services--presented as initiated contact volume--for years 1-5 based on the growth model.

Table 1 Projected Contact Volume (in millions) by Growth, Year 1-5

Growth Models Year 1 Year 2 Year 3 Year 4 Year 5
Low Volume 6M 9M 10M 12M 13M
Medium Volume 9M 14M 18M 21M 24M
High Volume 12M 20M 27M 34M 41M

These estimates are based on three sources of volume under 988: baseline volume, diverted volume, and new volume.

Baseline Volume:

  • The volume of potential future Lifeline calls that may be serviced by 988. Based on historical Lifeline volume patterns across call, chat, and text modalities.
  • Assumed a moderate steady growth rate of 7% from year one to five.
  • Baseline growth estimates over five years range from 1% (low) to 14% (high) annual growth.

Diverted Volume:

  • The volume of a Lifeline crisis center's potential non-Lifeline contacts that may instead be serviced by 988 (this estimate does not include potentially diverted local contacts of crisis centers that are not currently members of Lifeline/988 network). This estimate is based on historical patterns and assumptions on individuals potentially choosing to use 3-digit 988 number over local numbers; and volume of potential future 911 volume that may be serviced by 988 (instead of 911) based on historical 911 data, academic literature, and possible considerations around systems change related to 911 diversion.
  • Assumed moderate growth rate of 1% first year, increasing to 20% in year five.
  • Assumed rates of diversion from current helplines, ranges from 23%-30% in year one to 69%-90% in year five; from 911, ranges from 1-2% in year one to 10-30% in year five.

New Volume:

  • New potential volume to 988 based on the estimated share of the potential serviceable population that has not been historically serviced by the Lifeline, local/regional centers, or 911, but may use 988 in the future (primarily driven by an assumption on the potential effect of marketing and awareness of 988 in the general population).
  • Assumed growth rates of 2%-5% year one, increasing to 5-15% in year five due to marketing (based on growth estimates from other similar crisis line services in Australia and the United Kingdom).

Center Level Cost Estimates

 Crisis centers play a vital role in meeting the vision and mission of 988. Their work to help people out of crisis is essential and unique in its sensitivity, with its use of clinical best practices, focus on building emotional connection and support, and direct impact on people's lives. As a result, crisis center work cannot be compared to most other types of call center work. Several other elements differentiate crisis centers from standard call centers:

  • More time engaging with callers due to the intense and personal nature of the conversation, resulting in longer handle times
  • More time for initial onboarding and training and dedicated hours for training refreshers and clinical coaching
  • Greater dedication to supervision and debriefing, and lower supervisor to counselor ratios to promote ongoing training and support
  • Balanced workdays, including wellness supports and programming, to avoid burnout and improve retention

The table below presents the many variables that affect cost, along with key assumptions that reflect Vibrant's understanding of crisis centers' administrative and clinical needs. These assumptions do not necessarily reflect the views, opinions, and policies of the U.S. Substance Abuse and Mental Health Administration (SAMHSA) or the U.S. Department of Health and Human Services. They were used to develop Vibrant's center-level cost estimates with the International Customer Management Institute (ICMI), a global consulting firm with expertise in contact center customer experience and optimization whose clients include the U.S. Department of Veterans Affairs, Independence Blue Cross, AmeriHealth, State Farm, USAA, and others. Inputs were informed by SAMHSA National Guidelines for Behavioral Health Crisis Care, contact center industry best practices, feedback from crisis center staff, historical Lifeline data, and projected future activities necessary to 988 operations. Vibrant conducted multiple analyses to understand the impact of these variables on costs.

Type Variables Impact on Cost Model Assumptions
Volume and scope Volume More contacts decrease cost because counselors are not idle; more calls increase overall costs because more staff and infrastructure are needed to meet demand. Volume for first 12 months of 988 implementation
Service Modalities Multiple modalities (e.g., phone, chat, text services) require infrastructure development and expertise in centers; handle times may be longer, so more staff are needed to maintain performance levels. Inbound and outbound, calls, chats, and texts
Handle Time Longer contacts require more staff to maintain performance levels; handle times may change depending on breadth and scope of services. 20 minutes
Service standards KPIs More aggressive Key Performance Indicators (KPIs) require more staffing and quality improvement functions and thus, increase costs. 74% answer rate across all channels with 85% of contacts connected in 20 seconds or less. (Currently, many centers have much higher call answer rates. Lifeline expects higher answer rates should be achieved in subsequent years as chat and text services are more broadly expanded in states)
Workforce and logistics Staffing

? Number

and type of staff

 More staffing requires increased funding for salaries, benefits, and other costs. Robust staffing plan based on best practices
? Paid vs. volunteer Paid staff require salaries and fringe; volunteers do not but still have costs related to training, supervision, management, and retention. Counselor salaries are based on current Bureau of Labor Statistics averages for social workers. All counselors are paid and professionalized.
?Training and Support More time spent on onboarding and refresher trainings, case conferencing, and debriefs improve quality and retention but require more staff to maintain service levels. 105 hours of initial training and 15 hours/month of coaching, debriefs, training.
?Remote work A flexible remote work policy allows for reduced capital, facilities, and maintenance costs. Allowed as volume grows
Network size More centers increase costs as each center will require infrastructure, with some duplicated costs. National network of approximately 200 centers
Routing Centralized routing allows for more efficient staffing but may lack local context. "Two models: "Independent" model routes an individual to their nearest local crisis center; "Centralized" model routes to the first available counselor in the individual's home state, which might not be the nearest local center. The second model option applies to states with multiple centers.

Considering these numerous factors and conditions, Vibrant estimates that, for the first year of 988 implementation only, a national cost per contact is approximately $79. However, every state and U.S. Territory has unique characteristics, and costs will vary. For example, states with very low call volume, or states with high costs of living, or states with many centers or only one call center, will have expenses that may be significantly higher or lower than the range provided here.

Potential Workload Forecast

While national demand for services is presented as the total number of initiated contacts, the potential workload forecast is defined as the total number of initiated contacts answered and the total amount of time, effort, and resources required to respond to those contacts.

Workload forecasts--presented as answered contact volume--are based on the moderate growth model for national demand, given the assumption of a national marketing campaign and gradual ramp-up of new capacity to meet demand. Volume was apportioned by state population using 2020 U.S. Census data. The proportion answered was then calculated by removing approximately one-quarter of contacts representing hang-ups and dropped contacts, a common occurrence in crisis work. Expected ratios of calls, chats, and texts were calculated based on historical Lifeline usage. Volume expected to be handled by the Veterans Crisis Line, which the U.S. Department of Veterans Affairs oversees, was not included.

There are several assumptions reflected in the forecasts that might change volume distribution across states as policymakers finalize decisions about the scope and structure of the services:

  • Workload forecasts assume that chat and text services are funded locally rather than nationally. This is different from how the Lifeline network currently operates, where chat and text services are delivered through national sub-networks that route individuals to the first available counselor regardless of their location, and volume is directed to the specific states/territories in which the centers are located.
  • Specialized support for high-risk populations may be handled nationally, reducing the overall work for each state. Plans include provisions for individuals that request specialized services to be routed to the first available qualified counselor regardless of their location.
  • The workload forecasts assume the 988 network will have access to and utilize geolocation data. This will enable calls to be routed more consistently with a state's population than is currently possible with routing based on phone number exchange.