As 988 takes shape across the country as the replacement for the 10-digit National Suicide Prevention Lifeline—part of the bipartisan National Suicide Hotline Designation Act—states continue to respond to the rise in workforce demand.
In this second episode of our series on building and preparing the crisis services workforce, host Taylor Moore, director of research science at ICF, discusses the challenges and successes in scaling 988 across Missouri. He’s joined by Casey Muckler, a suicide prevention specialist with the Missouri Department of Mental Health to explore the ways in which organizations can recruit, train, support, and retain a dedicated and inclusive workforce. Together, they cover topics including:
- Responding to and preparing for an increase in 988 calls—and readying the workforce for even further anticipated influxes
- Training support replacing qualification requirements to create a robust workforce
- Supporting crisis specialists to make them feel confident, comfortable, and empowered
- How call centers can leverage flexibility and remote opportunities to fill open positions
- Developing a comprehensive, trauma-informed training curriculum to provide high quality of care
- Delivering culturally responsive, person-first services to the public
- Securing funding for expanded services
- Recommendations for other state agencies and behavioral health care providers
Full transcript below:
Taylor: Welcome to our second episode of the ICF podcast on building the crisis services workforce. In our first episode of this series, we spoke with a representative from Rocky Mountain Crisis Partners in Colorado, one of the more than 200 crisis call centers across the country. And we discussed the workforce issues that were affecting call centers and their ability to answer calls.
In today's episode, we will hear a different perspective on the 988 implementation and workforce issues. This time, from the state-level perspective. We'll be discussing the decision-making, marketing, and policy decisions that have impacted one state's ability to support a successful launch of 988.
My name is Taylor Moore and I will be your host for this podcast. I'm a behavioral health researcher at ICF. Today, we are joined by Casey Muckler, a suicide prevention specialist in Missouri's Department of Mental Health. Casey will share about the accomplishments and ongoing work to implement 988 statewide and ensure a prepared and diverse workforce to answer crisis calls in Missouri.
Welcome, Casey. Thank you for joining me today. I want to give you a chance now to introduce yourself. Can you tell us a little bit more about who you are and your role at the Department of Mental Health?
Casey: Yes. Good morning, Taylor, and thank you for that introduction. My name's Casey Muckler. I am a 988 state coordinator for the Missouri Department of Mental Health. I really started as a suicide prevention specialist, but with all of the focus on crisis services across the nation, my role really turned into the 988 state lead. And so, what I do is oversee implementation of 988 in Missouri. And then I also assist with implementing other pieces of the crisis continuum.
Taylor: Great. Thank you, Casey. And thank you again for joining me today. So, I'd like to start by hearing more about how 988 functions in Missouri. Can you briefly describe how the call centers work in your state?
Missouri’s distinct approach to 988 infrastructure
Casey: Sure. Missouri has a unique approach to 988. We have a regional structure, so we have seven centers that cover the whole state of Missouri. We have one text and chat center and then six call centers that answer all calls for the state. Missouri has 115 counties, so there's a lot of coverage to consider here. So, we have six call centers that answer primary call coverage, and then we have one of those six that also offers backup coverage for the state. So, a call will route to one of those six call centers originally, and in the chance that a crisis specialist at those centers is unable to answer, the call is then routed to our backup center, which is prominent behavioral health. And that is our second opportunity to answer the call in-state and provide more of a localized response to the individual in crisis before it's routed back to the national backup network.
And then, in November of this year—now, I’ve got to get used to saying that—we're in 2023 now. In November of 2022, our text and chat center went live. So DeafLEAD is the text and chat center for us here in Missouri, and they started answering texts and chats in November of 2022. So, we have 24/7 and statewide coverage of all 988 calls, texts, and chats.So we have 24/7 and statewide coverage of all 988 calls, texts, and chats.
Taylor: Excellent. So how were these call centers established? How long has this network been set up in Missouri?
Casey: That's a good question. And the setup of these call centers in Missouri is not new. Missouri has historically had a program called Access Crisis Intervention, which we lovingly call ACI. And so, ACI is a network of crisis call centers that are offering local crisis call coverage for Missouri, and they also offer mobile crisis. So, this is historically what we've had in place here in Missouri, but it hasn't always operated uniformly across the state. It's very patchwork or has been very patchwork in the past. And so, with 988 coming into the light, we really took this opportunity to work towards 24/7 and statewide coverage of crisis contacts.
Early on we started with two national suicide prevention lifeline centers here in the state. And over time, with 988 coming live, we had been attempting to grow that membership to help reduce the burden on those two crisis call centers that were answering NSPL calls. And so, we were encouraging those ACI providers to come on board to get interested in being an NSPL [National Suicide Prevention Lifeline, now the 988 Suicide and Crisis Lifeline] provider. And over time, the membership grew from two to three to four, and then eventually we ended up with seven crisis centers that wanted two answer 988 contacts for the state. So, it was a long time of building that network, really establishing relationships between those ACI crisis centers and then also our 988 centers.
Preparing for 988 rollout and increased call volume
Taylor: So, I'm hearing that, really, the infrastructure has been built up over time. I'm curious—I was just browsing the latest data that was available in terms of call rates nationally and saw that, in November, nationally, the answer rate was at 88% and that the volume—the call volume—was at a 30% or 38% increase compared to the prior year of November 2021. So how's Missouri doing within those metrics since the launch of 988? Have you seen the call volume go up? Have you maintained your call answer rate? What's that look like in Missouri?
Casey: Yeah. I would say with 988 rollout, rollout here in Missouri went fairly smoothly. And I think that that was really due to a lot of preparation on the front end before 988 went live to really prepare for that transition. And so, we put Missouri's new routing structure in place months in advance prior to the official rollout in July in order to test it before things actually went live in July. So just to give that update, rollout was smooth for us, I think, because we had so much planned ahead of time.
When we think about the volume that we saw, we did see a pretty significant increase in volume from June to July of 2022. We went from approximately 3,000 calls in June to 4,000 calls in July. So that was a pretty significant increase in calls for our centers. And this volume really remained fairly steady and has remained fairly steady up until the most recent data we just saw, which was December of 2022. We have seen it slowly increase over the past few months, but the biggest spike really occurred from June to July when 988 went live. And then we also anticipate our volume going up quite a bit as we prepare for our statewide 988 campaign to launch, which is planned to be launched here this month, actually.
Replacing qualification requirements with training support to create a robust workforce
Taylor: Okay. You've seen the increase, you've seen that influx of callers. It's sort of leveling out, but you anticipate that next influx to come as more promotion happens. So it sounds like the infrastructure is in place, the groundwork has been done, but I know that there's also ongoing concern and attention being paid to the staffing of call centers—the workforce, really. And so, what's happening to Missouri to ensure that the workforce is there, it's ready, prepared? That there are people to answer the calls when people in crisis are calling? I hear the backup centers being a big piece of this as well, but tell me more about any workforce issues. How are you anticipating and getting prepared for that next influx of callers?
Casey: Yeah, workforce has been our top priority, really, since we started planning for 988, and that was before I came to the state in March of 2021. Workforce has been really the biggest concern of our 988 centers here and also the state. So workforce has been a big topic of discussion, but we're very grateful that it really hasn't plagued our 988 centers. It has the other pieces of our behavioral health system.
So one thing that we did early on to help prevent any sort of workforce issues was to lower our staffing qualifications. And we did this because we really wanted to put an emphasis on the training requirements and having a really robust and comprehensive training curriculum that would be available for all of our crisis specialists that are answering calls, texts, and chats. And so, our goal was to have crisis specialists feel confident and comfortable and ready to start taking calls. And we just felt like shifting the focus to making sure that they were adequately trained instead of relying solely on staff qualifications being at a certain level. That was really our best bet for ensuring that we can help with the workforce issues. So that is what we did at the state level.
Leveraging flexibility and remote opportunities to fill open positions
I know many of our centers have employed some really creative efforts in hiring for their 988 positions, such as hiring recruitment specialists that are dedicated to specifically hiring for the 988 positions that are open at their centers. Several have offered sign-on bonuses for folks, and then there's even some centers that are trying to hire out of state. But I think the biggest thing that has made centers successful is really allowing for remote opportunities. And so, some of our centers went from not having any remote positions at their agency to offering remote positions for 988. And I think that really helped with ensuring that they had the staff that they needed. And I think that seems to be the case with other centers and other states as well.
Taylor: Yeah, I think that's a common theme I've heard in our earlier conversations as well, the flexibility—flexibility in terms of where people are, where they're located, how they work, working from home, those remote opportunities like you said. And so, I think that's been a huge success story, I guess, in terms of being flexible to create the workforce to meet the need. And I am curious to hear more about the staffing qualifications of your approach in Missouri at the state level. It sounds like the approach has been to broaden the potential pool of folks who can answer calls by really ensuring that they're adequately trained, like you said, and that training curriculum.
Tell me more about that training curriculum. Is that something that you all have created at the state level? How has that gone? What successes have you had there, and what challenges have you had with that?
Casey: Yeah, and just one more thing before I talk about training. Just with the staffing qualifications, we had talked with our 988 centers and really a lot of our behavioral health providers about the qualifications that someone might need to be a crisis specialist. And each center employs their own qualifications as long as they meet state expectations. However, at the state level, we don't think that somebody needs a master's degree to be able to respond to people that are in crisis. There are a lot of other qualities that I think folks can bring to the table and they don't necessarily have to have a master's degree or a ton of years of experience to really succeed in a role as a crisis specialist. And so, that was the thinking behind that. And then just making sure that they are adequately trained. I think a lot of people can excel in that type of role without that type of experience or without that education level that may have previously been the expectation or maybe the expectation elsewhere. So that was just kind of our thinking with that.
Advancing behavioral health training curriculum through partnerships
The training curriculum that we put in place was we really... Let me back up. When we thought about training for 988, we knew we needed a comprehensive and very robust training curriculum for our crisis specialist. The way our ACI providers had been trained was really up to them so that each agency was expected to train their own folks, but we knew, with 988, we had to have a state developed or statewide training curriculum to ensure that everybody across the board is receiving the same type of training to offer a high quality of care.
So, we partnered actually with some crisis system experts out of Arizona, Solari Crisis and Human Services. They worked with us as consultants to help to create two statewide crisis specialists training curriculums. We did one for our 988 crisis call specialists and then another for our 988 text and chat crisis specialists. We know that there's some nuance and some differences between both of those modalities of working with people in crisis. And so, we wanted to make sure that we had a training curriculum that was best for each of those.
And so, they really worked to develop this comprehensive training curriculum for our centers. They worked with us at the state level, and we also communicated with the crisis specialists, with the crisis centers in each of these agencies to make sure that the training we were providing was going to be best practice, but it's also going to make sense for application, and it addressed all of the issues that our crisis centers wanted to have good training on. And so, we did offer training-of-the-trainer sessions for both of those. So all of our centers were able to send trainers to become trained.
There are a number of topics that are in this training curriculum that we wanted to hit on, so we wanted to make sure that we are training our folks on how to have proper phone etiquette when working with people, how to make sure that you're approaching each call with person-centered crisis care, how to empower crisis callers. And our training also reviews a lot of different core models and theories, as well as practical application. It goes into detail, trauma-informed care, stress management, and also a lot of information for self-care because we know our folks. Folks in this field often get burnt out and can be susceptible to burnout quite easily.
Our training also focuses a lot on cultural and personal awareness, diversity, and inclusion. And we are also working on an LGBTQIA+ suicide prevention training as well. And then, in the future, we're hoping to add to this training curriculum, add intellectual and developmental disabilities, a module on working with the intellectual and developmental disabilities community.
Taylor: That does sound quite comprehensive. So that is... You hit on some of the things that I was thinking of. And so, as you described it, you really covered some of those things that I was thinking of. I want to go back to a couple of those things you mentioned, the topics. But first, I wanted to just ask more. The training itself, how is that done? You mentioned that many of these crisis specialists are now working remotely. So do they get trained in person or is this training done over the computer? How are people trained given that our workforce is more remote these days?
Casey: Yeah. We offer a little bit of flexibility. So as we discussed, Missouri does have a regional crisis. We have a regional makeup of all of our 988 centers. And so the way we do things is not always a one-size-fits-all for each center. And it's especially apparent when you look at the size of each of these 988 centers. We have some 988 centers that are really tiny and small. They're in rural Missouri and they're not a big agency. And then we also have 988 centers here in Missouri that are really big agencies. And so, the operations of those centers are very different. And so, we know that when we approach 988 and we approach implementation of all of these pieces of 988, we have to have a flexible approach because there's not going to be a one-size-fits-all for each center. And what works for one center may not work for another center, especially in the case of workforce, because we know that some centers rely heavily on remote positions and some centers, like maybe our smaller centers, don't do any remote positions.
So, we really offer to our 988 centers the flexibility to train their folks how they see fit. So, what we did was we worked with Solari to create this robust, comprehensive, extensive training curriculum. We trained the trainers at each of these centers, and we taught them how to take this training and implement it into their already existing training, if that's what they're wanting to use, to build on what they already have in place, include any information about their own agency and the other services that they offer, and, I guess, the more community-level resources that they can take and put into this state-developed training curriculum. And then they take that and train their folks the way they see fit. So that may look like training some remote folks over the computer, but everybody has to go through this training curriculum. It's 80-plus hours, so it is very intensive. And then anything in addition is supplemental.
So that was really just our thought. We are unique. And so, we knew that the approach needed to be unique with training our folks. And so, we really just offer that flexibility to our centers to make sure that it's going to be most applicable to them
Focusing on staff self-care to provide high quality of care and prevent burnout
Taylor: So one of the other topics that you mentioned in the training curriculum was self-care. This, again, is another theme, but it's particularly related to the workforce and burnout, like you said. But we know that this job, as a crisis specialist, as somebody who's answering crisis calls for a number of hours during the day hearing and dealing with difficult topics—it can really lead to that burnout. And so, that self-care is important. So I think you acknowledge, I guess, the reason that's there, but really the retention piece. Do you think that this is... What kind of feedback have you gotten on that specifically in terms of helping people in this field of work deal with burnout? And tell me more about what self-care is involved for this, because we know this is a workforce issue. If we're going to spend 80 hours getting people trained to be great in their jobs, we want them to stay in their jobs too. So I think it's great that self-care is included, but tell me more about that. I think that's an important topic that others could probably learn from and what you're doing in Missouri.
Casey: Yeah, that's a very important topic. We do talk about it in our training curriculum, although I know that there's more that we can do here at the state to really work on making sure that retention is a top priority and self-care of our crisis specialists is a top priority. And it's funny you mentioned that because I was actually recently talking with one of the 911 coordinators here in Missouri about what they do for their folks because 911 telecommunicators also have a really high-stress job. And so, self-care is very important in their field as well.
And we got to talking about this idea of maybe doing some workshop where we could have both of our groups come together and really just focus on how we can help best support those crisis specialists and the 911 telecommunicators as they continue to work in their jobs. So it's a big picture idea. It's in the future, but I know that there's more we need to do here at the state to help support folks who are answering the calls. And I do think we are going to have some projects in the works in the future to hopefully do that.
Currently, I would say a lot of that retention stuff lands on the 988 crisis centers to help support their folks. We do check in with our 988 centers regularly and ask them about retention, how things are going, how hiring and staffing is going. And I'm not going to lie, a lot of them do say retention is a big issue, especially those bigger centers where they have hundreds of staff members that are answering crisis contacts. So retention is an issue, but they're working on... They are doing all the things that they can do to hopefully help keep folks engaged and make them feel like they are cared for. And I think a big part of that is really just hearing the crisis specialist offering those debriefs when they've had a really hard conversation with somebody, offering opportunities for them to step away and really take care of themself if needed. And so, a lot of them are focusing on that.
One thing that I heard recently from [someone at] one of our centers…that she thought was important and helpful in keeping folks engaged and retaining staff was she had started employing a program in which that center offers to pay money towards a crisis specialist tuition for a certain program after that person has worked a number of hours at the center. And so, I think things like that—really investing in the crisis specialists that you're employing—really goes a long way. Even small things.
One other thing that they did was they paid for someone's credentialing fee, which was I think $40 bucks. But it's even something small like that—just offering to invest in that person, no matter how small, no matter what it is—it really, I think, makes a difference to that person: "Oh, this organization cares about me. I like working here. They clearly care about my personal development." So I think that goes a long way. I'm sure our crisis specialists, or our crisis centers, our 988 centers would have more to say about that. But I do think retention is actually one of the areas we're struggling with. And we need to work on not just retention, but making sure our crisis specialists are maintaining their own health and safety in the job.
Taylor: That's great. I think that it is a struggle, and it sounds like you all are already trying things, and that's important. That's creative—the idea of really investing in staff. And I think it's not only helping them to feel that they have a meaningful job and providing something meaningful to invest in staff, but, in the long run, it's investing in the workforce. It's investing in building that crisis services continuum workforce. If we're encouraging people to continue in this line of work—to continue to contribute to this line of work, advance their education in some way, the credentials, like you said—I think that that goes a long way to continuing to build the workforce in general as well. So it sounds like a great opportunity to do something that will hopefully see the continued building of the workforce.
Delivering culturally-responsive, person-first services to the public
Taylor: I wanted to shift gears slightly. I think another piece of that you mentioned—a topic in the training curriculum that's really an important piece of training the workforce—is that I think you described it as the cultural and personal awareness for the crisis specialists when they're taking calls. And to me, that's about cultural competency—being culturally responsive to those callers. So it’s great to hear that that's an important piece that's already included in your curriculum. What more can you tell me about that? How is that an essential piece of the training? How does that show up in Missouri, and how crisis calls are answered to serve all of the people in Missouri?
Casey: Yeah, that's a great question. I know that one thing that we talked a lot about when we were working with Solari on creating this training curriculum and then we've talked with our 988 crisis centers and all of the crisis providers here in Missouri, is that we want to make sure that the services that we're offering to people in crisis are person-centered.
So one thing we're hoping that our crisis specialists focus on is not just hearing the voices of the people on the other line, but also really taking into account their choices and their perspective, and what would be the best outcome for them—and really trying their best to collaborate with that individual rather than: "This person called me. I am going to share my perspective and try to help them in whatever way I think is best." But really taking into account—there's a person on the other end of the line who has preference. They know themselves better than anyone. And so, really just making sure that the response that is offered to somebody in crisis on that phone call is collaborative. You're working with that individual, not for that individual. And so, that was really a big piece that I think we wanted to home in on when we were providing that training curriculum.
Securing funding for expanded behavioral health services
Taylor: Great. Great. So, tell me about how the state has supported the statewide efforts for 988 and been able to financially provide the funds needed to get you all to this place where you're able to meet the needs for the 988 call line.
Casey: The funding has been a really big piece and I think what has made us so successful in having all of these pieces fall into place. And our centers do so well with 988 rollout and continue to answer many calls, texts, and chats for Missouri. So, early on, I would say, before I came to the state, really, which was in March of 2021, our DMH staff and our 988 crisis centers and all of our behavioral health providers were really already having this conversation about 988. What is it going to be? What is it going to look like here in Missouri? How are we going to implement it, and how are we going to integrate it into our other pieces of the crisis system and the larger behavioral health system? And so, I think all of that really early discussion led to a lot of emphasis on the importance of making sure that 988 is well-funded and stood up.
And so, here at the state level, I know, when I first started, and several others that work at the Department of Mental Health really communicated upwards and outwards that historically the centers that are answering calls for the National Suicide Prevention Lifeline were severely underfunded and really saw very little funding for the services that they are providing. And for us to be successful in helping people that are in crisis here in Missouri, we need to put adequate funding in place to help support these centers, to help hire staff, update their phone systems, update their data collection methods—just all of the things that they need to do to prepare for 988 rollout. We knew that funding was going to be an integral piece of that.
So we were very lucky that we were able to receive some very early pieces of funding through federal block grants. And so, when we received that early funding, we were able to provide some initial funding for our 988 centers to start doing some of those things, like hiring staff and making all those changes that they would need to do and start preparing for the influx in volume and really to start preparing for rollout in general. So, I think that was well... It was at least one year prior to 988 rollout—I think it was a few months even sooner than that. So that early funding I think is really what was very helpful for our 988 centers to help them prepare.
And then, even after that, we continued to look at all of the funding that we could grab to help our 988 centers.
So, with several different funding sources, we were able to obtain adequate funding for our 988 centers for the first year of implementation. So that looked like the 988 state grant that is available through SAMHSA. I believe it's the 988 State and Territory Capacity Grant funding through that, as well as federal block grant dollars. And then we also received a state appropriation. And so, with all of that funding combined, we were able to adequately secure 100% of the funds that we anticipated needing for the first year of implementation.
Taylor: So state appropriation, that's not always an easy thing. And I think many... I hope that many of the folks that may listen to this podcast will hear that and say, "That's something that we try to do. We can't do. We want to do." Was there any secret success that helped to get that state funding to support your work?
Casey: Yeah. I know a lot of other states really looked into the fees, and we did as well. Very early on, we took a look into, can this be an opportunity for us to receive some funding for 988? I don't think it was the best approach for us here in Missouri. And so, we quickly shifted gears and started looking at how we can just grab any type of funding that comes our way that we could give to our centers, basically.
So, we started going down that route and it wasn't an easy feat. So, the state appropriation came with a lot of challenges, really working with DMH leadership as well as the legislators to make sure they understood the importance of 988 and all the ins and outs of what that looks like. But I think we are very lucky in that, here at the Department of Mental Health, we have a lot of really big cheerleaders who understand how important 988 is. As the front door of our behavioral health crisis system, they understood that we really needed to make sure that we got the funding to help our centers or else weren't going to be successful, and we weren't going to help as many people in crisis. And so, I think really having those champions in our state was really helpful in securing the funding that we needed.
In addition, it was well-supported at the capitol. So, lots of folks were very interested in helping to make sure that this was a priority.
Taylor: Great. It's always good to hear what your state's experience had been with that process and how you've been successful. I think that's important for others to hear that story and learn from that because I know that that sustainability piece and finding the funding to continue to sustain 988 and crisis care services in general, is going to be the next challenge for this field. Well, I think we're coming to the end of the things that I wanted to chat with you today about. But the last question to wrap up, are there any other successes you've had that have helped address the staffing demands or have led to really the success you've all had? In general, what kinds of words of wisdom would you like to share for others who may listen to this podcast and maybe in your shoes in other states? Anything else you would like to share?
Developing good working relationships with other behavioral health providers for holistic integration
Casey: Yeah, I guess I'll just share that we've had a lot of really good success here in Missouri, but our work is absolutely not even close to being done. So we have a lot of areas that we're working on as well. One that we even talked about, Taylor, was retention and making sure that our crisis specialists, that self-care is a big priority for us here in the state. Making sure that our crisis specialists are feeling supported and aren't getting burnt out is one that we are definitely still working on. And so, just recognizing where your state is at, or your center is at, looking at where you have areas of weakness and how you can address those, but also recognizing where you have come a long way and where you're succeeding currently.
So my, I guess, one recommendation I would say is that I guess for states and centers out there that are wanting to do more with 988, develop a really good working relationship with the providers or the centers that are in your state—not just your 988 centers, but all of your behavioral health providers because it's all connected. We want our whole crisis system to be integrated into our larger behavioral health system, and we want things to move smoothly. So I would say, one thing that made us successful was really just focusing on building those relationships and collaborating with the centers and the providers in our state early on. And that collaboration and communication can really just make all the difference. Those connections are so important. So, I know that that's one thing that really positioned us to be successful with 988. So, I would just encourage other states, if you're maybe not as close with the centers in your state, start developing closer relationships, start connecting a little bit more frequently.
And then I guess the other piece of advice that I was given that I think is really helpful is to connect with other states and other centers outside of your area. So, if there's an area in crisis services or an area in 988 implementation that you think you can do better in, there are crisis centers and states across the country that are doing amazing things. So, connect with those folks or check in with those folks. We talk with our Vibrant and our SAMHSA representatives often to say, is there a state that's succeeding in this particular area? And if so, can you help us make that connection so that we can get their perspective and see if this is something that we can replicate in our state or at our center? And I think that's been really helpful for us.
We've had states come to us and say things like, "We want to do more work in making sure 988 is well promoted in schools." And so, we have that conversation with them and we're able to share that. And with that conversation we hear from other states, maybe some ideas we hadn't thought of. And the collaboration is really important, I think.
Taylor: That's awesome. I think that's very wise, very important information and recommendations that you've shared here. And so, thank you. It's been a pleasure talking to you, Casey, about what your experience has been in Missouri and all the work you're doing. And like you said, I think the goal here is to share these stories through this podcast, through one way to connect with others, other states, other folks who are involved in this very important work. So, thank you again for joining me on today's podcast, and we will hopefully continue this conversation. As time goes on and we continue to grow the work, we'll talk again and hear about all the additional successes you've had in implementing 988 and the behavioral health crisis services and continuum care. So, thank you again, and we will talk again.
Casey: Absolutely. Thank you for having me.
Taylor: Thank you.