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Northwest Washington Indian Health Board (NWWIHB) Tribal Behavioral Health Native Connections Grant Application Abstract SM-23-021 Our vision for our NWWIHB Native Connections Project is to keep our Tribal youth and our communities Coast Salish Strong. To realize our vision, we propose to utilize findings from the Native Transformations Project to develop universal and selective prevention strategies that are culturally-grounded and strengths-based with the goal to build protection and resilience against substance misuse and suicide among youth 10 to 24 years. The NWWIHB serves an IHS “User Population” of 17,003 people in sis federally recognized tribes: The Lummi Nation, The Nooksack Indian Tribe, The Upper Skagit Tribe, The Samish Indian Nation, the Swinomish Tribal Community, and Tulalip Tribes. The mission of the board is to provide public health services and health advocacy through health education, health assessment and community health control and evaluation. The board of directors are made up of delegates from each of the respective tribes and meet monthly to oversee the boards operation and share information regarding heath issues within their tribal communities. The organizations Executive Director is responsible for the day-to day operations, administration and program performance. T The Northwest Washington Indian Health Board (NWWIHB) Native Connections Project aims to translate findings from the Native Transformations Project into community-driven and cultural substance misuse and suicide prevention strategies for the nearly 5000 youth 10 through 24 years residing in the NWWIHB service region. Deaths from drug overdose have reached epidemic levels within our Tribal communities in the Pacific Northwest. Rates of fatalities from opioid overdoses have increased rapidly over the past five years and impact most severely upon youth and young adults residing on their ancestral lands in rural and reservation-based Tribal communities. We acknowledge our tremendous strengths and resilience as Tribal people, and prior research through the Native Transformations Project demonstrates the power of the protective factors inherent in our Coast Salish culture and ways of living. The NWWIHB Native Connections Project aims to address critical gaps and unmet substance misuse and suicide prevention needs for youth and young adults residing the NWWIHB service area. We propose to accomplish the following goals 1) Promote Coast Salish Protective Factors among youth ages 10 through 24. 2) To increase tribal readiness and capacity in the NWWIHB service area to deliver youth prevention, referral follow up and postvention services as well as mental health promotion. 3) To develop and deliver community-driven strength-based and cultural prevention strategies using results from the Native Transformations Project and implement strategies with youth ages 10 through 24. 4) To keep our youth in our communities Coast Salish Strong.

Strengthening Tribal Community Wellness Through the FSIP Prevention and Intervention Program to Reduce Youth Suicide, Substance use/Misuse, Impact of Trauma, and Promote Mental Health Five Sandoval Indian Pueblo Inc, (FSIP) is on e of the oldest Native American non-profit organizations in New Mexico serving their consortium of 5 tribal and non-tribal communities in Sandoval County. FSIP provided Behavioral and Prevention services in rural communities where populations are small and access to care is limited. FSIP's program will provide prevention and treatment interventions in tribal communities to prevent and reduce suicide and substance use behaviors, reduce the impact of trauma and promote mental health among tribal youth through age 24. The majority of FSIP services are provided by tribal members and in such a manner that the value of tribal sovereignty, traditional culture, and community integrity are respected and preserved. The project will include tribal community members to be involved in all grant activities including planning, program implementation and evaluation. The program includes culturally responsive evidence-based models in both prevention and treatment interventions. Programming will be accomplished through a community-based approach using universal, selective, and indicated prevention and intervention strategies by enhancing service delivery systems. The enhancement of service delivery systems include: substance use, and trauma in both prevention and treatment interventions; implementing advocacy strategies through promoting wellness among tribal youth and their families; creating post-intervention protocols in response to suicide attempts as well as suicide contagion/cluster suicide; and promoting overall community health. The target goal of FSIP's Program is to serve 25% of the youth in tribal communities served annually. Additionally, through conducting the community readiness assessment (CRA), strategies including community engagement and outreach will be identified extending outreach efforts and engaging more youth and their families into programming. FSIP is committed to partnering with both tribal and non-tribal entities to maximize wellness.

The Nebraska Native Connections initiative is an inter-tribal effort to provide mental health and substance use/misuse services to Native American youth in reservation, rural/frontier, and urban communities throughout Nebraska. The Initiative aims to identify local policies, systems, and environmental change strategies that address suicide prevention, mental health promotion, and substance misuse for (AI/AN) youth, as well as to identify areas needing improvement. The Initiative will address the significant mental health and substance use/misuse needs of Native American youth in Nebraska. According to the 2017-2021 American Community Survey (ACS), there are 36,992 American Indian-Alone (or in combination) residents in Nebraska. Thirty-two percent are children and adolescents between the ages of 0-24 (n = 11,993). Native American youth in Nebraska are more likely to live in poverty, have less access to healthcare, higher absenteeism rates and lower graduation rates, and experience higher rates of trauma than other children in the state all of which negatively impact mental well-being and overall wellness. The Initiative will be implemented in partnership with a variety of community-based organizations, including tribal governments, schools, mental health clinics, and substance abuse treatment centers. A total of 100 Nebraska Native American youth will be served annually, 500 throughout the lifetime of the project. The Initiative will implement a number of strategies and interventions, such as: Determine the community's readiness to address suicide and substance misuse among AI/AN youth and develop a community action plan based on the results of the community readiness assessment. A tribal strategic action plan that addresses the needs of AI/AN youth regarding suicide prevention and substance misuse using a public health model multi-tiered approach will be developed. Furthermore, the project will develop and/or revise "postvention" protocols that reflect the traditions and culture of the community while also addressing coordination of care and intervention among youth-serving agencies for AI/AN youth. Amongst the key goals and objectives are: Goal 1: Identify local policies, systems, and environmental change strategies that address suicide prevention, mental health promotion, and substance misuse for AI/AN youth, and identify areas needing improvement. Objective 1.1: Partner with local organizations and stakeholders experienced in working with AI/AN youth for cultural insights and effective suicide prevention, mental health promotion, and substance misuse strategies within two months of project start. Goal 2: determine the community's readiness to address suicide and substance misuse among AI/AN youth. Objective 2.1: Based on the results of the community readiness assessment, develop a community action plan that outlines specific strategies and activities for addressing suicide and substance misuse among AI/AN youth.

San Diego American Indian Health Center (SDAIHC) is a private, non-profit 501 (c) (3) Federally Qualified Health Center (FQHC). SDAIHC was founded in 1979 by a group of Native American community leaders, who recognized the need for improved access to care for San Diego Native Americans/Alaskan Natives (AI/AN) and low-income populations in the San Diego area. The Native Connections Project, proposed by the San Diego American Indian Health Center (SDAIHC), will develop an integrated and culturally respectful system of care that identifies and responds to the mental health, substance use disorders, and cultural trauma needs of American Indian and Alaska Native (AI/AN) youth through the age of 24 years residing in the San Diego metropolitan area. The proposed project will serve urban Indians, a population that has been described as “invisible” because they are not affiliated with a single Tribe, reservation, or cultural tradition. The AI/AN population within San Diego County as race alone or in combination with one or more other races is reported at 96,918 by the U.S. Census Bureau. AI/AN race alone are reported at 38,916. An estimated one fourth or 25% of the population are youth ages 10 – 24 years of age. The Center for Disease Control and Prevention (CDC) July 2022 MMWR reports an increase in deaths from opioid overdoses from 14.4 to 16 per 100,000 population between 2019 and 2020. The same deaths amongst AI/AN youth ages 10-24 years were higher than other race or ethnic groups in 2020. Suicide rates were higher as well at 42.6 deaths per 100,000 people for males and 13.8 deaths for females as reported by CDC for the year 2021. Both prevalence of drug abuse and suicide are influenced by negative socioeconomic conditions including poverty, lack of affordable housing, food insecurities, limited educational and employment opportunities and limited access to physical and mental health services. Other factors may include adverse childhood experiences, violence, gang influences, low self esteem and bullying and others. The SDAIHC Native Connections project team will implement the evidenced-based SAFE-T model to include Universal Prevention Strategies and interventions to support the: (1) establishment of an integrated cross-community behavioral health program supporting awareness and prevention of mental health disorders, and suicidal and substance use behaviors within the AI/AN your population residing in SDAIHC’s service area; (2) engagement with local AI/AN community agencies and non-Native organizations, including public and private agencies, to establish a multi-sectoral system leading to improved coordination of culturally responsive mental health and trauma based services for AI/AN youth; and (3) development of a sustainable continuum of care services model for AI/AN youth as they transition to adulthood. To reach its overarching goals, SDAIHC will utilize its existing Youth and Community Advisory Boards and expand to include an Inter-Agency Advisory group to facility community collaboration and host an annual GONA. Other activities and training will be identified to increase awareness of cultural practices and preferences.

Native Connections project will be used to improve mental health plans, policies and procedures for American Indian youth up to age 24. The population to be served through this improvement in mental health services focused on the prevention of suicide, postvention, and substance use disorders are American Indian youth who are Tribal Members, Tribal Descendants, and Tribal members and Descendants of other Tribes in which the Saginaw Chippewa Indian Tribe (SCIT) serves. Project Goals and objectives are as follows: Goal One: To increase mental health plans, policies and procedures focused on suicide and substance abuse to address the needs of American Indian/Alaskan Native students and the community. Objective One: By January 2024, increase the capacity of SCIT to address mental health issues in youth suicide and substance misuse by 50% through the hiring of staff that will provide community readiness assessment, and strategic action planning. Objective Two: By September 2026, to increase evidence-based protocols, policies, procedures, and processes that address suicide and substance misuse, both prevention and postvention, by 50% through the development of transparent protocols and systems for the Tribe. Objective Three: By September 2026, increase cultural resiliency programs for youth and the community that promote coping skills and build protective factors against suicide and substance misuse in youth through the provision of culturally relevant programs, inclusion of Traditional Healer in mental health services offered to students, and community educational events. Objective Four: By April 30, 2024 and ongoing, increase understanding and needed systems for suicide and substance misuse in youth by 50% through the collection and analysis of data per grant requirements. As policies, procedures and processes are improved, the benefits of the grant are expected to impact all tribal youth. The expected number to be served each year, therefore, is 500 youth.

The Toksook Bay Native Connections project will utilize our ancestral strengths and traditional Yup'ik ways of life to deliver an evidence-based prevention service program for our youth called Qungasvik (Tools for Life). Our vision for substance abuse prevention, suicide prevention and mental health promotion in Toksook Bay is to strengthen our identity as Yup'ik People. Our vision aligns with SAMHSA's National Tribal Behavioral Health Agenda (TBHA) which, "elevates the importance of tribal identities, culture, spiritual beliefs, and practices for improving well-being." The goals of our Native Connections project are to: 1) Increase the capacity of the Toksook Bay Tribe and community to provide prevention services, and to promote positive behavioral health at home for young people 10-24 years old. 2) Increase positive childhood experiences and protective factors for young people at risk (10-24 years) by implementing an evidence-based practice that builds Yup'ik strengths through culture and connections. 3) Decrease youth alcohol and substance misuse by implementing an evidence-based practice that increases protection against alcohol initiation and binge use. 4) Increase reasons for life and reduce risk for suicide by implementing an evidence-based practice that addresses the impacts of trauma and builds meaning and purpose for youth. 5) Increase healthy social connections and intergenerational interactions among youth, Elders and community. 6) Measure youth outcomes from the prevention services and gather community-level data on youth behavioral health and holistic well-being. Our Toksook Bay Native Connections project will serve the entire community of 650+ members through universal prevention strategies and Tribal gatherings. Culturally-centered selective and indicated prevention strategies will focus on engaging 150 young people 10-24 years who are at risk in the community in peer-based and Elder-led activities that promote positive behavioral health and holistic well-being. Our community has already shown in our first Native Connections project that we can be leaders of change and that we can come together to surround our young people with teachings, practices and resources from our culture and our ancestors. We seek to build on our growing foundation of hope and healing with this new Native Connections project and become a model for sustained community change.

The Texas Health and Human Services Commission is applying for the 988 State and Territory Improvement Project in order to improve Texas' existing 988 crisis response system. HHSC plans to serve all Texans experiencing mental health crises by connecting them to a trained crisis counselor who can address their immediate needs or connect them to the appropriate resources. If awarded, HHSC plans to implement a multi-faceted approach to improve the already existing 988 services. This includes increasing the in-state answer rate, improving the 988 infrastructure and the coordination of crisis response services, improving 988 support for high-risk populations, ensuring comprehensive quality assurance, and increasing awareness of 988 and available resources throughout the state. In order to achieve these goals, HHSC will leverage its existing robust crisis continuum and conduct a comprehensive review of current statewide capabilities to inform future direction during the project period which may include contracting or subcontracting with entities to expand in-state 988 service capacity. HHSC plans to continue building on the work accomplished through the 988 State and Territory Cooperative Agreement awarded to HHSC for April 2022 through April 2024. In January 2022, Texas' in-state answer rate was 45 percent, and by April 2023, the in-state answer rate increased to 75 percent. Additionally, through the work of the 988 State and Territory Cooperative Agreement, HHSC pursued substantial improvements in the statewide 988 crisis system by expanding primary and backup coverage. HHSC will continue to allocate funding to the four 988 centers providing primary coverage and one 988 center providing backup coverage in order to expand workforce and reinforce services. HHSC has already begun creating a communication strategy plan to ensure education regarding 988 is accessible to all Texans, especially those in high-risk populations. HHSC is committed to enhancing its quality assurance plan to ensure those served through 988 are receiving the best service possible. HHSC and its partners are strongly committed to working towards the minimum required in-state answer rate of 90 percent by the end of fiscal year 2026. HHSC will contract with partners to ensure efforts are increased in recruiting, hiring, training, and expanding the behavioral health workforce in Texas to uniformly respond locally to persons who call, chat, or text 988 services.

The Wyoming 988 Cooperative Improvement is an opportunity for the two Wyoming lifeline call centers, Central Wyoming Counseling Center and the Wyoming Lifeline, to improve their workforce, protocols, and data collection to meet the demands of 988 calls, chats, and texts. The first priority is to begin accepting chats and texts in Wyoming and bring the in-state answer rate up to 90 percent. The project will strengthen the call centers' capacity for suicide prevention as well as strengthen reporting and communication efforts between the call centers and the Wyoming Department of Health. To achieve the long-term goal of improving access to 988 resources through calls, chats, and texts, originating in Wyoming, the following goals have been outlined: Goal 1: Expand recruitment, hiring, and training of 988 workforce to meet 90% of the state calls, chats, and texts demands by December 31, 2024. Goal 2: Implement additional technology to fully support 988 infrastructure and effective coordination across the crisis continuum by September 29, 2024. Goal 3: Improve 988 support and service for high risk and underserved populations throughout the grant period. Goal 4: Collaborate with 988 centers to enhance referral connections post-988 contact throughout the grant period. Through the development of a sustainability and quality assurance plans following the grant award, Wyoming is hopeful that the collaboration between the State, both lifeline centers, and other partners will strengthen follow-up services, referral resources, and communication, as well as improve data collection.

In July of 2022, Michigan took a significant step forward in prioritizing mental health by announcing the launch of the new 988 number. The initiative aims at revolutionizing the state's mental health crisis response by strengthening and expanding the network of crisis call centers and ensuring timely and effective support for all individuals experiencing a mental health crisis or any behavioral health related distress. Since the start of 988's go-live in July 2022, metrics have shown that calls received by Michigan call centers have steadily increased from 5,241 in June 2022 to 7,182 in June 2023. Before, during, and after 988's official go live, MDHHS has worked vigorously towards gradually increasing Michigan's service infrastructure over the past year. Since December, Michigan has consistently reached a 90% in state answer rate. Through the 988 State and Territory Improvement Grant, our goals moving into the next year are to focus on expanding Michigan's call center capabilities to answer 988 texts and chats, maintain Michigan's in state answer rate of at least 90% for all 988 calls, work towards improving the quality of interactions between call takers and 988 callers, and ensure that we are tailoring and efficiently marketing 988 to fit all Michiganders' needs, especially those considered high risk or underserved. This initiative will also involve continuing to maintain a close and collaborative relationship among state agencies, mental health organizations, community-based leaders, and stakeholders in order to establish a comprehensive and seamless system of care. With stable call infrastructure in place our new goal now is to focus on finding ways to improve the quality of services to all Michigan residents, but especially those who may be considered to be at a heightened risk. Michigan's primary center, MICAL, is now ready to expand its' capabilities to begin taking texts and chats. Reports outlining 988 text and chat metrics have indicated that the state demand for chat and text went from 247 in May of 2022 to 2,277 in May of 2023, implying both public interest and the expanding need to incorporate chat and text answering capabilities into MiCAL. Michigan has already invested considerable time and resources in the development and implementation of the 988 program. With additional funding provided through the "FY 2023 Cooperative Agreements for States and Territories to Improve Local 988 Capacity" grant, Michigan will be able to have the opportunity to expand its 988 capabilities and resources and work towards improving and tailoring current processes.

As the Single State Agency for substance abuse and mental health, Delaware Division of Substance Abuse and Mental Health (DSAMH) will oversee the implementation of the Delaware 988 State and Territory Improvement Cooperative Agreement. The goal is to improve state capacity in responding to 988 calls, chats, and texts from Delawareans of all ages. The funding will support the expansion of the workforce and infrastructure toward establishing a state-wide Behavioral Health Crisis Communication Center that serves as the central hub for Delawarean adults and children seeking mental health, suicide, and substance use crisis support services. Building on our ongoing work, DSAMH and our partner organizations seek to leverage this Cooperative Agreement program resource to: (1) enhance recruitment, hiring, and training of 988 workforce to meet at minimum 90 percent state or territory calls, chats, and texts demand;(2) implement additional technology and security measures to fully support 988 infrastructure and effective coordination across the crisis continuum;(3) improve 988 support and service for high risk and underserved populations; (4) develop and implement comprehensive quality assurance plans, to include identification and review of critical incidents; and (5) develop and implement comprehensive 988 communication plans in line with SAMHSA 988 partner toolkit. Based on the projected volume from Vibrant, we anticipate as many as 39600 individuals experiencing crisis episodes would be served annually.

The American Samoa Department of Health (ASDOH) is the applicant for this grant application. ASDOH proposes to utilize the FY 2023 988 State and Territory Improvement funding opportunity to develop and expand the American Samoa 988 crisis center and enhance the crisis response delivery system in the territory. The American Samoa 988 crisis center is an onboarding Lifeline crisis center which as such, cannot answer 988 calls originating from American Samoa making this the most significant gap in the delivery of 988 crisis response in the territory. Through this funding opportunity, ASDOH will be able to address gaps in services, build the workforce and operational capacity of the 988 crisis center, and improve crisis response services to ensure that individuals in American Samoa seeking assistance from 988 will get the service they need. This funding opportunity will help the territory to achieve official Lifeline crisis center status by addressing. The following project goals: 1. Increase the American Samoa 988 Crisis Response operational and workforce capacity to respond effectively to crisis and suicide calls received at the crisis center and helpline. 2. Increase coordination across the territory’s crisis response service system by developing a Territorial Crisis Response Plan and Protocol to be adopted by the 988 crisis center and primary crisis emergency first response services. 3. Reduce delays in delivering effective crisis response and involvement of 911 in crisis calls by establishing a Mobile Crisis Unit as an extension of the American Samoa 988 crisis center and helpline. 4. Increase and expand the territory’s phone coverage capacity to access the 988 number through phone, texts, and chats.

Virginia aims to maintain and enhance its crisis services and establish a comprehensive system that effectively integrates the National Suicide Prevention Lifeline to better support individuals in crisis throughout the state. Suicide deaths in Virginia have been slowly increasing since 1999, with a 25% increase observed between 2010 and 2018. However, there has been a recent slight decrease of 4.3% from 2018 to 2019. In response to these trends, Virginia has implemented a multifaceted approach to address the issue. Previous capacity grants allowed Virginia Call Centers to increase call answer rate from 52% (1886 calls, average speed to answer of 00:35) in January 2021 to 86% (4606 calls, average speed to answer of 00:41) in January 2022, and currently at 92%. To maintain these improvements, our state plans aim to enhance critical capacity and achieve goals in three key areas: improving call response, workforce development, and outreach. During these processes, ongoing evaluation of system needs and adjustments to the states sustainability plan will be made for ongoing system efficiency and efficacy.

The Illinois Department of Human Services/Division of Mental Health (DMH) will utilize the Illinois 988 Improvement Program Grant to continue the expansion of capacity of Illinois Lifeline Call Centers (LCCs) to respond to calls, texts and chats from Illinoisans to the 988 Suicide and Crisis Lifeline, as well as engage in additional activities to improve the 988 system in Illinois. This includes an investment in a comprehensive 988 communication strategy, enhancing data collection across all LCCs, further coordinating the 988 infrastructure with the larger behavioral health crisis continuum of care and the 911 system, and enhancing capacity for post-988 contact follow-up to Illinoisans. Through interagency and partner engagement and planning, DMH will ensure that the 988 system is fully prepared to assist individuals with substance use needs and will develop plans for quality assurance and measures of effectiveness and return on investment analysis. Illinois is a large state geographically with a total of 102 counties across 57,915 square miles and a population estimated at 12.85 million people. With the assistance of the current SAMHSA funded Illinois 988 Capacity Grant, DMH has successfully established statewide coverage of call centers, and has seen a rise from an 18% answer rate in June 2022 to 87% in April, 2023, a success which is expected to continue as DMH partners with the six LCCs currently doing this work in Illinois, as well as partnering with a seventh center that is currently in development. With the award of this grant, DMH is confident we can provide all Illinoisans experiencing a behavioral health crisis with the immediate and effective responses needed, from call takers who are familiar with the state's unique culture. Based on data provided by Vibrant on contacts from Illinoisans, it is estimated that a total of 125,977 Illinoisans will benefit from this program on an annual basis.

The proposal for the FY2023 988 State and Territory Improvement Program, or the "988 Tennessee Improvement Program" as referenced throughout this application, provides justification for the funding necessary to support enhancement of Tennessee's 988 infrastructure for crisis calls, texts and chats. Through this work, data will be collected to inform downstream impact to the current crisis continuum for both current and future calls, chat and texts that originate in Tennessee as part of the 988 network. Provision of effective services to these individuals is essential in ensuring they relate to services that are, very often, lifesaving. Utilizers of 988 to call, text or chat in Tennessee will receive effective and efficient screening, triage, intervention and referral services to ensure that they are met with appropriate resources in diffusing the crisis and normalize behavioral health concerns, along with the resources to assist in navigating these. Funding is proposed to ensure increased capacity in the provision of crisis follow-up services, so that all that present to 988 for support receive services to ensure de-escalation of the crisis, along with referral linkage as appropriate. Funding for implementation of formal marketing efforts is proposed to increase awareness of this resource, including the scope of services provided to those presenting in a mental health emergency. A robust evaluation is proposed within this program around staff training, along with evaluation of effectiveness in follow-up services in increased referral linkage and reduced recidivism. Last, this proposal included utilization of technology in ensuring all 988 providers are equipped with real-time, county specific resource information to ensure that the appropriate level of intervention and resource is provided. The Tennessee Department of Mental Health and Substance Abuse Services has a long-established partnership with the seven Tennessee based 988 providers, ensuring that services are available to individuals in all 95 counties across the state. Through the implementation of this grant program, it is the goal to enhance capacity and data collection efforts to ensure that Tennessee meets or exceeds 90% total contact handle rate. Additionally, TDMHSAS will continue to utilize data to identify needed capacity downstream as a result of any potential volume increases, along with utilization for quality assurance measures and overall program development.

The 988 State Improvement Project aims to utilize funds for the following objectives: 1) Facilitate effective coordination and collaboration between the 988/911 services across the Crisis Continuum in Colorado. Specific plans will be developed to account for regional differences; 2) Enhance collaboration and understanding with local Public Safety Answering Points (PSAPs); 3) Implement a comprehensive statewide quality assurance and continuous quality improvement plan; 4) Execute a 988/911 Integration Communication Plan and a statewide marketing campaign; 5) Improve Colorado's centralized resource directory, known as Colorado Ownpath; 6) Enhance the Rocky Mountain Crisis Partners (RMCP) Mobile Crisis Response Dispatch Portal to enhance referral tracking and follow-up care. To achieve these objectives, Colorado will establish regional workgroups that will inform statewide efforts and create regional process maps outlining crisis services. Statewide training for Public Safety Answering Points (PSAPs) will be provided to improve coordination between 911 and 988, and PSAP staff will be recruited to participate in regional workgroups. Monthly reports outlining 911 Resource Center and coordination efforts will be developed to increase awareness throughout the state. A state quality assurance plan will be created based on continuous data analysis and trend recognition. Trend data will be presented monthly to the steering committee and made available to the public through a data dashboard. The care directory in Colorado will be enhanced to track information related to individuals using the 988 services. A statewide marketing strategy will be implemented, and the campaign's effectiveness will be measured using industry-standard benchmarks. During the first six months of the calendar year 2022, Colorado's statewide crisis line experienced a significant increase in call volume, with a record high of 18,881 calls in May 2022. Although the volume for 988 remains considerably lower than the statewide crisis line, it has been steadily increasing each month, reaching a total of 52,949 calls from July 2022 to May 2023. Based on the current 988 call volume, this project is expected to serve approximately 63,539 individuals per year and 190,616 individuals over the lifetime of the project. However, the Behavioral Health Administration (BHA) anticipates a significant increase in 988 call volume as the implementation progresses and calls previously handled by the crisis line are transferred to 988. The 988 State Improvement Project will utilize funds to support Colorado's commitment to integrate the statewide crisis line and prioritize 988 as the primary point of access to Colorado Crisis Services. Colorado Crisis Services is the state's 24/7/365 crisis response system, available to anyone in Colorado, regardless of their ability to pay. This project will prioritize statewide behavioral health resource navigation and increase access to Colorado's most vulnerable populations in need of crisis response services and support.

Iowa 988 Improvement Cooperative Agreement Project Summary The Iowa Departments of Human Services and Public Health have joined to form the Iowa Department of Health and Human Services (Iowa HHS). The Department of Human Services is the applicant agency but will be referred to as Iowa HHS throughout the application. Iowa’s 988 State Planning Team, comprised of Iowa HHS staff, will collaborate with Iowa’s two 988 Centers (Centers), CommUnity Crisis Services and Food Bank (CommUnity) and Foundation 2 Crisis Services (Foundation 2) to improve 988 services in Iowa. Increasing Iowa’s capacity to answer 988 contacts originating from Iowa will improve answer rates in Iowa, ensure Iowa contacts are first routed to Iowa’s Centers, and increase access to local behavioral health services. Iowa HHS will work with Iowa’s two 988 Centers to identify, recruit, hire, and train the needed behavioral health workforce for the successful implementation of 988. Iowa’s target population is any Iowan experiencing a behavioral health crisis. Iowa anticipates 236,044 individuals to be served through this grant, 52,140 during year one, 83,593 during year 2, and 100,311 during year 3. During the first year of 988, Iowa answered 24,820 total contacts comprised of 17,744 calls, 4,022 chats, and 3,054 texts. Iowa HHS will continue to work closely with the Centers on building capacity to answer 988 calls, chats, and texts. Iowa will continue to build off work completed during the 988 Capacity Building Cooperative Agreement to connect individuals entering Iowa’s behavioral health system through 988 with community-based services including but not limited to mobile response. Utilizing a centralized resource and referral system will increase the connection between the Centers and community-based services including crisis services, substance use services, and certified community behavioral health clinics. Iowa HHS will develop a statewide education and marketing campaign utilizing SAMHSA’s 988 toolkit to increase awareness of 988 services. Iowa HHS will continue to work closely with Iowa’s 911 program manager, public safety answer centers, and the Centers on how to best serve Iowans through both systems.

Vermont is proposing to increase staffing to increase efficiency and implement technology to enhance coordination of mobile crisis outreach and 988 in order to meet the targeted answer rate of 90%.

Responding to an increase in call, text, and chat volume one year following the national transition to a 3 digit crisis number remains a major priority for Pennsylvania. Through strategic increases in staffing and incentives across all 13 call centers, PA aims to exceed and maintain a consistent instate answer rate of 90 percent, while also having the two in state call centers that respond to national text and chat answer no fewer than 90 percent of the texts and chats originating in Pennsylvania. PA through receipt of the 988 State and Territory Improvement grant funding, will further serve its 13 call centers and the people who call, text, or chat with the centers for help during a mental health crisis. Previous funding and a cooperative, collaborative working relationship of the call centers, project team, partners, counties, Vibrant, and SAMHSA have helped us to significantly improve our call answer rates, but consistency is key and this grant will help to solidify call answer rate goals and more. Call, text, and chat numbers indicate that the call centers have served well over 100,00 people since May 2022. We believe these numbers will increase substantially as staffing reaches full complement and as the public awareness campaign informs and encourages the use of 988. it is difficult to estimate how many we can or will serve, but we are committed to achieving the grant goals and therefore being able to reach as many people as need services. We will continue statewide committees Reach and maintain statewide metrics for 988 calls, texts, and chats Develop and implement a statewide communications plan Improve data collection from call centers to focus on high risk populations Develop a report on the states current mobile crisis service options Develop a joint report with the state 911 administrator Enhance the state capacity to ensure referral connections post 988 contact Develop a sustainability plan for sustaining call center workforce capacity and maintain the Lifeline key performance indicator metrics Develop a comprehensive quality assurance plan Engage with the state substance use policy team and 988 call centers to develop appropriate protocols and referral resources for 988 contacts requiring substance use crisis care.

Absent indirect costs, all funding shall support Utah's Crisis Center to expand workforce4 to answer 90% of all total contacts (calls, texts, and chats).

The Commonwealth of the Northern Mariana Islands (CNMI) Commonwealth Healthcare Corporation (CHCC) proposes through the CNMI 988 Program to coordinate a task force of key CNMI stakeholders and work collaboratively to improve and expand a 24-hour 988 crisis call system and crisis response services for CNMI community members on Saipan, Rota, and Tinian in need of behavioral health crisis care. T The CNMI CHCC, currently operates the CNMI 988 Program, as part of its CGC Behavioral Health Services to the islands of Saipan, Tinian, and Rota since January 2022. The CNMI CHCC 988 Program has prioritized the ongoing development and implementation of the 988 initiatives to operate the 988 Crisis Line 24 hours a day, 7 days a week with the CNMI 988 crisis line becoming active as of April 2023. Through this funding opportunity that focuses on improving local 988 capacity, the CNMI CHCC: Community Guidance Center proposes to complete ongoing and anticipated 988 program activities but to incorporate mechanisms needed for 24/7 crisis line coverage at a 90% rate and expand to incorporate and develop comprehensive crisis care services: the 988 crisis line, mobile crisis response services, and a stabilization unit on the islands of Saipan, Rota, and Tinian. The CNMI 988 Program aims to implement a comprehensive and collaborative approach focused on further developing, improving, and expanding the 988 crisis call and crisis response infrastructure; workforce capacity; system-level capacity, partnerships, and coordination; communications and marketing work plans; and data surveillance and evaluation to meet a projected 792 calls annually and 1,584 calls throughout the duration of this project. The following are the CNMI 988 Program goals and objectives: Goal 1: Expand the availability of and access to behavioral health crisis response services through the implementation of an effective and reliable 988 crisis call system. Goal 2: Increase the capacity of the crisis response workforce to respond, intervene, and provide follow-up to individuals experiencing a behavioral health crisis. Goal 3: Increase system-level capacity to implement a coordinated and effective response to behavioral health crisis needs. Goal 4: Continually increase the effectiveness of behavioral health crisis response through data surveillance and evaluation.

The Nevada 988 Lifeline aims to prevent deaths by suicide and to reduce harm from intentional, self-directed injuries for all persons experiencing behavioral health crises. As an integral part of the State's evolving crisis response system (CRS), the Nevada 988 Lifeline provides individuals in crisis with access to support services from trained professionals and paraprofessionals who can be reached by telephone, text and chat. A critical gap in the State's current crisis response system involves the in-state answer rates for calls, texts and chats that are received by the Nevada 988 Lifeline. Nevada's average answer rate for in-state calls is 73%. The State will use funding from the 'FY 2023 Cooperative Agreements to Improve Local 988 Capacity' to achieve a lower staff to supervisor ratio by increasing competitive pay rates and to provide corresponding training and support so that staff will be able to meet the standards established for call center personnel. In the absence of this support, the State anticipates that the crisis call center will not be able to increase the capacity needed to maintain or increase call answer rates and decrease wait times. By expanding Workforce capacity for call center answering and case management, the Nevada 988 Lifeline would be expected to respond with answer rates for calls/texts/chats that exceed 90%.

Population to be served: All Alaskans, Alaskans calling the 988 Suicide and Crisis Lifeline Number of people to be served: 40,000 Summary of project: Alaska’s need for improved suicide prevention and early interventions like the 988 Lifeline is tragically evident. In 2019, suicide was the leading overall cause of death for youth and young adults in Alaska aged 15-24. In addition to the high rates of suicide across all age groups, Alaska faces further challenges in the delivery of behavioral health services and the implementation of programming. Outside of the three largest cities (Anchorage, Fairbanks, and Juneau), all of Alaska’s boroughs/census areas are considered frontier by the state, with access to behavioral health services often only possible by boat, plane, or telehealth. Many of these rural communities experience significant health disparities, are historically underserved, and have populations that are majority Alaska Native. They suffer disproportionately from suicide, with Native Alaskan youth in these communities currently experiencing the highest rate of suicide in the nation.1 While the current 988 Lifeline response system in Alaska has made substantial progress since it was initiated, challenges to implementation on a statewide level remain. In Alaska there is only one accredited Crisis Call Center that is a member of the National Suicide Prevention Lifeline and from January-March 2021, there were 2,081 Lifeline calls attempted. Only 61% of those calls were answered. Increasing our Lifeline call answer rates to 90% is dependent upon an increase in staffing and capacity. Part of the 988-expansion plan outlined in this proposal includes increasing the call answer rate for Lifeline/988 calls. Another gap in services is the lack of 24/7 coverage for 988 text and chat, which is a priority under this proposal. A further need addressed under this funding is to add to our landscape analysis of the programmatic needs and costs associated with dispatching mobile crisis teams and building capacity to make referrals to tribal health organizations. The goals that will be guiding the objectives and activities proposed in this project are as follows: • GOAL 1: Increase the Capacity of Alaska’s 988 Response to Achieve a Call Answer Rate of 90% and Ensure Future Sustainability: • GOAL 2: Strengthen Partnerships for an Improved and Coordinated Response Across the Crisis Continuum • GOAL 3: Improve the Analysis and Use of Statewide Suicide Data to Better Inform Priorities, Policy, and Programming • GOAL 4: Develop an updated Alaska 988 Communications Plan that is Aligned with the 988 Partner Toolkit • GOAL 5: Improve The Continuous Quality Assurance Capacity For Alaska’s Crisis Call Center • GOAL 6: Improve Coordination With Tribal Health Organizations to Facilitate Community Engagement and Increase Referrals to Available Services • GOAL 7: Build a Comprehensive Network of 988 Referral Resources and Increase Post-988 Follow-up Capacity to Ensure Clients are Connected to Service 1 Wexler, L., Apala Flaherty, A., Begum, F., White, L., Kouassi, L., Wisnieski, D., Davis, A., & Ewell Foster, C. (2023). Describing meanings and practices related to firearms, safety, and household storage in rural Alaska Native communities. Journal of Rural Mental Health, 47(1), 30–40. https://doi.org/10.1037/rmh0000207.

Suicide is a significant public health issue in Arkansas, with the state ranking 11th in the country for suicide rates. To address this problem, the Arkansas Department of Health (ADH) established the Arkansas Lifeline Call Center (ALCC) in 2017 as the primary suicide prevention call center. However, there is a need for additional support and collaboration between ALCC, the Arkansas Crisis Center (ACC), and the Western Arkansas Counseling and Guidance Center (WACGC) to improve the overall answer rate and reduce reliance on national backup centers. The Arkansas 988 Capacity Project aims to increase collaboration and funding to expand the call center workforces, with the goal of reaching or exceeding a 90% answer rate for all calls, chats, and texts by September 2024. The project also focuses on enhancing the in-state chat and text response capabilities. By increasing staff and improving coordination, immediate improvements in answer rates can be achieved. The project also emphasizes consistent policies, appropriate responses to veteran callers, and increased access to services through partnerships with the Arkansas Department of Human Services. To achieve the project's goals, various strategies are outlined. These include hiring additional staff at ALCC, ACC, and WACGC, expanding chat and text services, conducting a media campaign to promote the 988 Lifeline services, establishing a comprehensive data reporting system, enhancing mobile crisis and crisis response teams, and developing a sustainability plan to ensure the long-term viability of the project. Collaboration with key stakeholders, training programs for emergency service entities, and comprehensive follow-up plans are also integral parts of the project. The project emphasizes ongoing evaluation and quality improvement, with the involvement of an evaluation contractor to monitor data and prepare regular reports. It also highlights the importance of a sustainability plan and the identification of funding sources to continue the project beyond the grant period. Continuous quality improvement protocols, meetings between call centers, and addressing behavioral health disparities further contribute to the project's objectives. By implementing the Arkansas 988 Capacity Project, the state aims to reduce suicide rates, improve crisis response services, enhance access to resources, and provide effective support to individuals in need. Through collaborative efforts, funding, and strategic planning, Arkansas endeavors to make a significant impact on suicide prevention and mental health support within the state.

West Virginia Bureau for Behavioral Health (BBH) is seeking funding through NOFO FG-23-006 (FY 2023 Cooperative Agreement for States to Improve Local 988 Capacity) to augment the 988 system in the state. West Virginia has one 988 Lifeline call center, First Choice Services (FCS), that will be the primary beneficiary of this funding. FCS will receive approximately 83% of the money to augment their crisis center staff by adding 8 crisis counselors, 1 data analyst, and 6 credentialed peers. The additional staff in these areas will be crucial as the 988 Lifeline expands. Money will also be allocated to training for call center staff. This will ensure the staff receives annual training on the continuum of services as well as specific training in peer and police programming. With the remainder of the money, BBH will hire a full time Project Evaluator who will oversee data collection and dissemination, maintain and prepare reports, give presentations to professionals and lay groups, and provide consultative and technical assistance as requested. The Project Evaluator will also develop relationships with behavioral health providers and other state agencies for the purpose of improving data collection. The funding through this cooperative agreement will further improve West Virginia's crisis continuum by increasing the workforce at both the center and state levels, providing better trainings, and assist with data collection to help make better informed decisions about the statewide crisis continuum. All of these things will improve 988 response for the whole state.

Through the 988 State and Territory Improvement Grant, South Carolina's (SC) Hope4SC grant initiative (988Hope) will focus on improving SC's response to 988 contacts (including calls, chats, and texts) originating in the state/territory. The goals of this project include enhancing the SC 988 infrastructure to increase answer rates, call care quality, and care transitions and implementing additional technology and security measures to fully support 988 infrastructures beyond the life of this grant and effective coordination across the crisis care continuum. This project will have a data-driven approach to improve 988 contacts in SC, as well as coordination with 911 and Mobile Crisis. The project will increase the workforce to ensure SC has an answer rate of 90% or higher for calls, chats, and texts. Including a focus on expanding MOUs between 988 call centers and 911 Public Safety Answering Points (PSAP), and Mobile Crisis, including leading a crisis care continuum collaborative involving Mobile Crisis, 911, and 988. Improvements around SC's follow-up care, data collection, communication plan, and referral policies will also be key points of this project. 988Hope is committed to strengthening 988 to improve crisis support for the people of SC. As of May 2023, SC answered 67% of calls, 34% of chants, and 31% of texts originating from the state. This grant will assist SC in improving its capacity to answer the steadily increasing calls, chat, and text contacts. 988Hope4SC (988Hope) expects to serve 45,000 people in year one, 50,000 in year two, and 55,000 in year three with a total of 150,000 people served over the life of the grant.