Better follow-up care leads to better outcomes for individuals in crisis. Centerstone is committed to sharing the insights, lessons, and best practices we’ve developed after more than a decade of providing follow-up support via phone, chat, and text. By offering this guidance, we aim to help organizations establish and enhance their own post-crisis follow-up programs, ultimately improving care and support for those who need it most.
Best Practices
for Crisis
Follow-Up
A Comprehensive Guideline
Centerstone’s Best Practices for Crisis Follow-Up
This guideline reflects a commitment to sharing the insights, lessons, and best practices that Centerstone has gleaned from more than a decade of experience in providing follow-up support to individuals in crisis who have reached out via a phone call, chat, or text. It is intended to aid those who may be establishing their own post follow-up program and offer ideas for enhancement of similar programs nationwide.
Every month1, the 988 Suicide & Crisis Lifeline (988) fields roughly half a million contacts in the form of calls, texts, and chats from people seeking support, either for themselves or for a loved one, for emotional distress, a mental health or substance use challenge, or a crisis. For many people, contact with 988 helps them feel better and navigate their situation. But the situations underlying a crisis typically do not disappear the following day, and chronic stress has significant neuropsychological impacts that can wear down the brain’s ability to function properly, including creating issues with learning, decision-making, and making connections with others.
While crisis hotlines can provide referrals to resources, some individuals in an emotional or suicidal crisis—especially those in ongoing crisis situations—need additional support to feel empowered to access community resources and navigate mental health care or substance treatment systems.
988 offers a place to talk about a crisis. After that first call, the crisis may have deescalated, but it might not be over. Follow-up offers support during different stages of the crisis as the person moves through it.
Repeated and continuous utilization of crisis services can also drain resources of crisis service providers. Ultimately, crisis services offer short-term stabilization; without connection to outpatient or community-based services and resources, individuals may continually fall back into crisis, which could involve unnecessary hospitalizations or encounters with law enforcement. The key to reducing this potential cycle is efficient and effective transitions from crisis services, to follow-up, to longer-term support.
Centerstone, a nonprofit behavioral health system and operator of local and national 988 Suicide and Crisis Lifeline centers, has embraced crisis follow-up for those reaching out to 988 via calls, chats, and texts and, its predecessor, the National Suicide Prevention Lifeline. Since 2014, Centerstone has been evolving its approach to crisis follow-up. At time of publication, Centerstone had completed the first year of a three-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to expand and study its Crisis Center Follow-Up Program in 20 primary counties, mostly rural, and as a backup provider in two secondary counties, both urban, in Tennessee.
1 Network Wide Monthly Reports
Literature reviewed by Centerstone shows that individuals dealing with repeated stressors and crisis situations are likely experiencing overactivated stress cycles, which can lead to neuropsychological impacts that diminish resilience, coping ability, and decision-making.
During an acute crisis, the brain activates the rest of the body to respond to the stressful event:
For individuals experiencing ongoing crisis, these neurological impacts can cause them to experience greater feelings of helplessness, disconnection, and powerlessness—heavily influencing and possibly hindering their use of follow-up resources, no matter how accessible those resources are made to the individual. To help individuals feel empowered to use the resources, it’s important for crisis centers to use interventions that counteract overactivation of the stress cycle. Crisis centers should consider using an evidence-based, standardized psychological first aid approach, like the Six C’s model, designed to help individuals develop resilience in the aftermath of a crisis situation.
Crisis follow-up involves providing ongoing support to individuals after they have experienced a crisis or received immediate crisis care, and can include contact strategies like telephone calls, caring contacts with emergency telephone numbers and safety measures, and letters and postcards of support. Most research has focused on discharge from emergency departments or inpatient treatment, which tend to be high-risk periods for individuals dealing with mental illness. Additional research has found that among psychiatric patients, 43% of suicides occurred within a month of discharge—nearly half of whom died before their first follow-up appointment. Follow-up calls to patients after hospital discharge also support the business of healthcare: a 2014 study found that follow-up calls provided a significant return on investment for payors, ranging from a return of $1.76 to $2.43 in savings for every $1 spent on follow-up calls. Additional research has shown follow-up programs to be highly effective in improving outcomes for individuals after a crisis event in other settings, including after crisis calls to 988.
Outcomes from Centerstone’s own programs have also demonstrated the effectiveness of telephonic follow-up to callers after a crisis contact. In 2015, Centerstone received an initial private grant to conduct telephonic follow-up services to crisis callers in Tennessee. The program involved follow-up within 24 hours of initial referral, and then again on days 7, 14, and 30. The program showed initial effectiveness among high-risk individuals referred to the program by a partnering emergency department, individuals were more connected to care, the rate of return to the emergency room was less than expected, and none of the nearly 200 program participants died by suicide during the grant.
From 2015 to present, Centerstone has received additional funding from the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) via the Substance Abuse and Mental Health Services Administration (SAMHSA) to operate Garrett Lee Smith and National Strategy for Suicide Prevention grants. This has allowed Centerstone to continue iterating on its follow-up program, and outcomes from 2015-2021 demonstrated that enhanced follow-up could be an effective care transition and/or intervention for youth/young adults and adults at high risk for suicide. Evaluation of outcomes from these grants showed that follow-up program participants experienced substantial (36%) decreases in proximal risk factors for suicidal ideation within one month of follow-up. Participants also reported growth in key factors related to recovery, like experiencing no domination of their lives by mental health symptoms and increases in personal confidence and hope. These outcomes suggested that “lower lift” service delivery modes like phone-based crisis-focused connection and support can be used as a “bridge” until one could connect with therapeutic services and/or needed social services and showed considerable cost savings due to the prevention of psychiatric hospitalizations for suicide.
Now having completed the first year of a three-year grant from SAMHSA to expand its Crisis Center Follow-Up Program, Centerstone has focused on reinforcing the foundations of the program including developing different pathways of care based on need, and refining its infrastructure based on learnings from previous efforts.
Centerstone’s approach to crisis follow-up is grounded in best practices learned from available research reviewed in developing the program, and centers around a simple core concept: being there for someone coming out of a crisis encounter until they can navigate the situation safely and effectively on their own. Follow-up programs are not a source of long-term care on their own; thus, Centerstone’s approach to follow-up is intended to be time-bound, serving as a bridge between a moment of crisis and connection to long-term supports or resources. Under this lens, Centerstone organizes its approach around encouraging linkage and engagement with community resources, promoting recovery, reducing unnecessary hospitalizations and involvement with law enforcement, and ultimately preventing suicides.
In earlier iterations of Centerstone’s programs, follow-up was offered to callers who exhibited imminent, high, or moderate risk for suicide. Program administrators soon recognized the benefit of follow-up across a broad spectrum of individuals, and Centerstone now offers all of those who reach out to 988 via calls, chats, or texts the opportunity to receive follow-up contact.
Entry into the program takes place during the initial contact to 988, when an individual provides consent to receive follow-up contact. It is imperative that the crisis staff who are obtaining consent are clear with individuals on the goals, offerings, and limitations of the follow-up program. Using plain language to describe the program and ask about the individual’s preferences, like comfort with leaving a voicemail or a message if someone else answers, should be part of the consent process. During this conversation, it’s important to ask the individual about the best time to call while noting their time zone. In addition, letting them know what the incoming phone number will be or how it may appear on caller ID can help avoid them dismissing it as a spam call.
Consenting individuals receive their first follow-up contact within 24 hours or less of the initial contact to 988. During this first follow-up call, follow-up specialists work to build rapport while also assessing the individual’s situation, including conducting a risk assessment using the Columbia Suicide Severity Risk Scale (CSSRS) and creating or reviewing a safety plan using the Stanley Brown Safety Plan. If follow-up specialists are unable to make contact after three attempts, the individual will be discharged from the program.
It’s common for individuals coming out of a crisis to feel overwhelmed, and they may not be feeling their best—either physically or emotionally. During the first few contacts with an individual, follow-up specialists should make a concerted effort and receive training on how to be gentle with the individual, recognizing they may be in a fragile or vulnerable physical and/or mental state.
As staff connect with an individual and better understand their circumstances, the person is placed on one or multiple established care pathways best suited to the support they need. Individuals may be assigned to one or more pathways and can move from pathway to pathway during their time in the program, especially as acute needs are met and potentially reveal others. Follow-up specialists should be flexible and ready to adapt their responses to the person’s needs to ensure they are on the most appropriate pathway(s). Centerstone’s care pathways include:
An individual may need referrals to support for basic needs, like assistance with housing, food, childcare, transportation, health insurance, employment, or other issues that can contribute to a crisis.
An individual may need referrals or support navigating mental health or other therapeutic services, including finding and making an appointment with a mental health clinician, substance use programs, accessing lifestyle coaching, or engaging in peer support services.
An individual is escalated due to any crisis, including moderate to high-risk suicidal or homicidal ideation. Safety is the main goal, and specialists work to support the individual in returning to a pre-crisis state.
It’s important to reinforce the offerings and limitations of follow-up early in conversations with individuals, and throughout their time in the program. From the first call, follow-up specialists make it clear that follow-up is a short-term service and the person’s time in the program will eventually come to an end. As an individual’s needs are met and risk is reduced, follow-up specialists remind individuals of the specific steps, actions, or resource linkages that have been made throughout follow-up, and preview that the individual is now approaching “graduation” or exit from the program. Strong written policy and procedure documents provide follow-up specialists with guidance about how to continually manage a person’s expectations and work towards a smooth exit from the program. Establishing formal memorandums of understanding (MOUs) with community partners to address barriers, like limited access to transportation or a lack of health insurance, can also aid in successfully linking individuals to resources and help build their trust in the therapeutic process. However, an inability to secure an MOU with a potential partnering organization should not hinder efforts to work collaboratively for the betterment of individuals and the community at large.
Many crisis call centers work with familiar callers, which in some cases can take significant staff time and resources, and follow-up programs experience similar challenges. For these individuals, setting clear boundaries and expectations can protect follow-up specialists’ time while remaining responsive and empathetic to the caller’s needs. For example, specialists use language like “We have 20 minutes today, and then I will reach back out to you at a scheduled day and time for our next call.” In addition, frontline crisis staff who take 988 calls from familiar callers requesting to speak with a follow-up specialist will take messages and enter them into an internal messaging system that is visible to all team members. This allows follow-up specialists to review the needs of the individual and provide an appropriate response while maintaining boundaries with an individual who calls frequently.
People can remain in the follow-up program for up to a year, though most typically exit the program after three to five calls over the course of about 90 days. Once follow-up specialists assess that a person is no longer at risk, or they request to exit the program, follow-up specialists complete a discharge and service overview with them. During the discharge process, Centerstone uses an exit survey to collect demographic data about individuals that have not already been collected in previous conversations and solicits feedback about ways to strengthen the follow-up program. The survey, distributed by email or text with consent, uses a scaled rating system to explore opinions, attitudes, and motivations about the program. The results are integrated into Centerstone’s Electronic Health Record system and analyzed by research evaluators to identify areas for quality improvement.
Having a clear articulation of success is critical in defining and achieving desired outcomes and program goals. It’s important to consider outcomes and goals that demonstrate improvement in a person’s quality of life, in addition to outcomes and goals that demonstrate improvement in a program’s infrastructure or completion of program activities.
Success is about making a connection, building that rapport. When you allow the caller to talk, they let you in more. That lets you get those risk assessment questions in, see what their suicide levels are, if you can offer them coping skills. Success is getting them from that high level to a lower level. It feels good when you can see them transitioning.
Some considerations for envisioning program success could include:
Clear measurable outcomes, indicators, and program goals should stem from an organization’s definition of success, with infrastructure, policies, procedures, and trainings built to support those program outcomes and goals. Examples of goals and indicators could include:
Continuous quality improvement efforts can help assess how the program is performing against its stated goals and objectives and identify opportunities to improve. Building time in staff workflow for regular and frequent reviews of program data and qualitative feedback, as well as creating space for open and honest discussion about program challenges, can lead to solutions and innovations that support better experiences for both follow-up specialists and those they are serving.
Centerstone follow-up specialists reported challenges with not being able to reach individuals at certain times of day. Program staff used this feedback to analyze call data and identified an optimal contact window of 3:00 p.m. – 7:00 p.m. Central for the program population. Follow-up specialists also provided feedback to program administrators about how their technology platform could be improved so they could more easily input and access useful information for each person—resulting in greater consistency and quality of data for program evaluation and better service to those in the program.
Several organizational factors contribute to effective implementation of a crisis follow-up program, including building a team staffed by individuals with necessary and diverse skill sets, providing ample and collaborative training to follow-up specialists, and instilling an organizational culture that prioritizes staff.
Bringing in the right team members, whether from currently employed staff or hiring externally, is key to the success of any crisis follow-up program. Finding the right fit for a follow-up specialist, even before they’ve been provided role-specific training, is perhaps the most important element in providing positive outcomes and experiences for both individuals in crisis and employees.
When advertising for follow-up specialist roles, it is important to include specifics about what the position entails, the opportunity for remote work if applicable (and if so, highlighted as a benefit), and other tangible and significant benefits like salary and the range of additional pay offered for shifts outside of normal business hours (if offered). To better reach potential candidates seeking helping professions, job postings could also list information and statistics about crisis services such as 988 and the crisis continuum to underscore the opportunity to make an impact in a follow-up specialist role. Any available information about career pathways and opportunities for employees to progress is also attractive to motivated potential candidates.
Rescuers make great first responders, but candidates for follow-up roles need to be helpers…
Empathy, care, and a lack of judgment towards the person on the other end of the call…
In crisis services, every day brings new challenges and opportunities to learn new skills…
Follow-up specialists who are patient, self-assured, and communicate clearly can help…
An individual is escalated due to any crisis, including moderate to high-risk suicidal or homicidal ideation…
For management positions in crisis services, Centerstone requires candidates to have or gain experience in a front-line crisis role. This could entail a new hire in a manager position spending a few weeks performing front-line response to crises. This helps managers better understand the nuances that differentiate crisis from long-term therapeutic care and serve as more effective problem-solvers, advocates, and leaders for crisis responders and follow-up specialists.
Centerstone has also utilized interdisciplinary teams to augment its follow-up program, including involving training specialists, clinical supervisors, quality assurance specialists, and information technology (IT) and data professionals. These individuals with diverse skills focus on specific areas of program support, alleviating undue burden on the follow-up program leadership and follow-up specialists. Involving multidisciplinary perspectives can help establish a strong program foundation and team structure that supports continuous quality improvement.
Given the demands of crisis work, Centerstone leadership recommends building in 24/7 access to a clinical supervisor or clinical consultant (or more than one, if feasible) for crisis responders and follow-up specialists. It is also critical to collaborate with and have access to IT and data professionals—the personnel who are responsible for setting up the technology platforms that follow-up specialists use, optimizing those platforms to capture desired metrics, and reporting on the data that are entered in them.
Centerstone employs a collaborative approach to training that blends live lectures with training staff, asynchronous instruction, and ample opportunities for role play and shadowing fellow follow-up specialists. Over the course of approximately three weeks, follow-up specialists are trained, tested, and evaluated in core competencies aimed at providing non-judgmental, effective service to individuals, as well as strategies to manage their own well-being.
Some of the most important training components are practicing active listening to gather information and assess a person’s situation and engaging in an empathetic way. Another critical area of training is building skills in talking about suicide. This means being comfortable asking questions in a risk assessment, responding calmly and appropriately to a person’s answers, and completing a safety plan with them.
Centerstone offers training on follow-up services to the 988 crisis specialists who receive the initial call, chat, or text and refer a person to follow-up. This cross-training has been useful for helping initial crisis specialists articulate the value of follow-up, set realistic expectations with individuals, and encourage consent to program participation. This training can also help reinforce documentation standards that support a smooth handoff to a follow-up specialist.
Organizational culture, the system of shared norms, beliefs, and behaviors of a group, is the undercurrent that dictates how value is provided to individuals. It is imperative that leadership provide the resources and support systems to allow teams to do their work, especially in crisis work where compassion fatigue and staff burnout can be common.
Centerstone leadership uses intentional strategies to get to know crisis services staff, which helps program leaders best support their teams and crisis staff identify ways they can practice self-care. Staff complete a questionnaire in which they share things like: (1) how they start their day, (2) what the theme song to their life would be, (3) their favorite restaurant, (4) a favorite way to spend free time, (5) where they would like to be in five years, and (6) one unique thing about them. They also complete a questionnaire that helps them identify what they need to feel like they had a successful interaction. This is centered on aspects of the interaction they can control and includes their ‘hype’ song.
Once they are cleared to work independently and after they have been responding to contacts for about two weeks, staff complete a self-care card that outlines important elements of self-care. This includes (1) how they prepare for their shift, (2) what coping mechanisms they use on shift when a stressful/emotional response is activated, (3) how they plan to reset to a place of calm, and (4) what they can do to make a transition from work to personal time so they can reset and relax. These cards are provided to clinical supervisors as a resource that both crisis staff and supervisors can revisit to help staff use and improve on their own self-care strategies.
My advice to anyone building a follow-up program: don’t be afraid to completely pivot from your original idea once you build it and get feedback.
Program leadership is intentional about scheduling time for follow-up specialists and staff to take care of themselves and provide guides and tips for self-care. Managers are encouraged to lead by example and will often end meetings early so follow-up specialists can take a short break from their workspace, go for a walk, listen to music, or do something for themselves. Managers also regularly assess program infrastructure to see how it helps or hinders staff mental wellbeing, examining, for example, if trainings are setting follow-up specialists for success.
Follow-up care is a relatively new concept in the realm of crisis services, and many providers—including Centerstone—are still iterating and refining their operations. To foster improvement, Centerstone encourages leadership, managers, and staff to be open to continuous change and regular evaluation of policies. Follow-up specialists are also encouraged to adapt and grow in their own skill sets and experiences and are provided opportunities for trainings and one-on-one mentorship to help them develop professionally.
Centerstone has seen some of its most important program innovations stem from open, honest, and regular communication among its team members. Managers regularly assess if the operating environment is conducive to sharing feedback without fear of punitive response. Feedback, questions, ideas, and discussion of challenges are encouraged from all team members.
Centerstone’s guidance on follow-up case load did not include a minimum or maximum number of daily calls that a follow-up specialist should make. This open guidance recognized that demand for follow-up services can ebb and flow depending on environmental circumstances like a natural disaster or other situational factors, and that when demand is high staff need to be equipped to meet it—regardless of a specific daily number of calls.
Recently, however, program staff expressed uncertainty about how many cases they should be taking on. Follow-up program leaders worked with staff to establish approximate weekly parameters for call volume. This updated guidance leads to shared norms that allow staff to have greater confidence in their own performance while retaining space for conversations about what works best for an individual follow-up specialist.
Centerstone has encountered challenges to crisis follow-up shared by crisis centers across the country.
Obtaining access to data like individual level demographics or health outcomes can be difficult, especially if a crisis center is not part of a closed behavioral health system (like Centerstone) or if the person is not part of that closed system. Asking about demographics in the context of connecting a person to the best possible resource can sometimes aid in gathering this information. In addition, Centerstone follow-up specialists often rely on individuals self-reporting their use of mental health services or resources. In tracking mortality, staff sometimes rely on published obituaries or learning from a loved one of a person’s death. This lack of access to data can pose challenges for broader program reporting and evaluation, including impact on cost savings.
Additionally, there is limited data on the long-term outcomes of participating in follow-up. Future studies could follow individuals over time to assess quality of life and health outcomes at longer intervals, such as 1, 5, and 10 years.
Currently, follow-up services are largely funded by federal and state grants. These grant-funded programs are helping demonstrate the value of follow-up care within the broader crisis continuum and healthcare system, but these programs need more sustainable funding structures to fully maximize their potential. As more evidence for the value and cost-saving potential of crisis follow-up services becomes available, it is possible that all payors will be motivated to fund follow-up programs. In addition, there may be opportunities to partner more closely with community groups that provide supports addressing social determinants of health (e.g., substance use programs, hospitals, housing supports, food assistance, childcare, employment, etc.) to explore more sustainable funding structures. Collecting success stories and sharing data with payors and other potential funders is important for demonstrating the value of follow-up programs with the intention of establishing more sustainable, payor-based funding for them.
During an initial 24-hour follow-up call, the individual described feeling suicidal. The caller reported having plans to take their own life, but did not want to act on them. They reported their family was unsupportive, and they were struggling to secure consistent housing. Follow-up specialists talked more with the caller, who realized they wanted to enter therapy. Follow-up specialists provided referrals to community resources for therapy, as well as housing resources.
The caller entered therapy and was able to make connections in the community to meet their basic needs. While the caller still describes having suicidal ideation, they have also reported feeling better and looking towards the future. They report having made valuable connections they needed and will soon graduate from the follow-up program.
During an initial 24-hour follow-up call, the individual reported feeling depressed, lacking a reason to live and feeling like a burden to their significant other. They revealed their gender identity as transgender and reported being met with discrimination when seeking care, both physical and mental. The individual also experienced intense anxiety, to the degree that pursuing employment was unattainable. The caller reported dissatisfaction with the confinement of their residence and the lack of outside activities.
The caller’s main goals were to develop a support system, complete a referral for gender reaffirming surgery, and seek employment. Over the course of six calls, the follow-up specialists used active engagement, reflection, exploring, collaboration, and emotional support, coping skills and resources. The caller was presented with various alternatives for support groups within the LGBTQIA+ community, with a particular emphasis on transgender support groups. Furthermore, they were provided with options to connect with workforce solution organizations to assist with employment. Additionally, the individual was empowered to advocate for themselves regarding their mental and physical health.
On the last follow-up call, the caller reported that they had been able to find a support group where they truly felt supported. After a medical visit, it was discovered that their estrogen levels were too high, which could have contributed to the sudden change in mood. The caller also reported that their reaffirming surgery referral was successfully submitted. The caller expressed gratitude to the follow-up program and felt they were in a place to continue their journey without follow-up calls.
During an initial 24-hour follow-up call, the individual presented with passive suicide ideation and disclosed issues managing their anger and choices made due to the lack of healthy ways to cope. The caller reported that due to past choices, connections with friends, the mother of their children, and father had been strained. The caller disclosed being an ex-convict, ex-MMA fighter, ex-hitman, drug dealer, recovering heroin user, and current methamphetamine user.
Over the course of 24 calls, the follow-up specialists gave space for the individual to vent and used interventions such as active engagement, exploration, de-escalation, collaborative problem-solving, and resource linkage. The individual was receptive to these interventions and shared that their motivation was to be a good parent for their children.
By call 14, the follow-up specialists collaborated with the caller to identify and establish the support the caller identified as needing. The individual secured a spot at a local detox and rehabilitation center. In addition, the caller was provided the opportunity to enroll in a carpentry program and their family offered support while the caller engaged in rehabilitation care.
As of March 11, 2024, the individual is on their road to recovery through admittance to the detox and rehabilitation center. At the time of writing, Centerstone staff were unable to have any communication with the individual. However, the caller indicated they would call to update the Centerstone team on their progress.
Crisis follow-up is a valuable component of the crisis services continuum. It fills gaps and provides support to individuals as they navigate a crisis and embark on a path towards stability and feeling better. Follow-up services can connect individuals to community anchors like long-term mental health care, supports for basic needs like housing and food, and other resources that can help build connections and foster a sense of hope.
Though follow-up care is still a relatively new concept in the crisis services continuum, its value is well-documented. We hope Centerstone’s approach offers other crisis service providers a blueprint for adding follow-up services to their offerings or enhancing existing services. With thoughtful planning, crisis service providers can create a positive and life-saving offering for individuals and a rewarding environment for program staff.
Senior Vice President, Crisis Services, Centerstone Becky.Stoll@centerstone.org
Vice President, 988 Crisis Services, Centerstone Kelly.Bombardiere@centerstone.org
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