Can SAMHSA and state leaders keep the promise of 988 without reporting on and supporting follow-up care?
When the FCC recommended to Congress in 2019 that 988 be designated as the new three-digit number for mental health and suicide crises, it described the evidence simply and powerfully: “Crisis call centers save lives.”
That statement was built on decades of research showing that connection saves lives — and that reconnection saves even more. In the same landmark report, the FCC highlighted a statistic that should guide our nation’s next steps: nearly 80% of people who received follow-up calls from Lifeline crisis centers said those calls stop them from killing themselves. The FCC noted that these callers said, “follow-up gave them hope, made them feel cared about, and helped them connect to further mental health resources.”
Those findings for the Lifeline were consistent with global research on the impact of follow-up contacts on preventing suicide. Yet somehow, an essential life-saving and human part of the 988 system — the act of reaching back out — remains largely unfunded, unmeasured, and underreported.
Are Follow-Up Contacts an Unfunded Mandate?
As much as any single intervention in suicide prevention, follow-up contact saves lives. Decades of studies — including the landmark research by Dr. Madelyn Gould and her team — have found that both structured and unstructured follow-up reduces suicides, suicidal ideation, and increases engagement in care. The data were so compelling that in 2012, the National Suicide Prevention Lifeline designated follow-up as a “recommended best practice.”
In truth, we would have made it mandatory then, but we faced a harsh reality: most centers lacked sufficient funding to even answer all incoming calls, let alone conduct outbound follow-up. In 2012, most calls in the Lifeline network were answered by trained volunteers. The use of volunteers made possible what underfunding would have otherwise prevented — the ability to show up for people, both during and after their active mental health crisis.
By the Numbers:
- 80% of callers say follow-up prevented them from killing themselves
- 91% of centers provided follow-up in 2015
- 75% did so with zero dedicated funding
- 0 state/federal public dashboards report follow-up (NRI)
By 2015, a survey of Lifeline centers showed that 91% were providing follow-up, yet nearly three-fourths of them were doing so with no dedicated funding. These centers, often staffed by dedicated volunteers, were providing this life-saving service out of commitment to best practices, not because they were adequately resourced to do so.
Crisis center expectations and funding have shifted dramatically since the advent of 988. Beginning in February 2023, Vibrant—988’s administrator—made follow-up a requirement for all 988 centers, specifically for individuals experiencing current suicidal thoughts (contact within 24 hours). In their directive to 988 centers, Vibrant stated that “increased funding for 988 presented 988 Lifeline Centers with an opportunity to move follow-up from a recommended best practice to a required best practice.” With new public investment flowing into 988, Vibrant’s follow-up mandate was operating under the assumption that centers would now have the resources to perform this outreach; that the recent sixfold increase in average funding per center over the past decade could support both inbound and outbound services.
Today, despite follow-up being a requirement, we have no systematic way of knowing whether states understand this obligation or are funding it appropriately. SAMHSA has been promoting follow-up for nearly two decades, awarding ten select centers up to $500,000 annually through three-year grants. These grants have generated the evidence base proving follow-up’s effectiveness. Yet there’s a critical disconnect: these grants go directly to a small percentage of 988 centers, not through the states where they operate, much less to all centers and states. These centers receiving a limited number of follow-up grants report their follow-up data to SAMHSA, not to state authorities. Meanwhile, SAMHSA’s $175 million in grant funding to all states for 988 capacity building in 2023 didn’t include follow-up or follow-up reporting as requirements.
The Invisible Service
The recent 2024 NASMHPD Research Institute survey revealed that nearly 22% of 988 callers in 31 responding states are receiving follow-up contacts—a data point I specifically requested they include after it was absent from their 2023 survey. This suggests that at least 31 states can report follow-up when asked.
Yet not even one of the 21 state dashboards reviewed by NRI includes follow-up contact data.
This invisibility isn’t just a data problem—it’s a sustainability and accountability problem. Think about what this means: thousands of life-saving follow-up calls are happening every day across our nation, yet they’re invisible to policymakers, funders, and the public. If we don’t count it, report it, or acknowledge it, how can we possibly fund it adequately? How can we demonstrate its value to legislators who control purse strings? How can we improve what we don’t measure?
This invisibility has real consequences. States routinely report on phone, chat, and text contacts answered, average speed of answer, abandonment rates, rollover rates to national backups, emergency services activations, and demographic data. But the one metric that tells us whether people are actually safer after calling 988—follow-up outcomes—remains hidden.
Why Reporting Follow-Up Contacts Matters
Follow-up contacts provide something that no other crisis metric can: true outcome measures. It’s only during follow-up calls that we learn whether our system worked for the people we serve. Did their encounter with crisis counselors help? Are they less distressed? Do they feel safer? Are they connected to ongoing care? Without this information, we’re flying blind, measuring efficiencies but not the true impact on the lives we are serving.
Reporting follow-up also demonstrates to the public the dedicated effort crisis centers make beyond that initial call. Every follow-up contact represents a proactive investment in someone’s wellbeing, a deliberate choice to reach out when that person might be struggling to reach out themselves. These contacts embody the caring that callers say matters most, yet they remain uncounted in our public accounting of 988’s impact.
Perhaps most practically, without tracking follow-up contacts—how many are offered, how many are consented to, how many occur—we cannot determine the true funding needs of this service. Dr. Gould’s research team has shown that suicide prevention benefits grow with the number of follow-up contacts, with minimum benefits at two contacts and maximum benefits at four or more. But how can we fund four contacts per caller if we’re not even counting the first one?
These were the guiding principles that led BHL’s development of our Follow-Up Module—to fully align with 988 best practices and capture the data needed for centers, states, and SAMHSA to measure the outcomes that matter most to people in crisis. Because follow-up care has been shown to reduce ER visits and prevent costly emergency interventions, even a modest investment in software to track these outcomes quickly pays for itself through de-escalating crises. It’s not only clinically sound—it’s fiscally smart.
Follow-Up: The Glue That Holds Crisis Care Together
In 2024, SAMHSA convened dozens of national experts in Washington to advise on updates to the National Guidelines for Behavioral Health Crisis Care Coordination Systems. Everyone agreed on the familiar “Three Pillars” of crisis care:
- Someone to contact
- Someone to respond
- A safe place to go
But a few of us argued for a fourth: Someone to follow up.
SAMHSA representatives acknowledged follow-up’s importance, arguing it should be integrated into all three existing pillars rather than standing alone. They reinforced this approach in the Guidelines published this January. But I and others raised a critical concern: if follow-up isn’t recognized as its own pillar, it becomes a funding afterthought to stakeholders building community crisis care systems. Without explicit recognition, the “continuity of care glue” that holds our crisis system together gets lost—along with the people we’re trying to serve.
This isn’t theoretical. We’re seeing it play out right now across the country. States are implementing crisis coordination platforms, establishing mobile crisis teams, and breaking ground on new crisis receiving facilities. But follow-up—the intervention that ensures these services lead to sustained recovery—remains under/unfunded and unreported in most jurisdictions.
A Call to Action
- Require and Standardize Follow-Up Reporting
States and SAMHSA should create clear guidelines for 988 centers to routinely collect and report follow-up data — including the number of people offered, accepting, and receiving follow-up; the number of contacts per person; and key outcome measures (e.g., reduced distress, safety, connection to care). These metrics should appear on all public 988 dashboards and reports.
- Align Funding with Requirements
In the next round of 988 State Capacity Grants (expected in 2026), SAMHSA should require that states ensure 988 centers receiving funds both provide follow-up services and report on them, consistent with the evidence-based 988 network requirements issued by Vibrant in 2023.
- Shift Federal Follow-Up Grants to States
SAMHSA’s follow-up grants — now awarded directly to individual centers — should instead be routed through states. This would allow statewide coordination, equitable funding, and consistent data collection across all 988 centers, not just a select few.
The Moral and Practical Imperative
988 is a rapidly transforming crisis response in America. Millions of people each year now reach caring counselors within seconds — a triumph of accessibility and coordination. But we risk mistaking access for outcomes.
Answering the call is only the beginning of helping people feel less distressed and suicidal. It’s the follow-up — the second call, the check-in text, the “How are you doing today?” — that often turns a moment of crisis into a bridge to recovery.
We must ensure that follow-up care is not an afterthought, not an unfunded mandate, and not an invisible act of compassion lost to data silence.
If we don’t report it, we won’t fund it.
If we don’t fund it, we won’t sustain it.
And if we don’t sustain it, we will lose people — quietly, needlessly, and preventably — between the cracks of our systems.
Follow-up is not a luxury. It is the lifeline after the Lifeline. It’s the system’s promise made real: You are not alone, not even after you hang up.
Let’s make sure our policies, dashboards, and budgets finally reflect that truth.