PROJECT SUMMARY On July 16, 2022 “988” will become the national toll-free dialing code for the National Suicide Prevention Lifeline (Pub. Law 116-172). The Lifeline receives 3.5 million calls annually and has demonstrated effectiveness at decreasing suicidality, hopelessness, psychological distress, and suicide death. The transition from the current 10-digit Lifeline dialing code to 988—a three-digit code like 911—is projected to potentially triple call volume. The impact of 988, however, will likely be determined by state policy responses to financing its implementation. The federal law that creates 988 encourages states to pass user fee legislation (e.g., a flat fee monthly per every cellphone plan holder in the state, identical to how 911 is financed). The current state policy landscape is extremely varied. As of January 2022, four states had passed user fee legislation and many others were considering such legislation. The proposed policy implementation project focuses on the characteristics, determinants, and impacts of 988 user fee legislation and other policy strategies used by states to finance 988 implementation. The project’s Specific Aims are to: 1) Characterize states’ 988 implementation financing strategies and identify determinants of implementation strategy adoption; 2) Explore perceptions of the financing determinants of 988 policy implementation success and acceptability and feasibility of legislative financing strategies to improve implementation; and 3) Determine the effects of 988 user fee legislation on the policy implementation outcomes of fidelity (Lifeline in-state answer rates) and reach (Lifeline state call volume rates), the effectiveness outcomes of suicide death and emergency department use for mental health crises and self- harm, and assess effect heterogeneity across demographic groups. These aims will be achieved by a legal mapping study, national surveys of 250 suicide prevention stakeholders (e.g., Lifeline call center leaders), 60 semi-structured interviews, and a difference-in-differences analysis comparing trends in implementation and effectiveness outcomes pre (2015-2021) and post (2022-2025) 988 implementation between states that did and did not pass 988 user fee legislation. The project team has expertise in policy implementation science (Purtle, Raghavan), suicide (Lindsey), law (Pomeranz), and quantitative policy analysis (Stuart). Practice partners include Vibrant Emotional Health, which administers the Lifeline, and the American Foundation for Suicide Prevention. The project is innovative because it advances the understudied area of policy-focused implementation science. The project is significant and will have impact because it focuses on a major federal policy in the early stage of implementation and because it will generate knowledge to inform implementation financing decisions related to 988—which is likely to be a primary gateway to mental health crisis and suicide prevention services for the foreseeable future. The project is aligned with NIMH’s Strategic Plan, which prioritizes suicide prevention, and the NIMH pledge to reduce the suicide rate by 20% by 2025.

PROJECT NARRATIVE This project is relevant to public health because it will generate knowledge about the effects of state financing policies on the implementation of the federal “988” law and the National Suicide Prevention Lifeline. The project will produce information about how the implementation of policies that finance the Lifeline can by optimized to prevent suicide death—a top priority of NIMH.