Recent federal investments have placed mental health crisis services under a national spotlight and incentivized states to support the delivery of these services. States are under increasing pressure to prepare and develop their workforce across the crisis continuum as demand for these services surges and the behavioral health workforce shortage persists. NASHP recently connected with state leaders from the Utah Division of Substance Abuse and Mental Health (DSAMH) to learn about the state’s approach to training and certifying its crisis workforce.

What led Utah to develop and mandate certification for crisis workers?

In 2018, Utah’s Behavioral Health Crisis Commission was beginning to anticipate and brainstorm around the upcoming 988 crisis number and conducted an assessment of crisis service provision across the state. While all crisis providers were providing twenty-four-hour access to crisis services, it looked different statewide. Some providers could provide immediate response, while others were not able to respond until 2 hours after the initial call. These circumstances fueled the desire to standardize the state’s crisis response, starting with crisis call centers. In an effort to standardize workforce training process and provide crisis workers the confidence and skills the job demands, the Utah legislature directed DSAMH to develop a forty-hour crisis certification training for the crisis workers who staff the statewide mental health crisis line, the statewide warmline, and local mental health crisis lines. State personnel administer the certification program along with a group of volunteer crisis care experts, and providers receive the certification training for free.

Which providers must complete the certification and what does statewide certification achieve?

All of this was put into place to bolster the crisis workforce and provide them with the tools necessary to provide more consistent, responsive care statewide. Utah therefore requires any provider operating within Utah’s statewide behavioral health crisis response system to complete the certification and satisfy the annual 8-hour continuing education requirement. Individuals who are eligible to apply for crisis certification include licensed behavioral health providers, individuals with a bachelor’s degree in a human service related field, certified peer support specialists, certified case managers, and certified family resource facilitators. The agency designed the certification requirement to elevate the standard of crisis care across the state, with the anticipated outcome of helping to prevent rapid burnout within this workforce. Since developing the crisis certification training content, Utah has also developed partnerships with local universities so that students pursuing behavioral health degrees graduate with the training under their belts.

How does Utah reimburse for crisis services?

A series of recent legislation has supported the provision of crisis services in Utah. Most recently, in 2020, Utah enacted HB 32, which provided additional support for crisis lines, warm lines, behavioral health receiving centers, and new mobile crisis outreach teams (MCOT) in rural areas. In 2021, Utah enacted SB 155, which created the Statewide Behavioral Health Crisis Response Account – a restricted state general fund account that houses legislatively allocated funding for crisis lines, MCOT, and receiving centers. On the reimbursement side, Utah is primarily a Medicaid managed care state. Behavioral health services, including some crisis services, are covered through Prepaid Mental Health Plans (PMHP) and Utah Medicaid Integrated Care (UMIC) plans. Utah Medicaid is currently working with the Centers for Medicare and Medicaid Services (CMS) to cover crisis line services through a cost allocation plan. Behavioral health receiving centers are carved out of Medicaid managed care plans and are reimbursed directly by Utah Medicaid.

What does the content of the Crisis Certification look like and how was it developed?

The Utah team connected with other states that had developed crisis training requirements. Arizona, Tennessee  and leaned heavily on the American Association of Suicidology when developing their 40-hour training model. The training content covers three major areas as they relate to crisis intervention:

• Attitudinal outcomes (acceptance of persons as different from oneself; a realistic and human approach to death; self-destructive behavior)
• Knowledge areas (basic suicidology; intervention strategies; community resources)
• Skill areas (ability to assess life-threatening situations; ability to mobilize community resources; provide efficient record keeping and policy implementation)

The content for crisis training is the same for all crisis providers in the state, whether they provide services through crisis call lines, mobile crisis units, and crisis stabilization facilities. The training model addresses the differences in setting and safety, and the Utah team is considering developing continuing education content that is geared toward specific provider types and settings. The coursework’s first day primarily focuses on how this work can and will be stressful, traumatizing, and hard. There are additional instructions on how to develop tools to prevent secondary trauma. The goal is to teach providers how to recognize those symptoms in themselves, prepare for this work, and engage in self-care.

How did your partnership with Weber State University develop?

Utah has recently enacted a statutory requirement that all community-based crisis workers must be certified, and general interest grew for incorporating standardized crisis and clinical suicide prevention programming into institutes of higher learning in Utah. Schools of social work were looking for ways to better equip students with actionable skills and credentials upon graduation. At the time, the national dialogue around 988 was picking up and underscored that Utah needed a competent and qualified behavioral health workforce. Utah’s partnership with Weber State University on crisis certification started about a year ago. Their inaugural class has received their crisis worker certification, and now Utah will track how they use their certifications through an internal certification management process.

How have you shaped your university partnerships to best align to the statutory requirements?

Utah’s agency is now working with additional university schools of social work, although it does not have formal agreements with any of its university partners. They send us their syllabi and the names of enrolled students, but because no money is exchanged and no confidential data are shared, they haven’t had to enter into contracts or use memoranda of understanding (MOUs). The Utah team checks in once a quarter with the Weber State team and helped them write a Learn & Work in Utah grant, a legislatively-driven program that allocates Coronavirus Aid Relief and Economic Security (CARES) Act funds to support training programs at Utah colleges and universities. These funds subsidize course tuition and textbook costs for enrolled students who will leave the course with a Utah Crisis Worker Certificate. Weber State offers the 3-credit hour course as an elective in the school of social work’s master’s program, although it will open registration to undergraduate, non-social work graduate students, and non-student professionals. The state is working with the University of Utah, which is going through Council on Social Work Education (CSWE) accreditation with the intention of requiring the crisis certification course for LCSW students. After completing the course, students can opt in to receive their crisis certification from the state. And Utah officials recently connected with Utah Valley University about partnering on a similar program, and the school is interested in making this a master’s-level required course.

How have you generated provider buy-in into the certification mandate?

Mobile crisis services are regionalized and contracted out through local mental health authorities (LMHAs) in Utah. Since mandating the crisis certification, Utah officials have started to see any previous uncertainty around certification abate and more of a collaborative function take hold. The Utah team began hosting collaborative calls about crisis services and opportunities for cooperative case resolution. They also started a committee of LMHAs with the sole purpose of generating local buy-in. All LMHAs operating a MCOT at the time were involved. In time, local authorities really began to appreciate the certification process. They were getting good feedback, and employers started wanting employees to go through training. All of this collaborative and grassroots effort garnered additional interest throughout communities, and now external stakeholders who do not identify as part of crisis system come to us to receive their training. These are groups like substance use disorder treatment providers and people who work in juvenile justice, and they recognize that the training provides a basic, useful skill set and want to be part of it. These professionals access the state operated crisis worker certification that the Utah Department of Health and Human Services offers every 1 to 2 months.

How has the crisis worker certification strengthened Utah’s behavioral health workforce?

Utah officials are trying to develop the crisis workforce while creating a pathway into crisis work, a field that is frequently met with fear, hesitation, and misinterpretation. People confuse behavioral health crisis work with Emergency Department work and/or assume that crisis workers need to be licensed masters level clinicians. Building out this programming and developing the curriculum has involved educating providers and university partners about what this work truly looks like. The crisis worker certification doesn’t require a bachelor’s degree in social work specifically but does require a human services undergraduate focus. Utah officials decided to tailor certification to the least experienced crisis service providers – at some point, everyone is going to be new with no experience, regardless of degree type. The Huntsman Mental Health Institute, our National Suicide Prevention Line (NSPL) affiliate and state level call center, created a certified crisis worker career path with associated income incentives. That program has been particularly successful in recruiting and retaining certified crisis workers.

How has Utah’s mandated certification shifted the crisis workforce paradigm?

Utah is an early workforce developer – getting ahead of the curve in 2018, and now there is so much movement nationally and statewide. There is momentum and incentive to develop a workforce that provide good crisis care and clinical suicide prevention. Utah officials have worked to equip their workforce so that they have a baseline understanding of what our crisis system is and are comfortable having these challenging conversations and doing this work. We are giving them the tools and setting expectations to create shared, common knowledge about what community crisis work is and what it isn’t, and how to provide quality service through the least invasive collaborative environment. We have explored the roles of crisis lines, mobile crisis services, and receiving centers none of this knowledge existed collectively before. It has been a tremendous amount of work, but the result has been very worth the investment.

Acknowledgements: This blog was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The authors would like to thank HRSA project officer Diba Rab and her colleagues for their guidance and helpful feedback, as well as policy leaders from Utah for their time and insight.