Call Log OMB Supporting Statement (2-20-09)

National Suicide Prevention Lifeline—Crisis Center Call Log

SUPPORTING STATEMENT

A. Justification

1. Circumstances of Information Collection

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services (CMHS) is seeking OMB review and approval of a Call Log for use by its National Suicide Prevention Lifeline Network (“Lifeline Network”).

The Lifeline Network consists of a system of toll-free telephone numbers that routes calls from anywhere in the United States to a network of 125 certified local crisis centers across the country. People who are in emotional distress or suicidal crisis can call at any time, from anywhere in the Nation, to talk with a trained worker who will listen to and assist callers in getting the help they need. Calls within the network are routed to an available crisis center closest to the caller, providing callers with immediate access to local resources, referrals, and expertise.

Since 2007, SAMHSA has partnered with the Department of Veterans Affairs (VA) to use Lifeline as a front end for its Veterans Suicide Prevention Hotline. Callers to the Lifeline Network hear a prompt telling them to “press 1” if they are a U.S. military veteran or calling about a veteran. Callers choosing this option are immediately routed to a Department of Veterans Affairs crisis center in New York, staffed by VA professionals.

• Call Log (Attachment A). A brief form designed to monitor basic trends in calls received. This would be the first time that crisis centers will be asked to collect and report uniform data on individuals who use hotlines. 

• Call Log – Spanish Translation (Attachment B).

The Call Log data collection effort will contribute to the SAMHSA/CMHS’s National Outcome Measures/NOMS in the “Access/Capacity” domain, in that they will quantify the number of persons served by age, gender, race, and ethnicity. The goal of this effort is to enhance services provided by networked crisis centers, increase their accessibility to people at risk for suicidal behavior, and optimize public health efforts to prevent suicide and suicidal behavior.

SAMHSA has been conducting ongoing evaluations of the national network since 2003. Results published in the June 2007 issue of Suicide and Life Threatening Behavior showed that (1) among crisis callers, distress decreases during and after calls; (2) crisis hotlines are reaching seriously suicidal callers; 14% of suicidal callers spontaneously reported that the call saved their life; (3) hopelessness decreases during and after calls; and (4) suicidal intent decreases during calls.

Despite these encouraging results, and the fact that there are hundreds of crisis centers in the United States, there is little data available on trends in calls received, including the percentage of callers who are actually suicidal (reported to be between 5% and 20% [Eastwood, Brill, and Brown, 1976; France, 1982; Knickerbocker and McGee, 1973; Lester, 1972]). There is also little data on the demographics of callers, and on why people call hotlines.

The need for such information becomes especially critical in times of national crises, such as the current economic crisis. Data collected independently by some crisis centers that participate in the Lifeline Network indicate that the current economic crisis is prompting an increase in calls related to economic stressors. For instance, Contact Crisis Line, in North Dallas, handled 3,406 calls in 2008 from people concerned about joblessness, debt, and foreclosures—a 60 percent increase over similar calls in 2007. Between July and September 2008, the Georgia Crisis and Access Line reported a 64 percent increase in the number of calls from people in financial crisis, compared to the same period last year. Although calls to the Lifeline network as a whole increased by 31% between September and November 2008 compared to the same period last year (from 111,600 to 145,900), SAMHSA has no way of knowing to what extent that increase might be related to callers in financial crisis. This is the kind of data for which the Department of Health and Human Services and SAMHSA routinely receive media inquiries, and periodically receive Congressional and White House inquiries. (Note that since September 2008, SAMHSA has responded to media requests on this topic from a variety of news outlets, including CNN, New York Times, and National Public Radio.)

A number of early studies suggested that telephone crisis services do not reach individuals at risk for suicide or attract lower-risk suicidal individuals (Clum et al., 1979; Greaves, 1973; Lester, 1972). In fact, many surveys do show that the most frequent callers to hotlines are young white females (Mishara & Diagle, 2000; CDC, 1992; Miller et al 1984; King, 1977), who are at greater risk for suicide attempts, but at lesser risk for death by suicide. However Scott (2000) found that baby-boomers are more likely than previous generations to use mental health services, including hotlines, which may indicate that the demographics of hotline users are changing.

Although Kalafat, Gould, and Munfakh (2005) also found that females were more likely than males to call crisis services, they also found that the overall profile of callers indicated telephone crisis services were reaching seriously suicidal individuals: Over half of the suicidal callers they identified had current plans to harm themselves when they called the crisis service and nearly ten percent had taken some action to hurt or kill themselves immediately prior to the call. Mishara et al. (2005) had similar findings, with females more likely than males to call the centers, a large proportion of the callers being in crisis, and a substantial percentage of the crises involving suicide.

The program is operated under authorization of Section 520A of the Public Health Service Act (42USC290bb-32). Each year, beginning with the 2001 appropriations bill, Congress directed that funding be provided for the Suicide Prevention Hotline program. Since 2001, SAMHSA has awarded a series of three grants to organizations to manage the hotline network. Most recently, in 2007 SAMHSA awarded a 5-year grant to Link2Health Solutions, a subsidiary of the Mental Health Association of New York City.

2. Purpose and Use of Information

The Call Log will collect basic information so that SAMHSA can monitor caller trends and enhance services provided by networked centers. With the data collected (including date, time of day, caller age, gender, ethnicity, veteran status, what prompted the call, and how the caller heard about Lifeline), SAMHSA will be able to measure which populations Lifeline is reaching and when particular groups are calling, and report trends to the network membership and the public, as appropriate. Monitoring the demographics of crisis hotline users and their presenting problems is critical to knowing who is being served, whether the individuals most at risk for suicidal behavior are being served, tailoring hotline services and counselor training to the needs of callers in crisis, and marketing services to reach individuals at highest risk to increase their access to Lifeline services. It is also critical to SAMHSA’s ability to respond to Congressional and White House inquiries.

Lifeline has a Spanish-speaking subnetwork of nine crisis centers, which callers can access by pressing “2” after hearing the Spanish greeting. Attachment B is a Spanish version of the Call Log for use by those centers.

3. Use of Information Technology

Call Log

Crisis counselors will have the option of completing paper or online (http://www.suicidepreventionlifeline.org/cgi-bin/rws3.pl?FORM=Call_Log) versions of the Call Log. If they prefer a paper version, the crisis center will mail the completed forms to SAMHSA’s grantee monthly.

4. Efforts to Identify Duplication

The information will be collected only for the purposes of this program and is not available elsewhere.

5. Involvement of Small Entities

Nearly all of the 125 networked crisis centers are small not-for-profit organizations that are not dominant in the field and would be considered to be “small entities” by OMB. Based on its knowledge of the field and solid relationships with many of the crisis centers, SAMHSA/CMHS believe that the crisis centers perceive the Lifeline Network to be a crucial component of their service mandate. They recognize the fact that their own organizations and clients will benefit as SAMHSA enhances crisis counselor training, optimizes Lifeline’s technological capacity, and increases public awareness of and accessibility to Lifeline’s services. The centers have expressed their willingness to provide any information that will facilitate its development. The brief amount of time needed to complete the Call Log will not have a significant impact on the small entities; in fact, SAMHSA believes that translating the data into practical results will be a significant benefit to the centers.

6. Consequences If Information Is Collected Less Frequently

The Call Log will be completed for all appropriate calls for the duration of the grant (4 years) so that SAMHSA can effectively monitor trends in Lifeline’s callers.

7. Consistency with the Guidelines in 5 CFR 1320.5 (d) (2)

This information collection fully complies with 5 CFR 1320.5 (d) (2).

8. Consultation Outside the Agency

The notice required in 5 CPR 1320.8 (d) was published in the Federal Register on March 19, 2008, Volume 73, Number 54, page 14825. No public comments were received.

As SAMHSA was developing the Call Log, staff asked three crisis center directors to review the materials in February and March 2008. Their suggestions were incorporated, including simplifying the script, transferring instructions from a separate sheet of paper onto the Call Log, and modifying the list of “What Prompted the Call.” They agreed that in the final version, the information requested is reasonable and straightforward, and written in plain, unambiguous language. The following crisis center directors reviewed and commented on these materials:

Charlotte Anderson

Director

211 Hotline

PO Box 63305

North Charleston, SC 29419

(843) 747-3007

David Covington

Chief Operating Officer

Behavioral Health Link

75 Piedmont Ave., NE, Suite 256

Atlanta, Georgia 30303

(404) 420-3202

David Westbrook

Executive Director

Oregon Partnership

6443 SW Beaverton-Hillsdale Highway, Suite 200
Portland, OR 97221

(503) 244-5211

9. Payment to Respondents

Crisis centers are independently funded entities, which receive a $2,500 stipend from SAMHSA’s grantee in recognition of their Lifeline-related work. Centers all sign a written agreement stating that they will follow a number of network policies and procedures. One component of the agreement is a statement that they will “make best efforts to document basic information” regarding Lifeline callers, through the Call Logs.

Individual counselors and callers will not receive payment.

10. Assurance of Confidentiality

The nature of the topics discussed during crisis counseling calls necessitate that crisis centers routinely maintain logs and records in appropriately secure areas. These materials are not shared with SAMHSA. All networked crisis centers are accredited by independent bodies, which specify that appropriate provisions be made for maintaining protection in the storage, retrieval, use, and disposition of records. (Accrediting bodies include the American Association of Suicidology, The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities [CARF], the Alliance of Information & Referral Systems [AIRS], the Council on Accreditation, and CONTACT USA.)

No identifiable information will be collected for or written on Call Logs. Counselors who work in crisis centers that do not use online Call Logs will submit completed forms to their supervisors, who will follow that center’s standard confidentiality procedures for storage and retrieval. At the end of the month, the crisis center will mail the forms to a central location for compilation and analysis.

To prevent interception of online Call Log data, the online Call Log will be password protected and encrypted using 128 bit SSL Encryption, the same method of protection that online banks use. Once the data is on the grantee’s server, it is only accessible from the Data Coordinator’s computer onsite and is password protected. 

11. Questions of a Sensitive Nature

The Call Log will be completed by trained crisis counselors, including some mental health professionals and some trained, lay volunteers. Because callers contact crisis centers for help with a range of very personal and sensitive problems, counselors commonly ask callers sensitive questions. The kind of sensitive questions asked in the Call Log are more routinely asked in everyday life: age, race, and ethnicity. Additionally, the Call Log script includes reassurances to the caller that the information cannot identify them, that responding to the questions is voluntary, and that they are welcome to call back at any time, whether or not they decide to answer the questions.

12. Estimates of Annualized Hour Burden

The response burden estimate for the Call Log is based on pretests with four crisis counselors in March 2008.

The estimated annual response burden¹ to collect this information is as follows:

Type of Respondent	Number of Respond-ents	Responses Per Respond-ent	Total Responses	Hours Per Response	Total Hour Burden Per Respond-ent	Total Hour Burden, All Respond-ents	Hourly Wage	Total Hour Cost
IT Worker (extract, reformat, upload; ACCs)	1002	12	1,200	.5	6	600	$15	$9,000
Caller (question response; NCCs)	26,6403	1	26,640	.05	.05	1,332	--	--
Volunteer Crisis Counselor (form completion; NCCs)	3754	365	13,500	.08	2.9	1,088	--	--
Paid Staff Crisis Counselor (form completion; NCCs)	375	36	13,500	.08	2.9	1,088	$17	$18,500
Total	27,490	-------	54,840	-------	-------	4,108	-------	$27,500

13. Estimates of Annualized Cost Burden to Respondents

If the cost in the table above is divided equally among the 125 crisis centers, each center would bear an annualized cost of $440.

14. Estimates of the Annualized Cost to the Government

The annual cost to the Government will include approximately $60,000 for grantee staff time (data manager and coordinator) and $15,000 for Columbia University for data analysis. The cost will also include approximately 40 hours for the Government Project Officer (GS-14, Step 2; $1,510) to coordinate with the grantee. Finally, each networked crisis center receives a $2,500 stipend (total: $312,500) to help offset costs for participating in the Lifeline network, which includes an agreement to complete Call Logs. The total annual cost is estimated to be $389,010.

15. Changes in Burden

This is a new project.

16. Time Schedule, Publication, and Analysis Plans

Time Schedule

Activity Date

OMB approves submission

Data collection begins 1 month after OMB approval

Preliminary analysis of Call Log data 7 months after OMB approval

Report of preliminary Call Log data completed 9 months after OMB approval

Analysis of first year’s Call Log data 13 months after OMB approval Report of Call Log data completed 15 months after OMB approval

Publication

SAMHSA will routinely use the data collected to report NOMS data, respond to White House and media inquiries, and provide feedback to its networked crisis centers. There are no plans to publish data in professional journals.

Analysis Plans

A crucial aspect of evaluating the Lifeline network is collecting data that shows whether the network is reaching the populations this program is designed to reach. This data is not only valuable to the Federal government in determining the efficacy of this project, but also to local crisis centers. The data from the Call Logs will allow SAMHSA to provide member centers with information about how the Lifeline is helping them reach persons in need within their own communities and in the Nation as a whole.

The descriptive analysis primarily will utilize frequency distributions and counts from the items in the Call Log in order to address such questions as:

1. What is the age distribution of the callers?

2. What is the gender distribution of the callers?

3. What is the time distribution of the calls?

4. What geographic areas are the calls from?

5. How are callers hearing about Lifeline?

6. What problems are prompting the calls?

Examples of the questions that outcome analyses will address include:

1. Are marketing strategies yielding diverse populations?

2. How do caller demographics correlate with the demographics of individuals who are at high risk for suicide?

3. Is there a need to broaden outreach and marketing efforts?

4. How do the mental health issues addressed in crisis counselor training correlate with the issues presented by callers?

5. Is there a need to modify crisis counselor training so that it covers issues that are more relevant to caller needs?

Such analyses will highlight areas of need for future network development.

17. Display of Expiration Date

The expiration date for OMB approval will be displayed on all data collection instruments for which approval is being sought.

18. Exceptions to Certification Statement

This collection of information involves no exceptions to the Certification for Paperwork Reduction Act Submissions. The certifications are included in this submission.

B. Collections of Information Employing Statistical Methods

1. Response Universe and Sampling Methods

The Lifeline Network currently receives approximately 37,000 calls monthly and it is estimated that fewer than 10% of those calls represent people in suicidal crisis. Implementing a sampling procedure to capture data just on suicidal callers would reduce the number of completed Call Logs to a level that would be inadequate to analyze. Additionally, the crisis center directors who were consulted, as well as the counselors who pre-tested the Call Log, believe it would be less burdensome for crisis counselors to remember to complete a Call Log on all appropriate callers, instead of on every (for instance) tenth caller.

2. Information Collection Procedures

Through regular Lifeline Network communications (blogs and e-mails) crisis center directors are already aware that they will be completing the Call Logs after OMB approval. They have already had an opportunity to see the draft Call Log online. After OMB approval, they will receive a letter (Attachment C) with additional information and the announcement of Call Log Webinars and/or online training for staff.

Call Logs will be completed by trained crisis counselors, who will have the option of completing the form on hard copies or online (http://www.suicidepreventionlifeline.org/cgi-bin/rws3.pl?FORM=Call_Log).

Eleven of the twenty items (e.g., date and time of call; caller gender; what prompted the call; for whom the person is calling; whether emergency outreach was dispatched, etc.) can be completed after or during the course of the call, without asking the caller specific questions. The nine remaining items do require the counselor to ask the caller questions (e.g., age, race/ethnicity, how they heard about the Lifeline, whether they have served in the U.S. military, etc.), if those topics were not previously discussed during the course of the call.

The instructions specify that the counselor should only ask the caller questions if (1) the call is about to end (i.e., the caller is stable has already received appropriate referral information) and (2) in the opinion of the counselor, asking the questions will not make the caller uncomfortable or destabilize him/her. The instructions emphasize that “we rely on and respect your judgment as a trained crisis counselor” in deciding whether to ask questions. The script includes reassurances to the caller that the information cannot identify them, that responding to the questions is voluntary, and that they are welcome to call back at any time, whether or not they decide to answer the questions.

3. Methods to Maximize Response Rates

Each networked crisis center receives a small stipend ($2,500) for participating in the Lifeline network. In addition to agreeing to a number of policies and procedures to ensure the provision of quality services, participating centers also agree to complete Call Logs on all appropriate calls. From the time they agreed to participate in the network, the crisis center directors have been amenable to completing the Call Logs because they knew that their centers would receive enhanced crisis counselor and management training and benefit from targeted efforts to market Lifeline’s services.

SAMHSA’s grantee monitors the monthly number of Lifeline calls that each crisis center receives. When data collection begins, they will compare the number of Call Logs submitted by each center with the number of calls they received. The grantee will contact the directors of centers that do not submit Call Logs for at least 75% of their calls, asking that the directors intervene to improve the response rate. Directors whose centers do meet their goal will receive “thank you” e-mails and will be acknowledged in a monthly newsletter sent to all networked centers.

4. Tests of Procedures

During the week of March 13, 2008, four crisis counselors, two from The Center for Information and Crisis Services (Lantana, Florida) and two from the LifeNet Crisis Center (New York), pilot tested the Call Log with two callers each. The Florida counselors used the online form and the New York counselors used the hard copy.

One of the crisis center directors wrote, “The crisis counselors felt that the majority of the info from the call log is either info we already try to get within the context of the call (with the exception of race/ethnicity) or will be able to add without much difficulty.” The other crisis center director agreed and added that the Call Log was easy to understand and use.

No one had trouble completing the online or hard copy versions of the Call Log. No changes to the Call Log were deemed necessary after the pilot testing.

5. Statistical Consultants

The Mental Health Association of New York City (the SAMHSA Lifeline grantee) subcontracted with the following researcher to help develop the research design and analyze the results:

Madelyn S. Gould, Ph.D., M.P.H.

Professor

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5329

The SAMHSA project officer responsible for receiving and approving deliverables is:

Richard McKeon Ph.D., M.P.H.

Center for Mental Health Services

SAMHSA

1 Choke Cherry Road, Room 6-1015

Rockville, MD 20857

240-276-1873

Sources

Centers for Disease Control and Prevention. 1992. Youth Suicide Prevention Programs: A Resource Guide. Atlanta: Centers for Disease Control.

Clum GA, Patsiokas AT, & Luscomb RL. 1979. Empirically based comprehensive treatment program for parasuicide. Journal of Consulting and Clinical Psychology, 47, 937-945.

Eastwood MR, Brill L, Brown JH. 1976. Suicide and prevention centres. Canadian Psychiatric Association Journal, 21(8): 571-575.

France MH. 1982. Seniors helping seniors: A model of peer counseling for the aged. Canada’s Mental Health, 30(3): 13-15.

Greaves G. 1973. An evaluation of a 24-hour crisis intervention clinic. Canada’s Mental Health, 21(3-4): 13-15.

Kalafat J, Gould MS, & Munfakh JL. 2005. Final progress report: Hotline evaluation and linkage project category II. Unpublished manuscript.

King GD. 1977. An evaluation of the effectiveness of a telephone counseling center. American Journal of Community Psychology, 5, 75-83.

Knickerbocker DA, McGee RK. 1973. Clinical effectiveness of nonprofessional and professional telephone workers in a crisis intervention center. In: Lester D, Brockopp GW, Editors. Crisis Intervention and Counseling by Telephone. (pp. 298-309). Springfield, IL: Charles C. Thomas.

Lester D. 1972. The myth of suicide prevention. Comprehensive Psychiatry, 13(6): 555-560.

Miller HL, Coombs DW, Leeper JD, & Barton SN. 1984. An analysis of the effects of suicide prevention facilities on suicide rates in the United States. American Journal of Public Health, 74, 340-343.

Mishara BS, Chagnon F, Daigle M, Balan B, Raymond S, Marcoux I, Bardon C, & Campbell JK. 2005. A silent monitoring study of telephone help provided over the Hopeline network and its short-term effects. Unpublished manuscript. Centre for Research and Intervention on Suicide and Euthanasia (CRISE), University of Quebec at Montreal.

Mishara BL & Daigle M. 2000. Helplines and crisis intervention services: Challenges for the future. In: Lester D, Editor. Suicide Prevention: Resources for the Millennium. (pp. 153-171). Philadelphia: Brunner-Routledge.

Scott V. 2000. Crisis services: Befrienders International: Volunteer action in preventing suicide. In: Lester D, Editor. Suicide Prevention: Resources for the Millennium. (pp. 265-73). Philadelphia: Brunner-Routledge.

List of Attachments

1. Call Log

2. Call Log (Spanish version)

3. Letter to Crisis Center Directors

1 Estimates based on 444,000 calls annually.

2 100 (80%) of the networked crisis centers currently collect this data electronically (automated crisis centers or ACCs). An IT worker would need to extract, reformat, and upload those records monthly.

3 25 (20%) of the networked crisis centers do not currently collect this data (non-automated crisis centers or NCCs) and counselors would therefore need to ask Callers questions from the Call Log. A 30% response rate is anticipated. 444,000 total annual calls x (20% of the centers) = 88,800 annual calls answered by NCCs x (30% response rate) = 26,640 Call Logs completed by NCCs.

4 Estimate based on crisis centers’ average staffing level of 30 counselors, 50% (15) of whom are volunteer. 25 non-automated centers x 15 volunteer counselors = 375 volunteer counselors.

5 Estimate assumes that incoming calls will be equally divided among volunteer and paid counselors. 26,640 calls  750 total counselors = 36 calls per counselor.

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