Journal of Health Care for the Poor and Underserved

Priority Population

Michigan's warmline was designed to meet the needs of people living with SMI whose mental health care and ancillary support services were affected by COVID-19. People with SMI are particularly vulnerable to the effects of the COVID-19 pandemic.^1,7 These vulnerabilities include not only health risks posed by COVID-19 itself, but also social risks resulting from physical distancing and isolation, as well as disruptions in mental health care delivery.^8,9 Even before the advent of COVID-19, people with SMI faced some of the most profound heath disparities in the nation, with average mortality up to 25 years earlier than the general population.¹⁰ In Michigan, state policies designed to save lives through physical distancing starting in March 2020 resulted in an abrupt, widespread shift away from face-to-face mental health services, including within the publicly funded community mental health (CMH) safety net. While clinical mental health services such as medication management and psychotherapy continued in person and through telehealth, ancillary services such as support and socialization groups were disrupted, and Michigan's 53 peer-run drop-in centers for people with SMI experienced periodic closures. While people living with SMI were the priority population for whom the warmline was established, anyone living in the state of Michigan was eligible to use the warmline free of charge.

Description of the Program

The warmline operated seven days a week, 10 a.m.–2 a.m., including holidays. It focused on two distinct services: (1) providing emotional support and active listening for callers distressed by the pandemic or other stressors, and (2) referring callers with specific unmet health and social needs to appropriate resources. The warmline was operated by peer workers who were trained and certified by the state of Michigan to provide peer support services.¹⁰ Responders included certified peer support specialists and certified peer recovery coaches, some of whom also had a community health worker certification. When a caller self-identified as a veteran, they were given the option of speaking with a veteran peer worker if desired. When providing peer support, warmline responders used reflective listening and were encouraged to share parts of their personal recovery story to inspire hope. Health, mental health, and social service resources were often shared with callers. While not advertised as a crisis line, warmline responders were prepared to transfer callers to the National Suicide Prevention Lifeline when needed. The warmline allowed callers to remain anonymous except on the very rare occasion of danger to self or others, in which case the responder would contact their immediate supervisor, who would contact 911 if a wellness check was needed. Out-of-state callers needing assistance would be referred to local resources and www.warmline.org to find other warmline resources, although out-of-state callers in extreme distress would be provided with some support followed by warm handoff to another number.

There is a robust research literature on the benefits of peer support services for people living with SMI.¹¹ Less is known, however, about peer-run warmline programs specifically. Approximately 39 states have established peer-run warmlines.¹² Different programs vary greatly in staffing (e.g., paid peer employees versus volunteers), call [End Page 497] volume (between 100 and 1,500 calls per week), call management technology, and crisis procedures; what these programs have in common is an emphasis on mental health recovery, peer support, and availability outside traditional business hours.^5,12 The PARTNERS Act (HR 8016), a bill introduced to congress in August 2020, proposed establishing a centralized network of peer support warmlines.¹³ While the bill did not receive a vote in Congress, the fact that it was sponsored suggests growing recognition for the potential benefits of warmlines. Research on warmlines has found that warmline services can reduce feelings of isolation among people living with mental illness in the community, and that callers found it helpful to talk to a peer who could relate to their struggles.^3,4

Implementation

The warmline was advertised broadly throughout the state of Michigan through print, radio, and television announcements by public health officials, local sheriff and state police offices, Governor's press briefings,⁶ and Michigan Department of Health and Human Services (MDHHS) staff. Twenty warmline responders obtained two to three hours of training every month from MDHHS, which included topics such as trauma-informed care, motivational interviewing, Adult and Child Protective Services reporting requirements, and guidance on handling challenging calls. Trainings emphasized using recovery-oriented language during every call. MDHHS also provided every-other-week meetings for warmline responders, rotating between a staff support meeting and a training session. A supervisor, who was also a peer worker, was immediately available when responders could not address questions or concerns on their own. The supervisor would also help responders debrief and process difficult calls that might have felt emotionally challenging.

A process evaluation was conducted to ensure warmline operation was consistent with the intended goals and service users. The evaluation was reviewed by the University of Michigan Institutional Review Board and designated as a non-regulated program evaluation. Warmline responders logged anonymized encounters using a web form, which they could access from their personal phones or a computer. Data from the forms were used to create a weekly report for the State of Michigan that detailed warmline activities. The form contained fields such as time spent on each call, topics covered, and specific resources provided. The form also characterized the caller according to three possible levels. Level 1 callers just wanted to talk (for example, to receive emotional support or discuss coping skills). Level 2 callers wanted to talk, but also needed a specific resource. Level 3 callers were in crisis (for example, had suicide plans or had serious mental health or substance abuse concerns). A Level 3 designation would automatically lead to the call being transferred to local crisis units, 911, or the National Suicide Prevention Lifeline. The forms intentionally did not include information that was clinical in nature; for example, the warmline responders did not ask callers to disclose their diagnoses, use of mental health services, or other medical information, as it was felt that this could detract from focusing on the caller's concerns and blur the distinction between peer support and a clinical service.

From April 13, 2020, through May 17, 2021, the warmline received a total of 26,584 [End Page 498] calls. Of these calls, 92% were Level 1, 7% were Level 2, and 1% were Level 3. The calls included reflective listening, discussions about coping skills, discussions about wellness, and the peer worker sharing elements of their recovery story. Eighty one percent of calls involved discussing COVID-19 at least briefly. Of the calls characterized as Level 2 or 3, the top resources provided were mental health support groups (73%), community mental health access or crisis contacts (59%), other clinical services (44%), referral to their current mental health provider (32%), education or training (28%), COVID-19 resources and information from the State of Michigan (25%), and medical care (19%). Some callers received multiple resources during their call.

One unanticipated experience during implementation was the high proportion of high-volume callers using the warmline. Responders did not collect identifying information from callers; however, certain high-volume callers became well known to the responders, with two or three individuals placing calls up to 20 times per day. High-volume callers made it more difficult for other callers to access the warmline. The warmline ultimately addressed this issue by placing a limit of four calls (one per shift) of up to 20 minutes per person, per day.

The program evaluation also included semi-structured qualitative interviews of warmline service users. The semi-structured interview protocol was collaboratively designed by the coauthors. The protocol focused on eliciting narratives about experiences with the warmline. Representative items included, "How did you learn about the warmline?" and "Can you please walk me through how your call with the warmline went, starting from when you got connected with a peer?" A faculty member [AL] provided qualitative interview training to a peer specialist [MF], who conducted the interviews. During a six-week period during summer 2020, warmline service users were invited to participate in interviews to discuss their experiences with the warmline. Twelve interviews were conducted. These were audio-recorded and reviewed by the coauthors. Themes were developed from rapid analysis¹⁴ of the audio recordings through weekly discussion of audio content by the entire study team. All 12 interviewees discussed having mental health concerns. Several stated that they were referred to the warmline by CMH staff or living in a group home. Some specifically discussed "peerness" as important to their experience. For example, when asked what was helpful about the warmline, one respondent stated, "I think that sharing experiences that were similar to the question or problem that I had, that I called for. Like let's say I was feeling depressed, or manic, or something more complex than just depression or anxiety. I talked to them about medication, I talked to them about experiences I had in the 20 years I've been in mental health recovery." It was also found that for many high-volume callers, use of the warmline was largely driven by distress related to loneliness rather than specific mental illness concerns or the direct effects of COVID-19. For example, when asked why they decided to use the warmline, one caller noted, "I call because I'm bored and lonely." Another stated, "I need someone to talk to. I'm just sitting here in a room by myself." Another stated, "I have a pretty isolated life."

Although these 12 interviews likely did not capture all relevant perspectives, the interviews led to an understanding that high-volume callers were likely to have high unmet needs for social engagement, and in response, MDHHS opened one of its conference [End Page 499] lines to create a twice-weekly peer worker-led phone support group. Individuals known to the warmline responders to be calling four or more times per day were invited to join the support calls, which included topics such as loneliness, isolation, and sharing ideas and strategies to address these issues. With call limits and the start of the conference call service, approximately 30 frequent callers decreased their calls to under two calls per day for the remainder of the initiative.

In July 2020, warmline leadership sent a web survey to the 19 peer warmline responders, all of whom participated in the survey. The survey consisted of 18 questions, focusing on the support and feedback they received from supervisors. The majority reported that their relationship with the peer supervisors was positive, and that support was provided during challenging calls. Respondents indicated that they enjoyed providing support to others by using personal experience to connect with people. When asked for the main reason they believed people would call the warmline, they indicated isolation, loneliness, emotional support, and mental health support. Some of the peers also indicated that working on the warmline helped them with their own recovery journey.

Lessons Learned

Ultimately, the program evaluation proved to be helpful in testing some of the assumptions underlying the initiative, resulting in specific changes to its implementation. As was anticipated when the program was proposed, the warmline proved to be a resource highly sought-after by Michigan residents. It was hoped that the warmline would siphon non-crisis callers away from other telephone lines such as the National Suicide Prevention Lifeline and, at the same time, would not be confused for being a number to call during a mental health crisis. As the evaluation indicated that only 1% of calls were characterized as level 3 crises, the approach and marketing strategy were thought to be successful in that regard. High-volume callers made it more difficult for other callers to access the warmline and felt overwhelming to warmline responders. As the program evaluation's qualitative interviews suggested that high-volume calling was driven in part by loneliness, a phone support group using an MDHHS conference line was established to meet these needs. One limitation of this study was that we did not obtain diagnostic or clinical information from callers, resulting in difficulty characterizing the population that was reached. However, the marketing of the warmline, and the fact that all interviewees described mental health challenges, suggest that the warm line was successful in reaching the intended priority population. This evaluation indicated that the warmline was being appropriately used as a resource during a critical early phase of the pandemic. Future research may focus on the question of whether warmlines cause measurable, sustained improvements in mental health, psychosocial functioning, quality of life, or loneliness.

Sustainability

When the Michigan warmline was first implemented, a simultaneous project was occurring legislatively. Michigan Public Act 12 of 2020 was passed, which created a new behavioral health integrated crisis and access system called the Michigan Crisis [End Page 500] and Access Line.¹⁵ It is modeled after SAMHSA's National Guidelines for Behavioral Health Crisis Care.¹⁶ The Michigan Crisis and Access Line contract was awarded to Common Ground, a nonprofit crisis services agency. Given the possible benefits of providing a more integrated and seamless experience between the crisis line and the peer warmline, Common Ground took over implementation of the warmline. Following the transition to Common Ground, call volume increased substantially to 43,541 calls over a 16-month period. Due to increased call volume, the number of peer warmline responders increased from 19 to 25. Thus, although the warmline was initiated to address a reduction in in-person services during the pandemic, there is a sustained and growing demand for telephone-based peer support to address persistent needs in the community.