Implementation of Safety Planning at 988 Crisis Centers in Missouri: A Mixed Methods Study.

Background: The United States faces a growing behavioral health crisis. To improve access to crisis services, the federal government launched the easy-to-remember number, 9-8-8, for the National Suicide Prevention Lifeline in July 2022. However, little is known about the quality of care provided through 988 crisis lines, particularly regarding the use of evidence-based practices, such as Safety Planning. This study examined variation in employee attitudes toward Safety Planning, how it is operationalized, and factors that influence its implementation on crisis lines in Missouri. Methods: We used a convergent triangulation mixed methods design. A survey assessed demographics and attitudes toward Safety Planning using the Intervention Appropriateness Measure (IAM), Feasibility of Intervention Measure (FIM), and Acceptability of Intervention Measure (AIM). Semi-structured interviews explored staff' experiences in depth. Regression models identified predictors of attitudinal measures, and qualitative data were analyzed using the Twenty-First-Century flexible coding approach, integrating deductive and inductive methods. Results: Of the 97 respondents, 79.4% were frontline crisis counselors and 20.6% were in leadership positions. In quantitative analyses, average scores on the IAM, FIM, and AIM were all high; however, graduate-level education was negatively associated with scores. Interviews (n = 28) revealed overall strong support for Safety Planning. The synthesis of these interviews resulted in four themes, including (1) counselor's attitudes, (2) caller characteristics, (3) caller-centered practices, and (4) quality assurance practices and culture. Most barriers and facilitators to Safety Planning were related to the social, economic, and health circumstances surrounding callers; organizational supports (e.g., culture, training, quality monitoring, feedback) were important drivers. Conclusions: Safety Planning is viewed positively by 988 crisis line staff in Missouri, which is facilitated by organizational supports; however, there are barriers to its utility and impact, such as caller circumstances and the brief, phone-based structure of care. To our knowledge, this is one of the first empirical examinations to understand the use of Safety Planning at 988 crisis centers. Findings underscore the need to refine conceptualizations of "quality" in crisis services, to examine how evidence-based practices like Safety Planning vary within and across 988 centers, and to identify meaningful, appropriate, and feasible accountability metrics.