This document does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0655z1.DOCX
DATE: 6/19/2023
HOUSE OF REPRESENTATIVES STAFF FINAL BILL ANALYSIS
BILL #: CS/CS/HB 655 Suicide Prevention
SPONSOR(S): Health & Human Services Committee and Children, Families & Seniors Subcommittee,
Trabulsy and others
TIED BILLS: IDEN./SIM. BILLS: CS/SB 914
FINAL HOUSE FLOOR ACTION: 115 Y’s
0 N’s GOVERNOR’S ACTION: Approved
SUMMARY ANALYSIS
CS/CS/HB 655 passed the House on April 20, 2023, as CS/SB 914.
The Commission on Mental Health and Substance Abuse (Commission) studies and recommends
improvements to the mental health and substance abuse services available within the state.
The bill renames the Commission as the Commission on Mental Health and Substance Use Disorder and
requires the Governor to appoint to it a representative of the statewide Florida 211 network. The bill broadens
the purpose of the Commission, requiring it to assess the adequacy of the current infrastructure of Florida’s
988 Suicide and Crisis Lifeline system (988 system) and other components of the state’s crisis response
services. The bill also expands the duties of the Commission to require the Commission to:
1. Provide recommendations on how managing entities can work with community stakeholders to support
the 988 system and other crisis response services;
2. Conduct an overview of the current infrastructure of the 988 system;
3. Analyze the current capacity of crisis response services, including services provided by mobile
response teams and centralized receiving facilities;
4. Evaluate and make recommendations to improve linkages between the 988 system infrastructure and
crisis response services;
5. Identify available mental health block grant funds; and
6. Identify available funding sources through Medicaid.
The bill requires the Commission to submit annual interim reports through January 1, 2025, and a final report
by September 1, 2026. The bill also repeals the Commission on September 1, 2026.
First responders are often exposed to incidents of death and destruction that can result in the development of
behavioral health conditions, such as post-traumatic stress disorder (PTSD) and depression. However, studies
have shown that first responders experience positive benefits from mental health help and support and
encouragement from their peers.
The bill authorizes affiliated first responder organizations to designate peers to provide support to first
responders. Affiliated first responder organizations include but are not limited to regularly organized volunteer
firefighting departments, volunteer ambulance services, or combination fire departments. The bill also specifies
that a first responder peer includes active, volunteer, and retired responders. Further, the bill permits the use of
telehealth to diagnose post-traumatic stress disorder in first responders for the purposes of obtaining worker’s
compensation benefits.
This bill has an insignificant fiscal impact on the Department of Children and Families which can be absorbed
within existing resources. This bill has no fiscal impact on local governments.
The bill was approved by the Governor on June 16, 2023, ch. 2023-252, L.O.F., and will become effective on
July 1, 2023.
STORAGE NAME: h0655z1.DOCX PAGE: 2
DATE: 6/19/2023
I. SUBSTANTIVE INFORMATION
A. EFFECT OF CHANGES:
Background
Mental Health
Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope
with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or
her community.
1
The primary indicators used to evaluate an individual’s mental health are:
2
Emotional well-being- Perceived life satisfaction, happiness, cheerfulness, peacefulness;
Psychological well-being- Self-acceptance, personal growth including openness to new
experiences, optimism, hopefulness, purpose in life, control of one’s environment, spirituality,
self-direction, and positive relationships; and
Social well-being- Social acceptance, beliefs in the potential of people and society as a whole,
personal self-worth and usefulness to society, sense of community.
Mental illness is collectively all diagnosable mental disorders or health conditions that are characterized
by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress or
impaired functioning.
3
Thus, mental health refers to an individual’s mental state of well-being whereas
mental illness signifies an alteration of that well-being. Mental illness affects millions of people in the
United States each year. Nearly one in five adults lives with a mental illness.
4
During their childhood
and adolescence, almost half of children will experience a mental disorder, though the proportion
experiencing severe impairment during childhood and adolescence is much lower, at about 22%.
5
Suicide Prevention
Suicide is the act of taking one's own life by intentional self-harm or self-inflicted injury.
6
It is a serious
public health problem that contributes to premature death, long-term disability, loss of productivity, and
significant healthcare costs.
7
Suicide is among the leading causes of death in the country, making the
prevention of suicide a public health priority nationally and within Florida.
8
The most recent data ranks
suicide as the 12
th
leading cause of death nationally in 2020 and the 8
th
leading cause of death in
Florida in 2019.
9
The graph compares suicide data in Florida and nationally for 2015-2020.
10
1
World Health Organization, Mental Health: Strengthening Our Response, https://www.who.int/news-room/fact-sheets/detail/mental-
health-strengthening-our-response (last visited February 20, 2023).
2
Centers for Disease Control and Prevention, Mental Health Basics, http://medbox.iiab.me/modules/en-
cdc/www.cdc.gov/mentalhealth/basics.htm (last visited February 20, 2023).
3
Id.
4
National Institute of Mental Health (NIH), Mental Illness, https://www.nimh.nih.gov/health/statistics/mental-illness (last visited February
20, 2023).
5
Id.
6
Florida Department of Health, Suicide Prevention, available at https://www.floridahealth.gov/programs-and-
services/prevention/suicide-prevention/index.html (last visited February 24, 2023).
7
Center for Disease Control and Prevention, Suicide Prevention, available at https://www.cdc.gov/suicide/resources/prevention.html
(last visited February 24, 2023).
8
DCF Office of Substance Abuse and Mental Health (SAMH), Suicide Prevention Coordinating Council 2021 Annual Report, available
at https://www.myflfamilies.com/sites/default/files/2022-12/2021%20Suicide%20Prevention%20Coordinating%20Council%20Annual%
20Report%20-%20Final.pdf (last visited February 24, 2023). According the Center for Disease Control and Prevention WISQARRS
Leading Causes of Death Reports, suicide was the twelfth leading cause of death in the U.S. in 2020. See National Health Information,
Suicide, at https://www.nimh.nih.gov/health/statistics/suicide (last visited February 25, 2023).
9
Id. See also Florida Department of Health, FLHealthCHARTS.com Statistical Brief Suicide Deaths in Florida, 2019, at
https://www.flhealthcharts.gov/Charts/documents/StatisticalBriefs/SuicideDeaths2019.pdf (last visited February 27, 2023).
10
DCF Office of Substance Abuse and Mental Health (SAMH), Suicide Prevention Coordinating Council 2021 Annual Report, available
at https://www.myflfamilies.com/sites/default/files/2022-12/2021%20Suicide%20Prevention%20Coordinating%20Council%20Annual%
20Report%20-%20Final.pdf (last visited February 24, 2023).
STORAGE NAME: h0655z1.DOCX PAGE: 3
DATE: 6/19/2023
Data Sources: Centers for Disease Control and Prevention National Center for Injury Prevention and Control (2021) Web-
based Injury Statistics Query and Reporting System (WISQARS); Florida Department of Health Bureau of Vital Statistics.
Suicide-related thoughts and behaviors can impact anyone, of any gender, age, race, or socioeconomic
background. However, specific groups experience higher rates.
11
Nationally, there is a higher rate of
death by suicide among men, non-Hispanic Whites, non-Hispanic American Indians or Alaska Natives,
youth who are of diverse gender expressions and sexual orientations, and individuals aged 45– 64
years and 85 years and older.
12
In 2020, suicide was the second leading cause of death for people
ages 10-14 and 25-34 , the third leading cause of death among individuals between the ages of 15-24,
and the fourth leading cause of death among individuals between the ages of 35 and 44.
13
Suicide is associated with several risk and protective factors. As with other human behaviors, suicide
does not have a single determining cause. Instead, it occurs in response to multiple biological,
psychological, interpersonal, environmental, and societal influences that coincide, often over time.
Therefore, a combination of situations could lead someone to consider suicide.
14
Suicide is preventable if risk factors associated with suicide are diminished while protective factors are
increased.
15
Risk factors increase the possibility of suicide (but may not be direct causes), while
protective factors help lessen risk factors. Known risk factors include:
Individual: history of depression and/or other mental illnesses, hopelessness, substance abuse,
certain health conditions, previous suicide attempts, violence victimization and perpetration,
genetic/biological determinants.
11
Id.
12
Id.
13
National Health Information, Suicide, at https://www.nimh.nih.gov/health/statistics/suicide (last visited February 25, 2023).
14
Id.
15
Supra, note 10.
STORAGE NAME: h0655z1.DOCX PAGE: 4
DATE: 6/19/2023
Relationship: high conflict or violent relationships, sense of isolation, lack of social support,
family/loved one’s history of suicide, financial and/or work stress.
Community: inadequate community connectedness, barriers to health care (e.g., lack of access
to providers and medications).
Societal: availability of lethal means of suicide, unsafe media portrayals of suicide, stigma
associated with help-seeking and mental illness.
16
Protective factors include:
Coping and problem-solving skills.
Cultural and religious beliefs that discourage suicide.
Connections to friends, family, and community support.
Supportive relationships with care providers.
Availability of physical and mental health care.
Limited access to lethal means.
17
Support services are available to those who are experiencing suicide-related thoughts and behaviors.
These services, such as the National Suicide Prevention Lifeline, provide a safety net in moments of
crisis and connections to ongoing mental health support.
18
Post-Traumatic Stress Disorder
According to the American Psychiatric Association, PTSD is a psychiatric disorder that may occur in
people who have experienced or witnessed a traumatic event, such as a natural disaster, serious
accident, terrorist act, war, or rape; or people who have been threatened with death, sexual violence, or
serious injury.
19
Exposure to an upsetting traumatic event may be indirect rather than first hand. PTSD
can occur if a person learns of the violent death of a close family member or friend, or is repeatedly
exposed to the horrible details of trauma.
20
Symptoms of PTSD may begin shortly after the traumatic event, or may not appear until years after the
event. For a person to be diagnosed with PTSD, symptoms must last for more than one month and
must cause significant distress or interfere with the individual’s daily functioning.
21
Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts
about the event. This can lead to avoidance of any stimuli that recalls the traumatic events, negative
thoughts about oneself or the world, and changes in emotional reactions to events, like being easily
startled or having trouble sleeping or concentrating.
22
Rates of PTSD are higher among veterans, police officers, firefighters, and emergency medical
personnel.
23
Behavioral Health Acute Care System
The Department of Children and Families (DCF) administers a statewide system of safety-net services
for substance abuse and mental health (SAMH) prevention, treatment and recovery for children and
adults who are otherwise unable to obtain these services. SAMH programs include a range of
16
Supra, note 6.
17
Id.
18
Supra, note 8.
19
American Psychiatric Association, What is Posttraumatic Stress Disorder, https://www.psychiatry.org/patients-families/ptsd/what-is-
ptsd (last visited April 27, 2023).
20
Id.
21
Id.
22
Mayo Clinic, Post-traumatic stress disorder (PTSD), https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-
disorder/symptoms-causeds/syc-20355967 (last visited April 27, 2023).
23
Id.
STORAGE NAME: h0655z1.DOCX PAGE: 5
DATE: 6/19/2023
prevention, acute interventions (e.g. crisis stabilization), residential treatment, transitional housing,
outpatient treatment, and recovery support services. Services are provided based upon state and
federally-established priority populations.
The behavioral health acute care system is a complex system that includes a variety of entities and
integrated components that are essential for providing a public health safety net and comprehensive
crisis response system for those with mental health and substance use disorders. This graphic
indicates the entities involved in the system regarding mental health specifically. Additional entities are
involved regarding substance abuse, such as addictions receiving facilities and detoxification units.
Source: Florida Mental Health Institute, USF, 2014 Baker Act User Reference Guide.
Crisis Response System
The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) identifies three
components to an ideal crisis response system: someone to talk to, someone to respond and
somewhere to go. Florida has various crisis support services that address the different components.
The 988 Suicide & Crisis Lifeline helps to ensure that an individual has someone to talk to. Mobile
response teams respond to the crisis, and the centralized receiving facilities, crisis stabilization units,
and hospitals provide some place to go.
As the single state authority for mental health and substance abuse, DCF administers the Statewide
Office for Suicide Prevention and facilitates the development of strategies for preventing suicide. The
agency also oversees and sets policy for Mobile Response Team services, Centralized Receiving
Facilities, and Crisis Stabilization Units, as well as other crisis services.
24
Central Receiving Facilities
24
DCF, Agency Bill Analysis HB 655 (2023), p. 2. (on file with the House Children, Families, and Seniors Subcommittee).
STORAGE NAME: h0655z1.DOCX PAGE: 6
DATE: 6/19/2023
Florida’s “No-Wrong-Door-Model” is a model for the delivery of acute care services to persons who
have mental health or substance use disorders, or both, that optimizes access to care, regardless of
the entry point to the behavioral health care system.
25
A central receiving facility supports the no-
wrong-door-model by providing a central point of entry or intake for assessment and referral of
individuals experiencing a mental health or substance abuse crisis.
Central receiving facilities are capable of providing assessment, evaluation, and triage or treatment or
stabilization of persons with mental health or substance use disorders, as well as co-occurring
disorders.
26
Through the assessment process at the central receiving facility, each individual is referred
to the most appropriate level of care (inpatient and/or outpatient) and to the appropriate service
provider that can meet the individual’s identified needs.
Central receiving facilities serve specific geographic areas. However, an area may be served by one or
more facilities. As of July 1, 2022, there are 15 central receiving facilities.
27
Central receiving facilities
serve the following counties:
Alachua Hernando Marion
Brevard Hillsborough Orange
Broward Jefferson Osceola
Citrus Lake Sarasota
Collier Leon Sumter
Duval Liberty Taylor
Franklin Madison Volusia
Gadsden Manatee Wakulla
Mobile Response Teams
A mental health crisis can be an extremely frightening and difficult experience for both the individual in
crisis and those around him or her. It can be caused by a variety of factors and occur at any hour of the
day.
28
Family members and caregivers of an individual experiencing a mental health crisis are often ill-
equipped to handle these situations and need the advice and support of professionals.
29
All too
frequently, law enforcement or EMTs are called to respond to mental health crises and they often lack
the training and experience to effectively handle the situation.
30
Mobile response teams (MRT) can be
beneficial in such instances. MRTs support the no-wrong-door-model as these teams travel to the acute
situation or crisis to provide assistance and meet the level of need of individuals in crisis, wherever the
crisis occurs.
MRTs provide readily available crisis care in a community-based setting and increase opportunities to
stabilize individuals in the least restrictive setting to avoid the need for jail or hospital/emergency
department utilization.
31
Response teams are available statewide in all 67 counties to individuals in
need, regardless of their ability to pay, and must be ready to respond to any mental health
emergency.
32
Historically, MRTs generally focused on youth and young adults under 25 years old but
most teams have now increased their capacity to serve individuals of all ages.
33
Telehealth can be used
25
S. 394.5473((1)(d), F.S.
26
Id.
27
Eleven facilities are funded under the dedicated “Central Receiving Facility” appropriation in the annual General Appropriations Act.
The remaining four facilities are funded with nonrecurring proviso project appropriations this year. See DCF, Agency Bill Analysis HB
655 (2023), p. 3.
28
Department of Children and Families, Mobile Response Teams Framework, (August 29, 2018), p. 4
https://myflfamilies.com/sites/default/files/2022-12/Mobile%20Response%20Framework.pdf (last visited Feb. 27, 2023).
29
Id.
30
Id.
31
Id. at 2
32
Id. Mobile response services are required to be available 24 hours per day, 7 days per week.
33
DCF, Agency Bill Analysis HB 655 (2023), p. 3.
STORAGE NAME: h0655z1.DOCX PAGE: 7
DATE: 6/19/2023
to provide direct services to individuals via video-conferencing systems, mobile phones, and remote
monitoring.
34
It can also be used to provide assessments and follow-up consultation as well as initial
triage to determine if an in-person visit is needed to respond to the crisis call.
35
SB 7026 (2018) funded additional mobile response teams to serve areas of the state that were not
being served by such teams at a total of $18.3 million.
36
In 2019, MRT reports showed an 80%
statewide average of diverting individuals from involuntary examination.
37
For Fiscal Year (FY) 2022-23,
DCF received additional funding allowing for the implementation of 12 new teams and the expansion of
30 existing teams.
38
There are currently 51 MRTs serving all 67 counties in Florida.
39
Through the
expansion, it is estimated that an additional 14,743 individuals will be served statewide.
During FY 2021-22, MRTs received 25,495 calls, where 28 percent of those calls originated in a school,
and 72 percent of those calls required an acute response (an in-person response). Of the calls
requiring an acute response, 84 percent of them were diverted from an involuntary examination, which
highlights the role MRTs play in reducing unnecessary psychiatric hospitalizations.
40
HB 945 (2020) required crisis response services to be provided through MRTs.
41
DCF must contract
with a managing entity to procure mobile response teams throughout the state to provide immediate,
onsite behavioral health crisis services to children, adolescents, and young adults ages 18-25,
inclusive, who:
42
Have an emotional disturbance;
Are experiencing an acute mental or emotional crisis;
Are experiencing escalating emotional or behavioral reactions and symptoms that impact their
ability to function normally within their environment; or
Are served by the child welfare system and are experiencing or are at high risk of placement
instability.
When procuring an MRT, the managing entity must, at a minimum:
43
Collaborate with local sheriff’s offices and public schools in the planning, development,
evaluation and selection processes;
Require that services be made available 24 hours per day, 7 days per week, with a response
time of 60 minutes;
Require that the provider establish response protocols with local law enforcement agencies, the
child welfare system including child welfare community-based care lead agencies, and the
Department of Juvenile Justice;
Require access to board-certified or board-eligible psychiatrists or psychiatric nurse
practitioners; and
Require MRTs to refer children, adolescents, or young adults and their families to an array of
crisis response services that respond to their individual needs as necessary to address an
immediate crisis event.
34
Supra note, at 7.
35
Id.
36
See Chapter No. 2018-3, L.O.F.
37
Florida Department of Children and Families, Report on Involuntary Examination of Minors, 2019, (Nov. 2019), p. 4,
https://myflfamilies.com/sites/default/files/2022-12/Report%20on%20Involuntary%20Examination%20of%20Minors%202019.pdf (last
visited February 27, 2023).
38
DCF, Agency Bill Analysis HB 655 (2023), p. 3.
39
Id.
40
Id.
41
See Chapter 2020-107, L.O.F.
42
S. 394.495(7)(a), F.S.
43
S. 394.495(7)(c), F.S.
STORAGE NAME: h0655z1.DOCX PAGE: 8
DATE: 6/19/2023
The bill also established the minimum standards for MRTs. At a minimum, an MRT must:
44
Triage and prioritize requests, then, to the extent permitted by available resources, respond in
person within 60 minutes of prioritization;
Respond to a crisis in the location where the crisis is occurring;
Provide behavioral health crisis-oriented services that are responsive to the needs of the child,
adolescent, or young adult and his or her family and enable them to deescalate and respond to
behavioral health challenges through evidence-based practices;
Provide screening, standardized assessments, early identification, and referrals to community
services;
Provide care coordination by facilitating the transition to ongoing services;
Ensure a process for informed consent and confidentiality compliance measures is in place;
Promote information sharing and the use of innovative technology; and
Coordinate with the managing entity and other key entities providing services and supports to
the child, adolescent, or young adult and their family.
National 988 Suicide and Crisis Lifeline
Since its inception in 2004, the National Suicide Prevention Lifeline, currently known as the 988 Suicide
and Crisis Lifeline (988 system or Lifeline), has provided a national toll-free phone number that
connects callers who are in suicidal crisis or emotional distress to free and confidential emotional
support.
45
The Lifeline is composed of a national network of over 200 local, independent, and state-
funded crisis centers. Vibrant Emotional Health (Vibrant) is the administrator of the service, which is
funded by SAMHSA.
46
The Lifeline serves as a national mental health safety net for the public by routing callers to the nearest
of 180 local crisis call centers. To improve and streamline the Lifeline system, on October 17, 2020,
Congress passed the National Suicide Hotline Designation Act of 2020, to designate 988 as the
universal telephone number for the nation’s suicide prevention and mental health crisis hotline.
47
This
was done to simplify the existing 10-digit toll free number and to redirect mental health crises currently
coming into the nation’s 9-1-1 emergency system. The 988 dialing code became available nationally in
July 2022.
48
Florida’s 988 Suicide and Crisis Lifeline System
All Lifelines nationwide must be fully accredited by Vibrant to take 988 calls, texts, or chats. In Florida,
there are 13 active 988 Lifeline or local crisis call centers (Lifeline Member centers) that are a part of
the 988 network.
49
Most of the state’s Lifeline Member centers are affiliated with 2-1-1 United Way,
while the other centers are housed in comprehensive non-profit or county mental health centers.
50
Florida’s 211 Network is authorized to serve as the single point of coordination for information and
referral for health and human services under s. 408.918, F.S.
51
44
S. 394.495(7)(b), F.S.
45
988 Suicide & Crisis Lifeline at https://988lifeline.org/about/ (last visited February 24, 2023). Also see DCF Office of SAMH, Suicide
Prevention Coordinating Council 2021 Annual Report, available at https://www.myflfamilies.com/sites/default/files/2022-
12/2021%20Suicide%20Prevention%20Coordinating%20Council%20Annual%20Report%20 -%20Final.pdf (last visited February 24,
2023).
46
Id.
47
National Suicide Hotline Designation Act of 2020 (Pub. L. No. 116-172).
48
SAMHSA, 988 America’s Suicide Prevention and Mental Health Crisis Lifeline, at https://www.samhsa.gov/sites/default/ files/988-
factsheet.pdf (last visited February 24, 2023).
49
DCF, Agency Bill Analysis HB 655 (2023), p. 2. Also see Prevention Coordinating Council 2021 Annual Report, supra at note 39.
50
Id.
51
DCF Office of SAMH, Suicide Prevention Coordinating Council 2021 Annual Report, available at
https://www.myflfamilies.com/sites/default/files/2022-
12/2021%20Suicide%20Prevention%20Coordinating%20Council%20Annual%20Report%20 -%20Final.pdf (last visited February 24,
2023).
STORAGE NAME: h0655z1.DOCX PAGE: 9
DATE: 6/19/2023
In preparation for the transition to a three-digit number, Vibrant facilitated the issuance of privately
donated grant dollars to help states plan for the implementation of 988. In February 2021, DCF
received a planning grant from Vibrant to create a 988 grant team and a statewide planning coalition
that was tasked with preparing a 988 implementation plan for Florida.
52
Florida’s 988 Planning Coalition
was established, composed of a diverse array of more than 50 behavioral health professionals, and
met monthly to plan for the 988 implementation.
53
After implementation, the Coalition remained active
and regularly meets with DCF. Members of the Coalition include:
54
NSPL/988 Suicide and Crisis Lifelines
Regional managing entities
Law enforcement officials
Mental health advocacy groups
Florida Behavioral Health Association
Seminole Tribe representatives
911 public safety answering points leaders
Vibrant Emotional Health representatives
988 Capacity Building Grant
The 988 Coalition created a strategic plan based on eight core considerations for infrastructure and
capacity building that was submitted to Vibrant. To address the 988 Planning Coalition’s top concern of
funding to increase capacity, in Fiscal Year 2022-2023 DCF received $8,461,833 for 988
implementation in the annual General Appropriations Act under the Supplemental Community Mental
Health Block grant. In 2022, DCF also applied for and received the SAMHSA 988 State and Territory
Cooperative Agreement Capacity Building Grant (“988 Capacity Building grant”) and was awarded $5.2
million in April 2022, plus an additional $2 million as a supplemental award in December 2022.
55
As a requirement of the 988 Capacity Building grant, DCF engages in ongoing analysis of the current
988 system. This includes constant analysis of metrics on call volume, in-state answer rates, speed to
answer, duration of calls, and the following key performance indicators:
Workforce Development: The number of people in the mental health and related workforce
trained in mental health-related practices/activities that are consistent with the goals of the
grant.
Partnership/Collaborations: The number of organizations that entered into formal written
inter/intraorganizational agreements (e.g., Memorandums of Understanding/ Memorandums of
Association) to improve mental health-related practices/activities that are consistent with the
goals of the grant.
Screening: The number of individuals screened for mental health or related interventions.
Referral: The number of individuals referred to mental health or related services.
Access: The number and percentage of individuals receiving mental health or related services
after referral.
In addition, DCF holds regular monthly meetings with Lifeline Centers, quarterly meetings with the
broader 988 Coalition, and works with centers one-on-one to help troubleshoot challenges and provide
technical assistance. DCF also has regular meetings with federal project officers, Vibrant Emotional
Health representatives, and participates in all national meetings and calls.
52
Id.
53
After the 988 implementation, the planning coalition has continued to meet and actively recruit stakeholders. See DCF, Agency Bill
Analysis HB 655 (2023), p. 5.
54
DCF, Agency Bill Analysis HB 655 (2023), p. 3.
55
Id.
STORAGE NAME: h0655z1.DOCX PAGE: 10
DATE: 6/19/2023
Commission on Mental Health and Substance Abuse
The Marjory Stoneman Douglas High School Public Safety Commission
In response to the shooting at Marjory Stoneman Douglas High School on February 14, 2018, the
Florida Legislature passed SB 7026, the Marjory Stoneman Douglas High School Public Safety Act
(Act). The Act’s provisions addressed school safety and security by creating the Office of Safe Schools
(OSS) within the Florida Department of Education (DOE) and requiring increased coordination among
state and local agencies serving students with or at-risk of mental illness, among other provisions. The
Act also created the Marjory Stoneman Douglas High School Public Safety Commission (MSD
Commission), to investigate system failures in the Marjory Stoneman Douglas High School shooting
and prior mass violence incidents and develop recommendations for system-wide improvements.
The MSD Commission submitted its initial report on January 2, 2019, which contained numerous
school safety and security recommendations
56
that the Legislature addressed in SB 7030 (2019),
Implementation of Legislative Recommendations of the Marjory Stoneman Douglas High School Public
Safety Commission.
57
The MSD Commission’s second report, submitted on November 1, 2019,
provided recommendations related to safe-school officers, threat assessments, juvenile diversion
programs, and mental health, among other recommendations.
58
The MSD Commission is authorized to
issue annual reports and is scheduled to sunset on July 1, 2023.
59
In February 2019, Governor Ron DeSantis requested, and the Florida Supreme Court convened, a
grand jury to study systemic school safety failures. The grand jury was tasked with investigating
whether specific public entities failed to act or committed fraud that undermined the school safety
activities that the Act and subsequent legislation required.
60
The Grand Jury’s third report, issued in
December 2020, included an analysis of the state’s mental health infrastructure and found systemic
problems are impacting mental health:
61
The current mental health system is underfunded leading to an inability to diagnose and
properly treat mental health problems;
The system is too decentralized with national, state, and local entities providing parallel and
duplicative resources with little to no coordination;
Many of the entities involved work for different agencies with different goals; and
DCF is not currently equipped or empowered to exercise the degree of leadership and control
necessary to correct problems in the system.
To address such problems, the Grand Jury recommended the Legislature appoint a commission to
specifically examine the provision of mental health services in the state.
62
The Legislature should ensure that relevant stakeholders have an opportunity to participate in
and provide knowledge to the commission.
56
Marjory Stoneman Douglas High School Public Safety Commission, Initial Report (Jan. 2, 2019),
http://www.fdle.state.fl.us/MSDHS/CommissionReport.pdf (last visited February 25, 2023).
57
Chapter 2019-22, L.O.F.
58
Marjory Stoneman Douglas High School Public Safety Commission, Second Report (Nov. 1, 2020),
http://www.fdle.state.fl.us/MSDHS/MSD-Report-2-Public-Version.pdf (last visited February 25, 2023).
59
Section 943.687(9), F.S.
60
Ron DeSantis, Governor of Florida, Petition for Order to Impanel a Statewide Grand Jury, (Feb. 13, 2019), https://efactssc-
public.flcourts.org/casedocuments/2019/240/2019-240_petition_72393_e83.pdf (last visited February 25, 2023); In re Statewide Grand
Jury #20, No. SC19-240, 2019 WL 908518 (Fla. Feb. 25, 2019), https://efactssc-public.flcourts.org/casedocuments/2019/240/2019-
240_disposition_145442_d04i.pdf (last visited February 25, 2023).
61
Statewide Grand Jury # 20, Third Interim Report of the Twentieth Statewide Grand Jury, (Dec. 10, 2020), https://efactssc-
public.flcourts.org/casedocuments/2019/240/2019-240_miscdoc_365089_e20.pdf (last visited February 25, 2023).
62
Id. at p. 21
STORAGE NAME: h0655z1.DOCX PAGE: 11
DATE: 6/19/2023
The commission should consider how to best provide and facilitate services in dual diagnosis
cases.
63
Additionally, the commission should be charged with structuring and staffing a permanent,
agency-level entity to manage mental health, behavioral health, and substance abuse and
addiction services throughout the state.
64
Lastly, a cabinet-level agency should be created and funded to administer disparate sources of
funding and services relating to the state’s mental health system.
65
Commission on Mental Health and Substance Abuse
In 2021, the legislature created the Commission on Mental Health and Substance Abuse
(Commission).
66
The Commission consists of 19 members, which include the Secretaries of DCF and
the Agency of Health Care Administration (AHCA). The remaining members are appointed by the
Governor, the President of the Senate, and the Speaker of the House of Representatives.
67
The Commission was created to:
Examine the current methods of providing mental health and substance abuse services in the
state;
Improve the effectiveness of current practices, procedures, programs, and initiatives in
providing such services;
Identify any barriers or deficiencies in the delivery of such services; and
Recommend changes to existing laws, rules, and policies necessary to implement the
Commission’s recommendations.
68
Under current law, DCF is required to provide administrative and staff support services to the
Commission as it carries out its statutory functions.
69
State agencies are also required to assist the
Commission in a timely manner when needed.
70
The duties of the Commission include:
1. Conducting a review and evaluation of the management and functioning of existing publicly
supported mental health and substance abuse systems in DCF, AHCA, and all other relevant
state departments;
2. Considering the unique needs of people who are dually diagnosed;
3. Addressing access to, financing of, and scope of responsibility in the delivery of emergency
behavioral health care services;
4. Addressing the quality and effectiveness of current service delivery systems and professional
staffing and clinical structure of services, roles, and responsibilities of public and private
providers;
5. Addressing priority population groups for publicly funded services, identifying the
comprehensive delivery systems, needs assessment and planning activities, and local
government responsibilities for funding services;
6. Reviewing the implementation of ch. 2020-107, Laws of Fla.;
71
63
The Grand Jury describes “dual diagnosis” cases as cases that lie at the nexus of mental health, substance abuse, and law
enforcement interests.
64
Supra, note 61 at p. 23.
65
Id. at p. 24.
66
See Chapter 2021-170, L.O.F.
67
S. 394.9086(3), F.S.
68
S. 394.9086(2), F.S.
69
S. 394.9086(1), F.S.
70
S. 394.9086(4)(b), F.S.
71
2020 House Bill 945 (Silvers) requires managing entities to implement of a coordinated system of mental health care for children and
expands the use of mobile response teams (MRT) across the state. It requires the Florida Mental Health Institute within the University
of South Florida to develop a model protocol for school use of MRTs. The bill also requires AHCA and DCF to identify children and
adolescents who are the highest users of crisis stabilization services and take action to meet the needs of such children. Lastly, the bill
STORAGE NAME: h0655z1.DOCX PAGE: 12
DATE: 6/19/2023
7. Identifying gaps in the provision of mental health and substance abuse services;
8. Providing recommendations on how managing entities may promote service continuity;
9. Making recommendations about the mission and objectives of state-supported mental health
and substance abuse services and the planning, management, staffing, financing, contracting,
coordination, and accountability of mechanisms best suited for the recommended mission and
objectives; and
10. Evaluating and making recommendations regarding the establishment of a permanent, agency-
level entity to manage mental health, behavioral health, substance abuse, and related services
statewide.
The Commission is required to submit an interim report and a final report, to the Governor and the
legislature of its findings and recommendations on how to best provide and facilitate mental health and
substance abuse services in Florida.
72
The interim report was submitted on January 1, 2023.
73
The final
report is due September 1, 2023. Unless saved from repeal through reenactment by the Legislature,
the Commission will cease on September 1, 2023.
First Responders and Mental Health
A first responder is a law enforcement officer,
74
firefighter,
75
or an emergency medical technician or
paramedic
76
employed by state or local government.
77
Additionally, a volunteer law enforcement officer,
firefighter, or emergency medical technician or paramedic engaged by the state or a local government
is also considered a first responder.
78
First responders are often exposed to incidents of death and destruction that can result in the
development of behavioral health conditions, such as PTSD, depression, and suicide.
79
Approximately
30 percent of first responders develop behavioral health conditions as compared to 20 percent of adults
in general population.
80
A study by the Ruderman Family Foundation revealed that 35 percent of police
officers have suffered from PTSD and 46.8 percent of firefighters
81
have experienced suicidal
requires AHCA to continually test the Medicaid managed care provider network databases to ensure behavioral health providers are
accepting enrollees and confirm that enrollees have access to behavioral health systems.
72
S. 394.9086(5), F.S.
73
The Commission on Mental Health and Substance Abuse Legislative Report, January 1, 2023, available at
https://img1.wsimg.com/blobby/go/04dad2ad-e4b1-42e4-b8b4-
42d4f2bb4407/downloads/Mental%20Health%20Commission%20Interim%20Report%201.1.20.pdf?ver=1673462392875 (last visited
February 24, 2023).
74
The term “law enforcement officer” means any person who is elected, appointed, or employed full time by any municipality or the
state or any political subdivision thereof; who is vested with authority to bear arms and make arrests; and whose primary responsibility
is the prevention and detection of crime or the enforcement of the penal, criminal, traffic, or highway laws of the state. The term
includes all certified supervisory and command personnel whose duties include, in whole or in part, the supervision, training, guidance,
and management responsibilities of full-time law enforcement officers, part-time law enforcement officers, or auxiliary law enforcement
officers but does not include support personnel employed by the employing agency. S. 943.10, F.S.
75
The term “firefighter” means an individual who holds a current and valid Firefighter Certificate of Compliance or Special Certificate of
Compliance issued by the Division of State Fire Marshal within the Department of Financial Services. S. 633.102, F.S.
76
The term “emergency medical technician” means a person who is certified by the Department of Health to perform basic life support.
The term “paramedic” means a person who is certified by the Department of Health to perform basic and advanced life support. S.
401.23, F.S.
77
S. 125.01045, F.S.
78
Id.
79
Miriam Heyman, Jeff Dill & Robert Douglas, The Ruderman White Paper on Mental Health and Suicide of First Responders,
RUDERMAN FAMILY FOUNDATION 7, 9 (2018), https://issuu.com/rudermanfoundation/docs/first_responder_white_paper_final_
ac270d530f8bfb (last visited March 24, 2023) and SAMHSA Disaster Technical Assistance Center Supplemental Research Bulletin,
First Responders: Behavioral Health Concerns, Emergency Response, and Trauma, May 2018 at https://www.samhsa.gov/
sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf (last visited March 25, 2023.
80
SAMHSA Disaster Technical Assistance Center Supplemental Research Bulletin, First Responders: Behavioral Health Concerns,
Emergency Response, and Trauma, May 2018 at https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-
firstresponders-may2018.pdf (last visited March 25, 2023).
83
Wes Venteicher, Increasing suicide rates among first responders spark concerns, FIRERESCUE NEWS, (Mar. 19, 2017),
https://www.firerescue1.com/fire-ems/articles/222673018-Increasing-suicide-rates-among-first-responders-spark-concern/ (last visited
March 24, 2023).
STORAGE NAME: h0655z1.DOCX PAGE: 13
DATE: 6/19/2023
thoughts.
82
Further, a 2015 survey of 4,000 first responders found that 6.6 percent had attempted
suicide, which is more than 10 times the rate in the general population.
83
First responders are more
likely to die by suicide than in the line of duty, according to the Firefighter Behavioral Health Alliance.
84
Peer Support
Peer support consists of a person in stable recovery from mental health problems helping someone
who needs assistance with establishing or maintaining his or her recovery.
85
Peer support services
include social supports, such as mentoring, training, peer-led support groups, and assistance
completing everyday tasks.
86
Peers are not health care practitioners, but their support extends the
reach of treatment beyond the clinical setting into the everyday environment of those seeking a
successful, sustainable recovery process from mental health issues.
87
A survey by the Journal of Emergency Medical Services revealed that first responders were less likely
to contemplate suicide when they felt supported and encouraged at work.
88
One study showed that
while some firefighters reported positive experiences with professional mental health help, others felt
more distressed after such intervention. Alternatively, these firefighters reported benefits from peer
support, such as bonding with their fire crew after negative incidents, which can reduce the stigma,
scheduling difficulties, lack of access, lack of trust, and fear or repercussions that may prevent first
responders from seeking mental health care.
89
First Responders and Worker’s Compensation Benefits for PTSD
Florida’s Worker’s Compensation System
Workers’ compensation is a no-fault system that provides medical benefits and compensation for lost
wages when an employee is injured or killed in the course of employment. Employers must secure
coverage and may do so by purchasing insurance from an authorized carrier, qualifying as a self-
insurer, or purchasing coverage from the Florida Workers’ Compensation Joint Underwriting
Association, which is the state-sponsored insurer of last resort. In return for providing compensation,
the employer is relieved of liability for workplace injuries, and may only be sued for intentional acts that
result in injury or death.
90
To be compensable, a work-related accident must be the major contributing cause (more than 50
responsible) of any resulting injury or illness, as demonstrated by medical evidence.
91
Workers’
compensation benefits for a nervous or mental injury are typically allowed only if an employee suffers a
physical injury that triggers a mental injury.
83
Wes Venteicher, Increasing suicide rates among first responders spark concerns, FIRERESCUE NEWS, (Mar. 19, 2017),
https://www.firerescue1.com/fire-ems/articles/222673018-Increasing-suicide-rates-among-first-responders-spark-concern/ (last visited
March 24, 2023).
83
Wes Venteicher, Increasing suicide rates among first responders spark concerns, FIRERESCUE NEWS, (Mar. 19, 2017),
https://www.firerescue1.com/fire-ems/articles/222673018-Increasing-suicide-rates-among-first-responders-spark-concern/ (last visited
March 24, 2023).
84
Heyman, Dill & Douglas, supra note 74, at 19.
85
Substance Abuse and Mental Health Services Administration, What Are Peer Recovery Support Services?, (2009),
https://store.samhsa.gov/system/files/sma09-4454.pdf (last visited March 24, 2023).
86
Id.
87
Substance Abuse and Mental Health Services Administration, Peers, https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers
(last visited March 24, 2023).
88
Journal of Emergency Medical Services, Survey Reveals Alarming Rates of EMS Provider Stress and Thoughts of Suicide, (Sept. 28,
2015), https://www.jems.com/2015/09/28/survey-reveals-alarming-rates-of-ems-provider-stress-and-thoughts-of-suicide/ (last visited
March 25, 2023).
89
Substance Abuse and Mental Health Services Administration, First Responders: Behavioral Health Concerns, Emergency Response,
and Trauma, DISASTER TECHNICAL ASSISTANCE CENTER SUPPLEMENTAL RESEARCH BULLETIN (May 2019), 10, 12,
https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf (last visited Mar. 13, 2020).
90
Ss. 440.015, 440.09, 440.10, 440.38, and 627.313, F.S.
91
S. 440.09(1), F.S.
STORAGE NAME: h0655z1.DOCX PAGE: 14
DATE: 6/19/2023
Occupational Disease - First Responder PTSD Diagnosis
In addition to on-the-job injuries, employers may be required to pay compensation or furnish benefits if
an occupational disease caused death or disablement, is due to the nature of the employee’s
occupation, and the employee contracted the disease during the course of his or her employment.
92
In
general, occupational diseases are compensable if:
93
A condition peculiar to the occupation causes the disease;
The employee contracts the disease on the job;
The job presents a particular hazard of the disease;
The incidence of the disease is substantially higher in the occupation than in the public;
The nature of the employment was a major contributing cause of the disease; and
Epidemiological studies show that exposure to the specific substance involved, at the levels
to which the employee was exposed, may cause the precise disease sustained by the
employee.
94
In 2018, the Legislature created special rules for certain first responders, making PTSD a compensable
occupational disease for firefighters, paramedics, emergency medical technicians, and law
enforcement officers who suffer from PTSD after experiencing certain qualifying events, even though
they were not physically injured.
95
PTSD is a compensable condition under the worker’s compensation
program only if:
96
The PTSD resulted from the first responder acting within the course of his or her employment;
and
The first responder is examined and subsequently diagnosed with the disorder by a licensed
psychiatrist, who is an authorized treating physician for workers’ compensation, due to one of
the following events:
o Seeing a deceased minor;
o Witnessing the death of a minor;
o Witnessing an injury to a minor who subsequently dies before or upon arrival at a
hospital emergency department;
o Participating in the treatment of an injured minor who dies before or on arrival at a
hospital emergency department;
o Transporting an injured minor who dies before or on arrival at a hospital emergency
department;
o Seeing a decedent whose death was due to grievous bodily harm of a nature that
shocks the conscience;
o Witnessing a death (including suicide) that involved grievous bodily harm of a nature that
shocks the conscience;
o Witnessing a homicide, whether criminal or excusable, including murder, mass killing,
manslaughter, self-defense, misadventure, and negligence;
o Witnessing an injury (including an attempted suicide) to a person who dies before or
upon arrival at a hospital emergency department if the person was injured by grievous
bodily harm of a nature that shocks the conscience;
o Participating in the treatment of an injury (including attempted suicide) to a person who
dies before or upon arrival at a hospital emergency department if the person was injured
by grievous bodily harm of a nature that shocks the conscience; or
o Transporting a person who was injured (including by attempted suicide) who dies before
or upon arrival at a hospital emergency department if the person was injured by grievous
bodily harm of a nature that shocks the conscience.
92
Ss. 440.09, and 440.151, F.S.
93
S. 440.151, F.S.
94
S. 440.151(2), F.S.
95
S. 112.1815(5)(a), F.S.
96
Id.
STORAGE NAME: h0655z1.DOCX PAGE: 15
DATE: 6/19/2023
The worker’s compensation law requires a licensed psychiatrist to examine and diagnose PTSD in a
first responder in order for medical benefits and compensation for lost wages to be covered under the
program. However, current law is silent as to whether the psychiatrist may use telehealth to examine
and diagnose the patient, for worker’s compensation purposes.
Telehealth
Telehealth is not a type of health care service, but rather is a mechanism for the delivery of health care
services. Health care professionals use telehealth as a platform to provide traditional health care
services in a non-traditional manner. These services include, among others, preventative medicine and
the treatment of chronic conditions.
97
Section 456.74, F.S., enacted in 2019, regulates the use of
telehealth by Florida and out-of-state healthcare providers.
Current law broadly defines telehealth as the use of synchronous or asynchronous telecommunications
technology by a telehealth provider to provide health care services, including, but not limited to:
98
Assessment, diagnosis, consultation, treatment, and monitoring of a patient;
Transfer of medical data;
Patient and professional health-related education;
Public health services; and
Health administration.
Current law sets the standard of care for telehealth providers at the same level as the standard of care
for health care practitioners or health care providers providing in-person health care services to patients
in this state. This ensures that a patient receives the same standard of care irrespective of the modality
used by the health care professional to deliver the services.
Health care services may be provided via telehealth by a Florida-licensed health care practitioner, a
practitioner licensed under a multistate health care licensure compact of which Florida is a member,
99
or a registered out-of-state-health care provider.
100
Current law authorizes all licensed health care
practitioners to provide services through telehealth.
101
Any service a practitioner can perform under
their license can be performed using telehealth.
Specifically, a licensed psychiatrist is authorized to provide services through telehealth, and may
examine, diagnose, and treat patients via telehealth.
102
The telehealth law is a licensure law, and does
not address the use of telehealth services for purposes of determining medical coverage and employee
compensation under the worker’s compensation program.
Effect of the Bill
Commission on Mental Health and Substance Use Disorder
The bill renames the Commission on Mental Health and Substance Abuse the Commission on Mental
Health and Substance Use Disorder.
97
U.S. Department of Health and Human Services, Report to Congress: E-Health and Telemedicine (August 12, 2016), available at
https://aspe.hhs.gov/system/files/pdf/206751/TelemedicineE-HealthReport.pdf (last visited May 4, 2023).
98
S. 456.47(1)(a), F.S.
99
Florida is a member of the Nurse Licensure Compact. See s. 464.0095, F.S.
100
S. 456.47(4), F.S.
101
These are professionals licensed under s. 393.17; part III, ch. 401; ch. 457; ch. 458; ch. 459; ch. 460; ch. 461; ch. 463; ch. 464; ch.
465; ch. 466; ch. 467; part I, part III, part IV, part V, part X, part XIII, and part XIV, ch. 468; ch. 478; ch. 480; part II and part III, ch. 483;
ch. 484; ch. 486; ch. 490; or ch. 491.
102
Psychiatrists are licensed under chs. 458 and 459.
STORAGE NAME: h0655z1.DOCX PAGE: 16
DATE: 6/19/2023
The bill broadens the purpose of the Commission to require the Commission to assess the adequacy of
the current infrastructure of Florida’s 988 Suicide and Crisis Lifeline system and other components of
the state’s crisis response system.
The bill expands the Commission to include a representative from the statewide Florida 211 Network,
appointed by the Governor, increasing the membership to 20. The bill also expands the duties of the
Commission. In addition to the ten duties in current law, the bill requires the Commission to:
1. Provide recommendations on how the managing entities can work with community stakeholders
throughout the state to further support the state 988 system and other crisis response services;
2. Conduct an overview of the current infrastructure of the 988 system;
3. Analyze the current capacity of crisis response services throughout the state, including services
provided by mobile response teams (MRT) and centralized receiving facilities. The analysis
must include:
o Information on the geographic area and total population served by each MRT and the
average response time to each call made to the MRT;
o The number of calls that an MRT was unable to respond to due to staff limitations, travel
distance, or other factors; and
o The veteran status and age groups of individuals served by the MRTs.
4. Evaluate and make recommendations to improve linkages between the 988 system and crisis
response services within the state;
5. Identify available mental health block grant funds that can be used to support the 988 system
infrastructure and crisis response services within the state, including any available funding
through the opioid settlements or through the American Rescue Act, the Coronavirus Aid, Relief,
and Economic Security Act, or other federal legislation;
6. In consultation with AHCA, identify sources of funding available through the Medicaid program
specifically for crisis response services, including funding sources that may be available by
seeking approval of a Section 1115 waiver submitted to the Centers for Medicare and Medicaid
Services.
7. Evaluate and make recommendations regarding skills-based training that teaches participants
about mental health and substance use disorder issues, including, but not limited to, mental
health first aid models.
Further, the bill expands the reporting obligations of the Commission by requiring the Commission to
submit annual interim reports through January 1, 2025, and extending the date by which the
Commission must submit its final report to September 1, 2026.
The bill extends the repeal date of the Commission from September 1, 2023, to September 1, 2026.
First Responders
Peer Support
The bill amends s. 111.09, F.S., to authorize an affiliated first responder organization, in addition to the
first responder’s employing agency, to designate peers to provide support to first responders. The bill
defines an affiliated first responder organization to include, but is not limited to, any of the following
organizations:
Regularly organized volunteer firefighting departments or associations;
Regularly organized volunteer ambulance services; or a
Combination fire departments, as defined in s. 633.135(1).
The bill also authorizes active, volunteer, and retired first responders to serve as first responder peers.
These provisions help facilitate peer support services for first responders. The provisions also, ensure
that first responders receive support and encouragement from peers with whom they can relate to,
STORAGE NAME: h0655z1.DOCX PAGE: 17
DATE: 6/19/2023
have experience working as or with first responders, and who understand the physical and emotional
conditions or issues associated with being a first responder.
First Responders and Worker’s Compensation for PTSD Diagnosis
The bill expressly permits the use of telehealth to diagnose post-traumatic stress disorder in first
responders for the purposes of obtaining worker’s compensation benefits.
The bill provides an effective date of July 1, 2023.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
This bill has an insignificant fiscal impact on the Department of Children and Families which can be
absorbed within existing resources.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
None.