Polk County, Iowa
Urban/Rural Population: 95.05 percent/4.91 percentii
In September 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Association of Counties (NACo) and the Laura and John Arnold Foundation (LJAF) hosted the Data-Driven Justice and Behavioral Health Design Institute (Design Institute) in Rockville, Md. The Design Institute convened 13 teams committed to the Data-Driven Justice (DDJ) initiative. Teams were selected through a competitive process to work directly with expert faculty in facilitated sessions and workshops to create action plans for developing and using integrated data systems that would aid their jurisdictions in identifying high utilizers of jails and crisis services. This case study is part of a series highlighting counties that participated in the Design Institute.
When Polk County joined DDJ in 2016, it joined over 140 counties and other local and state governments to reduce the frequent and repeat cycling of high utilizers with mental illnesses, substance abuse disorders and chronic health conditions through jails, emergency rooms, homeless shelters and other crisis services. Through DDJ, Polk County is working to divert high utilizers from the jail to treatment providers and support programs that can address the health conditions that are at the root of individuals’ recurring use of crisis services. Diverting high utilizers from the jail and into community-based programs is part of the strategy Polk County is using to ensure the jail is used in appropriate situations, especially as the county works toward reducing the overall jail population. By identifying and diverting high utilizers from jail, Polk County is not only able to improve individuals’ housing stability, treatment engagement and community integration, but also reduce jail time, emergency room visits, hospital days and emergency medical service transports. These outcomes are consistent with the Board of Supervisors’ commitment to service excellence, fiscal responsibility and enhancing residents’ quality of life, all of which are articulated in the county’s mission statement.
Guided by the county’s mission and building off decisions and investments made by the Board of Supervisors, Polk County is creating a robust diversion system through its health provider network, thus helping the county use community-based resources as a better alternative to jail for individuals with complex needs. In 2001, the county developed a county-wide mobile crisis team that is dispatched through the police. Polk County leaders have since added a 23-hour crisis observation center, a 90-day crisis stabilization center, a pre-petition screener to identify local alternatives to civil commitments and a post-booking jail diversion program. In Polk County, a county-funded hospital is contracted to provide all crisis services, including the mobile crisis team and observation and stabilization centers.
Often, the mobile crisis team responds to residents who are not currently connected to long-term services offered through Polk County Health Services (PCHS). When mobile crisis is called, an individual is typically treated in the field and rarely taken to jail or even the crisis observation center. PCHS relies heavily on mobile crisis, more so than it does on law enforcement, to notify them about individuals who need long-term services.
To improve the quality of life for high utilizers, the county identified two interrelated priorities while attending the Design Institute. First, Polk County leaders are focusing efforts on enhancing the county’s data collection and tracking abilities by identifying a technology solution that would allow them to pull and analyze data from multiple health and social services systems in order to uncover high utilizers with multiple system interactions. Second, although Polk County already has robust behavioral health services in place, leaders are emphasizing a data-driven approach toward identifying what services and supports best meet the needs of high utilizers and any gaps in resources available in the community. For example, the county funds intense services models including assertive community treatment, forensic assertive community treatment and wraparound service programs, but continues to assess whether such services are working for a high utilizer population that has not been connected in the past or stayed engaged with programs previously offered. Through its DDJ efforts, Polk County is positioning itself to understand what service approaches will work for people with high needs before their situations escalate and become more critical.
Making Progress by Leveraging Resources and Relationships
Polk County maintains the Management Information System (MIS), which stores data from the health system, including mental health information. That system can also receive booking information from the jail. The county’s MIS was developed about 20 years ago and tracks social determinants of health indicators for all individuals that receive case management and long-term services and supports. Each indicator demonstrates the effectiveness of services and supports provided through PCHS and its network of service and case management providers. Emergency room visits, hospital stays, days in jail, housing, and employment status are examples of the types of indicators the MIS helps the county track.
The MIS data system provides the capacity to share information between providers and county systems. It helps users from within the provider network identify in what services a client participates and allows case managers to stay informed if a client is booked into the jail. When a client of PCHS is booked into jail, a notification is sent to case managers that are affiliated with that person through PCHS and informs them to contact the jail’s medical unit about the person’s medications. The notification offers an opportunity for case managers to collaborate with the justice system on identifying alternatives to jail and developing a discharge plan.
The county hospital, which is a crisis services provider, also has access to MIS. This allows a social worker with the hospital to notify a case manager about a client who has been admitted. Although the county hospital is active in providing services and responding to the needs of high utilizers, Polk County is working to involve other hospitals in the county. It is in part doing this by learning from the success of its neighbor, Johnson County, where the county is developing a strategy to access and use hospital data through the state’s health information exchange.
Polk County is also working to automate the use of homeless system and shelter data to identify high utilizers and determine their needs as part of its DDJ strategy. PCHS has a good preexisting relationship with the Continuum of Care Board (CoCB), which coordinates housing, services and other assistance for individuals affected by homelessness in the county. Currently, Polk County is manually using information from the Homeless Management Information System (HMIS) to identify individual high utilizers. PCHS and CoCB meet on a weekly basis to discuss people who are classified in HMIS as chronically homeless and develop strategies to better understand why those individuals are not connected to resources and then engage them in services.
One of the ways PCHS and CoCB seek to engage individuals is through their respective housing programs. Both have rapid rehousing programs with separate funding streams. PCHS is working to rehouse individuals who have a diagnosis that meets program criteria, including high utilizers. This, in turn, allows the CoCB to target its efforts on individuals who are eligible for a rapid rehousing program support but qualify under different criteria.
Moving Forward and Advancing New Ideas
Polk County is building relationships with stakeholders who have a role in responding to and interacting with high utilizers. Initially, fire and emergency medical services (EMS) were hesitant to engage in discussions about sharing individual-level information. The Board of Supervisors was instrumental in securing their participation in conversations about and eventual involvement in the county’s strategy to identify high utilizers by explaining how the process can benefit fire and EMS. Using its leadership position within the county, the Board of Supervisors has also convened meetings with area hospital partners and city mayors to convey the importance and value of developing a comprehensive approach to identifying high utilizers.
The number of law enforcement agencies with officers who are trained in crisis intervention teams (CIT) is also expanding throughout Polk County as officers from city police departments and the suburban parts of the county receive training. After the Design Institute, the Des Moines Police Chief also suggested one-hour trainings twice a week for 10 weeks to teach officers about the diversion options available in the county. The county is also encouraging group homes in the PCHS provider network to train staff on the appropriate use of police services and how to deescalate crisis situations to reduce service calls. Since group homes are a safe environment with a service provider, the county is exploring how to use mobile crisis as a response in these situations, without involving law enforcement.
Polk County also plans to upgrade its information system to support data integration and enable cross-system decision-making. Part of Polk County’s action plan from the Design Institute was to restructure the Criminal Justice Coordinating Council to include the CoCB, the county hospital and the county’s IT department. The addition of these stakeholders will enable workgroups that can address the issues needed to better coordinate services and responses across systems. The IT work group is already looking at different technology and software solutions to help facilitate data integration across departments. The workgroup is researching how other counties across the country—such as Johnson County, Kan., and San Diego, Calif.—are integrating data across systems. The work group’s recommendations will help Polk County make an informed decision about technology solutions that best fit the county’s needs.
The county is also considering developing a mobile application (“app”) for law enforcement to use in the field. The app would allow an officer to enter a person’s name to see what diversion options exist for that individual given what the data system knows about his or her circumstances. The app would also provide officers with the contact information of case managers. Currently, Polk County has Smart911, a free service that allows county residents to create a medical profile for people affiliated with an address. When a 911 call involves a county resident with a profile, that crucial information aids decisions made by emergency responders when arriving to the location.
Participating in the Design Institute strengthened Polk County’s efforts to reduce the use of jail for individuals with complex health and social needs and develop better system responses to high utilizers. The Design Institute introduced ideas about what is possible and forged relationships among the group that attended the meeting, setting the foundation for deeper dives into DDJ planning and development.
NACo would like to thank Annie Uetz, Polk County Health Services Program Planner, for providing information on the county’s efforts.
i U.S. Census Bureau. QuickFacts: Polk County, Iowa. https://www.census.gov/quickfacts/fact/table/polkcountyiowa/PST045216 (accessed December 21, 2017).
ii U.S. Census Bureau. Urban and Rural Population by State Data, 2010. https://www.census.gov/geo/reference/ua/urban-rural-2010.html (accessed December 21, 2017).Standard