In many counties across the United States, there are a handful of residents who are familiar to many if not all crisis service providers and responders.
In Johnson County, Kansas, one young adult had multiple ambulance service runs, was receiving rental and food pantry assistance, serving probation, booked into the Adult Detention Facility multiple times, was actively receiving outpatient services and had received triage services several times at the community behavioral health facility, all within a 12-month period.
This individual was potentially assigned with six different case managers or clinicians all attempting to provide wraparound services to a clearly high-needs resident.
In many communities, these service systems do not have the means to communicate with one another and share this information. Case managers may be unaware of other services being provided and unintentionally leading residents in conflicting or redundant directions. An uncoordinated approach can be frustrating or overwhelming for individuals already in vulnerable situations and decrease the person’s likelihood of long-term treatment engagement and successful recovery.
In 2008, Johnson County hired a consulting group to look at their human services system and the resulting report painted a clear picture of the number of redundancies and gaps in service provision.
Like the young adult interacting with six departments and offices, there were numerous individuals with multiple case managers pointing them in different directions and other individuals who could have benefitted from services but were falling through the cracks.
Familiar faces — individuals with complex behavioral health needs who frequently cycle through jails, emergency rooms, homeless shelters and other crisis services — represent a unique need within the behavioral health continuum, as they touch multiple systems across communities and often require long-term or intensive case management services to ensure treatment engagement and successful outcomes.
NACo’s Data-Driven Justice Initiative supports communities in better aligning resources to improve outcomes for familiar faces through cross-system data-sharing platforms or strategies that coordinate care from one provider to another with the goal of engaging vulnerable residents in effective treatment and reducing costs to these service systems.
Communities have developed different approaches in order to share sensitive data across systems. In some cases, data-sharing platforms pull limited or “de-identified” data to match individuals across providers so that communities can identify their highest utilizers and build a case management or reentry plan. Another option is to pull all the data to a provider with access to sensitive information, such as a behavioral health service provider. In some communities, individuals are asked to sign a universal release of information so that their data can be shared across systems.
Johnson County, Kan. developed My Resource Connection, a sequel server that pulls data on a view-only basis. The server extracts data each night from diverse data systems throughout the county, matches individuals by name, date of birth and case manager and provides a report each morning that shows specific services each individual is receiving.
The system also generates an email to case managers to notify them when they have a mutual client with another provider in the county — meaning one of their clients was entered into another data system, for example, the jail management system — enabling the case manager to take quick action in creating a reentry or response plan.
My Resource Connection does not store data, nor does it release any health-related information, such as a diagnosis. It simply matches individuals, generates that information and from there, it is incumbent on the case manager to request additional information (which may require privacy releases) or take further action.
Through cross-system data-alignment strategies that identify who a community’s familiar faces are, the services they need and which service or agency connections need to be forged or strengthened, the DDJ (data-driven justice_ initiative demonstrates how information and data-sharing can break the cycle of costly, frequent incarceration and improve outcomes for familiar faces.
In counties without a behavioral health crisis response system, law enforcement dispatch followed by a jail booking or an emergency department admission is often the de facto response to a crisis situation. There is consensus that jail is not the appropriate setting to treat mental illness nor is a hospital emergency department an effective, long-term care solution, yet residents experiencing a behavioral health crisis often have nowhere else to go and law enforcement has no other safe response option.
While the mental health needs of residents being booked into jails have been the impetus for many aspects of criminal justice reform, counties are encouraged to engage with DDJ to build out the connections among service providers in their communities, where these needs are most appropriately met. A reduced reliance on law enforcement and jails to meet a community’s mental health needs allows law enforcement to devote more time and resources on public safety needs, also improving overall community wellbeing.
One segment of local government, one department or one agency cannot address all of the needs of familiar faces alone.Hero 1