Improving Outcomes through Coordinated Health and Justice Systems

BACKGROUND

Orange County is a Familiar Faces Initiative (FFI) Peer-Learning Site modeling effective cross-sector data sharing and familiar faces programming for the FFI community. In 2017, Orange County faced a growing number of high-needs residents with complex behavioral health conditions who were frequently cycling through the county’s jails, homeless shelters, emergency departments and other crisis services. In FY2021-2022, data from the Orange County Sheriff’s Department and Health Care Agency showed that approximately 1,256 individuals were booked into custody four or more times, and the associated costs for the resources available to those  individuals represented about 15-20 percent of the County’s total budget. Seeking a better model that would both reduce costs and improve outcomes for this small number of people, Orange County Supervisor Andrew Do developed a vision for county service providers to share data and develop individualized case plans to meet the specific needs of each high-needs person. This case study highlights Orange County’s implementation of a  data-sharing technology platform and care coordination program to improve outcomes for familiar faces.

SYSTEM OF CARE DATA INTEGRATION

In 2017, the Orange County Board of Supervisors directed county staff to design, develop and implement a technology solution to integrate data points integral to coordinating care for the county’s most vulnerable residents. The vision was for every county department involved in the care of these individuals to have access to their sister agencies’ data. The System of Care Data Integration (SOCDIS) launched on December 24, 2020. SOCDIS is an IBM platform that acts as a data clearinghouse for nine databases. Those nine databases represent five county departments and contain mental health, homeless, housing, social services benefits, physical health, probation and other criminal justice information.

The Office of Care Coordination within the County Executive’s office manages SOCDIS and operates the multi-disciplinary functions required to work with familiar faces identified through reports pulled from the system. Currently, the office pulls two reports from SOCDIS, one for individuals who have become familiar faces to homeless service providers and one for individuals who have become familiar faces to the corrections system. The county defines familiar faces in the homeless cohort as individuals who have active records in five or more databases within SOCDIS. Familiar faces in the corrections cohort represent individuals who were booked into jail four or more times in one year.

CARE PLUS PROGRAM

Complementary to SOCDIS was the development of the Care Plus Program (CPP). Also managed by the county’s Office of Care Coordination, CPP is an expedited service delivery program for the highest utilizers of the county’s system of care, as identified by SOCDIS reports. CPP is consent-based; only clients who have signed an authorization form allowing access to their information can participate. Orange County piloted CPP for approximately 80 individuals from within the homeless cohort.

CPP uses a combination of data sharing, case management and multi-disciplinary teams (MDT) pulling in partners from the sheriff’s department, behavioral health provider, local police departments and other systems. The goal of the program is to improve the county’s response to its most vulnerable residents by identifying appropriate programs and services and expediting linkages to them. CPP clients receive services or begin treatment within 60 business days from the date the client signs the authorization form. A team of CPP care coordinators enroll clients in programs, confirm benefits, send appointment reminders, offer transportation to appointments and court dates and a host of other services. The MDT meets weekly to case conference and discuss progress and any arising issues. Once a client’s  case is successfully managed and they are no longer within the highest level of need, the team moves the case to ongoing virtual case coordination. The Office of Care Coordination is regularly evaluating the effectiveness of CPP and the associated services by comparing  CPP clients’ rate of improvement with non-CPP clients.

To transform our justice system, mental illness and substance use must be addressed, both from an upstream prevention perspective as well as a rehabilitation and restorative perspective. This involves coordination between different sectors within our systems of care and incarceration. Leadership from elected officials to form visions, create public narratives and effectuate system changes is a critical first step.” -- Supervisor Andrew Do, Orange County, Calif.

NEXT STEPS

On May 3, 2022, the County Executive’s Office and the Sheriff’s Office hosted a Data Integration Corrections Cohort meeting with 56 attendees from county departments, community-based organizations, local law enforcement and the courts to determine how each of these agencies can gain access to data through SOCDIS, engage in care coordination through CPP and design a workflow for care coordination focused on the familiar faces within the corrections system. During the meeting, stakeholders identified 1,056 individuals who returned to the county jail four or more times in fiscal year 2021 and accounted for 5,260 bookings. Of those 1,056 individuals, approximately 300 remained in the jail. The county is in the process of requesting consent from these 300 individuals to enroll them in CPP to pilot a corrections cohort, with the goal of reducing recidivism.

NACo would like to thank Lilly Simmering, Deputy County Executive Officer, Doug Becht, Director of Care Coordination, Natalie Dempster, Program Manager for the Care Plus Program and Liz Guillen-Merchant, Director of Performance Management and Policy for sharing information on Orange County. Ms. Simmering can be reached at Lilly.Simmering@ocgov.com, Mr. Becht at DBecht@ochca.com, Ms. Dempster at NDempster@ochca.com and Ms. Guillen-Merchant at Elizabeth.Guillen-Merchant@ocgov.com.

This case study was created with support from Arnold Ventures as part of the Familiar Faces Initiative, seeking better outcomes and lower incarceration rates for individuals who frequently cycle through jails, homeless shelters, emergency departments and other local crisis services.