Connecting Care at the County Level

Key Takeaways

From Our Partners

This post is sponsored by NACo corporate partner, Netsmart

The Weight Counties Carry

There’s been a recent shift in the way counties think about public safety. After decades of largely reactive policies such as deploying law enforcement to manage crises, rapidly filling jail beds, cycling individuals repeatedly through emergency rooms and courtrooms on an almost predictable schedule, county leaders are arriving at a more proactive conclusion: that the work of keeping communities safe begins well before a 9-1-1 call is ever placed.

Commissioners, health officers and public safety leaders sit at the intersection of every system that touches a life in crisis such as law enforcement, justice, behavioral health, housing authorities and community-based organizations to name a few. No level of government is better positioned to observe the gaps, and no level of government carries a greater incentive to close them.

The Cost of Disconnected Systems

Consider what the typical journey looks like for a person with needs across multiple county systems. That person may have a diagnosis on file at the community mental health center, a prescription history at the county hospital, perhaps an open case with probation and a pending referral to a substance use treatment facility. Each of these systems exists, in isolation, with genuine intent to help. Unfortunately, none of them can access what the others know, often limiting and delaying access to necessary care.

Limited real-time data sharing means the officer responding to a mental health crisis has no way of knowing, for instance, if the individual he’s confronting was discharged from a crisis unit mere hours earlier, or that the individual’s case manager made a series of unanswered support calls the previous week. Without that context, the most likely outcome is a trip to the emergency room, a night in jail or both — neither of which constitutes real care. As it stands, jails have become the largest de facto behavioral health providers in many American counties.

Strengthening Connection

The counties making meaningful progress share one common insight: the solution is not to build entirely new systems. The path to successful community care lies in connecting the infrastructure that already exists. By connecting existing crisis resources every provider would be able to access the same near-real-time view of an individual at the moment of care.

This is the design philosophy behind platforms like Netsmart CareManager, a population health management hub that is cloud-based and electronic health record (EHR)-agnostic. It spans existing agency systems to aggregate clinical data, social determinants of health, criminal justice records and community service interactions into a single longitudinal view of each person. CareManager automates risk stratification, surfaces high-priority individuals before they reach crisis and enables shared care plans that cross agency boundaries. The practical effect is that a case manager, a diversion officer and a probation supervisor can, finally, share the same vantage point.

Where Connected Care Shows Up

In the field, the co-responder model of pairing law enforcement with a behavioral health clinician has produced real results nationwide. However, co-response that lacks critical information results in only half an intervention. When a co-responder team shares real-time access to an individual's treatment history, current medications and prior crisis encounters, a potentially volatile situation becomes a coordinated care opportunity. Counties with integrated co-responder programs report fewer unnecessary arrests, lower emergency department utilization and faster connections to appropriate care. Diversion from the criminal justice system doesn’t just reduce county costs; it also makes a huge impact on the life of individual being cared for.

Another critical moment comes when an individual is released from jail. That date, when known in advance, is an opportunity for providers to proactively intervene. Effective re-entry coordination begins before the cell door opens: initiating benefit enrollment, establishing medication continuity and scheduling a first community appointment while the individual is still incarcerated. This type of warm handoff establishes a direct connection between jail-based care staff and the receiving community provider. Counties with structured reentry programs consistently report reduced recidivism and improved community stability. When people have access to housing, medication and support, their prospects improve.

Measuring What Matters

Counties sustaining these support programs benefit from visibility into outcomes such as recidivism rates, service engagement, emergency department utilization and program performance . Solutions like a population health platform can help aggregate this data at the program, provider and population levels, offering near-real-time dashboards that shift the conversation from compliance reporting to actionable insight. The county health officer and the county administrator can share the same conversation about outcomes that their clinical staff is having with individuals and then be empowered to make resource decisions accordingly.

The interoperability and care coordination strategy opportunity belongs to county leaders who understand their communities well enough to know where the gaps are and have the authority to close them. The infrastructure, the evidence and the technology already exist. What remains is the decision to connect them.