New Resource! Announcing FFI Peer-Learning Sites!

The Familiar Faces Initiative (FFI): Improving Outcomes through Coordinated Health and Justice Systems launched on May 12, underscoring community leaders’ commitment to improving life outcomes for high-needs residents with complex behavioral health conditions. At the launch, the National Association of Counties (NACo) announced new opportunities for counties and cities to engage in this work, including the launch of Peer-Learning Sites to model effective cross sector data-sharing and familiar faces programming.

NACo is excited to announce the inaugural FFI Peer-Learning Sites. Each of these four counties maintains an impressive data-sharing platform or strategy that enables the county to identify their familiar faces—residents who are cycling through jail, emergency departments, homeless shelters or other crisis services at a high frequency. In addition, each county has a program that is specifically designed to support familiar faces and improve outcomes through jail reentry planning, intensive case management, wraparound services and other innovative approaches.

  • Bexar County, Texas Bexar County stakeholders share data across behavioral health, medical and justice systems through a data software called Signify. A cross-jurisdictional team uses the data to identify the most vulnerable familiar faces for their “Top 100” program, which provides stabilization services and ongoing case management. The Top 100 program has resulted in drastically reduced hospitalizations and associated costs.
  • Johnson County, Kan. Johnson County’s IT department built an internal data-sharing component to its service and resource database, My Resource Connection (MyRC). The internal component of MyRC allows service providers to input client data and identify mutual clients between various agencies. In addition to coordinating care, analyzing de-identified and aggregated data from MyRC provides an overview of trends or gaps in care that the county uses to update existing services or implement new services to meet the needs of the community.
  • Minnehaha County, S.D. Minnehaha County engages multiple partners within the community that represent all the service needs of familiar faces through a Coordinated Assessment Reentry Team (CART). CART engages with familiar faces through referrals and uses the data shared to build an in-depth understanding of a person’s needs and then connect them to the most appropriate resources.
  • Orange County, Calif. Orange County built an internal data integration system, the System of Care Data Integration System (SOCDIS), that pulls together nine databases from five different county departments. The county’s Office of Care Coordination uses the data to identify its familiar faces and engage these residents in their Care Plus Program. Care Plus is a program of multi-disciplinary teams that provide case management to assist vulnerable residents by identifying appropriate services and expediting linkages to care.

Over the next year, the FFI Peer-Learning Sites will support the FFI network through one-on-one calls, presentations and responding to inquiries on the FFI Community Message Board. NACo will also highlight the work of each site through publications and events. The FF Leadership Network will visit two of the sites to experience a deeper dive into the various systems that help support familiar faces in their counties.

Interested in becoming a Peer-Learning Site? Email Nina Ward ( and include a short description of the data-integration technology or strategy for sharing data across behavioral health and justice systems and the familiar faces/care coordination program in your jurisdiction.

Interested in asking a question or connecting with a Peer-Learning Site? Email Nina Ward ( and include which peer site you’d like to connect with and at least three available dates and times.

As part of the Familiar Faces Initiative, the FFI activities of the Peer-Learning Sites are generously supported by Arnold Ventures.