Familiar Faces Initiative: Model Jurisdictions for Improving Health outcomes Through Coordinated Health and Justice Systems

In 2022, NACo relaunched the Familiar Faces Initiative during Mental Health Awareness Month to support counties and cities in better meeting the needs of their familiar faces—individuals with complex health and behavioral health conditions who frequently cycle through jails, homeless shelters, emergency departments and other crisis services. Four Peer Learning Sites across the country (Bexar County, Texas; Johnson County, Kan.; Minnehaha County, S.D. and Orange County, Calif.) have been instrumental in providing models of cross-sector data-sharing that align service delivery and integrate systems of care to improve outcomes for high-needs residents. In parallel, the CSG Justice Center has supported several counties in New Mexico and Georgia in state-wide familiar faces projects. These projects garner support for familiar faces programs across all three branches of government to elevate, scale and support local best practices at a state level.

Review the recording of NACo’s celebration of the one-year anniversary of the Familiar Faces Initiative, which includes discussions with each of the Peer Learning Sites and information about state and county collaboration to better support familiar faces in local communities.

WATCH HERE: Familiar Faces Initiative: Model Jurisdictions for Improving Outcomes through Coordinated Health and Justice Systems (naco.org)

County Strategies to Provide Supportive Housing for Familiar Faces

What does it take to house and support familiar faces? Familiar faces are individuals who frequently cycle through jails, homeless shelters, emergency departments and other crisis services. Familiar faces often have complex health and behavioral health conditions that can result in overuse of these costly services without improving their situations, leaving communities paying for poor outcomes. In response, many counties are developing coordinated continuums of care to address the systemic and individual challenges associated with multiple systems involvement. One of the most important tools for counties to effectively improve long-term outcomes is housing, and in particular supportive housing. Review the recording of NACo’s panel discussion with experts and county leaders who have developed innovative funding models to support housing programs and facilities for familiar faces within their communities.

WATCH HERE: County Strategies to Provide Supportive Housing for Familiar Faces (naco.org)

County Strategies to Recruit and Retain a Strong Behavioral Health Workforce

Counties are developing innovative solutions in response to behavioral health workforce shortages across the country. As qualified behavioral health workers seek employment in the private sector or different professions altogether, county providers are struggling to recruit and maintain the workforce necessary to meet the growing demand for services. Review the recording of NACo’s panel discussion of innovative solutions to behavioral health workforce challenges.

WATCH HERE: County Strategies to Recruit and Retain a Strong Behavioral Health Workforce (naco.org)

Using Public Safety Funds to Support Community Members’ Behavioral Health Needs

Law enforcement officers are often the first responders when a person is experiencing a behavioral health crisis. In many cases, individuals who repeatedly call 911 or cycle through jail become ‘familiar faces’ to law enforcement with poor outcomes. Three law enforcement officials joined NACo on October 12 to discuss how they use public safety funds to support the behavioral health needs of community members. Each of the officials featured on this webinar are funding behavioral health roles and services as integral components of their public safety departments.

  • Sheriff Elias Diggins of the City and County of Denver, Colo. reallocated an executive level role to create a Chief of Mental Health Services position and hired a clinical psychologist, Dr. Nikki Johnson. Dr. Johnson oversees all aspects of mental health in the department and jail, from entry to exit. She has led the implementation of a crisis response team, restoration and transition unit, mental health step-down unit, medication-assisted treatment unit and harm reduction release program through which individuals leaving custody receive a kit with naloxone and fentanyl test strips. Since its inception, the jail has distributed more than 900 kits to individuals leaving custody.
  • Sheriff Jerry Clayton of Washtenaw County, Mich. used funds allocated to his office from an eight-year county millage for mental health and public safety improvements to launch a LEADD (Law Enforcement Assisted Diversion + Deflection) program. LEADD provides officers the option to divert people charged with low-level offenses into intensive case management and connection to services. While LEADD programs are typically operated out of other departments, Sheriff Clayton integrated jail and mental health data and found that individuals in his county jail with a behavioral health condition had double the average length of stay and rate of recidivism. In response to this disparity and a lack of alternatives, he invested in LEADD to better “support community safety through supporting community wellness, one individual at a time.”
  • Chief Mike Ward (Ret.) of Alexandria, Ky. created a social worker position within his police department to serve as a secondary responder. Sixty-seven percent of calls for service in Alexandria were non-criminal and many were re-occurring calls, requiring the skillset and expertise of a social worker rather than a police officer. The social worker responds to non-criminal calls with an officer or at the police department to connect individuals to services. This position represents about half the cost of hiring, training and equipping a new sworn officer, and the model has now been emulated across the commonwealth of Kentucky.

The full recording of the discussion can be accessed here. Join the conversation on the Familiar Faces Initiative Community Message Board. Contact Nina Ward, Senior Program Manager for Behavioral Health and Justice at nward@naco.org with any additional questions.

Sharing Data Across Justice and Behavioral Health Systems: 2022 NACo Annual Conference Workshop Summary

The Familiar Faces Initiative (FFI) seeks better outcomes and lower incarceration rates for individuals who frequently cycle through jails, homeless shelters, emergency departments and other local crisis services by empowering communities to share data and integrate care options between health and justice systems.

Data sharing and care coordination build on the principle that if service providers can better understand the needs of their clients, they can be more targeted and more effective in their support for these individuals. Through FFI programs, county health, safety and human services departments and providers work to meet residents’ needs with essential support systems through increased collaboration, communication and cooperation.

During Sharing Data Across Justice and Behavioral Health Systems at the 2022 NACo Annual Conference, session attendees gained insight into how county governments, law enforcement, service providers and medical facilities can share behavioral health and justice data to improve inter-agency care, thus improving individual outcomes. Throughout the session, speakers from Adams County, Colo., Johnson County, Kan. and Minnehaha County, S.D. presented on data-sharing strategies and how they are supporting our highest-need residents.


Adams County, Colo.

Adams County centers its data-sharing efforts around people experiencing homelessness and building a better understanding of their needs through service utilization data. By entering into data sharing agreements with municipal partners, Max Cercone, Senior Performance Evaluator for the Adams County Department of Community Safety & Well-Being, shared that he and his team of data scientists input all participating partners’ data into R, an accessible, open-source technology platform. The team then uses a software package called record linkage to match individuals across disparate data sets. Cercone explained that the underlying engine of R and record linkage is a regression model that score matches based on selected variables such as first name, last name, date of birth and, if available, social security numbers. The data matches provide a more holistic picture of how people cycle through homeless service systems across Adams County, Denver and Boulder County. These data help the county better serve individuals with the highest needs through opportunities for outreach and connections to appropriate programs and services.

Minnehaha County, S.D.

Minnehaha County operates a jail reentry program, Alliance, which aims to reduce high recidivism rates among familiar faces to the county jail. Recognizing a need to involve multiple partners that represent all the service needs of familiar faces, Brett Johnson, Director of Alliance, shared that the program developed a Coordinated Assessment Reentry Team (CART). CART is comprised of medical, mental health, jail and detox staff, as well as the homeless outreach team at the Minnehaha Community Health Center. CART engages with familiar faces through referrals from pretrial services staff, public defenders, public advocates and community members. The participation of multi-sector agencies allows CART to create holistic case plans that connect people to the most appropriate resources.

Read more about Minnehaha County’s approach here.

Johnson County, Kan.

In 2016, the Johnson County Department of Corrections implemented a mental health screening process to better understand the needs of individuals cycling through the jail. The Department then shared this information with the county’s community mental health center. The resulting data indicated that the county’s familiar faces received services across a vast portfolio of providers, including the jail. Mike Brouwer, Johnson County’s Criminal Justice Coordinator, explained that in response to the number of disparate providers serving mutual clients, a former county manager initiated a data-sharing application that supports case management, My Resource Connection (MyRC).

MyRC is a comprehensive database that takes all Johnson County human services client data and de-identifies it to allow for cross-agency sharing and input of information. Each client in the application is assigned a system identification number to protect their privacy, and staff from each agency can input information about contacts and case notes into the system without accessing each other’s notes. While MyRC is set up as a resource for human services agencies, an individual’s probation officer can also receive a notification of contact with another agency. Detailed information can be shared if the individual has signed a release of information. MyRC helps to identify mutual clients between multiple service providers while protecting personal information. In addition to helping these agencies coordinate care, the county uses MyRC data to identify trends or gaps in services and create policies and programs to better support community members.

Read more about Johnson County’s approach here.

Navigating Privacy Laws

Guidelines established by the Health Insurance Portability and Accountability Act (HIPAA) and other privacy regulations were enacted to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care.[1] Each of the panelists shared innovative approaches to working across health and justice systems to share data and coordinate care while protecting the privacy of county residents.

  • In Minnehaha County, the community triage center and two area hospitals use release of information agreements that allow them to share information that helps divert people experiencing drug and alcohol withdrawal from the hospitals to the triage center.
  • Adams County uses data-sharing agreements with neighboring counties to access their Homeless Management Information Systems (HMIS) and public safety datasets and develop a better understanding of the needs of individuals that are utilizing services across jurisdictions.
  • Johnson County hired a HIPAA Compliance Officer at the inception of MyRC; this role has been a significant asset in terms of fostering collaboration amongst partners.

These types of partnerships between counties, providers and neighboring jurisdictions allow for improved care of individuals and better decision making for policy makers.

Watch the recorded session here.

Interested in learning more about the capabilities of cross-system data sharing platforms? Join NACo and the Familiar Faces Initiative (FFI) this October for a series of webinars featuring a technology and/or platform that shares and integrates data across behavioral health, health and justice systems. Register for the learning series here.

Additional Resources:


[1] Centers for Disease Control and Prevention. (2022). Health Insurance Portability and Accountability Act of 1996 (HIPAA): HIPAA Privacy Rule. https://www.cdc.gov/phlp/publications/topic/hipaa.html




Launch of the Familiar Faces Initative

The National Association of Counties (NACo) relaunched Data-Driven Justice as the Familiar Faces Initiative: Improving Outcomes through Coordinated Health & Justice Systems.

The Familiar Faces Initiative will support and empower communities to share data between health and justice systems and coordinate care options for individuals with complex health and behavioral health conditions who frequently cycle through jails, homeless shelters, emergency departments and other crisis services. Data-sharing allows communities to identify people who need help, connect them with the right services and address underlying issues to break the cycle of incarceration and crisis.

At the event, NACo announced:

  • Familiar Faces Initiative websitehttps://FamiliarFaces.NACo.org to serve as a central location for resources, events and announcements
  • Community Message Board for questions and discussions with peers and experts around data-sharing efforts and programs for familiar faces
  • An Advisory Board of influential organizations and associations that will guide the initiative and coordinate messaging around familiar faces
  • Applications to the Familiar Faces Initiative Leadership Network, which will support local leaders in championing these efforts in their jurisdictions. Applications are due June 3rd, and
  • Stay tuned! Peer learning sites to model effective cross sector data-sharing and familiar faces programming.

Access the event recording and materials here. 

To learn more, please reach out to Nina Ward at nward@naco.org.

Somewhere to Go During a Behavioral Health Emergency: Crisis Triage Centers and Behavioral Health Clinics

Counties are partnering with health care providers to establish crisis triage centers that offer in-person treatment and services to people experiencing a behavioral health emergency. These centers may offer short-term treatment, group and individual therapy, medical assessment, peer respite, medication administration and rehabilitation services, among other ongoing support options. In many counties, crisis triage centers are federally-funded Certified Community Behavioral Health Clinics (CCBHCs) that provide integrated and evidence-based services to residents. This webinar will provide an overview of crisis triage centers, offer examples from counties across the country and discuss the role of several key stakeholders. Participants will also have time to engage in discussion groups led by elected officials, behavioral health practitioners and criminal legal system stakeholders.



911 Dispatch: Innovations for Addressing Behavioral Health Crisis Calls

Counties and cities across the country are developing innovative approaches within 911 dispatch centers to respond to behavioral health crisis calls to reduce unnecessary jail and emergency department admissions and associated costs, improve public safety and engage vulnerable residents in effective treatment and recovery services. This webinar will feature a presentation on The Pew Charitable Trust’s recent research on 911 call centers’ capabilities to handle behavioral health crises and highlight localities that have developed innovations in 911 dispatch centers.



Non-Law Enforcement Responses to People Experiencing a Mental Health Crisis


Counties and cities across the country are looking for innovative ways to respond to 911 calls for service involving people experiencing a mental health crisis. Local leaders are exploring potential non-law enforcement responses through mobile crisis teams or other types of partnerships. This webinar will feature localities that have created such programs, their lessons learned and resulting best practices.


Coordinating a System Response to 911 Dispatch


Improving crisis response with strategies that divert those with behavioral health needs to appropriate care has become a primary area of focus for both county and city law enforcement. Innovative dispatch strategies include co-responder models with mental health clinicians, mobile crisis teams, Crisis Intervention Team (CIT) training for law enforcement officers or a combination of all three. Join NACo, in collaboration with our Stepping Up partners and Data Driven Justice network for a discussion on 911 dispatch intervention strategies with a special emphasis on data collection, screening and practical local approaches to resolving 911 calls safely without unnecessary justice system involvement.


Virtual Panel Discussion: Lessons Learned from Pilot Projects


Join Data-Driven Justice (DDJ) for an engaging virtual panel discussion on the outcomes of the two-year DDJ pilot program with three communities: Johnson County, Iowa; Long Beach, Calif. and Middlesex County, Mass. In 2018, Arnold Ventures selected these three communities to receive support for pilot projects to link data from local police, jail, hospital and other service providers to help identify “frequent utilizers.” Pilot counties leveraged cross-systems partnerships across justice, health and service providers to integrate data to guide frequent utilizers to the support they need, to avoid either hospitalization or incarceration.

During this discussion, Arnold Ventures will lead a conversation with the pilot sites to discuss progress and challenges with their projects and highlight lessons learned for DDJ communities doing this important work. Participants will have the opportunity to engage in Q&A with the pilot site leaders during follow-up DDJ Peer Engagement Group calls in October.

National Listening Session: COVID-19 Impacts and Innovations Across Justice and Behavioral Health Systems


Counties and cities are on the frontlines for protecting public safety, administering justice and supporting and maintaining the health and well-being of residents. As a result of the COVID-19 pandemic, jurisdictions are implementing changes to policies and practices within justice and behavioral health to continue to provide these vital services to meet community needs.

Please join Data-Driven Justice (DDJ) on Friday, May 22 at 2 p.m. EDT for a discussion on national and federal justice and behavioral health resources as communities continue to navigate the COVID-19 pandemic. DDJ members will hear from national leaders about available federal resources, but we also want to hear from DDJ communities about the impact of COVID-19 on their efforts to serve frequent utilizers of their health, human services and justice systems. Please come prepared to share innovations and continuing challenges in your communities.


  • Chris Asplen, Executive Director, National Criminal Justice Association (NCJA)
  • Ayla Colella, Director, Practice Improvement, National Council on Behavioral Health

Community Discussion Questions:

  • How is your community promoting social distancing within your justice systems? How has it impacted your DDJ work?
  • How has behavioral health service delivery changed as a result of social distancing or a shift to telehealth? What has the impact been on your work with people with mental illness?
  • How are communities making sure that individuals with mental illness being released from jail are getting access to needed services or has creating warm handoffs been a challenge?
  • What is your community’s approach to reopening its justice and behavioral health systems? What policies or procedures within justice and behavioral health is your community considering maintaining after social distancing measures have lifted?