Identify “high utilizers”

Counties are tracking people who frequently utilize multiple systems and designing interventions to address this high-need population.

For more information on this practice, see these resources:

• Identifying High Utilizers
• How to Reduce Repeat Encounters: A Brief for Law Enforcement Executives
• Data Driven Justice

Local Examples

Fulton County, GA Fulton County Detention Center and Emory University

• Using the following measures, leaders are tracking people who frequently utilize the emergency, criminal justice, and housing systems:
  • Emergency: Number of ER visits
  • Criminal Justice: Bookings into the Fulton County Jail, contact with the Fulton County Superior Court, jail mental health data
  • Housing: Number of people experiencing homelessness as indicated by the Homeless Management Information System
• Once identified, people who are high utilizers are connected with intensive community-based services.

For more information on this example, see:

• Data and Evaluation Learning Community featuring Fulton County’s High Utilizers program.

Bernalillo County, NM

• To create a list of this population, personnel in Bernalillo County’s Department of Behavioral Health Services first look at two data points:
• People who have been booked into the Metropolitan Detention Center at least two times in the previous 18 months; and
• Who among those booked at least twice in the previous 18 months has received either Detox or Public Inebriate Intervention Program (PIIP) services in the previous 18 months.
• To validate the list, they:
• Send it to the New Mexico Department of Health to review how many ED visits each person made in the previous 18 months.
• Look at the jail management system to determine:
• Each person’s intake screening score;
• If the individuals on the list have a serious mental illness diagnosis and/or were labeled as suicidal; and
• Whether they were placed in the jail’s Psychiatric Services Unit.
• The list is then uploaded to the databases of the Care Campus and the Resource Reentry Center, which provide community-based behavioral health and reentry services, respectively. When a person on the list enters either of these locations, a boundary spanning intensive case manager offers to empanel the individual onto her/his caseload, create an individualized plan, and link them with needed services and supports in the community.
• Currently, Bernalillo County compiles this list quarterly.

For more information on this example, see this resource:

• Frequent Utilizers PowerPoint Presentation, Bernalillo County