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It's been a decade since we launched Stepping Up. Read about the initiative's impact—and future.

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:

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:

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:

Type

Policy & Practice

Measures

3 - Increase connection to treatment
4 - Reduce recidivism

Last updated: May 20, 2020