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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:


Policy & Practice


3 - Increase connection to treatment
4 - Reduce recidivism

Last updated: May 20, 2020