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Background and Link to the Health & Human Services (HHS) Transformation – Familiar Faces Initiative

The Familiar Faces initiative is systems mapping, design, and improvement work centered on creating a system of integrated care for complex health populations that can eventually benefit any user of publicly-funded health services. Familiar Faces are a sentinel population defined as individuals who are frequent utilizers of the King County jail (defined as having been booked four or more times in a 12-month period); indeed, 94 percent of these individuals have a behavioral health condition (mental health and/or substance use condition).

Please visit the HHS Transformation website and Familiar Faces website for more information.

Intensive Care Models – Background:
Evidence-based, best and promising practices exist for individuals experiencing homelessness, who also have complex behavioral health and primary care conditions who are often incarcerated as a response to this lack of access healthcare and other social determinants of health. A literature review of new and innovative models that are also culturally responsive has driven much of the idea of a “flexible care management team” in the Familiar Faces Future State Vision.  This Intensive Care Management Team is one “go-first” strategy in this broader vision.

     King County      REACH     UW Medicine Harborview   Plymouth Housing Group

The Familiar Faces Intensive Care Management Team:
The Familiar Faces Intensive Care Management Team has adopted the name Vital and will provide comprehensive and integrated services to adults who are experiencing behavioral health challenges (mental health conditions and/or co-occurring substance use issues), need an intensive level of community-based support, and may be experiencing homelessness.


ICMT Staffing consists of a team of multi-disciplinary integrated staff

Services began in July 2016.

Target Population to be served is 60 adult individuals who meet both of the following utilization criteria:

  1. Four or more bookings in the King County Jail within a 12-month period; and
  2. That the above criteria occurs twice in a three-year time frame as defined and updated by the County.

Individuals enrolled into ICMT services also will need the level of care provided by this intensive team and this will be assessed by BHRD DRS staff in collaboration with ICMT providers.

Services provided by the ICMT will be an intensive, flexible community-based team that provides mental health and substance use disorder treatment integrated with primary health care and life skills development.  This comprehensive team-based approach will center the participants’ self-determination and individual recovery goals.  The ICMT will also provide ongoing coordination with criminal justice system partners in order to support reentry and reduce incarceration and crisis system utilization. The following evidence-based and best practices will be used in this service delivery:

  • Motivational Interviewing
  • Permanent Supportive Housing from a Housing First Approach
  • Assertive Outreach/Engagement
  • Trauma-Informed Care
  • Harm Reduction
  • Integrated Care and Care Coordination
  • Culturally Responsive Services; Alignment with King County Equity and Social Justice

Housing: A continuum of housing options may be used and some dedicated housing resources will be available to provide permanent supportive housing for individuals enrolled in ICMT.

Diversion Framework: The ICMT will be coordinated closely with the Law Enforcement Assisted Diversion (LEAD) Operations group and will be able to staff referrals from law enforcement as well as have prosecutorial resources to assist with pre-filing diversion and other criminal justice navigation support (e.g. warrant quashing).

Service Delivery & Best and Evidence-Based Practices

  1. Motivational Interviewing
  2. Permanent Supportive Housing from a Housing First Approach
  3. Assertive Outreach/Engagement
  4. Trauma-Informed Care
  5. Harm Reduction
  6. Integrated Care and Care Coordination
  7. Culturally Responsive Services; Alignment with King County Equity and Social Justice

Provider Services will be provided by Evergreen Treatment Services REACH program in coalition with Harborview Behavioral Health. Initial housing units/housing case management will be provided by Plymouth Housing Group.

Funding provided by:

King County Mental Illness and Drug Dependency Action Plan
& King County Veterans, Seniors and Human Services Levy

Program Administered by:

King County Diversion and Reentry Services
Behavioral Health and Recovery Division (BHRD)

Contact: Margo Burnison, or Jesse Benet,


Contact Us

Phone 206-263-9000

TTY Relay: 711

Fax: 206-296-0583