Douglas County pilots ‘Familiar Faces’ care coordination using My Resource Connection

Douglas County officials and partner agencies used a commission work session to outline an 18‑month pilot that links the county’s My Resource Connection (MyRC) data platform to a cross‑agency “Familiar Faces” initiative aimed at coordinating care for a small number of residents who repeatedly use emergency, justice and social services.

County staff and partner providers said the project aims to reduce repeat emergency‑department visits, jail bookings and street homelessness by surfacing patterns of service use and convening multidisciplinary “huddles” to intervene for people with complex needs.

MyRC is a two‑part platform with a public front end for resource searches (job openings, food pantries, transportation) and a restricted back end that aggregates service contacts across participating providers so authorized care coordinators can see where a person has touched the system. Bob Trianski, Douglas County director of behavioral health projects, described it as “a window into a person's interaction with the system” and said the tool can support trauma‑informed care by letting providers see a client’s recent emergency department visits, jail bookings and active case managers before engaging.

Why it matters

County leaders said the group targeted by Familiar Faces is small—roughly a few dozen people—but disproportionately costly to the system. Using MyRC automation to surface the county’s top 25 users in a 60‑day period, staff calculated $341,000 in consumed services; county staff cautioned that figure is “vastly underestimated.” Officials argued that modest reductions in repeat use could produce tangible savings for emergency providers and county services while improving outcomes for people who are chronically underserved.

How the platform and project work

- Access and privacy: County staff and partner agencies emphasized privacy controls. Jill Jellikerson, county administrator, said all users have unique credentials tied to their employer and role and “all users go through training and intensive training before they can use it.” The team has been working with legal counsel and with partners that are subject to 42 CFR Part 2 (federal rules that limit sharing of substance‑use treatment records) to align access. Consent for sharing is embedded in the LMH emergency department release form, Trianski said.

- Usage and training: Matt Cravens, the county’s data lead, reported a 63% increase in aggregate MyRC usage across organizations from 2021 to 2024. He highlighted increases at Bert Nash (from about 826 aggregate days in 2021 to roughly 1,700 in 2024) and Heartland RADAC (from near zero in 2021 to about 431 days in 2024). Training for new users has been moved to Douglas County to accelerate onboarding, and staff include practical demonstrations from frequent users during sessions.

- What a “hit” means: Staff clarified that a MyRC “hit” or click does not equal a completed referral. A click can be a case manager opening a client’s record, viewing an ambulance run or opening a community resource listing. Trianski and others said MyRC is not a referral management system and does not automatically close referral loops, though an optional outreach/referral form has been built into the platform and routes intake items into partner workflows.

Familiar Faces workflow and early results

Partners defined “familiar face” differently by setting thresholds that reflect their settings: the Treatment and Recovery Center (TRC) uses three or more visits in a month; mobile response teams use three or more referrals in 30 days; one police partner uses 10 or more calls for service in a 10‑day window. Any partner can submit an online familiar‑faces referral form. County staff then run a MyRC crosswalk to assemble redacted usage data and decide whether to convene a familiar‑faces huddle.

Officials offered multiple case examples of coordinated intervention: a pregnant person living in a vehicle who was engaged by a peer supporter, attended prenatal care and delivered a healthy baby after a coordinated huddle; a TRC patient with a traumatic brain injury who required 153 days of work across agencies before discharge to a residential nursing setting; and a person whose severe dental pain had driven disruptive behavior and who was escorted to Heartland for orientation and dental care, then reengaged with services. County staff said one high jail‑utilizer did not return to custody for seven months after a familiar‑faces intervention.

Limitations and next steps

Staff described the work as experimental and not yet formalized for scale. Trianski said the program currently operates with strict privacy practices—participants informally described the approach as “fight club” principles—and the county has not yet banked centralized referral tracking or routinely published identifiable case details. Technical barriers remain: partners’ electronic health record transitions have delayed data feeds and complicated integration. The county aims to have all behavioral‑health partners feed extracts into MyRC by April and to develop a formal process for tracking referrals, outcome metrics and costs.

Commissioners and providers also discussed messaging and storytelling. Staff said they plan to be cautious about public narratives to avoid retraumatizing people who are the subject of interventions even as they explore ways to surface aggregated wins and cost savings to potential funding partners.

The county and its partners portrayed the initiative as a testable, data‑driven way to reduce repeat crisis use while improving care coordination. Officials said the project has produced “proof of concept” wins and asked the commission to support continued efforts to formalize workflow, expand partner integrations and analyze cost impacts.