Site Snapshot: Update on How Three Counties Are Serving High-Needs Populations

November 5, 2021

Across the U.S., hundreds of jurisdictions have committed to improving their systems’ responses to “high-needs” or “priority populations”—community members who frequently and repeatedly encounter law enforcement, jails, emergency departments, and other social services.

The CSG Justice Center is highlighting three of these communities: Bernalillo County, New Mexico; Fulton County, Georgia; and Polk County, Iowa. Each of these jurisdictions is both a Stepping Up Innovator and a MacArthur Foundation Safety and Justice Challenge site. This snapshot will focus on the sites’ successes and challenges in their work with priority populations, as well as some of their upcoming goals. Read more about where these counties started.

Bernalillo County, New Mexico

Highlights to date:

  • Bernalillo County developed a cloud-based, Health Insurance Portability and Accountability Act (HIPAA)-compliant system to house its priority population list, enabling the county to better serve people entering the system.
  • The county, along with the City of Albuquerque, analyzed gaps in behavioral health service access and provision.


  • Clients in the priority population face long waits at the emergency department, and there are waiting lists for services such as case management, prescriptions, and housing.
  • There are insufficient resources to provide appropriate interventions and interrupt unnecessary use of high-cost services.
  • Data sharing across systems and providers is limited apart from the cloud-based priority population list.
  • Initiation and engagement in voluntary crisis services are low among community members who can benefit from these interventions.

Upcoming goals:

  • Collaborate with the Motor Vehicle Division to ensure that booking sheets can be used as a form of ID for people released from jail.
  • Implement an outpatient clinic that will connect people leaving jail to medication until they can establish care with a primary provider.
  • Increase access to buprenorphine at the jail to reduce relapse and recidivism rates among people with opioid use disorder.
Our department has partnered with local behavioral health providers and health systems to build out services, increasing the chances of success for the people we encounter most frequently and reducing the burden on our criminal justice system.
Charlie Verploegh
Assistant Director, Bernalillo County Department of Behavioral Health Services

Fulton County, Georgia

Highlights to date:

  • Local stakeholders developed a proposal to convert a portion of the unused city jail into a Center for Diversion and Services—a pre-charge law enforcement drop-off site with a variety of co-located services.
  • An analysis from the Atlanta Police Department (APD) found that, from 2009 to 2020, 87 of the 100 individuals in their priority population cohort amassed 3,602 contacts with APD during that period. More than 50 percent had 30 or more contacts, with one person having 217. Only one of them was referred for diversion through the Policing Alternatives and Diversion Initiative.
  • Another analysis found that jail bed days alone for the 2017–2019 priority population cohort cost the city and county $1.3 million per year.


  • There are insufficient options for people to be diverted from jail and high-cost emergency services.
  • Service providers are unable to identify and communicate about shared clients.
  • Significant COVID-19-related backlogs in the Fulton County Court System make reentry coordination challenging for members of the priority population with multiple court cases.

Upcoming goals:

  • Flag members of the priority population in encounters with APD officers and divert them to the Policing Alternatives and Diversion Initiative to reduce arrests.
  • Address gaps in the continuum of care, through a new multi-agency initiative, for people who experience chronic homelessness, have serious and persistent mental illness, and have frequent law enforcement or emergency room contacts.
We want dispatchers, first responders, and other critical stakeholders to have access to integrated data to increase connections to community providers who can support people in need and reduce incarceration as the ‘go-to’ response.
Kristin Schillig
Court Support Manager, Superior Court of Fulton County

Polk County, Iowa

Highlights to date:

  • The priority population project team developed a data platform in partnership with Polk County IT that aggregates a list of the 100 people with the most frequent jail bookings and 911 calls.
  • The county created a Resource and Referral Line to connect community members to mental health and disability services and provided related training to law enforcement officers and paramedics.
  • Paramedics at the county’s largest fire department reviewed and streamlined the referral process for community-based services.


  • There are limits to identifying the priority population through 911 data: 911 calls are linked to addresses rather than individuals, making it impossible to identify specific people in the priority population when an address has multiple residents; obtaining data from all three of the county’s 911 communications centers has been difficult; and county staff have to review call notes manually to identify whether the call was related to mental health.
  • Participation in substance use treatment is low as compared to that of mental health treatment.
  • The priority population lacks engagement in crisis services.
  • County agencies struggle to reduce excessive calls for service from one or two members of the priority population who repeatedly request services they already qualify for or receive.

Upcoming goals:

  • Train jail diversion staff to use the priority population data platform.
  • Add a mental health clinician to the 911 Call Center to reduce police/emergency medical services dispatch.

Develop and implement a non-police-based crisis response team and a community-based crisis stabilization team.

We plan to add a mental health clinician to the 911 Call Center so the non-emergency calls can be transferred to the clinician. The clinician will provide the needed support and resources.
Annie Uetz
Program Planner, Polk County Health Services

Photo by Mat Napo on Unsplash.


About Stepping Up

Stepping Up is a national initiative comprising over 500 counties committed to reducing the number of people with mental illnesses in jails. Stepping Up is jointly led by The Council of State Governments Justice Center, the National Association of Counties, and the American Psychiatric Association Foundation.

About the Safety and Justice Challenge

The Safety and Justice Challenge, an initiative of the John D. and Catherine T. MacArthur Foundation, seeks to reduce over-incarceration by changing the way America thinks about and uses jails. The Challenge supports efforts to improve local criminal justice systems across the country by safely reducing over-reliance on jails, with a particular focus on addressing disproportionate impact on low-income individuals and communities of color.

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