Partners:

• Advance Community Health
• Raleigh Police Department
• Raleigh/Wake Partnership to End Homelessness
• Healing Transitions
• Oak City Cares
• Southlight Healthcare
• WakeBrook
• Wake County Health & Human Services
• Wake STEP Clinic
• RHD NC

Executive Team:

• WakeMed Health & Hospitals
• Duke Raleigh Hospital
• UNC REX Hospital
• Wake County Housing Affordability & Community Revitalization Department
• Alliance Health
• Wake County EMS
• Wake County District Attorney
• Wake County Sheriff’s Office
• Triangle Family Services
• Wake County Manager’s Office

The Wake County Familiar Faces Health Collaborative aims to improve the health and wellbeing of Wake County’s most vulnerable residents by meeting their individual needs and goals through a “whole person” approach where medical and social service providers across the care system share information and collaborate to provide integrated, holistic, and trauma-competent care.

“Familiar Faces” are the most frequent users of emergency, medical, social, law enforcement, homeless, and other public services. Failure to address social determinants of health (SDOH) for this most vulnerable population has caused unnecessary illness and poor quality of life as various county systems overlook key needs of individuals. Additionally, these repeated interactions (often with high-cost services) are costly.

The following strategies aim to reduce Familiar Faces disparities:

1. Assemble Wake County cohort to complete Robert Wood Johnson Clinical Scholar Program.

2. Develop an early intervention approach to provide prevention services and calculate return on investment for described services.

3. Implement a data system that identifies high utilizers and helps to coordinate services for them.

4. Develop an approach that prioritizes those in highest need for services.

5. Assign high risk individuals to a coordinated team who will take responsibility for aligned care and continuity of services.

6. Provide front line responders with needed information about these individuals and close the gap between front-line responders and case managers.

7. Work to improve the use of NC Care 360 as a tool to help meet identified gaps in social determinants of health.

Vision

All people of Wake County — including vulnerable individuals with multiple, complex needs — can sustainably live safe, fulfilling, and meaningful lives.

Values

• Respect & Empowerment
• Collaboration
• Diversity, Equity & Inclusion
• Data-driven Approach
• Trauma-competent Care