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.

The Problem

Our healthcare system is fragmented, confusing and full of gaps. For Familiar Faces – our most vulnerable community members – this can mean poor health, homelessness, food insecurity and more.

The Solution

An integrated, whole-person care system that brings together multiple providers to address all needs through a shared process and coordinated plan.

Wake County's most vulnerable populations. Known as “familiar faces,” these residents have frequent interaction with:

• Criminal justice and correctional systems;
• Emergency medical services;
• Homelessness services;
• Physical and mental health services; and
• Substance abuse detox and treatment services.

Usually, health information can only be shared with one organization, or sometimes across a few medical providers. Our data-sharing platform will allow both medical healthcare data and social services data to be shared with multiple organizations so providers can work together to create coordinated, successful community care plans. This can include:

• Predictive modeling of accurate, local data to identify actual and potential high utilizers across the system.
• Care coordination via collaborative care management with new/redesigned cross-organizational workflows.
• Information sharing across the care system via an integrated data-sharing platform for service providers.
• Program analytics with system-wide data sources to guide piloting, evaluation and iteration of program activities.

In 2023, Familiar Faces program participated in Live Well Wake's Mental Health Workgroup. Familiar Faces served as a strategic partner in connecting residents to mental health services. 

In 2024, Familiar Faces remained as a strategic partner in connecting residents to mental health services. In addition, with the launch of Wake County's new Behavioral Health Department. The Familiar Faces program along with other behavioral health programs across the county government will undergo a new transition period under the leadership of the county's first ever Behavioral Health Director.