Wake County Familiar Faces Health Collaborative

Our project involves engaging and coordinating community stakeholders to provide integrated health services to vulnerable individuals with complex needs and who have frequent interaction with crisis systems because current systems are unable to meet their needs.

Recent literature shows that the lack of integrated services for those most vulnerable within a community leads to worse outcomes and costly human suffering. The RWJ Clinical Scholars team members all work for organizations (Wake County Government, WakeMed Health & Hospitals, Duke University Health System, and UNC Health) with deep roots in the community. Individually and collectively, they work with and among networks of community stakeholders and service providers who have a substantive understanding of institutional strengths and gaps related to services for the target population.

Our team seeks to engage vulnerable community members and front-line service providers to understand barriers and challenges associated with service delivery and support systems for this population. Utilizing existing data sources within our community, our team seeks to understand what it takes to partner, integrate, and deliver a holistic care model to familiar faces, vulnerable individuals who have frequent interactions with crisis safety-net systems. This information will provide valuable insight to improve upon existing 2 strategies to develop an empathetic human-centered design that addresses systemic problems to improve services and health outcomes. Our efforts will include utilize continuous quality improvement practices to allow for ongoing improvement efforts and broad community adoption.