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The Vital Program

The Vital Program

Behavioral Health and Recovery Division

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Health & Human Services (HHS) Transformation – Familiar Faces Initiative

The Familiar Faces Initiative focuses on systems mapping, design, and improvement work centered on creating a system of integrated care for complex health populations that can eventually benefit any user of publicly-funded health services. Familiar Faces are a sentinel population defined as individuals who are frequent utilizers of the King County jail—defined as having been booked four or more times in a 12-month period. 94% percent of these individuals have a behavioral health condition. 

Please visit HHS Transformation and Familiar Faces for more information.

Intensive Care Models

Evidence-based, best and promising practices exist for individuals experiencing homelessness, who also have complex behavioral health and primary care conditions and are often incarcerated as a result of social determinants of health, such as a lack of access to healthcare. A literature review of new and innovative models that are also culturally responsive has driven the idea of a “flexible care management team” in the Familiar Faces Future State Vision.  The Familiar Faces Intensive Care Management Team is one “go-first” strategy in this broader vision.

For More Information

Contact Stephanie Moyes

Intensive Services Coordinator

(206) 263-3559

  Additional Resources

Resources for Providers

The Familiar Faces Intensive Care Management Team

     King County      REACH     UW Medicine Harborview  

The Familiar Faces Intensive Care Management Team has adopted the name "Vital" and provides comprehensive and integrated services to adults who are experiencing behavioral health challenges, need an intensive level of community-based support, and may be experiencing homelessness.

Vital Staffing Model 2019

ICMT Staffing

Consists of a team of multi-disciplinary integrated staff with services that began in July 2016.

Target Population

60 adult individuals who meet both of the following utilization criteria:

  1. Four or more bookings in the King County Jail within a 12-month period; and
  2. That the above criteria occurs twice in a three-year time frame as defined and updated by the County.

Individuals enrolled into ICMT services also will need the level of care provided by this intensive team and this will be assessed by BHRD DRS staff in collaboration with ICMT providers.


An intensive, flexible community-based team that provides mental health and substance use disorder treatment integrated with primary health care and life skills development. This comprehensive team-based approach will center the participants’ self-determination and individual recovery goals. The ICMT will also provide ongoing coordination with criminal justice system partners in order to support reentry and reduce incarceration and crisis system utilization. The following evidence-based and best practices will be used in this service delivery:

  • Motivational Interviewing
  • Permanent Supportive Housing from a Housing First Approach
  • Assertive Outreach/Engagement
  • Trauma-Informed Care
  • Harm Reduction
  • Integrated Care and Care Coordination
  • Culturally Responsive Services; Alignment with King County Equity and Social Justice


A continuum of housing options may be used and some dedicated housing resources will be available to provide permanent supportive housing for individuals enrolled in ICMT.

Provider Services will be provided by Evergreen Treatment Services REACH program in coalition with Harborview Behavioral Health. Initial housing units/housing case management will be provided by Plymouth Housing Group.

Funding provided by: King County Veterans, Seniors and Human Services Levy

Program Administered by: King County Diversion and Reentry Services, Behavioral Health and Recovery Division (BHRD)

Key OutcomesVital Program Outcomes, 2020

ContactShanna Clinton,

Contact Us

Phone 206-263-9000

TTY Relay: 711

Fax: 206-296-0583