Dual Diagnosis Cross-Functional Team





When the Dual Diagnosis Cross-Functional Team (DDCFT) was convened by Mayor Fischer in January 2013, the initial focus involved individuals with co-occurring disorders, but more specifically targeted chronic alcohol intoxicants, who were revolving in and out of the jail and the local criminal justice system.  Although the serial inebriate population had historically been dropped off by the Louisville Metro Police Department at The Healing Place, the community’s “Sobering Up Station,” the open access detox beds were no longer available because the beds were being filled by a younger population of individuals abusing heroin and opiates.



Using a reactive problem solving method, the DDCFT gathered data and information to better understand the impact of the dual diagnosis population on community service providers and to identify opportunities for system improvement. The DDCFT is the first Metro cross-functional team to involve local government representatives along with participants from community-based medical, mental health and substance abuse treatment agencies.  The formation of the DDCFT also represents the first time that representatives from criminal justice, medical, mental health and substance abuse agencies have come together to work on a common solution for coordinating and delivering care to the target population of high system utilizers.


DDCFT—Initial Phase

After meeting on a biweekly basis for six months, the DDCFT generated a series of potential solutions that were presented to Mayor Fischer in July 2013.  The identified solutions included: applying for grants and external funding to support team initiatives; developing a registry of the top 100 system utilizers; developing a repository of existing programs, services and capacities; developing community-wide pathways and protocols (including a complex case management network and specialized public safety diversion protocols); and coordinating advocacy efforts.


DDCFT—Implementation Phase

Following a short hiatus during the summer of 2013, the DDCFT launched its implementation phase in November 2013.  In addition to implementation of identified solutions from the initial phase, the DDCFT expanded its focus beyond chronic alcohol intoxicants and began moving toward creation of a new community-wide and cross-agency network for case coordination and management of high system utilizers.


GAINS Center Sequential Intercept Mapping Workshop

In response to an application submitted in February 2014, Louisville was selected as one of seven national sites chosen to host a GAINS Center Sequential Intercept Mapping Workshop.  The workshop was held on July 9, 2014 and focused on identifying early opportunities for diverting dually diagnosed individuals from the justice system.  Priority recommendations identified during the workshop included promoting early diversion (pre-arrest); expanding the number of open access detox beds; and using the Homeless Management Information System (HMIS) as the backbone for the new Community Care Management Network (CCMN).


2nd Report-Out Session with Mayor Fischer

In September 2014, the DDCFT held its second Report-Out Session with the Mayor.  In addition to highlighting areas of progress, the DDCFT identified its next steps, which included designing and implementing a Community Care Management Network Pilot Project and developing early diversion (pre-arrest) protocols.  Advocacy efforts included maintaining and expanding the Forensic Assertive Community Treatment Program and encouraging action at the state level to suspend versus terminate Medicaid benefits following a period of incarceration.


DDCFT Accomplishments to Date

  • First Metro Cross Functional Team to include external community partners
  • First time that a number of diverse community organizations joined together to share information and discuss systemic concerns
  • DDCFT has met on a regular basis since January 2013 and maintained continuous member engagement
  • Presented five solutions at the initial Report Out Session with Mayor in July 2013 and took action on three (pursuing grants; advocacy; and compiling inventory of current programs and services)
  • Developed an Issue Brief on the work of the DDCFT for distribution through member professional organizations during the 2014 session of the Kentucky General Assembly
  • Team has recognized the power of speaking with a common voice in advocacy efforts
  • As the focus broadened to development of a Community Care Management Network, the membership expanded to include new organizations and representatives
  • Developed common Release of Information and MOU for data sharing among agencies participating in the new network
  • Monitored and established a liaison to related efforts at the state level including the Emergency Department Super Utilizer Task Force
  • Applied and selected as one of seven jurisdictions nationally to host a GAINS Center Sequential Intercept Mapping Workshop on July 9, 2014
  • DDCFT is included in a national inventory compiled by Laura and John Arnold Foundation researchers from the Johns Hopkins Bloomberg School of Public Health and the Harvard Medical School on how the Affordable Care Act (ACA) is making communities safer and impacting public health outcomes
  • Upon completion of initial assignments, the Release of Information and Standardized Outcomes Work Groups were combined to form a Steering Committee charged with designing the CCMN Pilot; two new task groups were formed to focus on  technology issues related to the Homeless Management Information System and public safety protocols
  • DDCFT members participated on a panel, entitled “Bridging the Gap: Using Information Technology to Improve the Health of Justice-Involved Individuals” in Rockville, Maryland on September 17-18, 2014
  • DDCFT members signed a resolution advocating for suspension versus termination of Medicaid benefits that was submitted to the Secretary of the Kentucky Cabinet for Health and Family Services in February 2015
  • DDCFT members participated in a Cook County Learning Collaborative on ACA Jail Enrollment to Health Care in March 2015; through technical assistance provided by the Center of Health and Justice at TASC, an action plan was developed to enhance enrollment of jail inmates for Medicaid benefits, establish a jail discharge coordinator position to link individuals to community treatment upon release and explore new options for pre-arrest diversion
  • The newly established discharge planning program, Familiar Faces Action and Community Transition (F2ACT) was launched in July 2015 to ensure that individuals being released from custody are provided with necessary medications, transportation, shelter, clothing and a “warm hand-off” to treatment and other service providers in the community
  • Surveyed DDCFT members to identify service delivery and reimbursement issues related to Medicaid expansion and forwarded input to the state for consideration during renegotiation of Managed Care Organization contracts
  • DDCFT members and local criminal justice stakeholders were invited to participate in the National Law Enforcement Assisted Diversion (LEAD) Convening in Washington, D.C. in July 2015; a team of DDCFT members and local criminal justice stakeholders traveled to Seattle in November 2015 to gain operational knowledge of the LEAD Program
  • Louisville Metro, in conjunction with Seven Counties Services, Inc., received a grant award under the Second Chance Act Reentry Program for Adults with Co-Occurring Substance Abuse and Mental Disorders in November 2015 to expand in-jail reentry case management and add a Peer Support Specialist to provide a  “warm hand-off” to services following release from custody
  • The work of the DDCFT has been highlighted as part of Louisville Metro’s participation in the Innovative Communities and Data-Driven Justice Initiative launched by the White House in January 2016 to target the needs of high system utilizers and individuals detained on a pretrial basis due to inability to make bail; the initiative provides a national network for sharing information on data exchanges and creative local approaches
  • The DDCFT developed a legislative advocacy agenda during the 2016 session of the Kentucky General Assembly to highlight proposals supported by the team and member organizations
  • Through funding appropriated by the Kentucky General Assembly (S.B. 192), Metro Corrections has incorporated evidence-based substance abuse treatment, including Integrated Dual-Disorder Treatment and Medication Assisted Therapy (MAT) with Vivitrol, into the existing in-jail substance abuse treatment program
  • In preparation for launch of the CCMN Pilot, the DDCFT, in conjunction with the University of Louisville School of Public Health, developed the pilot research design and proposal for Institutional Review Board submission
  • The DDCFT established parameters for the CCMN Network Pilot and HMIS operation; network agency representatives have been enrolled and operational training has been provided



The DDCFT represents first Metro Cross Functional Team to include external community partners and the first time that a number of the diverse community organizations have come together to share information and discuss systemic concerns. As the focus broadened to the development of a Community Care Management Network, the membership expanded to include new organizations and representatives. Metro Government and community-based agencies participating in the DDCFT are listed below. 

Mayor's Office

Louisville Metro Criminal Justice Commission

Office of Performance Improvement

Louisville Metro Police Department

Louisville Metro Department of Corrections

Louisville Metro Emergency Medical Services

Louisville Metro Department of Community Services

Louisville Metro Emergency Management Agency

Jefferson County Attorney's Office

Louisville Metro Department of Public Health and Wellness

The MORE Center


KentuckyOne Health

University of Louisville Hospital

Our Lady of Peace Hospital

Seven Counties Services

Jefferson Alcohol and Drug Abuse Center

Family Health Centers

Family and Children's Place

Healthy Reentry Coalition of Kentucky

Louisville-Jefferson County Public Defender Corporation

Greater Louisville Medical Society

NAMI of Louisville

NAMI of Kentucky

The Healing Place

The Coalition for the Homeless

Louisville VA Medical Center


University of Louisville School of Public Health and Information Sciences

University of Louisville Department of Psychiatry and Behavioral Sciences

Volunteers of America



The DDCFT identified the need for a coordinated community-wide response to high system utilizers, also known as "familar faces"—individuals with substance abuse, as well as related medical and mental health issues, who rapidly and repeatedly revolve in and out of the local criminal justice and health service delivery system. Team members recognized that in the absence of information sharing and coordinated case management, community agencies operate and provide services in silos; case managers frequently are unaware that their clients have been incarcerated; an individual may have multiple case managers; referrals and services are being duplicated; individuals in need of services are falling through the cracks; and the most expensive resources (jail, emergency rooms, hospital beds) become the chosen options by default.The DDCFT proposed creation of a new Community Care Management Network (CCMN) to coordinate care delivery for high system utilizers who may be referred from five potential points of entry—mental health, substance abuse, criminal justice, homelessness, and medical/dental. 

Rather than create a new stand-alone program, the DDCFT opted to network existing resources and establish the necessary infrastructure to support information sharing and case coordination across a broad range of community partners. The DDCFT elected to use the existing Homeless Management Information System (HMIS) as the backbone for the new network, which is now comprised of 12 participating community organizations. The HMIS system is operated statewide by the Kentucky Housing Corporation and coordinated locally by the Coalition for the Homeless. The system employs ServicePoint Software (Bowman Systems) for case management and tracking purposes and will easily support the information sharing and case management needs of participating network agencies with only minor modifications. Using the HMIS, participating organizations can view and track individuals as they encounter other organizations in the CCMN.  The DDCFT envisions that the CCMN, through its use of the HMIS, will improve information sharing between agencies, which will ultimately improve the coordination of care for individuals particiapting in the CCMN.


CCMN Diagram

HMIS Process Flow