The St. Cloud Police Department knew of unstable citizens who were constantly being detained by officers, the Stearns County Human Services Department had a roster of people with addictions who were practically living in detox, and the Stearns County jail had a list of inmates whose mental health crises kept them coming back to confinement.

But it was only recently, when the agencies compared notes, that they confirmed a troubling suspicion — their lists all bore the same names.

The discovery two years ago led to a partnership between the agencies and CentraCare, a St. Cloud hospital and clinic provider, to identify “active utilizers” of the criminal justice, social service, and emergency medical systems, and to work together to help them.

“Every one of us had a piece of the puzzle, but we didn’t have that whole picture,” said Capt. Mark Maslonkowski, who directs the county jail.

Now the partnership identifies the people who are stuck in the system — most of whom are uninsured and homeless — and connects them with clinical care and housing options.

Maslonkowski said it was pivotal to have CentraCare take over medical care in the jail, because its providers can work with inmates and then, on release, coordinate their care at an outpatient clinic. That’s especially important if they have started treatment in jail for addictions and need follow-up visits or prescription refills, he said.

Many of these individuals don’t know where to begin and find it overwhelming to gain the insurance coverage and medical attention they need to address their mental health or substance abuse issues, said Melissa Huberty, Stearns County Human Services administrator. “Its just easier for them to … go on and live the life that they’ve been living,” she said.

The partnership is showing signs of success, including moving 58 people into stable housing. Detox admissions have declined 10 percent over the last year, said Julie Ellis, who directs the county’s community support division. “I can’t think of another reason why that would be except for this partnership,” she said.

Police custodial detentions of people in mental health or substance abuse crises have declined from 358 in January 2018 to 263 last month, said St. Cloud police Cmdr. Jim Steve.

A key to the partnership is CentraCare outreach workers who connect with people after their detentions and get them back into routine medical care. Some patients had been blacklisted by other clinics because they have missed too many appointments due to transportation glitches or other barriers, said CentraCare’s Katy Kirchner, who directs medical care at the Stearns and Benton County jails and at the follow-up community clinic.

“What I’ve heard from the patients,” she said, “is, ‘You know, you guys don’t give up on us.’ ”