Scattered across Pierce County, and every corner of America, are people who fall through safety nets for the elderly, disabled, and those suffering from mental illness.
They struggle to care for themselves, but also aren't getting long-term medical care or social services.
Some try to quietly manage mental illness or physical disabilities on their own. Others are elderly and isolated. Without friends and family looking after them, they deteriorate in their homes.
Many end up leaning heavily on emergency services. In Pierce County, some members of this population call 911 more than 300 times a year because they're scared or lonely, suffering psychiatric symptoms, or even for minor problems like running out of coffee filters.
Pierce County leaders formed a team of specialists this fall tasked with reaching those people, stabilizing them, and getting them help.
County officials say it's the first program of its kind in Washington State designed in part to reduce unnecessary 911 calls. It's part of a broader push to fill what some leaders see as gaps in the county's mental-health system.
KNKX trailed the county's five-member Mobile Community Intervention Response Team while the program was getting off the ground this fall. You can listen to that story above.
Their work offers a lens into a population that's often invisible, as well as shortfalls in state and federal healthcare and social-service systems designed to help them.
"We have a large population of people who are just sort of forgotten," said Traci Krieg, the program's director.
In one of the their earliest cases, the team found a woman in her 70's living in a dark and cluttered mobile home in Puyallup without heat.
Suffering from advanced kidney disease, depression, and early-stage dementia, she had been released from a hospital against her wishes after Medicare declined to cover a long-term stay, Krieg said.
"She's scared and afraid," Krieg said after an initial visit to the home in October. "She can't even walk through her house because it's so full of stuff. She doesn't have any food or toilet paper or help. She shouldn't have to live in this kind of situation."
Members of the team delivered groceries, managed her medications, and checked on her for weeks as she awaited an appointment with the state's Home and Community Services Division.
The team juggles about 10 such cases at a time.
Pierce County contracts with the Tacoma mental-health nonprofit Comprehensive Life Resources to run the program. After a pilot period in the fall, county leaders decided to fund through program through 2018 at a cost of $750,000.
The program's launch follows two years in which mental health care was a central topic of debate and discussion among Pierce County leaders.
A year ago, county lawmakers voted down a sales tax hike that would have raised an estimated $10 million a year for mental health and addiction treatment programs. Pierce County remains the only densely-populated county in Washington without the 1/10 of one percent sales tax.
Pierce County Executive Bruce Dammeier made new mental health programs a theme of his first State of the County address this year.