(This story has been updated with additional information.)
FLINT, MI -- Just months after the federal government recognized a health emergency because of Flint's water in 2016, the Genesee County Health Department was drowning in what came next.
The county couldn't keep up with followup care for hundreds of city kids identified with lead poisoning during the Flint water crisis - more than 200 at the start of the new year, according to state and county records requested by MLive-The Flint Journal through the Freedom of Information Act.
When the state Department of Health and Human Services assessed the county's performance in providing after-care to children with blood lead levels above 5 micrograms per deciliter, it found 85 percent - 173 of 204 children -- had not been connected to the program set up to make them better.
The county's own statistics show that by mid-March, 73 percent of children referred for after-care were not active in case management.
But by May 2016, the county's contract to handle the work had been terminated because of low levels of engagement and a reluctance to take federal resources offered to improve its performance, MDHHS spokeswoman Geralyn Lasher said.
"We didn't have enough families getting that nurse management," Lasher said. State and federal health officials concluded, "We've got to go to Plan B. We're not serving enough people."
The case management program was later transferred to the Greater Flint Health Coalition's Children Healthcare Access Program, which has continued to develop plans of care for affected children.
In every other part of Michigan, similar programs are run by county health departments, which follow up on elevated blood lead levels reported to the state by doctor's offices and clinics.
"We have no other third party, non-local health department that does the nurse case management for elevated blood lead levels," Lasher said in an email. "I am not aware of any time prior that other local health departments were not the ones handling this."
The documents detailing the county's problems managing the program jibe with recent allegations by a former Health Department secretary, who said in the film "Fahrenheit 11/9" that she was told to falsify blood lead test results at least in part because the agency didn't have the capacity to respond to the crisis it was seeing.
The county Board of Commissioners has denied those claims by Cook-Hawkins, but special Flint water prosecutors have shown interest in whether crimes were committed as blood lead results were reported to the state.
Cook-Hawkins has told The Journal she has shared information with investigators since taking her claims public.
To date, 15 current and former city and state employees, but none from the county, have been charged with crimes related to the water crisis.
Commissioners released a statement to The Journal, confirming termination of the contract for lead case management because MDHHS officials "were not satisfied with the number of enrollees into this program."
"When we started this case management program, (the Health Department) received a list of elevated levels dating back to April 2014 from the state," the county's statement says. The county "was charged (with) contacting families, in some cases, 18 months after the fact.
"Many of the families (were) very leery of anyone that was contacting them because of the media attention surrounding the crisis and therefore declined services. On numerous occasions families were non-committal on the initial contact and then later declined services on follow-up calls.
"We contacted nearly all of the families that were identifiable multiple times," the statement says. "Frankly, many did not understand the difference between the Genesee County Health Department and the state of Michigan and were distrustful of any governmental agency."
Although the county continues to contact families after receiving weekly notices of children with elevated blood lead levels, CHAP continues to handle case management, and the county tells families to expect to hear from the agency.
State data shows the percentage of children six years and under in Flint with blood lead levels of 5 mcg/dL or more spiked well above percentages from all of Michigan and the rest of Genesee County during the 17 months the city used the Flint River as its water source.
The number of children with elevated blood lead levels in Flint peaked in the third quarter of 2014, the first full quarter after the water source switch in April.
Researchers have called the use of river water the trigger of the city's water crisis, which resulted in elevated levels of lead, chlorination byproducts and bacteria in water.