Bernalillo County Pathways to a Healthy Community (Text Version)
On September 27, 2010, Daryl T. Smith made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (404 KB).
Bernalillo County Pathways to a Healthy Community
Daryl T. Smith, Program Manager
University of New Mexico Health Sciences Center
Office of Community Affairs
September 27, 2010
History of Pathways
Past to Present
2006: Need for health navigators to assist uninsured residents is identified by community stakeholders
2007: Pathways model is introduced and a working group formed to study and adapt to county needs
2008: Collaborative planning is organized to define desired outcomes for a local Pathways model
2008: Public funding negotiated and MOU signed
2008: CCCLN relationship develops
2009: Hub is established and contracts with community organizations initiated to launch Pathways Project
- Funding from County Government and UNM Hospital per MOU from 2009-2017.
- ≥ $800,000/year.
- 80% of funding goes to community-based organizations.
- Thirteen  community organizations contracted to implement Pathways.
- Hub at UNM Health Sciences Center Office of Community Affairs.
- Active Community Advisory Group.
- People in Bernalillo County will self report better health.
- People in Bernalillo County will have a health care home.
- Health and social service networks in Bernalillo County will be strengthened and user friendly.
- Advocacy and collaboration will lead to improved health systems.
Cross-section of Community Organizations Involved in Pathways
- A New Awakening—Counseling agency serving people coming out of incarceration.
- First Nations Community Healthsource—FQHC serving a large off-Reservation Native American population.
- Enlace Comunitario—domestic violence organization serving primarily immigrant women.
- Bernalillo County Resident
- Difficult to Reach:
- Low income
- Uses ER frequently
- Housing instability
- Not receiving services
Image: A silhouette of a woman's head is shown with issues listed in squares over her head: Diabetes Treatment, Food, Housing, Counseling, Dental.
Role of Community Health Navigators
- Find most at-risk community members.
- Build trust.
- Assess and identify problem[s].
- Guide clients thru Pathways steps.
- Complete Pathway/achieve meaningful outcome.
- Document information in database.
Image: A silhouette of a woman's head and shoulders is shown wearing a badge labeled "Health Navigator."
22 Pathways Defined
- Behavioral Health
- Child Care
- Child Support
- Domestic Violence
- Food Security
- Heat & Utilities
- Health Care Home
- Homelessness Prev.
- Income Support
- Legal Services
- Medical Debt
- Substance Use/Abuse
- Vision & Hearing
Sample of Completed Pathways
- Health Care Home—Client has appropriate health coverage or financial assistance program in place to establish health care home and has seen a provider a minimum of 2 times at their new health care home.
- Dental Care—Same as above, replacing the term "health care home" with "dental care home".
Sample of Completed Pathways
- Employment: Client has found a steady job and is gainfully employed for a minimum of 3 months.
- Food Security: Client has achieved food security and has had over the last 3 months, access to a minimum of 2 hot meals per day.
- Homelessness Prevention: CHN assures that the client has obtained and maintains stable housing for no less than 3 months.
CCCLN Scorecard Advantages
- Medical Home is a primary outcome for our project.
- Model Expansion - National research efforts to formalize care coordination model should benefit us locally.
- Local Evaluation Challenges:
- Broad & complex application of original Pathways model in Bern. County.
- Commitment to send majority of funding out to community based activities.
- Bernalillo County's Project adds approximately 40-50 new clients each month.
- Several questions in the score card are not asked at the local level (e.g. insurance status of client).
- Access to a medical home is often not a priority for the client, and may be delayed in lieu of other pathways.
- Insufficient resources for evaluation.
Benefits to the Community
- Participation in the National Learning Network has proven to be very beneficial to the development and implementation of our local model.
- Other counties in New Mexico have expressed an interest in developing a similar model in their communities.
- Bernalillo County model was selected as an example for AHRQ's Innovations Exchange Web site.
- More buy-in from the navigators when they know that their concerns and/or suggestions are acted upon.
- Participation in National Learning Network has helped minimize the number of changes required to our local model.
- Utilization of standardized scorecard brings uniformity to the Network while allowing for flexibility at the local level.
Daryl Smith—Program Manager
(505) 272-0823 or Dtsmith@salud.unm.edu
Leah Steimel—Director of OCA
(505) 272-8813 or Lsteimel@salud.unm.edu
David Broudy—Pathways Evaluator
(505) 841-4145 or email@example.com
Bill Wiese—Pathways Evaluator
(505) 272-4738 or Wwiese@salud.unm.edu