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). Free PowerPoint® Viewer (Plugin Software Help).

Slide 1

Bernalillo County Pathways to a Healthy Community

Daryl T. Smith, Program Manager
Pathways Project
University of New Mexico Health Sciences Center
Office of Community Affairs
September 27, 2010

Slide 2

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

Slide 3

Our Model

• Funding from County Government and UNM Hospital per MOU from 2009-2017.
• ≥ $800,000/year.
  • 80% of funding goes to community-based organizations.
• Thirteen [13] community organizations contracted to implement Pathways.
• Hub at UNM Health Sciences Center Office of Community Affairs.
• Active Community Advisory Group.

Slide 4

Community-defined Outcomes

1. People in Bernalillo County will self report better health.
2. People in Bernalillo County will have a health care home.
3. Health and social service networks in Bernalillo County will be strengthened and user friendly.
4. Advocacy and collaboration will lead to improved health systems.

Slide 5

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.

Slide 6

Pathways Client

• Bernalillo County Resident
• Difficult to Reach:
  • Low income
  • Uninsured
  • Unemployed
  • Uses ER frequently
  • Housing instability
  • Not receiving services
  • Hungry

Image: A silhouette of a woman's head is shown with issues listed in squares over her head: Diabetes Treatment, Food, Housing, Counseling, Dental.

Slide 7

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."

Slide 8

22 Pathways Defined

• Behavioral Health
• Child Care
• Child Support
• Dental
• Depression
• Diabetes
• Domestic Violence
• Education/GED
• Employment
• Food Security
• Heat & Utilities
• Health Care Home
• Homelessness Prev.
• Housing
• Income Support
• Legal Services
• Medical Debt
• Pharmacy/Medications
• Pregnancy
• Substance Use/Abuse
• Transportation
• Vision & Hearing

Slide 9

Sample of Completed Pathways
Health-related

• 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".

Slide 10

Sample of Completed Pathways
Societal-related

• 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.

Slide 11

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.

Slide 12

Challenges

• 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.

Slide 13

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.

Slide 14

Lessons Learned

• 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.

Slide 15

Contact Information

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 broudy.david@gmail.com

Bill Wiese—Pathways Evaluator
(505) 272-4738 or Wwiese@salud.unm.edu