Bernalillo County Pathways to a Healthy Community (Text Version)

Slide presentation from the AHRQ 2010 conference.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current as of December 2010
Internet Citation: Bernalillo County Pathways to a Healthy Community (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/smith-d/index.html