Daryl T. Smith, Program Manager Pathways Project 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 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

Our Model  Funding from County Government and UNM Hospital per MOU from  ≥ $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  Funding from County Government and UNM Hospital per MOU from  ≥ $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

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 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

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 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

Pathways Client  Bernalillo County Resident  Difficult to Reach  low income  uninsured  unemployed  uses ER frequently  housing instability  not receiving services  hungry  Bernalillo County Resident  Difficult to Reach  low income  uninsured  unemployed  uses ER frequently  housing instability  not receiving services  hungry

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  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

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

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”. 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 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.  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. Co.  Commitment to send majority of funding out to community based activities  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. Co.  Commitment to send majority of funding out to community based activities

Challenges  Bernalillo County’s Project adds approximately 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  Bernalillo County’s Project adds approximately 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 website  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 website

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  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

Contact Information Daryl Smith – Program Manager (505) or Leah Steimel – Director of OCA (505) or David Broudy – Pathways Evaluator (505) or Bill Wiese – Pathways Evaluator (505) or Daryl Smith – Program Manager (505) or Leah Steimel – Director of OCA (505) or David Broudy – Pathways Evaluator (505) or Bill Wiese – Pathways Evaluator (505) or