Through a network of approximately 30 community health navigators (CHWs) employed by the 17 partner organizations contracted by our office, Pathways focuses its efforts on identifying and working with the most difficult to reach residents of Bernalillo County, to connect them with a wide variety of health and social services. This program follows an outcomes-based step-by-step national model (Pathways). Our office serves as the “hub” and provides ongoing training and support of the CHWs, collects and analyzes data to ensure that participants of the program are having many of their needs met, and addresses system problems that inhibit access to these important services.

• Five year grant through Bernalillo County aimed to reduce potential child abuse
• Three Types of Advers Childhood Experiences
  • Abuse – Physical, Emotional and Sexual
  • Neglect – Physical and Emotional
  • Household Dysfunction – Mental Illness, Incarceration, Domestic Violence, Substance Abuse, Divorce, Homelessness and Food Insecurity
• Five Community Health Workers conduct in-person screenings (pre-COVID-19) at UNMH Pediatric Emergency Room Department
• Over 7,700 face-to-face interventions (Pre-Covid-19)
• 42.4% of high-risk patients (0-10 yrs old) receive referrals to Pediatric Psychologist, Dr. Miller for further assessment via WPPSI and Baileys testing, where CHWs then connect and provide warm hand-offs to recommended referral agencies

• Aims to decrease hardships related to unmet social needs such as housing stability, food insecurity, access to utilities, lack of transportation, and interpersonal safety
• Program initially designed to address the opioid epidemic in Bernalillo County, but is not limited to only opioid addictions
• Criteria
  • Co-occurring disorders with a primary diagnosis of substance abuse in addition to
  • 2 ER visits in the past 12 months and
  • 1 incarceration in the past 24 months (not limited to Bernalillo County boundaries)
• Three year grant with the City of Albuquerque
• Sub-contract with 6 Community-Based Agencies, employing 8 intensive case managers (ICMs)
• ICMs typically carry an average case load of 16-18 high-needs clients, providing long-term services as needed

• Provide housing vouchers for qualifying recently incarcerated individuals through newly funded (for CHWI) Bernalillo County grant 
• Provide intensive case management to 600+ clients (focused on high needs clients) currently waiting for housing vouchers, with aim to reduce number of clients lost while on wait list; will actively seek and connect to housing once vouchers become available to our program
• Four in-house Community Health Workers will carry a 15-20 client caseload with 2 in-person visits per month

• Criteria 
  • Two UNM Emergency Department visits in a 12 month period
  • In need of at least 1 of 5 Social Determinants of Health – Housing, Food Insecurity, Transportation, Interpersonal Safety, or Utilities
  • Resident of either Bernalillo, Sandoval, Torrance or Valencia Counties
• Two Community Health Workers engage clients at UNMH Emergency Department and Labor and Delivery unit, the Eubank Women’s Clinic, and the Westside Emergency Housing Center
• CHWI is 1 of 20 agencies selected for this nationwide research project
• Five year federal contract with Medicare and Medicaid services
  • Year 1 was solely dedicated to screening clients, resulting in over 75,000 people screened; Years 2-5 added a quarterly quota of 300 navigations conducted, meaning client had ‘buy-in’ for services referred

CHWI employs CHWs to do outreach, health promotion, and work as advocates for systemic change. Currently we have three CHWs concentrating their efforts in three geographic regions of Bernalillo County (Southeast Heights/International District, South Valley and Pajarito Mesa). These CHWs are collaborating with multiple partners in Bernalillo County who are part of "Healthy Here," the locally defined name for the Centers for Disease Control and Prevention (CDC) REACH (Racial and Ethnic Approaches to Community Health) grant.

Healthy Here is a collective impact initiative in Bernalillo County committed to reducing chronic disease in the Hispanic/Latino and Native American populations in the International District and South Valley through environmental and systems changes that increase access to healthy food, physical activity, and self-management of chronic disease.

Partners include Presbyterian Healthcare Services (PHS), Bernalillo County, First Choice Community Healthcare, the International District Healthy Communities Coalition, Adelante Development Center, and numerous others.

Our office, in partnership with MCOs and primary care clinics in NM, places CHWs side by side with healthcare personnel from participating clinics to educate, support and connect their patients with needed resources. As part of this effort the Office for Community Health has created a "Social Determinants Prescription Pad" — a tool that allows health care providers to identify social determinants of health for each patient and refer them to CHWs located within the same healthcare clinic.

This tool is being used in the five clinics where our CHWs are co-located: In Bernalillo County - First Choice Community Healthcare in the South Valley, three UNM Hospital primary care clinics (South East Heights, Southwest Mesa and North Valley), and two Hidalgo Medical Center clinics in Grant and Hidalgo counties.