Pathways Program

Pathways is designed to reduce unmet needs, address health inequities, and improve the overall health of the residents of Bernalillo County. It focuses on positive health outcomes by utilizing community health navigators as care coordinators who connect at-risk residents to resources and follow their progress toward improved health outcomes. Meaningful outcomes for the clients are reached by following a step-by-step approach (Pathways). While individual clients attain improved health, common systems issues are also brought to light and result in stronger service coordination.

About Pathways

Three primary activities happen through Pathways:

  • Client services:  Culturally and linguistically competent Community Health Navigators identify and recruit difficult-to-reach clients, build a relationship of trust with them, and assess their risks and needs. Clients, with the guidance of Navigators, choose the outcomes they wish to attain. Navigators then guide the client along different pathways, each of which is specific to a prioritized need (such as housing, employment, education/GED, health care etc.), until meaningful outcomes are achieved.
  • Community collaboration:   The Navigators, are employed by the community organizations that receive Pathways funding. On a monthly basis, the Navigators and other local Community Health Workers (CHWs) meet, network, share information, and receive ongoing training; all of which leads to improved collaboration, strengthening of resources, and enhanced service coordination for clients.
  • Assessment of system effectiveness:   Navigators and their community organizations that employ them often identify systemic barriers that inhibit access for their clients to certain services. These barriers are documented in the web-based, password-protected Pathways database and periodically shared with the Pathways Community Advisory Group, Bernalillo County, the City of Albuquerque, and others, all of whom work collectively on solutions to overcome these barriers.

Pathways Mission & Goals

  • Connecting underserved county residents with health care and other support systems and assisting them as they navigate through it;
  • Coordinating services for the underserved residents to achieve positive individual-level health outcomes;
  • Assuring collaborative planning and improvement of our health care system.

Community defined Goals:

  • 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

Community Input & Planning Process

Since the idea of bringing a Pathways Program to Bernalillo County was born in 2007, the planning has followed a community-based participatory planning process with multiple organizations to determine program goals and gain their interest. Examples of this process include:

  • Pathways introductory workshop - In October 2007 Dr. Mark Redding, founder of Pathways, presented the model. Community organizations discussed how the model can work in Bernalillo County and planned for next steps.
  • Pathways Working Group - Soon after the introductory workshop, this was formed to continue the viability of the model for Bernalillo County. This group developed the Pathways mission, initial framework for the local model, and designed the collaborative planning process.
  • Collaborative planning meetings - Five half-day planning sessions took place from October 2008 through January 2009. Thirty-four (34) distinct community organizations regularly participated in the planning sessions.

At the closure of this collaborative planning process in January 2009, a project design team was formed, comprised of thePathways program manager, Pathways committee members of the former Health Sciences Center Community Advisory Council (CAC), , members of the Pathways Working Group, and a technical advisor from the UNM Health Sciences Center (HSC). Their charge was to finalize the program design and develop the Request for Proposal (RFP).

Since the initial roll out of the program in 2009, the Hub has coordinated standing monthly meetings with the Navigators where opportunities for continued community input is not only solicited, but encouraged.  The Navigators have made numerous suggestions and recommendations on how to improve the program based on their front line experiences, and as a result, the Hub continually works on improving the model to meet the needs of the residents of Bernalillo County.