Pathways Program Model

The Pathways to a Healthy Bernalillo County program was highlighted in the Federal Agency for Healthcare Research and Quality's (AHRQ) Innovations Exchange website as an innovative program that reduces health disparities.


"The Pathways to a Healthy Bernalillo County Program uses a version of the Pathways Model to identify vulnerable, underserved residents and connect them to health and social services. Clients are identified through interagency referral among the program's network of 13 community-based organizations. Community health navigators help clients access additional health and social services, assist with coordination of care, and monitor client progress. Participating agencies receive payments based on their ability to identify at-risk clients, connect them with needed services, and achieve positive outcomes, while a central hub and database help coordinate client services. The program has enhanced access to needed services for many of the more than 3350+ unduplicated clients served in its first 6+ years of operation, with more than 1760 completing all their pathways and exiting the program; by program design, each completed pathway indicates a successful outcome."

Pathways Model

Pathways assists difficult-to-reach populations in Bernalillo County which include low income, uninsured adults who may be experiencing one or several of the following:

  • Multiple or complex unmet needs and reports feeling unhealthy
  • Have had a minimum of one Emergency Room visit within the last year
  • Currently experiencing homelessness and disconnected from services
  • Urban off-reservation Native American not connected to or trusting of existing resources in Bernalillo County
  • Undocumented and/or limited-English proficient (LEP) immigrant who does not understand how to access existing resources and/or experiences barriers while trying to navigate the system
  • Hungry and averaging less than two full meals per day
  • Any of the above who are parenting young children


Pathways is designed to target key risk factors, including:

  • Poverty
  • History of incarceration
  • Culture: fear and dislike of system; ineffective use of community resources.
  • Self-reported poor health
  • Lack of an established medical home, dental care, or health insurance
  • Using the Emergency Room for non-emergency situations
  • Transportation barriers
  • Housing instability
  • Lack of identification cards
  • Behavioral health needs
  • Limited English proficiency
  • Unemployment

Pathways are specific to prioritized needs that a client has identified. For example, one client may identify finding housing as their pathway, another to establish a medical home, and another to obtain a GED. With the help and guidance of a Navigator, clients choose their pathways and work toward completing each one. A pathway begins with the identified problem and several action steps, leading to meaningful outcomes for the client. Critical benchmarks along every pathway include:

  • Risk assessment
  • Intermediate action steps that mark some success toward completing the pathway
  • A completed pathway.

Outcomes are reached when clients successfully complete their selected pathways.

The key to the success of this model is an extensive care coordination network. Quality performance and preventing duplication are priorities. We do this through:

  1. Community Health Navigators (Navigators):
    • May also be referred to as a Promotor/a, Community Health Worker, Case Manager, Outreach Worker or Community Liaison.
    • Work at a community agency that receives Pathways funding.
    • Finds individuals most at-risk and works with them to assess their needs.
    • Guides individuals (the client) through a series of steps (Pathways) to mark their progress toward improved health and well-being (health outcomes).
    • Reports system barriers that are encountered while guiding clients.
    • Documents all activities in the Pathways database.
  2. Hub:
    • Central support system (through UNM Health Sciences Center Community Health Initiatives under the Office for Community Health) for the contracted community-based organizations and their Navigators.
    • Provides ongoing communication, support, and training to the Navigators.
    • Maintains and monitors program database for program implementation and evaluation purposes.
    • Confirms that Pathways are completed and that there is no duplication of clients across pathways partners.
    • Prepares reports for the UNM Hospital, the Bernalillo County Commission, and the general public.
    • Conducts annual Report-to-the-Community
  3. Pathways Community Advisory Group (PCAG):
    • Serves as an external advisory committee to the Hub
    • Raises community awareness about the Pathways model
    • Works with Hub on strategies to effectively reduce systems barriers.

The Community Health Access Project (CHAP) in Richland County, Ohio serves as the original Pathways model from which all others evolved. Drs. Mark and Sarah Redding, both physicians, initiated this model in Ohio in 1999, which was based on their prior experiences working with Community Health Workers in remote areas of rural Alaska as physicians with the Indian Health Service (IHS). Their personal experiences in Alaska with the IHS led to the creation of the Pathways care coordination model, which has since been replicated in more than sixteen different geographic areas across the U.S.

The Muskegon Community Health Project developed a pathway that uses medical navigators to help newly released or paroled prisoners obtain their medical records, find a medical home, and access needed primary care and specialty services. The health navigation program began in Muskegon County and serves two neighboring counties in Michigan.