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 assists difficult-to-reach populations in Bernalillo County which include low income, uninsured adults who may be experiencing one or several of the following:
Pathways is designed to target key risk factors, including:
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:
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:
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.
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:
Pathways is designed to target key risk factors, including:
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:
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:
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.
