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Adaptations to the Pathways Model in Bernalillo County
July 2009 thru June 2017

The first 2 years of funding were considered the “demonstration phase” of this program. Since Pathways is a unique model in Bernalillo County, the then Office of Community Affairs and its partners expected that the model, as designed by the Pathways Design Team in 2008-09, would require modifications over the first 2-year period. This proved to be a successful strategy, and several changes did occur during the first 2-year phase and modifications/improvements have continued throughout this current 8-year funding cycle. It should be noted that much or what was learned in the first 2-year demonstration phase was also factored into the second Request-for-Proposal that was administered in early 2011, and again with the third Request-for-Proposals administered in early 2014. Below are some of the ongoing adaptations in chronological order:

Year One

Community Contractor Capacity to Adapt to Pathways Model

Two of the original organizations funded under Pathways recognized after the first several months of funding in 2009 that the model did not align well with the mission of their organizations and in early 2010, their contracts were canceled. The remaining funds were redistributed to more successful organizations. This proved to be a learning opportunity and informed the design of the Request for Proposals process for Phase 2.

Risk Score Assessment Instrument

The original risk score instrument used to determine appropriate candidates for Pathways participation became problematic early on in the project, as the navigators expressed their dissatisfaction with both parts of the point system assigned to each question as well as the overall score required to participate in the project. As a result, effective January 1, 2010, the points within the instrument were slightly modified and the overall score required to participate was reduced.

Fast-Track to UNM Hospital Services

Early on in the implementation, the navigators documented several examples where they had encountered difficulties with UNM Hospital’s Financial Assistance Program in terms of getting their clients enrolled in the appropriate financial assistance program, as well as securing appointments to primary and specialty care. In response to this, UNMH agreed to use its Care One Program as the conduit into UNMH’s system, and the navigators who were attempting to access services at UNMH, were asked to work through Care One. Initially, this appeared to work quite well and Care One’s case manager, Duly Arenivar, had done a commendable job in connecting Pathways clients to appropriate UNMH Programs and providers, in spite of the fact that this increased her workload considerably. This arrangement continued through the end of Year 2, but has been phased out since then.

New Pathways

Based once again on feedback from the navigators, two new pathways were added in the first year to the original list of twenty: Education/GED and Homelessness Prevention. These were designed through participatory sessions with navigators.

Formation of the Pathways Community Advisor Group (PCAG)

A Pathways Community Advisory Group (PCAG) was formed in response to dissolution of UNM HSC Community Advisory Committee (CAC). The PCAG currently consists of approximately ten members, none of whom are employed at UNM, and two who are actually former Navigators from the first 2-year period. Other members represent Presbyterian Healthcare Services, the Albuquerque Area Indian Health Board, the New Mexico Community Health Workers Association, the New Mexico Department of Health, Public Health Division, Bernalillo County, Office of Health & Social Services, First Choice Community Health, and others.

First Annual Report-to-the-Community

The program conducted its very first Pathways ‘Report to the Community’ in January 2010.

Year Two

Collaboration to Secure Additional Funding

In collaboration with Encuentro, MyCommunityNM, East Central Ministries, and Casa de Salud, the then Office of Community Affairs submitted a Brief Proposal to the Robert Wood Johnson Foundation’s Consumer Engagement Initiative to facilitate a process to design, adopt and promote community-defined standards for a patient-centered medical home that would incorporate the unique needs of the immigrant population in health care systems across Bernalillo County. Regrettably the collaborative was not invited to submit a full proposal for funding. Note: This effort did lead to a future Health Care Home study begun in Year 3 with Soda Creek Consulting and completed in Year 4 (mentioned in more detail later in this document).

New Pathway

Disability Income/Appeal pathway added, increasing the number of pathways to 23

Restructuring Budgets

The Hub had been hearing that several navigators were using their own money to assist participants in urgent situations without any recourse for reimbursement. As a result, and Emergency Fund line was added to each budget (approx. 3% of total budget) and a protocol developed that outlined appropriate use of the Emergency Funds.

Second Request for Proposal

Per the agreement with all of the organizations participating in the first 2-year demonstration phase, a second Request for Proposal was released in January 2011 for Years 3 thru 5.

Addressing Goal 3 - “Health and social service networks in Bernalillo County will be strengthened and user friendly”

The Hub reached out to the Lovelace Clinic Foundation Research to discuss the possibility of a partnership. A contract ensued for LCF Research to begin a study titled, “Structural Assessment of a Community Service Network”.

Year Three

New Participants to the Pathways Partner Network

The RFP process concluded in spring 2011 and five (5) new organizations joined the Pathways network: Catholic Charities Refugee Resettlement Program, Centro Sávila, Encuentro, New Mexico Immigrant Law Center, Samaritan Counseling Center. Regrettably, four (4) organizations from first 2 years were not refunded: Cuidando Los Niños, Hogares, Inc., New Mexico AIDS Services, & The Storehouse. The total amount for community contracts increased from $640,000 in first 2 years to $660,000 in the second phase of funding.

Expanding the Model

A pilot program was initiated with the Native American Community Academy (NACA) with funds provided by Chancellor Roth’s office to test the Pathways model in a school setting

Addressing Goal 1 - "People in Bernalillo County will self-report better health"

The Evaluation Team completed the first Pathways post-Program Client Survey in July 2011. Although sample population was limited to approximately 55 former participants, results showed that the overwhelming majority had positive experiences with the Pathways Program. Evaluation activities transferred from the now defunct HSC Institute of Public Health to the UNM Robert Wood Johnson Center for Health Policy

Second Annual Report-to-the-Community

The program conducted its second Pathways ‘Report to the Community’ in September 2011.

Reimbursement for 3rd Pathway

The navigators had made the case that the Hub should reimburse the organizations for more than 2 pathways per client, as although this would result in less clients being seen per organization, by adding reimbursement for a third pathway, the quality of the health and social services offered to the client would result in even better outcomes. This went into effect in Year 3 with the condition that one of the three pathways has a health care-related focus (i.e. behavioral health, dental, diabetes, health care home, pregnancy, pharmacy/medications, substance use, vision & hearing) thus remaining true to our second goal. “People in Bernalillo County will have a health care home”. This increased total reimbursement per participant from $1000 per person to maximum of $1425)

Completion of LCF Foundation Study

The Lovelace Clinic Foundation Research study titled, “Structural Assessment of a Community Service Network” was completed and a final report submitted. Results showed that at the Navigator level, a great deal of cross-agency collaboration was occurring, and at the Executive Direct/CEO level, more collaboration had occurred as a result of Pathways participation, but not quite at the level experienced by the Navigators.

New Pathway

A Driver’s License/I.D. pathway was added, increasing the total number of pathways to 24.

Addressing Goal 2 - "People in Bernalillo County will have a health care home"

A contract was initiated with Soda Creek Consulting, LLC to conduct a study titled, “Health Care Home: Experiences of Vulnerable Adults in Bernalillo County and Implications Moving Forward”.

Year Four

Working with a new Evaluation Team

All evaluation activities were transferred from UNM RWJF Center for Health Policy to UNM Institute for Social Research (ISR)

Testing out an Exit Interview

In an attempt to obtain more data from participants at the end of their Pathways experience, and to update their contact information for further follow-up, an Exit Interview was designed in English and Spanish and a contract was established with a former Navigator to conduct exit interviews with participants as they are completing the program. The results of this first year are being analyzed as of this writing.

Expanding the Model a bit more

A Pilot Program was initiated with the Rio Grande Community Development Corporation (RGCDC) supported by W.K. Kellogg Foundation funding to test Pathways model with children 0 to 8 years of age

Risk Score Instrument

The Risk Score Instrument was revised a second time (Version 3) adding several new legal questions (per the suggestion from the New Mexico Immigrant Law Center and agreed upon by all of the Navigators)

Restructuring Budget

Due to the length of time that it often takes to complete two of the most important pathways: Employment and Housing, the Hub attempted to create a financial incentive for the organizations/navigators by Increasing the reimbursement for the intermediate benchmark from $125 to $250 for the Employment and Housing pathways only.

Third Annual Report-to-the-Community

The program conducted its third Pathways ‘Report to the Community’ in October 2012.

Reducing the number of pathways

The Navigators expressed some confusion over the difference between the Depression and Behavioral Health pathways, so it was decided to combine the two and just stick with one Behavioral Health pathway, decreasing the number of pathways to 23. Note: At the beginning of Year 5, several other pathways will be combined and rewritten thus further reducing the number of pathways options.

Pathway Community Advisory Group (PCAG)

The program manager expressed concern about how the current composition of Pathways organizations focused heavily on the Spanish-speaking immigrant population, and that as a result, there were other smaller populations throughout Bernalillo County that were not being reached. PCAG was consulted about changing this second phase of funding, originally planned for a 4-year period, to a 3-year period thus requiring another RFP in early 2014. PCAG agreed unanimously and the program manager then met with every currently funded organization to inform them of this change. Fortunately there was very little pushback from the partner organizations.

Completion of Soda Creek Consulting study

The health care home study, “Health Care Home: Experiences of Vulnerable Adults in Bernalillo County and Implications Moving Forward”, conducted by Soda Creek Consulting, LLC was completed and several presentations already given on the results. A final report can be found on the Pathways website (Health Care Home Technical Report 2013). Note: As a result of this study, the final step of the Health Care Home pathway was re-written to more closely reflect the findings of the report.

Pathways Database Enhancements

It is important to note that throughout the first 4 years and through ongoing meetings between the Navigators and the UHP’s database consultant, Mitchell Steinberg from Ruby Creek Designs, a number of improvements/additions were made to the Pathways database that benefited the Navigators and the Project Hub (UHP), including the Evaluation Team.

Applying for National Pathways HUB Certification

The Urban Health Partners submitted an application to the National Pathways network to participate in a pilot HUB certification process through funding by the Kresge Foundation. Our Pathways Program was one of three selected nationwide to participate in this new endeavor.

Year Five

Reducing the number of pathways

In consultation with the Pathways Community Advisory Group (PCAG), the program decided to further reduce the number of pathways by folding the Diabetes and Pregnancy pathways under the Health Care Home. This decreased the number of pathways to 21.

Risk Score Instrument

The Risk Score Instrument was revised a third time (Version 4) by adding an additional question about difficulties due to prior incarceration and/or arrests, and breaking up another question that had actually been 2 questions in one: whether the person is actually homeless vs. the person being at risk of losing her/his home or apartment.

Departure of Urban Health Partners Director

In early fall 2013 Leah Steimel accepted a position with the New Mexico Health Insurance Exchange (NMHIX) to focus her efforts on the rollout of the Affordable Care Act. With Leah went a lot of historical knowledge and information about the Pathways Program in Bernalillo County. Once things had settled down for Leah, the program manager asked her to join the Pathways Community Advisory Group (PCAG), of which she graciously accepted.

Site Visit from National HUB Certification Team

In November 2013, three people from the National HUB Certification Team spent a couple days in Albuquerque learning about our program, meeting with the staff, visiting four of the partner organization sites, and even attending a monthly navigator meeting. They were also asking for feedback about the certification process itself (since this was new to them too) and had also provided areas where our program would need to improve in order to satisfy the certification criteria.

Fourth Annual Report-to-the-Community

In January 2014, the fourth Pathways Report-to-the-Community was conducted where the program highlighted its first 4-Year Report (halfway point). Of all the prior Reports-to-the-Community, this one in particular was very well attended with more than eighty (80) participants in the audience.

Third (and final) Request for Proposals

In January 2014, a new Request for Proposals (RFP) was released for the final 3-year period (July 2014 – June 2017). In this particular RFP, language was inserted that would emphasize applicants that could reach each of the priority populations and priority neighborhoods per a report released by the Bernalillo County CDC-funded CINCH Project. By writing the RFP where at a minimum, one organization focusing on each of the priority population/neighborhood would be funded, this ensured that some of the County residents that had not been reached out to in Years 3 thru 5, would become more of a focus in the final 3 years of funding.

Connections Pilot Program

In partnership with Albuquerque Ambulance Services, Ivette Bibb from our office launched a new pilot project with social work students from NMHU and NMSU. Albuquerque Ambulance would refer frequent 911 callers to Ivette and she would then assign students under her supervision to follow up with these individuals initially following the Pathways Navigator model. It was soon learned that the populations being served were very different from the Pathways population, so many changes were made, but the Connections Project was officially born.

Hiring of New Director and Name Change for Urban Health Partners

In February 2014 Claudia Medina (former ED for Enlace Comunitario) was hired as the new director for our office and the focus of the office shifted from an urban health/social determinants focus to a community health worker workforce development focus. The name of the office was changed to Community Health Worker Initiatives.

New Participants to the Pathways Partner Network

The RFP process concluded in spring 2014 and four (4) new organizations joined the Pathways network: Albuquerque Health Care for the Homeless, Crossroads for Women, Native American Community Academy, and the New Mexico Asian Family Center. Centro Sávila, Encuentro, Samaritan Counseling Center. Regrettably, three (3) organizations from Years 3 through 5 were not refunded: Catholic Charities Refugee Resettlement Program, First Nations Community Healthsource, and New Mexico Immigrant Law Center. Encuentro became part of the South Valley Collaborative (EleValle) and PB&J Family Services pulled out of EleValle and formed its own collaborative with Crossroads for Women. It is important to note that four of the applicants were collaborative applications between at least 2 organizations. Funding increased to approximately $700,000+ in July 2014.

Evaluation Team

The Institute for Social Research (ISR) spent much of FY13 and part of FY14 working on an IRB application for a cost study that they had planned on conducting. It was finally approved in fall 2013 and the ISR began to collect Pathways patient data from UMMH to assess the costs of Pathways patients to the hospital pre-Pathways vs. after connecting with a navigator.

Year Six

Reorganization of Urban Health Partners

In September 2014, the now defunct UHP offices were moved out of the Bradbury building closer to the HSC North Campus. In addition, the CARE NM Program now shares the same office space, and the CARE NM CHWs are now participating more in the monthly Navigator meetings. Also through the office, numerous new CHWs have been hired and based in clinic settings thus further expanding the Navigator/CHW network. The monthly meetings now average >30 participants representing Pathways, CARE NM, the clinic-based CHWs, and at times, a few of the Connections students.

First Attempt at Addressing Goal 4 - "Advocacy and collaboration will lead to improved health systems"

In fall 2014, Building Movement helped facilitate a prioritization process with navigators and directors/supervisors to determine which systems issues that have been documented over the first five years of the program would the Pathways partners’ priorities for addressing. The Income Support Division (ISD) and Motor Vehicle Division (MVD) were the two that the majority felt were most problematic.

In winter 2014/2015, two of the monthly navigator meetings were dedicated to face-to-face dialogue with leadership from both the Income Support Division and the Motor Vehicle Division. Many of the issues brought up with ISD were supposedly addressed with their new online enrollment system and some agency-wide policy changes. Over the next year, the navigators documented less systems problems with ISD, but NM Center for Law & Poverty is invited to January 2016 navigator meeting to explore this further. Problems with the MVD however, have persisted and will most likely require another face-to-face with MVD leadership early in 2016.

National Pathways HUB Certification

Program met virtually all of the Prerequisites and Standards for National HUB Certification and was granted certification on a “provisional” basis pending final determination of Standards.

Recognition of Pathways Model in BernCo Task Force Recommendations

The Bernalillo County Commission established a Healthcare Task Force to solicit input from the community on both the BernCo/UNMH Lease Agreement, as well as on the “conditions/language” the County should consider in their negotiations with UNMH for the next mill levy cycle. Without specifying the Pathways Program, one of the primary recommendations was as follows: “1.1. UNMH must provide a safety net program for uninsured and low-income residents that includes comprehensive medical services, behavioral health services, and navigation support.”

Completion of ISR Cost Study

The UNM Institute for Social Research (ISR) completed phase 2 of its cost study that focused exclusively on the costs of Pathways patients getting their health care at UNMH. The first phase of the study looked only at the direct costs of Pathways patients.  The second phase of the study compared their costs to a larger control group with similar characteristics.  The study did not produce the cost savings that the program had hoped for, but was very limited in scope since it focused exclusively on health care costs at UNMH and excluded all of the community-based primary care sites and all of the SDOH-related pathways.

Planning Partners & Supporting Organizations

  • A New Awakening
  • Adelante Development Center
  • Albuquerque Healthcare for the Homeless
  • Alta Mira
  • ARCA
  • Bernalillo County Local Collaborative
  • Casa de Salud
  • Casa Esperanza
  • Community Coalition for Healthcare Access
  • Cuidando Los Niños
  • East Central Ministries
  • El Centro de Igualdad y Derechos
  • Enlace Comunitario
  • First Nations Community Health Source
  • Good Shepard Center
  • Hogares
  • Interfaith Hospitality Network
  • Kapulli Izkalli
  • La Colmena, Inc.
  • La Plazita Institute
  • NARAL Pro-Choice NM
  • New Mexico AIDS Services
  • Parents for Behaviorally Different Children
  • Parents Reaching Out
  • Peanut Butter & Jelly Family Services
  • S.A.F.E. House
  • Samaritan Counseling Center
  • The Storehouse
  • Southwest Creations Collaborative
  • UNM School Based Health Center Program
  • Vietnamese Senior Citizen Association
  • Working Classroom
  • YMCA
  • Young Children's Health Center

Other supporting organizations:

  • Albuquerque Partnership
  • Bernalillo County Community Health Council
  • Catholic Charities, Refugee Resettlement Program
  • First Choice Community Health
  • Native American Community Academy
  • NM Community Health Worker Association
  • NM Department of Health, Public Health Division, Health Promotion Team
  • Rio Grande Community Development Corporation
  • Southeast Heights Health Coalition
  • St. Joe's Community Health
  • UNM College of Nursing Faculty and Students
  • UNM Hospital Administration Representatives
  • UNM Institute of Public Health
  • UNM Master of Public Health Program
  • UNM Medical Residents

Funding Pathways

The Bernalillo County Pathways to a Healthy Community is funded through an agreement between Bernalillo County Government and the University of New Mexico that directs slightly less than 1% of the County Mil Levy tax, or approximately $800,000 each year for eight years, to be used to improve access for the underserved of Bernalillo County in collaboration with community resources.This funding source came about through a collaborative effort among the community, UNM Hospital, and the County to better serve vulnerable and underserved populations.

Currently Funded Agencies 

Funded Agencies