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Daryl T. Smith, Program Manager Pathways Project University of New Mexico Health Sciences Center Office of Community Affairs September 27, 2010
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Daryl T. Smith, Program ManagerPathways Project
University of New Mexico Health Sciences CenterOffice of Community Affairs
September 27, 2010
History of Pathways Past to Present
History of Pathways Past to Present
2006 Need for health navigators to assist uninsured residents is identified by community stakeholders
2007 Pathways model is introduced and a working group formed to study and adapt to county needs
2008 Collaborative planning is organized to define desired outcomes for a local Pathways model
2008 Public funding negotiated and MOU signed2008 CCCLN relationship develops2009 Hub is established and contracts with community
organizations initiated to launch Pathways Project
2006 Need for health navigators to assist uninsured residents is identified by community stakeholders
2007 Pathways model is introduced and a working group formed to study and adapt to county needs
2008 Collaborative planning is organized to define desired outcomes for a local Pathways model
2008 Public funding negotiated and MOU signed2008 CCCLN relationship develops2009 Hub is established and contracts with community
organizations initiated to launch Pathways Project
Our ModelOur Model Funding from County Government and
UNM Hospital per MOU from 2009-2017 ≥ $800,000/year
80% of funding goes to community-based organizations
Thirteen [13] community organizations contracted to implement Pathways
Hub at UNM Health Sciences Center Office of Community Affairs
Active Community Advisory Group
Funding from County Government and UNM Hospital per MOU from 2009-2017
≥ $800,000/year 80% of funding goes to community-based
organizations Thirteen [13] community organizations
contracted to implement Pathways Hub at UNM Health Sciences Center
Office of Community Affairs Active Community Advisory Group
Community-defined OutcomesCommunity-defined Outcomes1. People in Bernalillo County will self report
better health
2. People in Bernalillo County will have a health care home
3. Health and social service networks in Bernalillo County will be strengthened and user friendly
4. Advocacy and collaboration will lead to improved health systems
1. People in Bernalillo County will self report better health
2. People in Bernalillo County will have a health care home
3. Health and social service networks in Bernalillo County will be strengthened and user friendly
4. Advocacy and collaboration will lead to improved health systems
Cross-section of Community Organizations Involved in
Pathways
Cross-section of Community Organizations Involved in
Pathways
• A New Awakening – Counseling agency serving people coming out of incarceration
• First Nations Community Healthsource – FQHC serving a large off-Reservation Native American population
• Enlace Comunitario – domestic violence organization serving primarily immigrant women
• A New Awakening – Counseling agency serving people coming out of incarceration
• First Nations Community Healthsource – FQHC serving a large off-Reservation Native American population
• Enlace Comunitario – domestic violence organization serving primarily immigrant women
Pathways ClientPathways Client Bernalillo County
Resident
Difficult to Reach low income uninsured unemployed uses ER frequently housing instability not receiving
services hungry
Bernalillo County Resident
Difficult to Reach low income uninsured unemployed uses ER frequently housing instability not receiving
services hungry
Role of Community Health Navigators
Role of Community Health Navigators
find most at-risk community members
build trust assess and identify problem[s] guide clients thru Pathways steps complete Pathway/achieve meaningful
outcome document information in database
find most at-risk community members
build trust assess and identify problem[s] guide clients thru Pathways steps complete Pathway/achieve meaningful
outcome document information in database
22 Pathways Defined22 Pathways Defined Behavioral Health Child Care Child Support Dental Depression Diabetes Domestic Violence Education/GED Employment Food Security Heat & Utilities
Behavioral Health Child Care Child Support Dental Depression Diabetes Domestic Violence Education/GED Employment Food Security Heat & Utilities
Health Care Home Homelessness Prev. Housing Income Support Legal Services Medical Debt Pharmacy/Medications Pregnancy Substance Use/Abuse Transportation Vision & Hearing
Health Care Home Homelessness Prev. Housing Income Support Legal Services Medical Debt Pharmacy/Medications Pregnancy Substance Use/Abuse Transportation Vision & Hearing
Sample of Completed Pathways
Health-related
Sample of Completed Pathways
Health-related
Health Care Home - Client has appropriate health coverage or financial assistance program in place to establish health care home and has seen a provider a minimum of 2 times at their new health care home.
Dental Care - Same as above, replacing the term “health care home” with “dental care home”.
Health Care Home - Client has appropriate health coverage or financial assistance program in place to establish health care home and has seen a provider a minimum of 2 times at their new health care home.
Dental Care - Same as above, replacing the term “health care home” with “dental care home”.
Sample of Completed PathwaysSocietal-related
Sample of Completed PathwaysSocietal-related
Employment: Client has found a steady job and is gainfully employed for a minimum of 3 months.
Food Security: Client has achieved food security and has had over the last 3 months, access to a minimum of 2 hot meals per day.
Homelessness Prevention: CHN assures that the client has obtained and maintains stable housing for no less than 3 months.
Employment: Client has found a steady job and is gainfully employed for a minimum of 3 months.
Food Security: Client has achieved food security and has had over the last 3 months, access to a minimum of 2 hot meals per day.
Homelessness Prevention: CHN assures that the client has obtained and maintains stable housing for no less than 3 months.
CCCLN Scorecard Advantages
CCCLN Scorecard Advantages
Medical Home is a primary outcome for our project
Model Expansion National research efforts to formalize care coordination model should benefit us locally
Local Evaluation Challenges: Broad & complex application of original
Pathways model in Bern. Co. Commitment to send majority of funding
out to community based activities
Medical Home is a primary outcome for our project
Model Expansion National research efforts to formalize care coordination model should benefit us locally
Local Evaluation Challenges: Broad & complex application of original
Pathways model in Bern. Co. Commitment to send majority of funding
out to community based activities
ChallengesChallenges Bernalillo County’s Project adds
approximately 40-50 new clients each month
Several questions in the score card are not asked at the local level (e.g. insurance status of client)
Access to a medical home is often not a priority for the client, and may be delayed in lieu of other pathways
Insufficient resources for evaluation
Bernalillo County’s Project adds approximately 40-50 new clients each month
Several questions in the score card are not asked at the local level (e.g. insurance status of client)
Access to a medical home is often not a priority for the client, and may be delayed in lieu of other pathways
Insufficient resources for evaluation
Benefits to the CommunityBenefits to the Community Participation in the National Learning
Network has proven to be very beneficial to the development and implementation of our local model
Other counties in New Mexico have expressed an interest in developing a similar model in their communities
Bernalillo County model was selected as an example for AHRQ’s Innovations Exchange website
Participation in the National Learning Network has proven to be very beneficial to the development and implementation of our local model
Other counties in New Mexico have expressed an interest in developing a similar model in their communities
Bernalillo County model was selected as an example for AHRQ’s Innovations Exchange website
Lessons LearnedLessons Learned More buy-in from the navigators when
they know that their concerns and/or suggestions are acted upon
Participation in National Learning Network has helped minimize the number of changes required to our local model
Utilization of standardized scorecard brings uniformity to the Network while allowing for flexibility at the local level
More buy-in from the navigators when they know that their concerns and/or suggestions are acted upon
Participation in National Learning Network has helped minimize the number of changes required to our local model
Utilization of standardized scorecard brings uniformity to the Network while allowing for flexibility at the local level
Contact InformationContact InformationDaryl Smith – Program Manager(505) 272-0823 or [email protected]
Leah Steimel – Director of OCA(505) 272-8813 or [email protected]
David Broudy – Pathways Evaluator(505) 841-4145 or [email protected]
Bill Wiese – Pathways Evaluator(505) 272-4738 or [email protected]
Daryl Smith – Program Manager(505) 272-0823 or [email protected]
Leah Steimel – Director of OCA(505) 272-8813 or [email protected]
David Broudy – Pathways Evaluator(505) 841-4145 or [email protected]
Bill Wiese – Pathways Evaluator(505) 272-4738 or [email protected]
