PathwaystoaHealthyBernalilloCounty

AnnualReport

July2015–June2016

CHWInitiatives

OfficeforCommunityHealthUNMHealthSciencesCenter

August2016

TableofContents

Page

ExecutiveSummary 1

Introduction 4

• Table1:CharacteristicsofBernalilloCounty 4 • Table2:CharacteristicsofKeyPathwaysZipCodes5

Background 6PopulationServed 6Results 8

• Table3:PathwaysCompletionRates-Year6vs.Year7 8• Table4:Top10PathwaysCompleted–Years1,2,&3vs.Years5,6,&7 9• Outcome#1:PeopleinBernalilloCountywillself-reportbetterhealth 9• Outcome#2:PeopleinBernalilloCountywillhaveahealthcarehome 11• Outcome#3:HealthandsocialservicenetworksinBernalilloCounty12

willbestrengthenedanduserfriendly• Outcome#4:Advocacyandcollaborationwillleadtoimprovedhealthsystems14

PathwaysHubCertificationPilotProgram 14 SampleofNavigatorSuccessStories 15SampleofSystemsBarriers 17DescriptionofProgramExpansion&Innovation 18

• ExpansionofCurrentEfforts • SupportfortheEducation=HealthInitiative• Provide“In-reach”toMDCInmatesandNavigation

SupportforTheirReturntotheCommunity• ImproveQualityAssurance

ProgramOutcomes 21AdditionalCommentsfromthePathwaysProgram 22Conclusion 23

AppendixA–BreakdownofPathwaysAccomplishmentsbyOrganization 24AppendixB-NumberofPathwaysCompleted 25AppendixC-PathwaysEnrollmentTrends 27AppendixD-PathwaysFinancialReport 29

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ExecutiveSummary

ThisistheseventhannualreportforthePathwaystoaHealthyBernalilloCountyProgram.ItprovidesasummaryofthesecondyearofPhase3(Years6through8)ofprogramimplementation.ThePathwaysProgramisadministeredthroughtheUniversityofNewMexicoHealthSciencesCenter,OfficeforCommunityHealth(OCH),CommunityHealthWorkerInitiatives(CHWI)underanagreementsignedbetweentheUniversityofNewMexicoHospital(UNMH)andtheHealthSciencesCenter(HSC).Underthisagreement,UNMHtransfersnolessthan$800,000peryearforthedurationofthemilllevy(2009-2017)totheOCH.TheOCHcontractsover80percent(>$660,000)ofthisamounttosupporttheworkofcommunityhealthnavigators(CHNs)atthirteencommunity-basedorganizationsinBernalilloCounty.Forfiscalyear2016,theprogramhadcontractswithcommunitypartnerorganizationstotaling$710,000.Contractsareawardedthroughacompetitiveprocess.Overthepastyear(year7oftheprogram),1,004separatepathwayswerecompleted.HealthCareHome(116),IncomeSupport(88),FoodSecurity(84),Employment(80),Education/GED(78),LegalServices(75),Vision&Hearing(65),andHousing(64)toppedthelistofpathwayscompleted.Tocompleteapathway,anindividualmustachievethepathway’sfinalstep,ahealthyoutcome.Thisisagreataccomplishmentanddemonstratestheimportanceofincludingmanyofthesocialissuesthatimpacthealthwithinthelistofpathwaysfromwhichclientsmaychoose.Onlyoneofthetopeightpathwayscompletedoverthepastyearisspecificallyhealth-related(HealthCareHome),althoughallhaveanimpactonaperson’shealthand/orwellbeing. Additionally,duringthisperiod,521personsenrolledintheprogram,morethan308completedtheirinvolvementintheprogram,and271remainactive.Another210werelosttofollowupeitherbecausetheywithdrewfromtheprogram(66)orwereinactivated(144)duetodifficultymaintainingcontact.Itshouldbenotedthatsinceclientscarryoverfromonefiscalyeartothenext,thenumbersabovealsoreflectclientsthatwereactivepriortoJuly2015.Aswehavelearnedovertheyears,thevastmajorityofPathways’participantsleadtransientlivesandhaveamultitudeofcomplexneeds.Whilethenavigatorsdotheirbesttoassesstheirclients’levelsofprogramreadiness,therealitiesoflifeatthemarginsofteninterferes.Despitethesechallenges,theretentionratesarestillveryadmirable,anddemonstratethepersistenceofthenavigatorsintheireffortstoensurethatclientsdonotfallthroughthecracksastheyattempttoaccesshealthandsocialservices.Theprogramcontinuallyemphasizestheimportanceofregularlyupdatingclientcontactinformation,butevenso,someareinevitablylosttofollowup.Overthepastyear,thePathwaysProgramconducted44exitInterviewswithparticipantswhohadcompletedtheprogram.Tosummarize:98percentofexitintervieweeswereeither‘completelysatisfied’(25%),‘mostlysatisfied’(34%),or‘satisfied’(39%)withtheprogram;91percentagreethatwhattheyachievedbycompletingtheirpathwayswillcontinuetohelpthem;and75percentsaidthattheirhealthhadeither‘improved’(48%)or‘greatlyimproved‘(27%)comparedtowhentheybeganparticipatinginPathways.Formorespecificinformationontheexitinterviews,pleaserefertopages8and9ofthisreport.

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AmajorprojectundertakenbythePathwaysProgramthisyearwasgatheringfeedbackfromtheagencieswhohavebeenfundedbyPathwaysoverthelastsixyears.PatriciaRodriguez-Espinoza,aMPHgraduatestudent(anddoctoralstudent)implementedthisprojectaspartofheryear-longCommunityHealthPracticumwiththeprogram.AsurveytoolwasdevelopedwithagreatdealofinputfromthePathwaysCommunityAdvisoryGroup(PCAG)andadministeredto40differentpeoplerepresentingeithercurrentlyfundedPathwayspartnerorganizationsorformerly-fundedpartners.Theseincludednavigators,theirsupervisors,andmanyexecutivedirectors.PatriciapresentedasummaryofherfindingsatarecentPathwaysReporttotheCommunityheldinMay,whichhighlightedtheexcellentfeedbackthattheprogramreceivedfromitspartners.Inaddition,afullwrittenreportwasdevelopedthatprovidesmoredetailandhasbeensharedwiththepartnersthatparticipatedintheinterviews.Thisreportwillalsobesharedwiththecommunityatlarge.Patriciadidanexcellentjobthatfarexceededprogramexpectations.WewereveryfortunatethatsheselectedPathwaysforherCommunityHealthPracticum!InNovember2015,thePathwaysProgrambegancontractingpart-timewithDr.KellyO’Donnellwho,inadditiontodoingathoroughassessmentofthePathwaysdatabase,iscurrentlyworkingonacostanalysisforfivespecificpathways:healthcarehome,housing,education/GED,behavioralhealth,andemployment.Dr.O’Donnellwillbeestimatingreturnoninvestment(ROI)foreachofthesepathways.TheprogramintendstocontinueworkingwithDr.O’DonnellinFY17aswell.Duringthepastyear,theCommunityHealthWorkerInitiatives(CHWI)andtheHSCOfficeforCommunityHealthpartneredwithPresbyterianHealthcareServices(PHS)inthedevelopmentofanAccountableHealthCommunities(AHC)grantapplicationfundedbytheCentersforMedicare&MedicaidServices(CMS).OtherpartnersinthisapplicationincludedtwoUNMHcommunity-basedclinicsandtheUNMHEmergencyDepartment,FirstChoiceCommunityHealthcare,FirstNationsCommunityHealth,AlbuquerqueHealthCarefortheHomeless,HealthInsight,RoadrunnerFoodBank,CommunityDentalServices,theBernalilloCountyCommunityHealthCouncil,andtwoofPresbyterianMedicalServices’Albuquerquesites,amongothers.NotificationofawardsshouldbereleasedinSeptember/October2016,andwefeelthatwemadeaverystrongcaseforAlbuquerquetobeselected.Shouldthisapplicationbefunded,anadditionaltenCHWpositionsshouldbefilledattheclinicalsitesmentionedabove.ThesenewCHWswilljointheonesalreadyintegratedintotheUNMHclinicsandFirstChoiceinanefforttoscreen75,000MedicaidbeneficiariesinBernalilloCountyusingatooldesignedbyCMStoidentifyandaddressthesocialdeterminantsofhealth.Inaddition,thegrantcallsforalltheparticipatingpartnerstoworktogethertodevelopaplanandalignresourcestodealwiththesystemicissuesthataremoreprevalentamongtheindividualsscreenedbytheCHWs.TheroleoftheCHWIwillbetoimplementtheprojectateachclinicsiteincludinghiring,training,andsupervisingalltheCHWsandcollectingandanalyzingdatacollectedateachsite.

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Lastyear,inadditiontocontinuingtoworkwithUNMHtointegrateCHWsatallitsprimarycareclinics,theCHWIstartedaformalpilotproject:IntegratingPrimaryCareandCommunitySupport(IPaCS),whichplacedanadditionalCHWatthreeUNMHclinics(SEH,SWMesaandNorthValley)andataFirstChoiceclinic(SouthValley).TheseadditionalCHWshavebeenscreeningMedicaidbeneficiaries(membersofBCBSandMolinaonly)forsocialdeterminantsandconnectingthosewhoscreenpositivewithservicesnecessarytoaddresstheirsocio-economicneeds.DatacollectedduringthepilotisbeinganalyzedbytheOfficeforCommunityHealthtoassessif,forthoseMedicaidbeneficiariesparticipatinginthepilot,healthcarecostswerereduced,healthoutcomeswereimproved,and/orthepatientexperiencewasenhanced.Oncecompleted,theresultsofthisevaluationwillbesharednotonlywiththepartnerMCOsbutalsowiththeNewMexicoHumanServicesDepartment(HSD),whichwilldetermineifthepilotshouldbeexpandedstatewide.AspartofthisprocesstheOCHcreatedamanualtoguideprimarycareclinicsonhowtoimplementasimilarprogram.TheseCHWshavebeenreceivingongoingtrainingfromourofficeandmanyarenowfullyintegratedandregularlyparticipateinthestandingmonthlynavigatormeetings.Insummary,thepastfiscalyearbroughtmanychanges,notonlytothePathwaysProgram,butalsototheentireCHWIoffice.Despitenumerouschanges,overitsfirstsevenyearsofoperation,thePathwaysProgramhascontinuouslyadaptedtobestmeettheneedsofBernalilloCountyresidents.Asaresult,theprogramhasbecomemoreestablishedandrecognizedinthegreaterAlbuquerquecommunityaswellasacrossthestate.

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Introduction

BernalilloCounty,NewMexico’smostpopulouscounty,hasgrownrapidlyinthepasttwo-plusdecades,requiringexpansionandadjustmentsofhealthsystemsandothersocialservicesinfrastructures.Regrettably,thesesystemshavebeenunabletokeeppacewiththeincreaseddemandforservices,andthusagrowingnumberofthecounty’sresidentshavebecomemarginalizedanddisengagedfromsupportscriticaltotheirhealthandwelfare.AccordingtotheUnitedStatesCensusBureau,thepopulationofBernalilloCountyincreasedfrom480,577in1990to556,002in2000,toanestimated676,685in2015,anapproximate41percentincreasesince1990.AdditionaldemographiccharacteristicsarepresentedinTable1below.Table1:CharacteristicsofBernalilloCounty BernalilloCounty NewMexicoPopulation,2015estimate

676,685 2,085,109

Personsunder5years,percent,2015Personsunder18yearsold,percent,2015-

6.2%22.7%

6.5%23.8%

Persons65yearsoldandover,percent,2015 14.7% 15.8%Percentofadultswithouthealthinsurance 25% 29%AmericanIndian/AlaskanNativepersons,percent,2015 6.0% 10.5%Black/AfricanAmericanpersons,percent,2015 3.4% 2.6%Asianpersons,percent,2015 2.8% 1.7%PersonsofHispanicorLatinoorigin,percent,2013 48.8% 48.0%WhitepersonsnotHispanic,percent,2015 39.8% 38.4%Foreignbornpersons,percent,2010-2014LanguageotherthanEnglishspokenathome,age5+,2010-14

10.9%31.2%

9.9%36.1%

Medianhouseholdincome,2010-2014 $48,390 $44,968Personsinpoverty,percentPercentofchildrenlivinginpovertyPercentoffamilieswithseverehousingproblems

18.7%25%

18%

21.3%28%18%

Percentofpopulation0to65yearswithouthealthinsurance 15.4% 16.8% References:http://quickfacts.census.gov/qfd/states/35/35001.htmlhttp://www.countyhealthrankings.org/app/new-

mexico/2016/rankings/bernalillo/county/outcomes/overall/snapshotAlthoughstatistically,manyBernalilloCountyresidentsappearbetteroffthantheaverageNewMexican,therearelargegeographicsub-regionswithinthecounty,primarilyinthesouthernhalf(i.e.InternationalDistrict,FarSoutheastHeights,SouthBroadway/SanJosé,SouthValley,andSouthwestMesa),wherehealthindicatorsareamongtheworstinthewholestate.Itisintheseneighborhoodsprimarily,wherethePathwaystoaHealthyBernalilloCountyProgramfocusesitsefforts.Asexpected,theseneighborhoodsarehometothemajorityoftheBernalilloCountyresidentsparticipatinginthePathwaysProgram.Table2onthenextpagepresentsdataforthezipcodeswithinwhichmostPathwaysparticipantsreside.

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Table2:CharacteristicsofKeyPathwaysZipCodes

Bernalillo 87105 87108 87121 87123

County S.Valley SEHeights W.Mesa FarSEHeights

Totalpopulation 676,685 57,878 38,150 77,052 43,626%under5years 6.20% 6.5% 7.1% 8.6% 7.4%%under18years 22.70% 25.5% 21.6% 32.5% 24.5%%65yearsandover 14.7% 13.4% 11.1% 6.1% 13.5%%Hispanic 48.8% 79.9% 50.1% 81.3% 41.7%%White,Non-Hispanic 39.8% 13.9% 34.2% 11.6% 43.3%%BlackorAfricanAmerican 3.4% 1.6% 2.8% 2.8% 4.1%%AmericanIndian 6.0% 3.6% 8.0% 2.6% 5.9%%Asian 2.8% 0.3% 2.2% 0.5% 3.4%Totalhouseholds 263,719 19,025 16,994 22,270 17,438Averagehouseholdsize 2.51 3.02 2.2 3.35 2.5Familyhouseholdswithchildren 73,924 5,913 3,717 10,390 5,036%singlemotherfamilies 30.0% 31.3% 43.0% 36.9% 37.3%%singlefatherfamilies 11.0% 11.1% 14.2% 10.6% 13.3%%birthsthataretosinglemothers 40.6 47.7 59.3 52.9 47.4%residentages16+inlaborforce 64.1% 58.4% 61.5% 65.9% 62.5%%laborforcethatisunemployed 8.7% 12.2% 11.6% 12.2% 8.2%%childrenages0-5,allparentsinlaborforce 62.8% 57.5% 63.4% 68.6% 65.8%Medianhouseholdincome $48,390 $36,676 $26,963 $41,856 $41,748Medianearningsforworkers $29,684 $23,257 $21,517 $24,903 $26,745%residentslivinginpoverty 18.7% 26.2% 35.7% 23.9% 21.3%%residents<18inpoverty 25.0% 39.0% 47.3% 32.6% 32.9%%residentsages18-64withouthealthinsurance 25.00% 32.00% 34.9 32.20% 23.80%%noninstitutionalizedresidentswithadisability 13% 15% 15% 11% 14%%residentsages5+speaklanguageotherthanEnglishathome 31.2% 55.1% 42.6% 51.8% 27.9%SpeakEnglishlessthan"verywell" 8.5% 16.5% 15.5% 17.4% 9.4%%populationages1+incurrentresidence1+year 84.0% 88.8% 76.2% 86.8% 82.1%%totalpopulationforeignborn 10.9% 16.6% 18.6% 19.0% 10.4%%foreign-bornnotaU.S.citizen 64.5% 72.2% 77.4% 75.6% 65.3%%foreign-bornfromAfrica 1.7% 0.0% 1.9% 0.1% 1.1%%foreign-bornfromAsia 18.4% 1.4% 11.6% 2.6% 21.1%%foreign-bornfromEurope 7.8% 0.8% 3.3% 2.3% 10.4%%foreignbornfromLatinAmerica 70.4% 97.5% 82.1% 94.9% 67.3%%residentsages25+,highschoolgraduateorhigher 88% 73% 80% 74% 87%Source:2010-2014AmericanCommunitySurvey5-YearEstimates

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Background

ThePathwaystoaHealthyBernalilloCountyProgramresultedfromanearly2-yearplanningeffortin2007-2008thatinvolvednumerouscommunitypartners,includingadvocates,theBernalilloCountyCommission,theUNMHealthSciencesCenterandHospitalstaff,localhealthandsocialserviceorganizations,faith-basedorganizations,andothers.TheprogramderivedfromacarecoordinationmodeldevelopedbyDrs.Mark&SarahRedding,twophysiciansinOhio,andisnowmodeledbynumerousotherpartnersacrosstheU.S.ItsprimarypurposeinBernalilloCountyistofindthemostdifficult-to-reachuninsuredpopulationsthroughoutthecountyandconnecttheseindividualstoavarietyofhealthandsocialservicesthusimprovingtheirhealthandwellbeingand,ultimately,thehealthofthecountyasawhole.Thisisaccomplishedthroughtheskillsandresourcefulnessofcommunityhealthworkers(navigators)whofirstbuildtrustwiththesehard-to-reachpopulationsandthenguidethemthroughthecomplexhealthandsocialservicessystems,resultinginpositivehealthoutcomes.Inaddition,theprogramaimstoidentify,document,andaddressmanyofthesystemsbarriersthatsurfacethroughthisPathwaysprocess.PathwaystoaHealthyBernalilloCountyhasbeenhighlightedintheFederalAgencyforHealthcareResearchandQuality’s(AHRQ)InnovationsExchangewebsite(https://innovations.ahrq.gov/profiles/community-health-navigators-use-pathways-model-enhance-access-health-and-social-services),andiscurrentlyoneofonlyafewsitesfromaroundthecountrythathasreceivedfullPathwaysNationalHubCertification.PopulationServed

ExamplesofthepopulationsthatthePathwayspartnerorganizationsfocustheireffortsonincludelowincome,uninsuredadultswhomaybeexperiencingoneormoreofthefollowing:

ú Havemultipleorcomplexunmetneedsandreportsfeelingunhealthyú Havehadaminimumof3hospitaland/orEmergencyRoomvisitswithinthelastyearú Currentlyhomelessandnotcurrentlyreceivingservicesú Urbanoff-reservationNativeAmericannotconnectedtoortrustingofthecurrently

existingresourcesinBernalilloCountyú Historyofincarceration,includingrecentlyreleasedreturningcitizensú Homelessornearhomelessú Undocumentedand/orlimited-Englishproficient(LEP)immigrantwhodoesnot

understandhowtoaccessexistingresourcesand/orhasrunintobarrierstryingtonavigatethesystem

ú Hungryandaveraginglessthantwofullmealsperdayú Anyoftheabovewhoareparentingyoungchildren

Whiletheorganizationsarenotlimitedtofocusingspecificallyonthepopulationsabove,itdoesappearthroughconversationswiththenavigatorsthatthesecharacteristicsprettyaccuratelydescribethepeoplethattheyhaveworkedwithoverthepastsevenyears.

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TheorganizationsthatreceivedfundingoverthisPhase3,3-yearperiod[2014-2017]include:

Ø AlbuquerqueHealthCarefortheHomelessØ EastCentralMinistries-OneHopeCentrodeVidaclinicØ EnlaceComunitarioØ NativeAmericanCommunityAcademy(NACA)Ø NewMexicoAsianFamilyCenterØ PB&JFamilyServices

§ CrossroadsforWomen§ RioGrandeCommunityDevelopmentCorporation(EleValleCollaborative)

§ VIDA/CasadeSaludFamilyMedicalCenter§ CentroSávila§ Encuentro§ LaPlazitaInstitute§ SouthValleyEconomicDevelopmentCenter

Ø SamaritanCounselingCenter

Belowisgeneraldemographicinformationincludinggender,primarylanguage,self-reportedrace/ethnicity,agedistribution,educationlevel,zipcodeofresidence,andmethodoflearningaboutthePathwaysProgram(InitialContact).ThesedatashowthatthePathwaysPrograminteractsmainlywith:

ú Women(73%)ofwhich73percentself-identifyasHispanic/Latinaú IndividualswhoseprimarylanguageisSpanish(54%)orEnglish(40%)ú Individualswhoself-reportasHispanic/Latino(73%)orAmericanIndianorAlaskan

Native(10%)ú Youngtomiddleagedadults(71%fallwithintherangeof20to49yearsofage)ú Ahighpercentageofpersonswithlessthanahighschooldiploma(62%)ú Residentslivinginthesouthernpartofthecounty(zipcodes87108,87105,87121,&

87123)makeup65%oftheparticipantpopulation;andú 42percentwerereferredtotheprogrambyanotheragency;28percentbyafriendor

familymember

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Results

AsnotedintheExecutiveSummary,overthepastfiscalyear(year7oftheprogram),521personsenrolledintheprogramand1,004individualpathwayswerecompleted.Approximately210eitherwithdrew(66)orwereinactivatedduetodifficultyfollowingupwiththem(144).Thisnumberisabithigherthaninpastyearsandtheprogrammanagerisintheprocessofsettingupsitevisitswitheachorganizationtobetterunderstandthepotentialreasonsbehindthis.GiventheunstablelivingconditionsofmanyPathwaysclients,itistobeexpectedthatasignificantnumberoftheparticipantswillnevercompletetheprogram.Atotalof308personssuccessfullycompletedtheirparticipationintheprogramoverthepastyear;107morethanthepriorfiscalyear.Ofthe1,004separatepathwayscompleted,HealthCareHome(116),IncomeSupport(88),FoodSecurity(84),Employment(80),Education/GED(78),LegalServices(75),Vision&Hearing(65),Housing(64),Dental(56)andBehavioralHealth(46)werethetoptenpathwayscompleted.Nineofthe21pathwaysidentified–IncomeSupport,FoodSecurity,Heat&Utilities,LegalServices,DomesticViolence,SubstanceUse/Abuse,Vision&Hearing,HealthCareHome,andTransportation-havecompletionratesofover60percentandcompriseover52percent(52.7%)ofthe1004mentionedabove.Onthecontrary,Housing,ChildSupport,Education/GED,Employment,HomelessnessPrevention,andDentalallhavecompletionratesof50percentorlessandcompriseonly306(30%)ofthepathwayscompleted.Thissharpcontrasthighlightssomeofthechallengesthatthenavigatorsfaceinaccessingservicesfortheirclients.Table3belowdemonstratesthatthesechallengeshaveremainedconsistentoverthepastyear:

Table3:PathwaysCompletionRates-Year6vs.Year7

Year6(June2015) Year7(June2016)

Education/GED–43% Education/GED–46%Housing–40% Housing–41%Dental–50% Dental–50%

Employment–45% Employment–46%HomelessnessPrevention–50% HomelessnessPrevention–48%

Table4onpage8comparesthetoptenpathwayscompletedforYears1-3(July2009-June2012)andYears5-7(July2013-June2016).WhatisparticularlyencouragingisthattheEmploymentandHousingpathwaysincreasedfromapproximately8percentand4percentofthetotalpathwaysinthefirstthreeyears,toroughly9percentand6percentofpathwaysoverthepastthreeyears.FromtheHub’sperspective,theseareprobablytwoofthemostchallengingpathwaystocompleteandthusthetwothattheprogramreimbursesatthehighest

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levelfor.Inaddition,LegalandDentalincreasedfrom~8percentand~4percentinthefirstthreeyears,to~9percentand~7percentrespectively.

Table4:Top10PathwaysCompleted–Years1,2,&3vs.Years5,6,&7Top10CompletedPathways-1,2,&3Top10CompletedPathways-5,6,&7

HealthCareHome-316(15%) HealthCareHome-346(12%)BehavioralHealth-235(11%) Legal-269(9%)

FoodSecurity-200(9%) Employment–-255(9%)Legal-175(8%) BehavioralHealth-208(7%)

Employment-171(8%) IncomeSupport–204(7%)Vision&Hearing-133(6%) Education/GED-195(7%)**Transportation-133(6%) Dental-193(7%)

Housing-86(4%) FoodSecurity-190(6%)IncomeSupport-79(4%) Housing-187(6%)

Dental-77(4%) Vision&Hearing-175(6%)**Education/GEDpathwaywasaddedinJanuary2011

Ashasbeenthenormoverthepastsevenyears,theperformanceoverthispastyearvariedfromorganizationtoorganization(seeAppendixAonpage22).Whilethesedataclearlydemonstratetheoveralleffectivenessoftheprogram,itisimportanttonotethatnumberscannotallbetakenatfacevalue,anddonotmeasureimportantfactorssuchasimprovementsinqualityoflife(i.e.decreasedstresslevels,financialstability,improvementsinhealth{physical,mental,spiritual},etc.)Also,duringthepastyear,fourofthe13partnerorganizationsbroughtonnewnavigators,requiringindividualizedorientationandtraining.Despitethis,approximately308unduplicatedindividualscompletedtheirinvolvementinthePathwaysProgramoverthepastyear,a28percentincreaseoveryear6.Roughly1,970participantscompletedthePathwaysProgramoverthefirstsevenyearsofimplementation!AsreportedinallofourAnnualReports,belowisabriefdescriptionofhowthePathwaysProgramrespondstothedesiredoutcomesdefinedbytheextensivecommunityplanningprocessthatprecededtherolloutoftheprogram:Outcome#1:PeopleinBernalilloCountywillself-reportbetterhealth

Thisyear,asintheprevioussix,itwasextremelychallengingtoconductpost-Pathwaysinterviewswithpastparticipants,assomanyofthem,despitetheirparticipationintheprogram,havehighlevelsofinstabilityintheirlives.Twoexamplesfromourriskscorequestionnairehelpexplainwhypost-completionfollow-uphasbeensuchachallengeoverthepastsevenyears:Atthetimetheyenteredtheprogram,50percentofparticipantsanswered‘yes’tothequestion“Haveyoulivedinmorethanthreeplacesinthepastyear?”;and42percentanswered‘yes’tothequestion,“Doyoulackaphonenumberwhereyoucanreliablybereachedorreceivemessages”?Inresponsetothis,ourofficebeganconductingexitinterviewsbytelephonewithasmanyparticipantsaswecouldtrackdownnearorshortlyafter

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theycompletetheprogramfullyunderstandingthatmanyoftheclientswouldneverbereachedbythismethod.Overthepastyear,thePathwaysProgramconducted44exitinterviewswithparticipantswhohadcompletedtheprogram.Thisaveragesouttoanapproximate14percentsamplepopulationofpersonswhocompletedtheirparticipationinthePathwaysProgramoverthepastyear.EneydaRamos,anundergraduatestudentworkinginourofficeconductstheexitinterviewsastimepermits.Shehassharedthatmanyoftheindividual’sphonenumbershadalreadybeendisconnectedand/ortheyhadmovedfromthelocationdocumentedinthedatabaseatthebeginningoftheirparticipation.Belowaresomeofthegeneralresultstakenfromtheexitinterviews:

• 98percentwereeither‘completelysatisfied’(25%),‘mostlysatisfied’(34%),or‘satisfied’(39%)withtheprogram;

• 91percentagreethatwhattheyachievedbycompletingtheirpathwayswillcontinuetohelpthem;

• 75percentreportedthattheirhealthhadeither‘improved’(48%)or‘greatlyimproved‘(27%)comparedtowhentheybeganparticipatinginPathways;

• 84percentsaidthat,sincetheirparticipationinPathways,theyhadnotgonetotheEmergencyRoomorbeenadmittedtoahospitalevenonce.Note:Thisquestiondiffersfromasimilarquestionaskedatthetimeofenrollment(“Overthepast12months,haveyougonetotheemergencyroomorbeenadmittedtothehospitalthreetimesormore”?),towhich48percentanswered‘yes.’

• 97percentsaidthattheyhadabetterunderstandingofhowtoaccesshealthandsocialservicesasaresultoftheirparticipationinPathways

Althoughasmallsampletheseverypositiveresponsespointtothemanyaccomplishmentsthatcannotnecessarilybemeasuredindollarsasmuchastheycaninimprovementsinpeople’slives,whichisreallywhatthePathwaysmodelaimstoachieve,andthatovertime,shouldresultinahealthierBernalilloCounty.Ourofficehasstruggledtofindabalancebetweenthenumberofcompletedpathwaysperparticipantwereimburseourpartnerorganizationsforandthetotalnumberofclientswecanserve.Currentlywereimburseforthreecompletedpathwaysperparticipant,whichaveragesouttoapproximately$1,500to$1,600perperson.Eachadditionalpathwaycostsapproximately$450to$500moreperclient.Whileadditionalpathwayswouldcertainlyhaveapositiveimpactontheindividualsbeingassisted,itwouldalsoreducethenumberofcountyresidentswhocouldbereachedunderthecurrentfundinglevels.Thisisanongoingdiscussionthatwillberevisitediftheprogramisexpanded.

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Outcome#2:PeopleinBernalilloCountywillhaveahealthcarehome

Overthecourseofthefirstsevenyearsoftheprogram,1,223unduplicatedpersons(~33%oftotal)workedontheHealthCareHomepathway,withatotalof767completingthefinalstep(healthyoutcome)ofthepathway.Thefinalstepisdefinedas,“CHNconfirmsthattheclienthasseenaprovideraminimumof2timesandthatclienthasestablishedacomfortablerelationshipwiththeprovider,hasconfidenceinaskingquestions,istreatedrespectfully,receivedwhole-personcare,andunderstandsfollow-uptreatmentplanifapplicable.”TheHealthCareHomepathwayisstillthemostcommonlyusedamongalltwentyonepathways,withEmploymentaclosesecondat1166;BehavioralHealthat925;Housingat856,andLegalServicesat776,roundingoffthetopfive.Overthepastyear,179participantsworkedontheHealthCareHomepathwaywith116completingthefinalstep.IntermsofwherethePathwaysparticipantscompletedandestablishtheirhealthcarehomes,belowarethetopfiveclinicsinorder:

1. OneHopeCentrodeVida@EastCentralMinistries(166)2. UNMHFamilyHealthClinic-SoutheastHeights(76)3. CasadeSaludFamilyMedicalOffice(72)4. FirstNationsCommunityHealthsource(65)5. UNMHFamilyHealthClinic–1209UniversityAve.(61)

RegrettablyasignificantnumberofPathwaysparticipantsareeithernoteligiblefororcannotaffordtotakefulladvantageoftheAffordableCareAct(ObamaCare).Throughanecdotalinformation,theNavigatorshavesharedthatmanypeople,iftheyfeelrelativelyhealthy,arenotinterestedinestablishingahealthcarehomeforfearofincurringamedicaldebtthattheycannotafford.TherearestilltensofthousandsofBernalilloCountyresidentsthatwillremaindependentonacountywidesafetynetevenafterfullimplementationoftheAffordableCareAct.AseriesofgoalsandrecommendationsweremadebytheBernalilloCounty-appointedHealthCareTaskForceinNovember2014toaddressthisissue,including,butnotlimitedto:

§ Goal1:AssureHealthcareCoverageforAllCountyResidents§ Goal2:MeetNativeAmericanHealthcareObligations§ Goal3:IncreaseAvailabilityofBehavioralHealthServices§ Goal4:BuildanIntegratedSystemofPrimaryCareandNavigationSupport§ Goal5:ProvideContinuityofCareforIncarceratedPeople§ Goal6:IncreaseCountyOversightandAccountabilityforMillLevyFunds

Fromtheprogram’sperspective,theBernalilloCountyCommissionhasbeeninnegotiationswithUNMHSCandHospitalleadershiparoundboththecurrentCounty/UNMHospitalLeaseAgreementaswellasplansforthemilllevyfundsoverthenext8-yearperiod(2017-2025).Itistheprogram’shopethattheserecommendationsarebeingconsideredinthenegotiationsasweapproachthenextmilllevyvoteinNovember2016.Thefinalagreementbetweenthe

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CountyandUNMBoardofRegents,alongwiththeNovembermilllevyvotewillobviouslyhavealargeimpactonthefutureofthePathwaysProgram.Outcome#3:HealthandsocialservicenetworksinBernalilloCountywillbestrengthenedanduserfriendly.

IntheinterviewsthatPatriciaconductedwithourcurrentandformerpartnerorganizations,thereweretwoquestionsintheinterviewtoolspecifictothis3rdgoal.Thequestionsreadasfollows:

“PleasespeakaboutwhetheryourparticipationinPathwayshasstrengthenedyourorganization’srelationshipswithotherPathwayspartnerorganizations?Ifso,pleasedescribeafewexamplesofnewcollaborations.”

“Havetherebeencollaborationswithnon-PathwaysorganizationsasaresultofyourengagementwithPathways?Doyoufeelthatthisisimportanttoyourorganization?Pleaseexplain.”Accordingtothefinalreport,withinthePathwaysnetwork,88percentofthefortypersonsinterviewedreportedincreasedorenhancedcollaborationsaswellasnewcollaborations.Inaddition,68percentexpressedthatcollaborationisessentialfornon-profitsthatserveat-riskpopulationswithlimitedresources.Intervieweesreportedthatintra-networkcollaborationenhancedclientoutcomesbyfacilitatingandexpeditingreferralsandcoordinationofservices.AlongwithcollaborationwithinthePathwaysnetwork,65percentreportedcollaboratingwithentitiesoutsideofthePathwaysnetwork.Anotherquestionrelatedtocollaborationasked,“HasyourparticipationinPathwaysexpandedcapacitywithinyourorganization?Inotherwords,hasitincreasedyourabilitiestoexpand“businessasusual”,orhasithelpedyourorganizationdiversifythelevelofservicesoffered?”Nearly80percentofthepartnersreportedhavingdiversifiedtheirservicesasaresultofparticipatinginPathways.ItwasstatedthatPathwayshasencouragedorganizationstoexpandtheservicestheyprovidetheirclients,andtoexpandhowtheythinkaboutclients’needsincontext.Ithasalsoenabledorganizationstodevelopexpertiseinareasthatwereinitiallyoutsideoftheirpurview.Overthefirstsevenyearsoftheprogram,Pathwayswillhavepartneredwithandfunded,atleastoveronefundingcycle,atotalof24differentcommunity-basedorganizationshereinBernalilloCounty,includingseventhathaveparticipatedsincetheprogrambeganin2009.Theseorganizationsinclude:

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o AdelanteDevelopmentCentero AddusHealthCareo AlbuquerqueHealthCarefortheHomelesso ANewAwakeningo CasadeSaludFamilyMedicalOffice*o CatholicCharitiesRefugeeResettlementProgramo CentroSávilao CrossroadsforWomeno CuidandoLosNiños(CLNKids)o EastCentralMinistries*o Encuentroo EnlaceComunitario*o FirstNationsCommunityHealthsourceo Hogares,Inc.o LaPlazitaInstitute*o NativeAmericanCommunityAcademy(NACA)o NewMexicoAIDSServiceso NewMexicoAsianFamilyCentero NewMexicoImmigrantLawCentero PB&JFamilyServices*o RioGrandeCommunityDevelopmentCorporation(EleValle)*o SamaritanCounselingCentero SouthValleyEconomicDevelopmentCenter*o TheStorehouse

*OrganizationsthathaveparticipatedinPathwaysfromthestartInsum,theHubisconfidentthatthis3rdcommunity-definedoutcomeisbeingmet.OnlyseveralweeksagoinJuly2016,ameetingwascoordinatedwiththemajorityofpersonsthatparticipatedinthissurvey,includingallofthecurrentExecutiveDirectorsandseveralmembersofthePathwaysCommunityAdvisoryGroup(PCAG),todiscusstheresultsofthissurveyandtodevelopanactionplan.Thedirectorsexpressedinterestinmeetingatleast2timesoverthisnextfiscalyear,asmostfelttheimportanceofcontinuedrelationshipbuildingandexploringopportunitiesforstrongercollaboration.ShouldPathwayscontinuetoreceivefundingduringthenextmilllevycycle(2017-2025),manyoftherecommendationsmadebythepartnersinPatricia’sreportwillbeincorporatedintothenext8-yearperiod.

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Outcome#4:Advocacyandcollaborationwillleadtoimprovedhealthsystems.

Thisoutcomehasconsistentlybeenthemostdifficulttoaddressforavarietyofreasons.Overthefirstsevenyears,theNavigatorshavedocumentedmorethanfivehundredtwentyseparatebarriersthattheyhaveencounteredinassistingtheirclientele.Manyofthebarriersdocumentedaresystemicinnature(e.g.poortrainingoffrontlinestaff,organizationalpoliciesthatareprohibitiveratherthanwelcomingand/orrestrictivetocertainpopulations,unreasonablylongdelaysinschedulingappointments,languagebarriers,etc.).Whenthebarriersdocumentedarequeried,thereareseveralinstitutions,bothlocalandstate,thatrisetothetopintermsofnumberoftimestheyhavebeendocumented.TheHubhasworkedcloselywiththeNMCenteronLaw&Poverty(CLP)overthispastyearontheCLASPgrantthattheyreceived.ThefocushasbeenontheStateHumanServicesDepartment,IncomeSupportDivision,whichoverseesboththeSupplementalNutritionAssistanceProgram(SNAP)andofcourseMedicaid.WiththeassistanceandparticipationoftheNavigatorsandotherCHWs,theHubhasbeenabletoprovideCLPwithnumerousdocumentedcasesofbarriersatthelocalISDofficesthathelpCLPwiththeirlegalproceedings.This4thcommunity-definedoutcomewasamajorpartofthediscussionthattheHubhadrecentlyattherecentmeetingmentionedonthepriorpage.WhileUNMH,particularlytheFinancialAssistanceOffice,hasbeenbroughtuponmanyoccasionsintermsofunnecessarybarriersbeingcreatedbythefrontdeskstaff,itisimportanttonotethatouroffice’slevelofcollaborationwithUNMHhasimproveddramatically.UNMHismakingasincereattempttoelicitfeedbackfromthecommunityontherevisionofallofitsbrochuresthatwillbeusedforthepublic,theywillbeactiveparticipantsintheAccountableCommunitiesforHealth(AHC)grantiffunded,andtheyhavebeengoodpartnersonoureffortstointegrateCHWsintoprimarycareclinics.Whilethereisalwaysroomforimprovement,especiallyaroundprogrameligibilityforundocumentedCountyresidents,itisourfeelingthattheserelationshipshavebeenstrengthenedconsiderablyoverthepastcoupleofyears.IndiscussionswiththePathwaysCommunityAdvisoryGroup(PCAG),theHubistryingtobemoreresponsivetotheconcernsbroughtupbytheNavigators,mainlywhytheHubrequeststhattheytakethetimetodocumentbarriersinthedatabasewhenrelativelynochangesorimprovementsfortheirclientshaveresultedfromthis.Wewillcontinuetoexplorewaystomoreeffectivelyaddressthisimportantcommunity-definedgoal.PathwaysHubCertificationPilotProgram

OurPathwaysProgramwasoneofthreeselectednationallytoparticipateinaHubCertificationPilotstudyfundedbytheKresgeFoundationandledbytheRockvilleInstituteinRockville,MDandtheGeorgiaHealthPolicyCenter.InApril2016,ourprogrammettherequirementsforLevel1Certificationwasawardedfullcertificationfora2-yearperiod.SixotherprogramsacrossthecountrywentthroughthisprocessduringFY16,utilizingthe“lessonslearned”fromthefirstthreepilotsites.AmeetinginAkron,OhioisscheduledforlateSeptembertolearn

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moreaboutthestatusoftheseeffortsatthenationallevel.OurprogramcontinuestobealeaderforthePathwaysmodelatthenationallevel.SampleofNavigatorSuccessStories

IneachreportitisimportanttoincludesomeofthemanypositivesuccessstoriesthathavecomeoutofthePathwaysProgramoverthepastsevenyears.Asmentionedearlierinthisreport,itissometimesverydifficultto“quantify”thedollarvalueofsuchstories,butvitallyimportantforthepublictoseehowthisprogramhasimpactedthelivesofmanyBernalilloCountyresidents.Belowaresamplesofthesestoriesoverthispastyearoffunding.Alargerlistcanbemadeavailableuponrequest.

o “Myclientisamiddle-agedladywithayoungdaughter.Thetwoofthemarebythemselveswithnoadditionalsupport,nofamily,andonlyfewfriendsinthiscountry.MyclientusedtospeakverylittleEnglish,justthenecessarywordstocommunicatewithotherpeople.Herdaughteralwaysjoinedinonherconversationstotranslate,eventhoughsheisonly12yearsold.Whenmyclientcametoseeme,shetoldmethatshejustneededapairofglassesbecauseshehadn'tbeenabletoupdateherprescriptionforafewyears.However,afterourconversationstogetherandwithmyencouragement,shedecidedtovisitthedentist,aswellastogotoschool.HerdaughterconvincedhertolearnEnglishandtofinishherGED.Atfirst,myclientwashesitanttodoso.ShesaidthatlearningEnglishwashardforher.Finallythough,IfoundaschoolforherandIenrolledheratCNM.Shestartedclassesthissemesterandeversinceshestartedattendingtheschoolshelookshappier,sheistalkingagreatdeal,andherself-esteemhasincreased.Sheisveryexcitedabouttheclass,herclassmates,herteachers,andtheprogressthatsheismaking.Herdaughter,amiddleschoolstudent,helpsherwithherhomeworkandassignments.Herdaughtertellsherhowimportantsheistoherandhowimportanttheschoolis.Itmakesmehappytoseemotheranddaughterworkingtogetherontheirgoals.Oncemore,thisprogramhasshownmehowimportantitis.

o “AclientwhohasbeenhomelessforoverayearafterfleeingadomesticviolencerelationshipwasfinallyabletosaveenoughmoneytorentanapartmentforherandhersonafterreceivinghelpfindingajobandfinishingherGEDclasses.ClientstillhassomestrugglesbutisinamuchbettersituationthanshewaswhenshefirstarrivedinAlbuquerque.”

o “Aclienthasbeenhereforover25+years.Shehadcometotheagencytogethelpwithgettingafreephoneandrecertifyingforfreephoneseveraltimes.Clienthadneveropenedupabouthersituationuntilshegotreallycomfortablewithnavigator.NavigatorqualifiedclientforPathwaysservicesandsheisextremelyhappythatsheisworkingongoalstobetterherlife.Eventhoughclienthasn’tfinishedanypathwaysyet,sheisjustsohappyforhavingtheopportunitytogethelp.”

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o “AclientwhocametoNMonafiancéevisa.Onceshegothereshewasterriblyabusedbyherfiancéeandwaslockedinaroomeverydayformanyhoursatatime.ThroughPathwaysservices,wewereabletogetclientconnectedwithlegalaidattorneytogetherprotectiveorder.Clientwasalsoreferredtogetcounselingandshereportedthatshefeelsmentallyandphysicallybetter.

o “________cametoourorganizationtothankmeforhelpinghimmoveintohisnewplace.HewassoexcitedthathesaidhefeltlikeTheJeffersonsmovingonup.Itwasgreattoseehowhappythisguywasandsomeofthestaff,includingmybossheardthisguy’sexcitement.Itwassocoolthathecameallthewayovertothankmeinperson.That’swhatPathwayisallabout,helpingpeopletomakeabetterlife.Clientiscleanfromthesubstanceshewasusingandisworkingongettingofftheprescriptions.HedoesacudetoxeveryotherWedandsaysitreallyhelpshim,soit’sgreattoseehowhappythisdudeis.”

o “Thissuccessstoryisstillintheprocess.Clienthasbegunaninvestigationonherpartnerandfathertoherchildren.Hehasbeentraffickingherforseveralyears.Aftermuchadvocating,legalservices,andcontactingHomelandSecurity,wehelpedgetthetraffickerinvestigated.Clienthasfoundajobandislookingintoschool.SheisworkingwithanattorneytohopefullyreceiveherU-Visa.Clientisalsoattendingachurch,whichshesaysshewasnotallowedtodowhenlivingwithhertrafficker.Clientisstillafraidofhertraffickergettingoutofjail,asitisapossibility,butwehavesafetyplanifthishappens.Youwouldhavetoseeabeforeandaftertojustseethechangeinconfidenceandabilitytotalkaboutthetrauma.”

o “AclientcametomesayingthatherhusbandwasdiagnosedwithCanceratUNMHandtheywerenotawareofavailablesourceofhelp.IsharedwithherthatUNMHhasaprogramattheCancerClinicthatwillhelpwithsomecostsandmedications.HeisnowbeingseenatUNMHCancercliniconaregularbasis,andismakinglotsofprogress.Ialsoscheduledheranappointmenttogetsomeforcounseling.Shehascontinuedtoseehercounselorandhasmadetremendousprogressbecauseshewasoverwhelmedandstressed.Nowshe’sgettingherlifebacktogether,enjoyingherchildrenandthewholefamily’sspiritsareup.”

o “ClientwasreferredtoNavigator.Clientidentifiesas_______andwasinneedofworkauthorization,wasnearly$20,000ofmedicaldebtat________,andwasunabletocontinuereceivingmedicalcareinthecommunity.Inadditionclienthadaheartconditionandunmetoralhealthneeds.Navigatorgotclientconnectedtoprimarycareprovideranddentalservices.ClientenrolledinUNMCareIndigentCareProgram,whichhelpedcovermuchofthecostsofmedicationsfortheheartcondition.Navigatorsubmittedanapplicationforfinancialassistanceonbehalfofclient.Clientcompletedthemedicaldebtpathwaywithalldebtsadjustedto$0.ClientobtainedSNAPandMedicaidbenefitswithassistancefromtheNavigator,andfinally,clientshowedtheNavigatorhis/hernewworkauthorizationcard!”

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o “Thisclientisa32singlemotherof5children.Clientandherchildrenfledfrom______approximately8monthsago,duetoseveredomesticviolenceshesufferedbyherex-partner,whoattemptedtokillclient.Clientandherchildren'sliveswereindanger,andduetotheseverityofthecase;clientandherchildrenweregrantedasylum.Whenclientcameto_______todoherintake,shehadalreadylivedinthreedifferentplacesinashorttimeandwasresidingatashelter.NavigatoraccompaniedclienttotheMexicanConsulateinordertoobtainfinancialassistanceandsomeoftheirbirthcertificates,andwiththisfinancialassistanceclientwasabletobuyshoesforherchildren.ClientwasabletotoobtainanapartmentthroughEnlace'sRentalAssistanceProgram.ClientalsowasabletoobtainfurnitureandhouseitemsthroughNMRapidRespond.NMILChasbeenhelpingclientonherimmigrationcase.”

SampleofSystemsBarriers

InthePathwaysdatabase,thereisasectionfortheNavigatorstodocumentanysystemicbarriersthattheymayencounterwhiletryingtoaccessservicesfortheirclients.Inaddition,eachquarterlyreportrequiredbytheHubasksaquestiononbarriersexperiencedoverthepriorquarter.Asaresult,overthepastsevenyearsofprogramimplementation,asignificantnumberofbarriershavebeenidentified.Belowisasmallsampleofhowthebarriersaredocumentedinthedatabaseandonthereports:

§ 6/16/2016-NavigatorwenttoChildSupportEnforcementDivision(CSED)withclienttofindoutthestatusofapplicationfiledbackinFebruary.AlthoughtheclientwastherewiththeNavigator,CSEDstillrefusedtogiveanypersonalinformationorstatusupdatesregardingthecaseeventhoughitwasfiled4monthsprior.

§ 6/06/2016-ClientwastoldthatshewasacceptedforhousingprogramthroughtheAlbuquerqueHousingAuthorityandwasgivenanamountofrentthatshewouldbepaying,whichwasaffordable.Afewdayslater,theytoldherthattheyhadmadeamistakewiththeamountofrentbecausetheyhadnotnoticedthatnotallchildrenhadasocialsecuritynumber.Theyincreaseherrentamountandherdepositamount,andthismadeitimpossibleforclienttoaffordit,andpreventedherfrommoving.

§ 3/02/2016–IncomeSupportDivisionsentanotificationlettersayingthatclientwasdeniedherMedicaidapplicationeventhoughshereceivedanapprovalletterandcardinDecember2015.ClientcalledtheIncomeSupportofficeandtherepresentativeapologizedfortheirmistakebutcannotactivateclient'sMedicaidcardagain.SheaskedClienttoreapplyforMedicaid.Thismeansthatclientwillhavenohealthinsurancewhilereapplying.

§ FollowupwithChildSupportEnforcementDivision.Wedon’tknowwhatkindofrulestheyfollowbuttheyalwaysmakeitveryhardfornavigator/casemanagertohelpourclientsuchastheexampleinthebarrierssection.Inaddition,notinthebarrierlistedabovebutwithotherclientsthatwehavehad,wewerenotabletohelpourclientmakephonecallstogetinformation.TheywillnotallowustohelpinterpretforourclientevenwhentheyarewithusbutthentheywillnotprovideaninterpreterotherthanSpanish.Therefore,wewouldhavetogointotheoffice.

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§ TherestillappearstobesomeconfusionaroundtheneweligibilitycriteriaforUNMCare(nowprimarilyasecondarycoverage)andthenewIndigentCareProgram,anenrollmentrequirementinordertoavoidbeingsenttoCollections.TheHubwillbearrangingapresentationbyUNMHstafffortheNavigators/CHWsatoneoftheupcomingmonthlymeetings.

Additionalinformationpertainingtosystemsbarriershasalreadybeenmentionedearlierinthisreportunder“Outcome#4:Advocacyandcollaborationwillleadtoimprovedhealthsystems”onpages13&14.DescriptionofProgramExpansion&Innovation

AsnotedinTable2onpage4,approximately18.7%ofBernalilloCountyresidents(~126,540persons)livebelowthefederalpovertylevel.Initsfirstsevenyearsoffunding,thePathwaysprogramhasreachedover3,700vulnerable,disconnectedBernalilloCountyadults,connectingthemwithawidearrayofhealthcareandsocialserviceresources,andconfirmingthattheyhaveattainedpositive,healthyoutcomes.Regrettably,thisnumberequatestolessthan3.0%ofthetotalnumberofCountyresidentslivinginpoverty,themajorcontributortopoorhealthstatus.ThePathwaysclientpopulationislargelyuninsuredandmanyhavebecomeeligible(forthefirsttime)forpublicorsubsidizedhealthcoveragethroughtheAffordableCareActthatbeganinJanuary2014.ManyoftheCommunityHealthNavigatorshaveandcontinuetoassisttheirclienteleinenrollinginthemostappropriateformofhealthcoveragethattheyareeligibleforunderthisnewlaw.PathwaysclientsresideinthepoorestareasinourCountyandacommunityneedsassessmentconductedbytheBernalilloCountyCollectiveImpactforCounty&NeighborhoodHealth(CINCH)programstaffin2012revealedsixgeographic“hotspots”wherepovertyandpoorhealthindicatorscollidetoindicateahighneedforconcentratedandcoordinatedeffortstowardhealthimprovement.ThePathwaysProgramhasalignedwiththeCounty’spriorityareasandfocuseditseffortsprimarilyinthesehotspotsareasoverthepastsevenyears.InthemostrecentRFPissuedinJanuary2014,allapplicantorganizationshadtocommittoservingresidentsfromatleastoneofthehotspotareas.AnunfortunateandprobablyunintendedconsequenceoftheincreasedfocusonthesocialdeterminantsofhealthbyCHWsandothersisthatthemajorityoffinancialresourcesadministeredbyMedicaidandManagedCareOrganizationsstaywithinhealthcaresettings,anddonotreachthecommunity-basedsocialserviceorganizations.Meanwhile,itisthestaffatthesecommunity-basedorganizationsthatreceivereferralsfromtheclinicstoaddressthesocialdeterminants,whichhasplacedanunfairburdenonNavigatorsandotherstaffattheseorganizations.AveryhighpercentageofthepeoplebeingreferredtothePathwayspartners

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areamongtheestimated~126,540Countyresidentslivinginpoverty.ThesereferralsalongwiththeexistingcaseloadoftheNavigators,iscreatingcapacityissueswithinthePathwaysorganizations.Thesecommunity-basednon-profitsareinneedofadditionalfundingthatwouldenablethemtohiremorestafftokeepupwiththedemandfortheirservices.Inaddition,Pathwayswouldliketosignificantlyexpanditsnetworkofpartnerorganizationstoenhanceexistingservicesaswellasprovideadditionalservicesthatcurrentlyarenotbeingofferedbyourexistingpartners.Shouldadditionalfundsbecomeavailable,theprogramhaslaidoutplansbelowforhowtobestusethesefundstoreachmoreCountyresidents:a) ExpansionofCurrentEfforts:

Pathwayswouldliketoincreasefundingformanyofourexistingcommunity-basedpartnerorganizationsatahigherlevel(approximately$100,000perorganization/2.0FTECHNs);increasethenumberofNavigatorsfromitscurrent18to~36;increasetheNavigatorminimumhourlyratefromitscurrent$14/hourtoaminimum$15/hour;andreimburseforafourthpathwayperparticipant(increasingtoamaximumpaymentperparticipantofapproximately$1,950).

b)SupportEducation=HealthInitiative:Withexpandedfunding,theprogramwillcommittosupportingtheEducation=HealthpilotprojectintheInternationalDistrict.Aten-blockareaintheSouthSanPedroneighborhood,consistingofapproximately425householdswillserveastheprimarylocationforprogramimplementationandiswithinoneoftheCINCH“hotspot”areas.MeaningfuloutcomesforindividualswillbeattainedusingthePathwaysmodeltoidentifyindividualsandprovidethemwiththestructuredsupporttonavigatecomplexsystemsandachieveeducationandemploymentgoals,aswellasconnectiontoahealthcarehome.AuniqueneighborhoodengagementstrategywillcomplementthePathwaysProgrammodel,usingCommunityHealthNavigators(CHNs)tovisitfamiliesthroughdoortodoorcanvassingonaregularbasis,andcompletingablock-by-blockauditofhouseholdgoalsforeducation,employmentandhealth,toorganizetheirwork.TheCHNswillsupport,andbesupportedbytheInternationalDistrictHealthyCommunitiesCoalition(IDHCC).Astimeandcapacityallowtheten-blockinterventionareawillbeexpandedinageographicallycontiguousmanner.Eachyear,educationandhealthimprovementactivitieswillreachanadditional150individualsand/orfamiliesintheInternationalDistrictthroughthisproject.

Althoughmanyservicesandresourcesareinplacetosupportindividualsandfamiliesthatarefacingeconomic,educational,housingandotherhealth-relatedstruggles,accessingthemcanbeverydifficultforpeoplelivingintheInternationalDistrict.AdultBasicEducationservices,forexample,maybelimitedtodaytimeoptions,makingitimpossibleforworkingpeopletoattend.AdiscussionwiththeSingingArrowCommunityCenter,forexample,revealedthatthereisdemandforAdultBasicEducationandGEDorequivalentpreparationclasses,butthesemustbeavailableintheeveninghours.Languagebarriersmakeaccessingservicesorresourcesdifficult,soincreasingaccessandavailabilityofEnglishasaSecondLanguageclassesisneeded,

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particularlywiththegrowingrefugeecommunityintheInternationalDistrict.Computerliteracyisalsoaneed,asmoreandmoreemploymentapplicationsareavailableonlythroughanonlineformat,andmanyjobsrequirecomputerskills.EducationadvocatesinthecommunityarelookingintoalternativestotheGEDexam.Projectfundingwillbededicatedtoreducingaccessbarrierstoeducationalservicesforthetargetareatoboostthepotentialforsuccess.c)Provide“In-reach”toInmatesatMDCandNavigationSupportsfortheirReturntotheCommunityWithexpandedfunding,PathwayshasproposedtoplaceNavigators(CHNs)inthejailtobeginthetrust-buildingprocesswithincarceratedpersonsscheduledforrelease.These

effortswillbemodeledafterasuccessfulprograminMuskegon,Michigan,wheretheprinciplesoftheoriginalPathwaysmodelwasappliedtoaprisonerreentryprogram.IntheMichiganexample,acommunitybasedorganizationcollaboratedwithprisonstovisitsoon-to-bereleasedprisonerstoprovideinformationaboutresourcesandservicestheymayneeduponrelease,andtoarrangeforMedicaidenrollmentandamedicalhomeassignment,includingtransferoftheirmedicalrecords.Oncereleased,thesameCHNwillcontinuetoprovidecarecoordinationservicessothatconnectionstohealthcareandotherneedsare

confirmed.

CurrentandpotentiallynewPathwaysorganizationsthatdemonstrateinterestandcompetencyinworkingwiththispopulationwillmakearrangementstoconduct“in-reach”sessionsattheCountyDetentionCentertoprovidehealthandsocialservicesinformationtoinmatesscheduledforreleaseinBernalilloCounty.Ideally,Navigatorswillbeginmeetingwithidentifiedinmatesinthejail2to3monthsbeforetheirreleasedatesothatuponreleasetheinmateswillconnectwiththesamePathwaysNavigatorswhocanthenimmediatelybegintoaddresstheircomplicatedcircumstances,suchasnoresidenceorfamilytostaywithuponrelease,lackofemployment,historyofaddiction,orcomplexhealthneeds,forexample.TheNavigatorwillcoordinatewiththecasemanagersandothersupportservicesinthejail,willensureMedicaidenrollment,andwillcontinuetoprovidecarecoordinationafterreleasetoconfirmpositiveoutcomesinvariouspathways.Iffeasible,aplantotrackrecidivismrateswillbemadeavailable.IntheMichiganprogram,theoverallrecidivismratefellfrom46to23.8%(March2012),forexample1.

d)ImproveQualityAssurance:

Withadditionalfundingourofficewouldliketosignificantlyincreasetheleveloffundingallottedforprogramevaluation;supportthedevelopmentofadatabasethatcancapturetheworkdonebyalltheCHWsinthefield(theonesatclinics,thePathwaysNavigators,theCHWsworkingwithMCOsthroughouroffice,andthesocialworkstudents);hirean

1MichiganPathwaysProjectLinksEx-PrisonerstoMedicalServices,ContributingtoaDeclineinRecidivism(citation)

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additionalstaffpersontofocusonqualityimprovement;andsettingasidefundingtosupportcontinuingeducationopportunitiesfortheNavigators.

ProgramOutcomes

InPathways,demonstratingoutcomesis,inonesense,streamlinedandstraightforward,and,inanothersense,complexandchallenging.AnintensefocusonoutcomesisoneofthefeaturesthatmakePathwaystoaHealthyBernalilloCountyuniqueanduniquelyeffective.AccountabilityisintrinsictothePathwaysmodel,guidinghowPathwaysadministrationinteractswithcommunityorganizations,howorganizationsinteractwithnavigators,andhownavigatorsinteractwithclients.ThePathwaysapproach--achievingmeaningful,measurableoutcomesthroughasystematic,transparentprocessthatdocumentseachcriticalsteptowardtheattainmentofwell-definedgoals–exemplifiesaccountabilitybyembeddingprocessevaluationinthedeliveryofservices.ThecontractsPathwaysentersintowithcommunityorganizationslinkpaymentstooutcomesandcontractadministrationemphasizescontinuousandthoroughdocumentationofclientprogress.Therefore,whenaclientcompletesthePathwaysprogram,threecriticaloutcomeshavealreadybeenachievedanddocumented.However,duetotheextremelyhigh-risk,oftentransientpopulationPathwaysserves,measuringlongtermoutcomesandtheextenttowhichthoseoutcomesimpacthealthismuchmorechallenging.Thereisanextensivebodyofhigh-qualityresearchdocumentingtheimpactonhealthofeachofthesocialdeterminantsPathwaysseekstoaddress.Further,thereisampleevidencethatimprovementsintheseareasimprovehealthoutcomes,and,moreoftenthannot,savemoney.However,arandomizedcontrolledstudytrackingPathwaysparticipantsovertimecouldeasilyconsumehalfofPathways’entirebudget.Administrativedatacollectedbypublicsectorserviceproviders,likeUNMHorthejusticesystem,canprovidesomelower-costinsight,butrarely,ifever,cansuchsystemsprovidethedepthofdatanecessarytoaccuratelytrackthemultiplecausalrelationshipsbetweensocialdeterminants,healthoutcomes,serviceutilization,andcost.Studiesthatignoretheselimitationsmayproduceresultsthatareinaccurateormisleading.Withlimitedrevenueandacommitmenttoreturningasmuchfundingaspossibletothehigh-needscommunitiesitserves,Pathwaysistrackinglonger-termoutcomesandmeasuringprogramimpactinfourprimaryways:

1. ExitinterviewswithclientsshortlyaftertheircompletionofPathways,conductedbyUNMstudentsemployedbyPathways.

2. ReturnoninvestmentanalysesofkeypathwaysbyUNMhealtheconomist,KellyO'Donnell,PhD,whoworkswithPathwaysonanon-going,part-timebasis.

3. Analyzingthepatternsofarrestandincarcerationforthe20percentofPathwaysclientswhohaverecentlybeenreleasedfromjailtomeasuretheimpactPathwaysmayhaveonrecidivism(negotiationstoobtainthesedataareon-goingwithBernalilloCounty).

4. ProvidingtechnicalsupportandguidancetoprogramevaluatorsfortheEleVallecollectiveofPathwayspartnerorganizations.Itishopedthatthisevaluation,fundedby

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theKelloggFoundation,willdocumentlonger-termoutcomesforthesubsetofPathwaysclientsservedbyEleVallepartnerorganizationsincludingCentroSavila,LaPlazitaInstitute,SouthValleyEconomicDevelopmentCenter,andCasadeSalud.

ThePathwaysprogramconnectsthecommunity’smostunderservedanddisenfranchisedmemberstoavarietyofservicesthattheyareeitherunawareoforunabletoaccesswithouthelp.Thesehard-to-reachindividualsareoftentheclientsforwhomtheservicesaremostbeneficial.Thus,the“valueadded”byPathwaysaretheconnectionsthatwouldnototherwisebemadeandtheadditionalbenefitscommunityorganizationsgeneratewhentheyservethehighestneedclients.TheReturnonInvestment(ROI)analysisoftheHealthCareHomepathway,duetobereleasedinAugust2016,findsthatconnecting713PathwaysclientstoHealthCareHomesproducednetbenefits(benefitslesscosts)of$1.7millionandabenefit-to-costratioof3.47overthelifeoftheprogram.ROIanalysesdrawonPathways’richclientdatabaseandtheextensivenotesNavigatorsincludeineachclientrecordtoprofilethePathwaysclientswhocompletespecificpathways.Aliteraturereviewisthenconductedtoidentifyhighqualityevaluationsandresearchstudiesthatestimatetheimpactonhealthcareutilization,healthoutcomes,andhealth-relatedcostsofprogramssimilartothosethatpathwaysnavigatorsconnecttheirclientsto.Effectsizes,derivedfromtheresultsofthemostrelevantandrigorousstudies,areusedtoestimatebenefits.CostsforboththePathwaysprogramandtheprogramsPathwaysclientsareconnectedtoaresubtractedtoestimatenetbenefit. AdditionalCommentsfromthePathwaysProgramTheFY2016allocationforthePathwaysprogramtotaledroughly$885,000.Eightypercent($710,000)ofthebudgetwasdistributedthroughcontractswithcommunityorganizations.PathwaysdistributedslightlylesstocommunitypartnersinFY2016thanitdistributedinFY2015duetothedecisionbyANewAwakening,earlyinthefiscalyear,tocanceltheir$55,000contract.ManyofthefundsforfeitedbyANewAwakeningwerere-appropriatedtoother,moresuccessfulpartnerorganizations,butthePathwaysadministrationretainedasmallamounttocontractwithDr.KellyO’Donnellforprogramevaluation.Theremaining$150,000supportedthe“hub”,whichisthecoordinatingbodyforprogramadministration,retentionofthedatabaseconsultant,andsupportforthePathwaysCommunityAdvisoryGroup(PCAG).TheUNMHealthSciencesCenter’sOfficeofCommunityHealthWorkerInitiativesservesasthehubforthePathwaysprogram.Theaverageamountpercontractforparticipatingcommunityorganizationsinthiscurrent(2016-2017)fundingcyclerangesfrom$50,000to$60,000peryear.ItishopedthatthenewcontractbetweenBernalilloCountyandtheUNMHSCwillprovideadditionalfundingforPathways.Iffundingisexpanded,theprogramproposestoincreasetheamountdistributedtocommunityorganizationstoapproximately$105,000,enoughtosupporttwofull-timecommunityhealthnavigatorsateachpartnerorganization.

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Pathways’programmanagercontinuestoserveonthestatewideNewMexicoCommunityHealthWorker(CHW)AdvisoryCouncilwiththeNMDepartmentofHealthOfficeofCommunityHealthWorkers.EstablishmentofthestatewideCHWboardpursuanttothe2014CommunityHealthWorkersAct(24-30-1,NMSA1978and7.29.5NMAC)hasalteredtheroleoftheAdvisoryCouncilandthusaffectedthenatureofitscollaborationwiththestate.

ConclusionOverall,the7thyearofPathwaystoaHealthyBernalilloCountywassuccessfulandchallenging.TheexcellentworkperformedbyPatriciaRodriguez-EspinozaandtheadditionofDr.KellyO’Donnell,haveprovidedinsightandinformationthatwelookforwardtoapplyinginthenexteightyearfundingcycle.Dr.O’Donnellcontinuestofinetunethedatacollectioneffortsandhasbeendevelopingaseriesofpathway-specificcostanalysesthatweintendtopublishthroughoutthefinalyearofthecurrentfundingcycle.Since2009,over3,750vulnerableBernalilloCountyresidentshaveworkedtowardcriticallifegoalswiththeaidofPathways.AppendixBonpage25providesanunduplicatedcountofclientsthathavecompletedeachpathwayoverthelastsixyears,including762whoacquiredahealthcarehome;535whosecuredgainfulemployment;524whoaccessedbehavioralhealthservices;515whoobtainedlegalservices;and349whofoundanaffordableplacetolive.ThesefiguresmakeevidentthepowerfulimpactthatthePathwaysProgramhasonthepeopleitserves.AsCountyofficialsandHealthSciencesCenterleadershipfinishnegotiatingthenewleaseagreementandwealllookforwardtore-authorizationofthemilllevyinNovember,weareproudofwhatPathwayshasaccomplishedinitsfirstsevenyears,andoptimisticthatvoters,CountyCommissioners,andHSCleadershipperceiveandvaluethecontributionPathwayshasmadetohealthandwell-beinginBernalilloCounty.

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AppendixA

BreakdownbyOrganizationofPathwaysAccomplishments(July2015–June2016)

PartnerOrganizations NumberofNewClients

ClientsCompleted

PathwaysStarted

PathwaysCompleted

Top3PathwaysCompleted

AlbuquerqueHealthCarefortheHomeless

37 19 143 65 IncomeSupport-13Dental-9,Legal-9

CasadeSaludFamilyClinic 47 26 190 78 FoodSecurity-20,HealthCare-10,Employment,Dental,Vis&Hear-8

CentroSávila 47 17 136 67 IncomeSupport-14HealthCare-11,Pharm/Meds-11

CrossroadsforWomen 48 27 140 81 Housing-26Employment-17,BehavioralHealth-12

EastCentralMinistries 30 29 97 88 Dental-19HealthCare-14,Vision&Hearing-14

Encuentro 18 18 82 61 Heat&Utilities-16,HealthCare-11,Employment,Vis&Hear,Educ/GED-8

EnlaceComunitario 64 16 255 71 Legal-12,Driver’sLic./ID-9,ChildSupport,HomelessPrev.-7

LaPlazitaInstitute 39 39 88 70 IncomeSupport-14,FoodSec-11,Housing,SubstUse,Employment-8

NativeAmericanCommunityAcademy(NACA)

20 4 106 39 Transportation-9IncomeSupport-8

NewMexicoAsianFamilyCenter

31 15 56 42 Legal-13IncomeSupport-7,DisabInc,HealthCare-5

PB&JFamilyServices 66 43 239 160 Educ./GED-28,FoodSecurity-25,Employment-20,HealthCare-15

SamaritanCounselingCenter 39 20 115 72 HealthCare-17Legal-14,Educ./GED-9,Employment-8

SouthValleyEconomicDev.Center

29 27 103 90 Vision&Hearing-23HealthCare-12,Educ./GED,Dental-10

Total 515 300 1750 984 6/28/16

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AppendixB

NumberofPathwaysCompletedFY10–FY16

Numberof

PathwayDefinitionofFinalStep(Completion)Persons Completed

HealthCareHome CHNconfirmsthattheclienthasseenaprovideraminimumof2timesandthatclienthasestablishedacomfortablerelationshipwiththeprovider,hasconfidenceinaskingquestions,istreatedrespectfully,receivedwhole-personcare,andunderstandsfollow-uptreatmentplanifapplicable

762

Employment Clienthasfoundconsistentsource[s]ofsteadyincomeandisgainfullyemployedoveraperiodof3months

535

BehavioralHealth Clienthasappropriatehealthcoverageorfinancialassistanceprograminplacetoestablishbehavioralhealthcarehomeandhasseenabehavioralhealthspecialistaminimumof3times.Clientreportsthattheyarenolongerexperiencingthenegativesymptomsthatbefore,interferedwiththeirqualityoflife

524

LegalServices Clientreportsthatlegalissuehaseitherbeenresolvedorthattheircurrentlegalsituationhassignificantlyimproved

515

FoodSecurity Clienthasachievedfoodsecurityandhashadoverthelast3months,accesstoaminimumof2hotmealsperday

470

Vision&Hearing CHNconfirmsthatclientcompletedservicesandhasobtainedaffordablenewpairofglasses,hearingaid,orotherneededservices

388

Housing CHNconfirmsthatclientisplacedandhasmovedintoanaffordablehousingunitforaminimumof2months

349

IncomeSupport Clienthasreceivedadebitcardwithavailableassistance 325DentalHome Clienthasappropriatedentalhealthcoverageorfinancial

assistanceprograminplacetoestablishadentalcarehomeandhasseenadentistaminimumof2timesattheirnewdentalcarehome

319

Education/GED CHNconfirmsthatclienthascompletedthecourseortermandhasestablishedaplantofulfilltheireducationalgoals

296

MedicalDebt CHNconfirmsthatclientisnowabletomanageoutstandingorremainingdebtandreportslessstressrelatedtotheirmedicaldebt.Clientunderstandswhatiscoveredundertheirfinancialassistanceplanandhasarecordkeepingsystemtomanagemedicalbills

217

Heat&Utilities CHNconfirmsthatclientisreceivingthenecessaryassistancetokeepallappropriateutilitiesturnedonandfunctioningforaminimumof2months

193

Transportation Clienthasfullunderstandingof,andoverthelast3months,hasaccessedtransportationroutesacrossBernalilloCounty

181

26

Driver’sLicense/I.D. Clientreceivedandhasinhis/herpossessiontheappropriateI.D.card

175

SubstanceUse/Abuse ClientreportsthattreatmentplanwassuccessfulandCHNconfirmsthatclientattendedatleast75%ofsessions

119

DomesticViolence CHNconfirmsthatclientunderstandsherownabilitiesandtheeffectsofdomesticviolenceinhersandherfamily’slives.Clientisinaplacethatissafeandfreefromdomesticviolence,andsustainsmentalandphysicalhealth

118

HomelessnessPrevention

CHNassuresthattheclienthasobtainedandmaintainsstablehousingfornolessthan3months

104

Pharmacy/Medications Clienthasovercomebarrierstoaccessingapharmacyandhas,ataminimumforthelast3months,receivedallnecessarymedicationsatanaffordablerate

88

DisabilityIncome/Appeal

CHNconfirmsthatclientisreceivingSSI(Medicaid)orSSDI(Medicare)checkandassistsclientwithchoosingappropriatemedicalproviderifeligibleORIfclient'sapplicationwasdenied,CHNassistsclientwithappealprocessandteachesclienthowtofileaproperappealifdeniedasecondtime

85

ChildCare Clienthaschildrenenrolledinalicensed,safe,andaffordablechildcaresettingforaminimumof3monthsandparentisknowledgeableonrequirementsforretainingchildrenonsiteandcommunicatesregularlywithdaycarestaff

74

ChildSupport CHNconfirmstheclienthasconsistentlyreceivedchildsupportpaymentsforaminimumof3months

39

CHN=CommunityHealthNavigator

27

AppendixC

PathwaysEnrollmentTrendsFY10-FY15

YearOne

(7/1/09–6/30/10)NumberofEnrolleesbyQuarter

NumberofCompletedPathwaysbyQuarterNote:Databasewentliveinmid-November

1st2nd3rd4th#of“New”Enrollees N/A 179 214 204

#ofCompletedPathways N/A N/A 111 333#ofClientsCompleting

ProgramN/A N/A 5 62

YearTwo(7/1/10–6/30/11)

NumberofEnrolleesbyQuarterNumberofCompletedPathwaysbyQuarterNumberofClientsCompletingProgram

1st2nd3rd4th#of“New”Enrollees 137 142 184 69

#ofCompletedPathways 227 170 138 193#ofClientsCompleting

Program130 107 108 93

YearThree(7/1/11–6/30/12)

1st2nd3rd4th#of“New”Enrollees 156 141 158 76

#ofCompletedPathways 122 168 247 283#ofClientsCompleting

Program81 52 76 95

YearFour

(7/1/12–6/30/13)NumberofEnrolleesbyQuarter

NumberofCompletedPathwaysbyQuarterNumberofClientsCompletingProgram

1st2nd3rd4th

#of“New”Enrollees 115 110 121 65#ofCompletedPathways 188 179 265 317#ofClientsCompleting

Program69 71 72 79

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YearFive(7/1/13–6/30/14)

NumberofEnrolleesbyQuarterNumberofCompletedPathwaysbyQuarterNumberofClientsCompletingProgram

1st2nd3rd4th

#of“New”Enrollees 116 126 113 69#ofCompletedPathways 154 221 252 360#ofClientsCompleting

Program76 52 95 172

YearSix(7/1/14–6/30/15)

1st2nd3rd4th

#of“New”Enrollees 150 166 154 97#ofCompletedPathways 127 213 266 321#ofClientsCompleting

Program36 46 59 102

YearSeven(7/1/15–6/30/16)

NumberofEnrolleesbyQuarterNumberofCompletedPathwaysbyQuarterNumberofClientsCompletingProgram

1st2nd3rd4th#of“New”Enrollees 144 111 122 144

#ofCompletedPathways 214 263 247 280#ofClientsCompleting

Program71 62 79 96

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AppendixD

PathwaysFinancialReport

Thru6/30/16CommunityContracts:

OrganizationAmountofContractExpenditures6/30/16Percent Spent(%)AlbuquerqueHealthCarefortheHomeless

$55,000 $42,241 77%

EastCentralMinistries $55,000 $54,866 100%EnlaceComunitario $60,000 $59,550 99%NativeAmericanCommunityAcademy

$45,000 $37,810 84%

NewMexicoAsianFamilyCenter

$30,000 $30,000 100%

PB&JFamilyServices $155,000 $155,000 100%RioGrandeCommunityDev.Corp.

$255,000 $252,502 99%

SamaritanCounselingCenter $55,000 $55,000 100%Totals $710,000 $686,969 97%

ProfessionalServices:OrganizationAmountofContractExpenditures6/30/16Percent Spent(%)

UNMInstituteforSocialResearch

$2,500 TransferredtoISRIndexCodeforFinal

Report

100%

RubyCreekDesign(Database)

$12,000 $4,980 42%

KellyO’Donnell@0.4FTE $19,930 $19,930 100%

Totals $34,430 $27,410 80%