PATHWAYS 4TH ANNUAL REPORT-TO-THE-COMMUNITY

January 15, 2014

Happy New Year!!!

Program Goals

Through a nearly 2-year participative community planning process that began in 2007, the four primary goals defined for the Pathways Program are:

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 will be strengthened and user- friendly

4. Advocacy and collaboration will improve health systems

Program Components

20+ Community Health Navigators

at 14 organizations

Pathways Community

Advisory Group(PCAG)

HUBUNM HSC

Urban Health Partners &

Evaluation Team

Partner Organizations (Years 3-5)

¨ A New Awakening¨ Catholic Charities Refugee Resettlement Program¨ East Central Ministries – One Hope Centro de Vida¨ Enlace Comuntario¨ First Nations Community Healthsource¨ Native American Community Academy (NACA) ¨ Samaritan Counseling Center ¨ Downtown Collaborative

¤ Encuentro¤ NM Immigrant Law Center EleValle South Valley Collaborative (RGCDC) – mini Hub¤ Casa de Salud¤ Centro Sávila¤ La Plazita Institute ¤ PB&J Family Services ¤ South Valley Economic Development Center

Role of Navigators

• Find most at-risk community members• Build trust• Assess and identify problems• Prioritize pathways in terms of importance• Guide clients through pathways steps • Confirm completed pathways/ meaningful outcome

achieved• Document information in database• Present systems-level barriers

Low income

Uninsured

Unemployed

Uses ERfrequently

Housinginstability

Not receivingservices

Hungry

PATHWAYS CLIENT

BERNALILLO COUNTY RESIDENTDIFFICULT TO REACH

Self-Reported Race/ EthnicityRace/Ethnicity Percent

ClientsAmerican Indian or Alaskan Native 11.0%

Asian or Pacific Islander 1.0%

Black or African American 4.0%

Hispanic or Latino 74.0%

White 8.0%

Other 2.0%

AmericanIndianorAlaskanNativeAsianorPacificIslanderBlackorAfricanAmericanHispanicorLatino

White

Risk Profile

An analysis of the data collected in our Risk Score Instrument reveals how vulnerable many adults are in our community:

§ 84% had been unable to get needed medical care§ 40% had 3 or more ER visits or hospitalizations in the

past year§ 48% had lived in 3 or more places in the past year§ 84% were at risk of losing their home or were homeless§ 83% were unemployed, and § 88% needed help finding work

(Pathways FY2013)

Current List of Pathways

¨ Behavioral Health¨ Child Care¨ Child Support¨ Dental Care¨ Disability Income/Appeal¨ Domestic Violence¨ Driver’s License/I.D.¨ Education/GED¨ Employment¨ Food Security¨ Heat & Utilities

¨ Health Care Home¨ Homelessness Prevention¨ Housing¨ Income Support¨ Legal Services¨ Medical Debt¨ Pharmacy/Medications¨ Substance Use/Abuse¨ Transportation¨ Vision & Hearing

Client Results by Fiscal Year

TotalClients

FY2014 238

FY2013 407

FY2012 531

FY2011 532

FY2010 597

Totals 2305

Completed Pathways

Completed Program

363 128

948 294

820 304

728 438

444 67

3303 1231

Health Care Home 36%Employment 33%Behavioral Health and/or Depression 28%Housing 21%Food Security 19%Vision & Hearing 18%Legal Services 18%Dental Care 16%Education/GED 14%Medical Debt 12%

Common Pathways

Time Associated with Completion of Pathways

Pathways # of Clients

# of Clients

Completed

% of Clients

Completed

Average Days to

Complete

Education/GED 334 126 38% 175

Housing 479 177 37% 168

Employment 753 311 41% 155

Dental Care 371 154 42% 152

Health Care Home 824 464 56% 145

BehavioralHealth/Depression

648 348 54% 120

Income Support (ISD) 187 135 72% 58

Sample of Final Outcomes

¨ Behavioral Health: Client has appropriate health coverage or financial assistance program in place to establish behavioral health care home and has seen a behavioral health specialist a minimum of 3 times.

¨ Education/GED: CHN confirms that client has completed the course or term and has established a plan to fulfill their educational goals.

¨ Employment: Client has found consistent source[s] of steady income and is gainfully employed over a period of 3 months.

¨ Health Care Home: CHN confirms that the client has seen a provider a minimum of 2 times and that client has established a comfortable relationship with the provider, has confidence in asking questions, is treated respectfully, received whole-person care, and understands follow-up treatment plan if applicable.

¨ Data collection methods for measurementq Completion of pathways & exiting program¤ Exit Interviews at or near time of completion¤ 6 to 9 month post-Pathways interviews¤ Sustained improvements in housing, employment, access to

health care, and other specific pathways for clients

Example: “ Compared to your health when you began Pathways, would you say your overall health is: much better, a little better, a little worse or about the same? 70% reported “much better” or “better” since they began participating in Pathways.

(2013 Exit Interviews with Pathways clients)

Outcome 1: People in Bernalillo County will self-report better health

OUTCOME 2: People in Bernalillo County will have a Health Care Home

Health Clinic TotalOne Hope Centro de Vida Medical Center 112First Nations Community Healthsource 55UNMH Family Health Clinics (1209) 48

UNMH Family Health Clinics (Southeast Heights) 43Casa de Salud Family Medical Office 36First Choice Community Health (South Valley) 26

First Choice Community Health (South Broadway) 14UNMH General Medicine Clinic Family 12UNMH Family Health Clinics (Southwest Mesa) 9

Presbyterian Healthcare Services 8

Total 470

Confirm connection to primary care servicesCompleted Health Care Home pathway

Outcome 2: People in Bernalillo County will have a health care home

v Health Care Home: Experiences and Criteria in the Pathways to a Healthy Bernalillo County Program (HRRC# 12-286)

¤ Focus groups interviews with Spanish-speaking immigrants, Off Reservation Native Americans, and formerly incarcerated individuals Completed

¤ Focus group interviews with Pathways Navigators Completed

¤ Key informant interviews with primary care providers & administrators Completed

Note: An upcoming Webinar on the results of this study is scheduled for Friday, January 24 from 12:00 to 1:30 p.m.

For more information, please contact Ivette Cuzmar @ 925-4707 or at: ICuzmar@gmail.com

Outcome 3: Health and social services in Bernalillo County will be strengthened and user friendly

v Implementation Assessment of the Pathways Program – will use a four part methodology

¤ Review of best practices for this type of program. This describes in general how these types of programs should operate.

¤ Interviews/surveys of contracted program administrators and Navigators to determine how the Pathways Program functions from their perspective, and to assess levels of collaboration pre vs. post-Pathways participation

¤ Review of client files to provide client level information that will inform our understanding of how the Pathway program operates and serves clients.

Outcome 4: Advocacy and collaboration will lead to improved health outcomes

¨ Ongoing documentation of systems barriers are entered into the database by the Navigators as they occur

¨ Approximately once per year, City and County officials are invited to attend standing monthly Navigator meeting to listen to systems issues directly from the front line.

¨ Periodically, barriers are queried and shared with Pathways Community Advisory Group, Navigators, and other advocates and different strategies are explored on how to best overcome these systems problems (often large systems).

Future Evaluation Plans

Cost Study: UNM’s Institute for Social Research will conduct a cost study of Pathways to Healthy Bernalillo County Program (Pathways Program). ISR completed a cost study of the City of Albuquerque Housing First program in 2011 and recently completed a phase one cost study of the City of Albuquerque Heading Home Initiative.

Patterns of Hospital Utilization by Pathways Clients: The goal of this proposed research is to study UNMH service utilization and costs patterns of Pathways Program clients pre-participation vs. present and compared to a matched control group of similar individuals who did not use Pathway Program services.

Ongoing evaluation plan:Incorporate what we have learned to date and provide direction for ongoing program evaluation and technical assistance for the duration of the program.

Contact Information

Daryl T. Smith, MPHPathways Program Manager

Urban Health PartnersUNM Health Sciences Center

(505) 272-0823 Dtsmith@salud.unm.edu

Paul Guerin, PhDUNM Institute for Social Research

(505) 277-4257 malachi@unm.edu

Thank you y Gracias!