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Service Delivery Innovation Profile

Care “Pathway” Connects Pregnant Substance Abusers to Medical and Other Services, Supporting  Birth of Babies with Viable Weights Who Are Free of Illicit Substances

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The Rio Arriba Community Health Council, a countywide health collaborative, developed a care “pathway” that uses counselors to provide assessment of and motivational interviewing to pregnant substance abusers. Based on client needs, the counselor helps the client obtain health insurance, obstetrics care, substance abuse counseling, nutrition support, parenting education, and other services. Over 2 years, the program has enhanced access to prenatal care and has helped the vast majority of clients to give birth to babies with a viable birth weight who are free of illicit substances.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation outcomes measures, including the percentage of clients giving birth to babies born with a viable birth weight and free of illicit substances.
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Developing Organizations

Rio Arriba Community Health Council
Espaniola, NMend do

Date First Implemented

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Patient Population

Race and Ethnicity > American indian or alaska native; Gender > Female; Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Substance abusers; Womenend pp

Problem Addressed

A small but significant number of women use illicit drugs and/or engage in binge drinking during pregnancy, leading to poor birth outcomes. Adequate prenatal care and substance abuse treatment can help improve outcomes, but relatively few pregnant substance abusers have access to such support.

  • A common, dangerous problem: Approximately 4 percent of pregnant women in the United States use illicit drugs, such as marijuana, cocaine, and heroin,1 while up to 10 percent engage in binge drinking.2
  • Leading to poor birth outcomes: Use of illicit drugs and alcohol during pregnancy often leads to poor birth outcomes, including low birth weight, premature birth, birth defects, and learning and behavioral problems.1
  • Unrealized potential of prenatal care and substance abuse treatment: Programs that provide or direct pregnant women to prenatal care and drug abuse treatment programs can help ensure positive birth outcomes,3 but the vast majority of women lack access to such support.

What They Did

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Description of the Innovative Activity

The Rio Arriba Community Health Council implemented the Pathways© Model, which uses community health workers to connect at-risk individuals to care and services through the use of individualized care pathways designed to produce healthy outcomes. The Rio Arriba pathway for pregnant substance abusers uses health workers to perform client assessment, conduct motivational interviewing, and help clients obtain needed services, including health insurance, obstetrics care, substance abuse counseling, nutritional support, parenting education, and baby products. Key elements of the pathway include the following:

  • Referring women to the program: At least half of clients self-refer to the program based on a recommendation from a peer. In addition, primary care providers, jail-based health providers and case managers, substance abuse counselors, and social workers refer clients to the program. Information provided in October 2012 indicates that more primary care providers are referring to the program, and they are beginning to refer a few highly medically fragile pregnancies; unfortunately, some of these babies are already diagnosed with a serious problem so that a healthy birthweight is not a likely or even a possible outcome.
  • Comprehensive assessment of issues: The client first meets with a social worker or clinical counselor, who conducts a comprehensive biopsychosocial assessment of the problems he or she faces using the Addiction Severity Index-Multimedia Version assessment tool.4 This tool identifies seven categories of recent and lifetime problems commonly experienced by substance abuse patients, including medical status, employment and support, drug use, alcohol use, legal status, family and social status, and psychiatric status.
  • Motivational interviewing: The social worker or clinical counselor gives the assessment to a care coordinator (a counselor who specializes in working with pregnant women), who works with the client to identify her needs, the steps she can take to avoid substance use, and the barriers she faces, and then helps the client become motivated to improve her life.
  • Connecting client to needed services: The care coordinator works with the client to facilitate access to needed services, as outlined below:
    • Medical and prenatal care: The care coordinator enrolls the client in the Medicaid program and then identifies an obstetrician/gynecologist so that the client can obtain medical and prenatal care, along with birth control after she has the baby. The care coordinator drives the client to medical care appointments if necessary. Each time the client attends a prenatal care visit, she earns a gasoline gift card.
    • Substance abuse counseling: The care coordinator offers substance abuse counseling to the client, and if she agrees, refers her to intensive, county-provided counseling services, which can continue after the birth.
    • Parenting support: The care coordinator refers the client to an organization called CareNet that serves needy pregnant women. CareNet offers a series of parenting videos; each time a client watches one, she earns gift certificates for purchases in the CareNet thrift store, which sells diapers, cribs, and other baby products. The care coordinator also refers the client to county-sponsored parenting classes.
    • Nutrition support: The care coordinator enrolls the client in the Women, Infants and Children (more commonly known as WIC) program so that she can receive food stamps.
    • Baby equipment and supplies: The care coordinator enrolls the client in a car seat program that distributes free car seats to needy individuals. In addition to the gift certificates for supplies noted above, the care coordinator also hosts baby showers at the county offices for clients, during which clients receive baby supplies and other gifts.

Context of the Innovation

The Rio Arriba Community Health Council serves Rio Arriba County, NM. This largely rural county, which covers 5,800 square miles, has approximately 40,000 residents, with 73 percent of residents being Hispanic and 14 percent Native American. A large portion of county residents have low socioeconomic status. Funded, operated, and staffed by the county’s Department of Health and Human Services, the council includes member organizations representing all major health stakeholders (e.g., Espaniola Hospital, three federally-qualified health centers, medical and behavioral health providers). The program developed in response to funding cuts at the state level (such as recent cuts in preventive services), which have generated increased demand for county-level services; part of the Council’s mission is to identify ways to help the county develop infrastructure to provide those services. Council representatives head a presentation by Mark Redding, founder of the Pathways Model, at a National Association of Counties health leadership forum; this presentation convinced them that the model could help improve health care service delivery in Rio Arriba County.

Did It Work?

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The program has enhanced access to prenatal care and has helped the vast majority of clients to give birth to babies with a viable birth weight who are free of illicit substances.

  • Improved access to prenatal care: At program entry, 13 of 27 total clients had needs related to access to prenatal care. At the end of the program, only one had this need. All 13 were referred for medical services (presumably prenatal care), and all referrals were successful.
  • Viable birth weight: In the first 2 years of the program, 22 of 25 clients who delivered gave birth to babies with a viable birth weight (defined as at least 5 pounds 8 ounces). Two of the babies born had a low birth weight (less than 5 pounds 8 ounces); a third baby had a very low birth weight (less than 3 pounds 8 ounces), but this was due to a congenital heart defect rather than substance abuse.
  • Babies free of illicit substances: In the first 2 years of the program, 22 of 25 clients who delivered had babies born free of illicit substances.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation outcomes measures, including the percentage of clients giving birth to babies born with a viable birth weight and free of illicit substances.

How They Did It

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Planning and Development Process

Rio Arriba Community Health Council is the hub that oversees evaluation and policy. The Rio Arriba Department of Health and Human Services provides the actual services. Other providers and stakeholders in the community sit on the council where they help to evaluate, plan, and develop various referral protocols. Key elements of the planning and development process included the following:
  • Engaging consultant: Mark Redding provided onsite consultation, helping council representatives to identify priorities and develop the county’s first pathway.
  • Identifying pregnant substance abusers as health priority: Mark Redding, county commissioners, and representatives from the health department, hospital, and health clinics considered which groups of county residents did not receive adequate health services. The group identified pregnant substance abusers as an underserved population, and recognized that targeting this group would help both the women and their babies.
  • Designing pathway, assigning tasks to staff: The group identified applicable resources and programs, designed the pathway, and then assigned specific pathway activities to existing staff.
  • Hiring evaluator: The Health and Human Services Department hired an outside evaluator to measure and track the impact of the program.
  • Developing new pathways: Information provided in October 2012 indicates that the council has developed two new pathways -- one related to emergency department care and one related to senior immunizations, which has led to new senior outreach efforts. The council plans to develop additional pathways to connect at-risk populations to needed services; pathways under development include three pathways related to helping individuals secure housing, employment, and education and one will help individuals dealing with substance abuse.
  • Developing an electronic patient record: Information provided in October 2012 indicates that, after a year of effort, the program has built and is currently testing an electronic patient record, which is allowing the program to track outcomes, barriers and other issues.

Resources Used and Skills Needed

  • Staffing: Program staff consists of two individuals (a social worker and a clinical counselor) who spend part of their time providing the initial assessment, along with a full-time care coordinator who serves approximately 30 clients at a time; these individuals were existing Department of Health and Human Services staffers asked to incorporate program activities into their daily routines without additional pay.
  • Costs: Data on program costs are unavailable; the primary costs for an organization adopting this type of program would consist of salary and benefits for staff. As noted earlier, however, this program did not entail the need for additional labor-related expenses, because it relied on existing staff who received no additional compensation.
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Funding Sources

U.S. Department of Health and Human Services; Rio Arriba County, NM; State of New Mexico Department of Health; OptumHealth Care Solutions; National Association of Counties
Among other grants, the Rio Arriba Community Health Council received an American Recovery and Reinvestment Act grant through the U.S. Department of Health and Human Services Strengthening Communities Fund; in addition, the National Association of Counties provided a small ($5,000) grant to help fund Mark Redding’s initial guidance for the project.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Do not let absence of large funder dissuade development: Many small, impoverished communities receive funding for services from multiple sources, and may not be able to identify a single funder willing to donate resources to design a new model of care. These communities can still make changes testing new care coordination activities on a small scale, and then seek additional funds once the model's efficacy has been demonstrated.
  • Convince staff to try new activities: It may be difficult to convince staff to adopt a new model of care when it involves extra work without additional pay. The Rio Arriba Director of Health and Human Services alleviated staff concerns by acknowledging the difficult population being served, by emphasizing that the project represented an experiment, and by promising staff they would not be penalized if the model did not work.

Sustaining This Innovation

  • Monitor and share data on program efficacy: Data showing the program's positive benefits can convince funders to provide additional resources to support ongoing operations, expansion, and refinement. Sharing positive outcomes also helps to motivate staff to continue engaging in program activities, and can help to solidify relationships with health care providers.
  • Develop information technology system: Program expansion can be difficult in the absence of an information technology system to track outcomes and allow case managers from multiple agencies to access comprehensive client information. The Rio Arriba Department of Health and Human Services is partnering with other agencies to identify resources to enable adoption of such a system.

More Information

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Contact the Innovator

Lauren Reichelt, MA
Health and Human Services Director
Rio Arriba County Department of Health and Human Services
1122 Industrial Park Road
Espaniola, NM 87532
(505) 753-3143

Innovator Disclosures

Ms. Reichelt has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Rio Arriba Community Health Council Web site:


1 Illicit Drug Use During Pregnancy. Fact Sheet. March of Dimes. 2010. Available at:
2 U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration Office of Applied Studies. 2008 National Survey on Drug Use & Health. Available at:
3 National Crime Prevention Council. Strategy: Prenatal Care and Drug Abuse Treatment for Pregnant Women. 2010. Available at:
4 National Institute on Alcohol Abuse and Alcoholism. Addiction Severity Index. Information available at: (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
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Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 13, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.