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Service Delivery Innovation Profile

Community Health Navigators Use Pathways Model to Enhance Access to Health and Social Services for Low-Income, At-Risk Residents

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The Pathways to a Healthy Bernalillo County Program uses an innovative approach to the original Pathways Model to identify vulnerable, low- and very low–income, underserved residents and connect them to health and social services. Clients are identified through interagency referrals, word of mouth, street outreach, and other means by the program's network of 13 community-based organizations. Community health navigators help clients access additional health and social services, assist with coordination of care, and monitor client progress. Participating agencies receive payments based on their ability to identify at-risk clients, connect them with needed services, and achieve positive outcomes, while a central hub and database help coordinate client services. The program has enhanced access to needed services for many of the more than 2,130 unduplicated clients served in its first 4 years of operation, with more than 1,080 completing all their pathways and exiting the program; by program design, each completed pathway indicates a successful outcome.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of clients served, exit interviews administered at or near the time of completion of the program, pathways completed, and client satisfaction. Given the multiple, complex needs of many of the people served by this program, it is highly unlikely that many of the clients would have gained access to the needed services and achieved the outcomes defined in the pathways without this program.
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Developing Organizations

Office for Community Health, University of New Mexico Health Sciences Center; University of New Mexico Health Sciences Center; Urban Health Partners
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Date First Implemented

Planning and development began in 2007, with the initial pilot running from July 2009 until June 2011. The second, 3-year phase began in July 2011, with five new organizations joining the network. In January 2014, a third competitive request for proposals will be released for the third and final 3-year phase under the current funding cycle.

Problem Addressed

Low-income, vulnerable populations often fail to obtain needed health care and social services via conventional avenues and are at high risk of untreated health problems that may require expensive inpatient and emergency department (ED) care. This problem is compounded further for persons without proper legal status.
  • Failure to receive needed services: At-risk individuals often cannot access needed health care and social services for several reasons, including the following:
    • Systemic barriers: These include policies that exclude undocumented immigrants from Medicaid as well as other programs that assist low-income U.S. citizens; difficulties trying to find a job, obtain housing, or secure health insurance1; and the stress and hardship of unpaid medical debts.
    • Lack of trust: Even when adequate community services and resources are available, many at-risk residents do not trust the community-based organizations and institutions providing them. Lack of trust may arise when clients have their social service applications denied, experience discrimination from front-desk staff, or are unable to submit appropriate documentation due to language barriers. In such circumstances, clients can become discouraged and stop seeking services.
    • Lack of coordination: On their own, many community agencies serving at-risk residents in Bernalillo County lacked the infrastructure and workforce needed to coordinate with other organizations to ensure that clients had their multiple needs met.
  • Increased likelihood of untreated medical conditions and uncompensated care: At-risk individuals unable to access needed services face an increased risk of untreated chronic health conditions.1 Eventually, these individuals require expensive, uncompensated inpatient and ED care. One study of rural hospitals estimated that self-pay patients represent a financial burden of $4 billion in rural hospitals nationwide.2 The University of New Mexico Hospital, for example, faced rising rates of uncompensated care at the time of the program's inception.

What They Did

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Description of the Innovative Activity

The Pathways to a Healthy Bernalillo County Program uses an innovative approach to the original Pathways Model to identify vulnerable, low- and very low–income, underserved residents and connect them to health and social services. Clients are identified through interagency referrals, word of mouth, street outreach, and other means by the program's network of 13 community-based organizations. Community health navigators help clients access additional health and social services, assist with coordination of care, and monitor client progress. Participating agencies receive payments based on their ability to identify at-risk clients, connect them with needed services, and achieve positive outcomes, while a central hub and database help coordinate client services. Key program elements include the following:
  • Target population: The program targets low-income, uninsured adults with risk factors, including multiple or complex unmet needs, self-reporting fair to poor health, lacking stable employment, feeling unhealthy, being unemployed, having had at least one ED visit during the previous year, being homeless and not receiving services, or averaging less than two full meals per day. The target population also includes individuals parenting young children; urban off-reservation Native Americans not connected to community resources; formerly incarcerated people experiencing difficulty obtaining employment and stable housing, among other needs; and undocumented immigrants or residents with limited-English proficiency (LEP).
  • Program referral: Members of this target population can be referred to the program by a variety of sources, including friends and family members (who referred nearly 30 percent of clients in the program's first 4 years), community health navigators, and other health and social service organizations familiar with the Pathways Program. Nearly 14 percent of the clients were identified through walk-ins to Pathways organizations, and another 13 percent were found through outreach by the community health navigators (updated December 2013). Many clients are enrolled through interagency referrals among the 13 organizations participating in the program network, including health clinics, social support organizations (e.g., counseling centers), and organizations working with immigrant populations. The program conducts selected outreach efforts, although it has been able to reach capacity without extensive use of formal marketing and promotion.
  • Initial assessment and enrollment by community health navigators: A group of 20 community health workers, called navigators, who are employed by network members, assess the immediate needs of the person referred, determine whether the individual would be an appropriate candidate for Pathways participation (i.e., has multiple needs), and then conducts an approximate 45-minute risk score assessment. The assessment questionnaire determines an individual’s eligibility based on identified needs and risks. It includes questions related to acute family issues, child and family care, diabetes, education, employment, general health and health limitations, housing status, medical services, mental and behavioral health, social issues, substance use, transportation, and other issues. For those deemed eligible, the navigator obtains consent before enrolling them in the program. The navigators obtain written consent from the individual prior to collecting any information, including the risk score instrument.
  • Ongoing management, using pathways: After enrollment, clients are assigned to a community health worker (navigator) who helps them complete the pathways that the client has prioritized. Each pathway outlines critical steps needed to achieve positive outcomes. The navigator works to build the client’s trust in the system of care, coordinates the services provided by participating community agencies, reports any system barriers encountered, and documents all activities in the program’s database. Key steps in this process are detailed below:
    • Assignment to pathways and community organizations: The navigator identifies the care pathways that address the client’s most critical near-term needs (although clients can be assigned to many different pathways). The 21 currently available pathways encompass medical issues as well as social determinants of health; sample pathways include behavioral health, child care, dental care, diabetes, domestic violence, employment, food security, health care home, housing, homelessness prevention, legal services, medical debt, and transportation. Depending on the pathways selected, the navigator refers the client to one or more community organizations, including those outside the network. The number of active clients per organization over the course of a year varies widely and can be as high as 40 to 50; approximately half of the partner organizations employ two navigators.
    • Ongoing monitoring: The navigators monitor each client's progress, providing support in accessing services. The navigators stay in touch with clients via telephone calls, occasional home visits, and scheduled or walk-in appointments. Key contact persons at the referral agencies confirm that clients have kept their appointments, received services, and made plans for followup. In the program's second year, partner organizations began creating a small emergency fund to help those with financial barriers keep appointments and/or complete pathways. Funds can be used to pay for such items as bus fare, identification card fees, driver's license fees, one-time utility payments, and prescription drug copayments. The emergency funds make up no more than 3 percent of the partner organization’s Pathways budget and originally were capped at $50 maximum expenditure per client. As of July 2013, the amounts expended per client are now at the discretion of the partner organization. Once the funds are spent, no additional Pathways funds can be used for emergency purposes. (Updated December 2013.)
  • Payments based on milestones in pathways: Participating organizations receive payments at three stages: after the initial risk assessment/enrollment in the program, after confirmation that the client has received necessary services, and after verification that pathways have been completed. Midway through the program's first year, community organizations that had underspent their budgets had their budgets reduced, and high-performing agencies received increased funding. Each organization can be reimbursed for up to three completed pathways per individual, with the total payment limited to $1,550 per client. Examples of outcomes associated with a completed pathway include the following:
    • Behavioral health: The client has appropriate health coverage or a financial assistance program in place to establish a behavioral health care home and has seen a behavioral health specialist a minimum of three times. The client reports that he or she is no longer experiencing the negative symptoms that previously interfered with his or her quality of life.
    • Employment: The client has found consistent source(s) of steady income and is gainfully employed over a period of 3 months.
    • Food security: The client has achieved food security, including access to at least two hot meals per day during the last 3 months.
    • Health care home: The navigator confirms that the client has seen a provider a minimum of two times and that client has established a comfortable relationship with the provider, has confidence in asking questions, is treated respectfully, has received whole-person care, and understands followup treatment plan if applicable (updated December 2013).
  • “Hub” for coordination and support: The Pathways Program under the Office for Community Health of the University of New Mexico Health Sciences Center serves as the project hub. Staff provide technical support and coordinate standing monthly meetings or training for the navigators, assist the partner organizations, and evaluate the program. A database maintained by the hub allows navigators to avoid duplication of services, confirm that care pathways have been completed, and collect data for reporting purposes. This program is one of three Pathways Programs nationwide participating in a national pilot study around Hub Certification, in partnership with the Georgia Health Policy Center at Georgia State University, the Rockville Institute Center for Pathways Community Care Coordination, Communities Joined in Action, and others.

Context of the Innovation

Image shows four community defined outcomes to improve the target population health.
Figure 1: The developing organizations focused on four main community outcomes to be achieved through implementation of the Pathways model. Pathways Presentation to the UNM Hospital Board of Trustees, September 2013. Used with permission.
The University of New Mexico Health Sciences Center is the largest academic health complex in New Mexico. Located in Albuquerque, the center focuses on four areas: education, research, patient care, and community outreach. In 2006, the Health Sciences Center established an Office of Community Affairs (now known as Urban Health Partners), following a December 2005 statewide summit to discuss the medical center’s public mission and address concerns about the costs of uncompensated care for indigent residents. This office was charged with improving the health of vulnerable populations in Bernalillo County by working with local organizations to eliminate barriers to services. The group defined specific community outcomes as programmatic goals, as outlined in Figure 1. After the summit, stakeholders wanted to achieve greater financial accountability and decided to dedicate 1 percent of the health center's county-generated funding to upstream, community-based efforts to help residents navigate health care and social service systems. Early in their tenure, office leaders became aware of the Pathways Model developed by Dr. Mark Redding and Dr. Sarah Redding and were attracted to its emphasis on leveraging community health workers and ability to track each client’s needs and progress across participating agencies. Program leaders felt that a similar approach could help at-risk county residents, including those with LEP, Native Americans living on and off reservations, immigrants, and other at-risk populations.

Did It Work?

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The program has enhanced access to needed services for 2,130 unduplicated clients served in its first 4 years of operation, with 1,080 completing all their pathways and exiting the program; by program design, each completed pathway indicates a successful outcome. Clients appear to be mostly satisfied or highly satisfied with the program.
  • Enhanced access to services: During its first 4 years (through June 2013), the program served 2,130 clients, with many of them gaining access to services they very likely would not have received without the program. Of these, 1,080 successfully completed all their pathways (indicating a successful outcome), 294 were actively working on one or more pathways, 506 had become inactive, and 170 had withdrawn from the program. Overall, more than 3,058 pathways were completed during the program's first 4 years, as clients may enroll in multiple pathways. The health care home pathway was most frequently completed (by 419 clients), followed by food security (283), employment (274), legal services (248), vision and hearing (215), behavioral health (211), housing (153), medical debt (150), transportation (127),  and dental (126). The number of pathways completed does not correspond to the completion rate; overall, 67 percent of those on the legal services pathway completed it as opposed to 41 percent on the employment pathway and 36 percent on the housing pathway. These rates do not take into account the fact that a client may have been enrolled for only a short period of time. (Updated December 2013.)
  • High retention rate: Just over two-thirds of participants (68.3 percent) remained in the program for the first 4 years, a very high retention rate given the difficult and unstable situations that many of these clients face on a daily basis. (Updated December 2013.)
  • High satisfaction: An ongoing and comprehensive analysis of the program, based on exit interviews since July 2012, found very high levels of satisfaction, with 67 percent of the 109 clients interviewed indicating they were either completely or mostly satisfied with the program. Another 23 percent indicated they were satisfied. (Updated December 2013.)
  • Ongoing evaluation: The ongoing analysis will also report on several measures related to the strength of the network, navigator performance and satisfaction, and the impact of the program on hospital utilization, changes in communitywide health status, and access to care. A 4-year summary report was released in October 2013 and is available at:
    (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of clients served, exit interviews administered at or near the time of completion of the program, pathways completed, and client satisfaction. Given the multiple, complex needs of many of the people served by this program, it is highly unlikely that many of the clients would have gained access to the needed services and achieved the outcomes defined in the pathways without this program.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Establishing organizational focus: The Office of Community Affairs was charged with building relationships with community groups, promoting system changes to eliminate barriers to care, sharing data for program planning, and encouraging leaders to address difficult issues. The office also became the project hub, overseeing management and evaluation activities.
  • Establishing work group to plan project: Following a community workshop in October 2007, a workgroup was formed to define the program’s mission and to adapt the Pathways Model for use in Bernalillo County. The group included representatives from community-based social service organizations, the New Mexico Department of Health, the University of New Mexico Health Sciences Center, the University of New Mexico Hospital, the Bernalillo County Community Health Council, community advocates, and others. Additional planning took place at a “kickoff” community meeting in September 2008 and at five half-day planning meetings with community-based organizations.
  • Securing funding: Efforts to secure funding for the program occurred in coordination with the planning process. Health Sciences Center leaders and community advocates met with the county commissioner in January 2008 to discuss potential funding for a client-centered navigator program. In April 2008, the Health Sciences Center and Bernalillo County agreed to fund the project with at least $800,000 annually for 8 years starting in 2009. In November 2008, passage of a mill-levy bond issue ensured that funding would be available through 2017.
  • Hiring program manager and design team: In January 2009, the work group hired a program manager and organized a design team. The team included several community health workers, some of the community advocates involved in the planning effort, staff from the Office of Community Affairs, and several members of a now-disbanded community advisory council. (This council provided input on planning the program to the University of New Mexico Health Sciences Center and then disbanded in early 2009.)
  • Contracting with agencies: The program manager issued a request for proposals in May 2009, inviting community-based organizations to apply for 2-year project grants of approximately $50,000 per year and to commit to identifying a community health navigator. The program received 12 applications and funded 11 of them, with awards totaling $643,610, or 80 percent of total funding for the project. The grantees included 15 organizations (10 individual organizations and one partnership of five agencies located near each other). In early 2011, a second request for proposals was issued, incorporating the many lessons learned during the first 18 months of the program. Four of the organizations participating in the first 2 years did not receive additional funding, with five new organizations joining the nine other original participants who did receive additional funding. Representatives from the new partner organizations attended a 2-day training and orientation in mid-July 2011. In January 2014, a third request for proposals will be released for the third and final 3-year phase under the current funding cycle.
  • Creating system to distribute funds: During the first year, each participating organization received approximately 35 to 40 percent of its grant award, prorated on a monthly basis, to cover the costs of being involved in the project. The other 60 to 65 percent was distributed as described earlier, based on the ability to identify clients, connect them to services, and complete pathways. Effective July 2011 and still applicable, each participating organization’s budget now has three main components: 30 percent of the total award will be drawn down equally each month to assist the organization with administration, personnel, and other costs; 3 percent will be set aside in an emergency fund as previously mentioned; and the remaining 67 percent is reimbursed based on the deliverables for client services received. (Updated December 2013.)
  • Pilot testing of assessment instrument: Program leaders conducted a pilot test of the risk score assessment instrument used to gauge eligibility for the program. Based on feedback from navigators, the instrument underwent several refinements. A fourth version of this risk score instrument went into effect in July 2013. Several questions pertaining to legal matters were added as well as one related to history of incarceration, and a prior question pertaining to currently experiencing homelessness versus at risk of becoming homeless was separated into two discrete questions. (Updated December 2013.)
  • Developing data management system and evaluation plan: The Institute of Public Health at the University of New Mexico Health Sciences Center provided technical guidance on development of the data management system and produced the program evaluation plan. These responsibilities were transferred over to the Robert Wood Johnson Center for Health Policy at the University of New Mexico in July 2011. Urban Health Partners contracts with the University of New Mexico Institute for Social Research on various program evaluation measures; some of these evaluation efforts are described in further detail below.
    • In 2011, Lovelace Clinic Foundation Research, under contract with Urban Health Partners, worked on a research study that attempted to measure the community networking benefits of the Pathways Program, both within the Pathways network as well as with external partners. The study was completed and is available in its entirety at
    • In late 2012 and early 2013, an additional study was conducted by the Urban Health Partners office based on experiences of the navigators and their numerous stories about the difficulties in obtaining health care access for their clients. The study, conducted by Soda Creek Consulting, LLC, is available at
    • Information provided in December 2013 indicates that the Pathways Program is now contracting with the University of New Mexico Institute for Social Research (ISR) as its primary evaluator. The ISR recently received approval from the university's institutional review board to conduct several studies—one analyzing a return on community investment, another looking at client use patterns at the University of New Mexico hospital pre-Pathways versus post-connection to a navigator, and a third comparing the Bernalillo County model with the other Pathways models around the country.

Resources Used and Skills Needed

  • Staffing: The pathways program manager works full-time on the project. Up until August 2013, the program manager was supported by the director of the Urban Health Partners (who spent approximately 30 percent of her time on the program). The director has moved on to another position and at present the Pathways Program and Urban Health Partners office are undergoing a reorganization within the Office for Community Health. A part-time administrator, funded through the Urban Health Partners office, assists with some of the administrative aspects of the program, including conducting exit interviews to clients finishing up the program. As noted earlier, the program includes 20 navigators employed by the participating community organizations.
  • Costs: In the first year, the participating community organizations received a total of $643,610, covered by the project’s overall funding of $800,000 per year. Total funding for the community contracts has increased to approximately $690,000 in year 5, representing approximately 82 percent of the total budget.
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Funding Sources

A May 2008 agreement between the Bernalillo County Government and the University of New Mexico provides the project with no less than $800,000 per year of funding through 2017 from the county mill-levy property tax. Additional requests for funding have been and will continue to be submitted to strengthen the evaluation component of the program.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Allow for ample planning and community input: It takes considerable time and effort to plan this type of program, secure funding, recruit community organizations, and get the program up and running. The Bernalillo program took roughly 2 years to launch, with much of the time spent soliciting input from the community. As Ms. Steimel, Director of Urban Health Partners, noted, “We were very careful to allow the process to be defined by the community players.”
  • Look beyond clinical determinants of health: To maximize gains in community health, focus on addressing the social determinants of health (e.g., housing, employment, adult education, food security) along with clinical issues such as medical, behavioral, and oral health.
  • Tap into multiple referral sources: Potential clients can be referred through a variety of methods, including by friends and family members, community health navigators or other staff at participating agencies, and health care professionals conducting home visits. Clients can also be identified through various outreach efforts. As the Pathways Program becomes more established in Bernalillo County, an increasing percentage of the clients are being referred to the program by a friend or family member.
  • Allocate sufficient resources to evaluation: In the design of the program and subsequent agreements made with the University of New Mexico Hospital and community advocates, program leaders focused on allocating as much funding as possible to community contracts. While this approach demonstrated a commitment to the community, it prevented the program from allocating sufficient resources to program evaluation, which has delayed the reporting of outcome indicators.

Sustaining This Innovation

  • Monitor caseload: Community organizations should monitor their caseload to ensure they do not surpass capacity as clients access multiple pathways. As Mr. Smith, program manager for the Pathways Program, explained, “I do promote the program, but cautiously, because there’s a finite set of resources, and the navigators can easily become overwhelmed. There is a lot more need than there are resources, and as the program has evolved, many more residents of the county are now quite familiar with the Pathways Program and partner organizations.”
  • Share data on program impact: Ongoing assessment and sharing of data on the program’s impact helps to ensure continued support. As noted, leaders of the Bernalillo County program feel that more resources should be devoted to evaluation. "We need to be able to demonstrate to the naysayers that the program is a very worthy investment that has had a positive impact on many families in Bernalillo County. One important evaluation indicator that never receives adequate attention is the fact that, according to the 109 exit interviews conducted over the past year, 83 percent of the respondents stated that they have been able to help others with information and resources they learned about through their participation in this program," Mr. Smith noted.
  • Solicit feedback and refine program as needed: Use feedback from navigators and clients to address problem areas, such as refining goals and defining additional pathways. For example, the Bernalillo program added education/GED, homelessness prevention, disability income/appeal, and driver's license/ID pathways in response to suggestions from navigators. As Mr. Smith noted, “When we started to plan the details of the model, we made sure that we had community health workers at the table. Their input was crucial, because this model depends on their work. They are the experts, and their input has really helped in the design and continuous improvement of the program.”
  • Manage navigator workforce: The Bernalillo County program experienced an unexpectedly high turnover rate among its navigators during the first 2 years, primarily because navigators found better paying positions elsewhere. In response, program leaders developed a training program for new navigators. Standing monthly navigator meetings are held to address topics of interest, learn about additional community resources, provide mini-workshops, and allow the navigators to mingle, network, and support one another. The program manager regularly informs the navigators about opportunities for continuing education and encourages their employers to support them in these efforts. In spring 2013, the program provided a 2-day nationally certified training on mental health/first aid and another mini-workshop on time management/organizational skills. The program is contracting with a consultant to develop 24 hours of training materials on service coordination and advocacy skills, community knowledge, and assessment. (Updated December 2013.)
  • Communicate with key stakeholders and learning networks on a regular basis: Ongoing support from the community can be maintained by hosting community meetings, working with a community advisory board, and issuing quarterly public reports. Program leaders note that their participation in the national Community Care Coordination Learning Network (CCCLN) had provided a good deal of support and technical assistance during the first 2 years of program operations. Regrettably, funding for the CCCLN expired in the fall 2011.

Spreading This Innovation

Urban Health Partners has shared information about the program with health planners in California, Florida, Michigan, Minnesota, Missouri, Ohio, Oregon, and across New Mexico who expressed interest in learning about the program and possibly replicating parts of it. The quality assurance manual developed by the program has been distributed and shared with interested individuals from across the country. This manual is being revised and is now available in Spanish. The Pathways Program is always willing to share its ideas, documents, and experiences with any organizations that are interested in learning more about how the program operates in the greater Albuquerque area.

More Information

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Contact the Innovator

Daryl Smith, MPH
Program Manager, Office for Community Health
University of New Mexico Health Sciences Center
1009 Bradbury SE, Room #5
Albuquerque, NM 87106
Phone: (505) 272-0823
Fax: (505) 272-7323

Innovator Disclosures

Mr. Smith reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

More information about the program can be found at:

A third annual report summarizing the first 3 years of program implementation was released in early September 2012 and is available on the Urban Health Partners Web site at:

A study evaluating the benefits of the program is available at:

Additional information was presented during the November 2010 meeting of the American Public Health Association and is available at:


1 The Henry J. Kaiser Family Foundation. The uninsured and the difference health insurance makes. 2010. Available at:
2 Bennett KJ, Moore CG, Probst JC. Estimating uncompensated care charges at rural hospital emergency departments. J Rural Health. 2007;23(3):258-63. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 06, 2013.
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.