Problem Addressed

• 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 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.

Description of the Innovative Activity

• 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, 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 more than 25 percent of clients in the program's first 3 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 15 percent were found through outreach by the community health navigators (updated September 2012). 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: Information provided in September 2012 indicates that a group of 22 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, 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 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 23 currently available pathways encompass medical issues as well as social determinants of health; example 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 (updated September 2012). 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; most 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 (up to $50 per client) 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 (up to $50), and prescription drug copayments.
• 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 $1,425 per client. Examples of outcomes associated with a completed pathway include the following (updated September 2012):
  • 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 client has appropriate health coverage or a financial assistance program in place to establish a health care home and has seen a provider a minimum of two times at his or her new health care home.
• “Hub” for coordination and support: The Urban Health Partners 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.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• Enhanced access to services: During its first 3 years, the program served 1,660 clients, with many of them gaining access to services they very likely would not have received without the program (updated September 2012). Of these (as of this writing), 860 successfully completed all their pathways (indicating a successful outcome), 316 are actively working on one or more pathways, 394 became inactive, and 126 withdrew from the program. Overall, more than 2,118 pathways were completed during the program's first 3 years, as clients may enroll in multiple pathways. The health care home pathway was most frequently completed (by 339 clients), followed by food security (212), employment (187), legal services (184), behavioral health (147), vision and hearing (146), medical debt (136), transportation (105), depression (97), and housing (89). The number of pathways completed does not correspond to the completion rate; overall, 49 percent of those on the depression pathway completed it as opposed to 34 percent on the employment pathway and 26 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.
• High retention rate: Just under two-thirds of participants (64.4 percent) remained in the program for the first 3 years, a very high retention rate given the difficult and unstable situations that many of these clients face on a daily basis.
• High satisfaction: An ongoing and comprehensive analysis of the program found very high levels of satisfaction, with 80 percent of the 55 clients interviewed indicating they were either completely or mostly satisfied with the program. This second round of post-Pathways client interviews is currently underway as of September 2012.
• 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.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• 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, and the University of New Mexico Hospital; 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 patient 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 proposal 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.
• Creating system to distribute funds: During the first year, each participating organization received half of its grant award, prorated on a monthly basis, to cover the costs of being involved in the project. The other half 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: 35 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 62 percent is reimbursed based on the deliverables for client services received.
• 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. Information provided in September 2012 indicates that a third version of this risk score instrument went into effect in July 2012; several questions pertaining to legal matters were added as well as one related to history of incarceration.
• 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. Information provided in September 2012 indicates that these responsibilities were transferred over to the Robert Wood Johnson Center for Health Policy at the University of New Mexico in July 2011. 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. Currently, Urban Health Partners is contracting with the University of New Mexico Institute for Social Research on various program evaluation measures, including an analysis of return on community investment.
  
  

Resources Used and Skills Needed

• Staffing: The Pathways Program manager works full-time on the project, supported by the director of the Office of Community Affairs, who spends 30 to 40 percent of time on the project. As noted earlier, the program includes 22 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 will average $660,000 per year for years 3 through 6, representing 82.5 percent of the total budget.

Funding Sources

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, food security) along with clinical issues such as depression, diabetes, 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.
• 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 evaluation.

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 at the Urban Health Partners, explained: “I promote the project, but am reluctant to promote it too heavily, because there’s a finite set of resources, and the navigators could easily become overwhelmed. Many people who qualify for the program come right to our partner’s doors, with no need to conduct outreach. As we enter our fourth year of operation, the word is definitely out in Bernalillo County.” (Added September 2012.)
• 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 it’s working well, and although we’re not there yet, we are headed in that direction," 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, and disability income/appeal 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, and began holding monthly navigator meetings to address topics of interest, with guest speakers invited to share their expertise. Information provided in September 2012 indicates that the program manager continuously informs the navigators about opportunities for continuing education and encourages their employers to support them in these efforts. In spring 2012, the program provided five trainings: one on the Pathways database/data quality, one on ethics and setting professional boundaries, two different sessions on motivational interviewing, and a final one on mental health/strategies for avoiding burnout.
• 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 (updated September 2012).

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