A Pilot Project for Improving Community and Individual Health

Community Health New Mexico proposes a community-based model that leverages community strengths, fills existing gaps, and provides extra help to those individuals most in need. Each community will be supported to create a network of community care based on the successful Santa Fe Connect Program.

The care network will be enhanced with the Community Health Workers who will provide individual support to the most vulnerable community members, including those referred from primary care providers or other community organizations and those who self-refer. CHWs will help individuals and households by extending the work of primary care providers to the home, providing basic preventive and health promotion information and support, and connecting families to needed health and social services. Finally, Health Extension agents will serve as community organizers and advocates, helping to fill gaps in care identified in the community. HEROs will work with community-based organizations and systems to strengthen local resources—particularly those relevant to social determinants of health.

Our model has two distinct but self-reinforcing aims:

  • First, we seek to enhance support systems at the community level to improve the social determinants of health of whole communities and improve access to and effectiveness of preventive measures, health coaching, as well as access to primary healthcare.
  • Second, we seek to make meaningful strides on the individual patient level by addressing adverse social determinants of health, enhancing health literacy, and supporting healthier behaviors and lifestyles, especially targeting the most vulnerable members of the community.

We propose a funding and oversight model which is based in state government and uses an ongoing, multi-year “Request for Proposals” process to local and/or statewide organizations. We strongly believe that the cost-savings to the Medicaid program in decreased Emergency Room visits and prevention of late-stage chronic disease care will pay for the program  long-term. To begin these programs and learn from implementation at the community level, we propose starting pilot programs in the areas of the state described below. We have met with community health leadership in  these regions and they are  enthusiastic about the Community Health New Mexico model. 

Regions involved

These cover regions with different healthcare and wellbeing needs

  1. San Juan County: including Shiprock and Farmington, both Native American and other groups
  2. San Miguel and Guadalupe counties: including Santa Rosa and Las Vegas, plus a large rural area
  3. Albuquerque’s International District: characterized by a large diversity of immigrants and natives
  4. Lea County: although median income is high, there are some pockets where healthcare and wellbeing need to be addressed

A schematic representation of the Community Health New Mexico model helps to visualize the way we propose to  improve New Mexicans’ health outcomes, build local community capacity, and strengthen and support our state’s healthcare systems.


  1. Community based organizations (CBOs) create the health-promoting, community-serving, comprehensive models which address social determinants, link to the primary care system and inform the other Model components by providing the infrastructure and scaffolding upon which other components contribute. 
  2. State agencies, community colleges, local non-profits contribute to the strength of the local backbone organizations by enhancing primary care and empowering communities to better respond to local issues and  contribute to communities as they address social determinants of health.
  3. University of New Mexico Health Sciences (UNM HSC) can train and deploy CHWs and HEROs,  through its Area Health Education Centers (AHEC), and will partner with communities in evaluating their programs while mobilizing university resources to support CBO health and social priorities, cross pollinate ideas and inspire new initiatives.
  4. Health Extension Regional Officers (HEROs) work with community organizations that affect health, strengthen local resources, provide technical assistance to local groups and link local stakeholders to agencies, higher education and policy bodies.  They become catalysts within participating communities to help identify, understand, and respond to local conditions that impede health and wellness. They enhance primary care practices by strengthening local resources to which those providers refer.
  5. Community health workers (CHWs) work with individuals to take health education initiatives into the community and lessen the  load on primary care. Primary care providers also can extend their effectiveness by referring to CHWs to follow up on their patients with home visits.
  6. A network of support to address social determinants of health is created utilizing “navigators” throughout the community. The CHNM system will use Unite US as its Social Referral Platform, linking household health and social needs with health and social service agencies while tracking the success of referrals and, in tandem with evaluators, impact on a set of health and social metrics (from Emergency Room use to high school graduation to rate of incarceration).