COMMUNITY HEALTH
NEEDS ASSESSMENT
2020
2
UNM Hospitals
Our Commitment
to Our Community
The University of New Mexico Hospitals is on a mission to improve the health and health
care of all New Mexicans. We cannot reach this goal without the support, wisdom and
active engagement of the many dierent communities we serve. In the summer of 2019,
UNMH asked Bernalillo County residents two very important questions: What do you
need? And what can we do better? The answers we heard showed us the many points
of view and top needs of county residents. Community responses are the driving force
behind the 2020 UNM Hospitals Community Health Needs Assessment.
As we traveled from neighborhood to neighborhood, the feedback clearly showed the
unique and diverse experiences of members in Bernalillo County communities. Several
common themes emerged: access to medical services, unmet behavioral health needs,
substance use issues, and health disparities. These are concerns shared by residents
of the South Valley, Northeast Heights, East Mountains, West Mesa and all points in
between. The University of New Mexico Hospital (UNMH) is working on behalf of all
Bernalillo County residents to increase access to services and decrease health disparities.
The 2020 Needs Assessment reflects the valuable input we received from the many
people who took the time to share their thoughts with us. It’s just the first step. As
we work to turn the insight gathered during our listening sessions into improvements
in health care quality and access, we look forward to working with the many people,
organizations, health care providers and public entities that share our deep commitment
to a healthier New Mexico.
Kate Becker
CEO, UNM Hospital
2020 Community Health Needs Assessment and Implementation Strategy
1
Table
of Contents
Executive Summary
About UNM Health System and the UNM Hospitals
• UNM Hospitals Awards & Designations
• Collaborating with the Community to Improve Access and Care
• Growing to Meet the Community’s Needs
• Partnering with Native American Communities
• The Children’s Hospital of New Mexico
• UNM Hospitals Clinic Map
CHNA Methodology: How the CHNA Process Works
• Part 1. Gathering Data: Listening Sessions
• Part 2. Gathering Data: Facts and Figures about the Health of Bernalillo County
Description of Community
• Demographic Characteristics
• Language
• Immigration and Citizenship
• Poverty
• Housing
• Educational Attainment
• Access to Healthy Food
• Access to Care
• Behavioral Health
• Seniors
• Maternal and Infant Health
• Adult Health Behaviors and Risk Factors
• Youth Health Behaviors and Risk Factors
• Chronic Disease
• Leading Causes of Death
• Unintentional Injury
Putting the Pieces Together: Identifying Top Health Needs
Appendix 1 - Figures
Appendix 2 - Tables
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71
1
UNM Hospitals
Executive
Summary
An in-depth Community Health Needs
Assessment (CHNA) is a systematic process
that gathers information on the most
important and unmet health needs from
community members and leaders. The
process provides a way for hospitals to work
with communities to rank health needs and
to develop and put into place strategies to
address those needs together. This report
is the product of the first two steps in the
five-part CHNA process shown in Figure 1.
UNM Hospitals is an academic hospital in
Albuquerque, New Mexico. UNMH serves all
New Mexicans, but most people getting basic
day-to-day health care services are residents
of Bernalillo County. As the state’s only
academic medical center and Level I trauma
center, UNMH is the main source of specialty
care for patients from across the state. UNMH
is part of the UNM Health System.
UNMH grew out of a collaborative eort
of the U.S. Bureau of Indian Aairs,
Indian Health Service, and Bernalillo
County. It began operation in 1954 as the
Bernalillo County Indian Hospital. Today,
the UNM Health System is New Mexico’s
fourth largest employer. Its 8,000 team
members and 1,290 faculty physicians
have a three-part mission to deliver the
highest quality patient care, educate
medical providers and other health
professionals involved in patient
care, and cutting-
edge research.
The 2020 UNMH
Community Health
Needs Assessment
seeks to recognize and elevate
the community’s health care
priorities and to set up a framework for
program and resource development to
meet those needs. To better understand
those needs, UNMH analyzed population
health data (information about the
health of specific groups) from a variety
of sources and held listening sessions
throughout Bernalillo County to ask for
community feedback about health care
service needs and priorities.
Gather
Information
Compile
Assessment
& Prioritize
Develop
Plan &
Strategies
Evaluate,
Report and
Repeat
Implement
Figure 1
2020 Community Health Needs Assessment and Implementation Strategy
2
A stakeholder group from within UNMH
that included the Ambulatory Executive
Committee, clinic and outpatient directors,
financial managers, and leadership from
the Oce of Diversity, Equity and Inclusion
reviewed both kinds of data developed for the
assessment. They chose the health care needs
to focus on over the next three years.
UNMH met with community members and
leaders to find and talk about possible
community-wide solutions in each focus
area. Hospital leadership also helped
develop strategies that build up and/or add
power to existing hospital resources and
current UNMH programs to address the four
focus areas.
INCREASING ACCESS TO BEHAVIORAL
HEALTH SERVICES
Increasing access to behavioral health
services is a top priority for policymakers
and community leaders throughout
Bernalillo County and New Mexico. UNMH
is a key participant in several major
initiatives to strengthen New Mexico’s
behavioral health safety net. Strategies
to improve access to behavioral health
services build upon and strengthen these
collaborations and include the following:
• expanded crisis and psychiatric
emergency services
• continued service development at the
Bernalillo County Care Campus and
Care Link Behavioral Health Home
• expanded programming for behavioral
health patients who are incarcerated
or returning to the community after
imprisonment
Doing a good job of addressing behavioral
health needs often requires meeting
patients where they are. To this end,
UNMH is also exploring ways to bring
behavioral health services into medical
clinics like obstetrics and gynecology.
Four areas emerged from this process:
• Increase Access to Behavioral
Health Services
• Improve Access to Medical Services
• Expand Access to Medical
Coverage and Financial Assistance
• Reduce Inequities that lead to
Disparities in Health Outcomes
3
UNM Hospitals
IMPROVING ACCESS TO MEDICAL CARE
As New Mexico’s only academic medical
center, UNMH is the state’s only place to get
many types of specialty care. High demand
for specialty services and widespread
provider shortages sometimes mean that
patients wait weeks or even months for
care. The most important strategy for
improving access to care is to increase the
number of doctors and advanced-practice
providers. We will also work on putting
dierent services in the same locations.
Finally, we will focus on streamlining
appointment, referral, and administrative
processes to increase the eciency of the
way we use limited health care resources.
EXPANDING ACCESS TO MEDICAL
COVERAGE AND FINANCIAL ASSISTANCE
New Mexico has taken important steps to
improve health insurance coverage rates,
but 1-in-10 New Mexico residents remain
uninsured, and, even with insurance, health
care can be expensive. UNMH provides
patients and their families with a variety of
services and supports to help manage and
oset health care costs; but communities
are not always aware of these services. We
will focus on outreach, communication,
and collaboration with the community
organizations who work daily with
economically vulnerable county residents
in order to improve access to financial help.
REDUCING INEQUITIES THAT LEAD TO
DISPARITIES IN HEALTH OUTCOMES
The details of people’s lives, including
where they live and work, their education
level and language, their income,
immigration status, race and gender, all
have an eect on their health, their access
to health care, and their health outcomes.
These factors, known together as the
social determinants of health, contribute
to the relatively poor health outcomes
often experienced by communities of
color. UNMH strategies to reduce health
disparities emphasize cultural humility and
address the social determinants of health.
They include the following:
• increased access to interpreter services
• analyzing UNMH quality data to
identify racial and ethnic disparities
• working with the Health System’s
Oce of Diversity, Equity, and Inclusion
to address disparities
2020 Community Health Needs Assessment and Implementation Strategy
4
• decreasing the number of patients who
leave the ED without receiving care
• connecting patients with community
resources to address issues like housing,
employment, food insecurity, and
domestic abuse
The next step in the CHNA process is to
work with community partners to put
these strategies into action. We will publish
yearly reports tracking our progress and
documenting community health results.
The UNM Health System serves all
New Mexicans’ needs for routine
medical procedures, chronic
disease management and care
during major health events. From
its central New Mexico base of
operations in Bernalillo County
to the four corners of the state,
UNMH and all of its clinics work
hard to identify and answer the
most important questions of
human health in our communities
through education, scholarship
and service.
5
UNM Hospitals
UNM HOSPITALS HEALTH PRIORITIES SUMMARIZED “SNAPSHOT” OF FOCUSES
Detailed Strategies in Implementation Plan
Focus 1: Increase Access to Behavioral Health Services
• Explore bringing behavioral health services
into medical clinics
• Continued service development at the
Bernalillo County Care Campus
• Expanded programming for patients are or
who have been in prison for mental health
reasons
• Consult with national experts on strategies to
increase access to behavioral health services
• Expansion of crisis services and psychiatric
emergency services
• Further development of the Care Link
Behavioral Health Home
Focus 2: Increase Access to Medical Services
• Locate specialty services within primary
care clinics
• Streamline the movement of patients between
specialty and primary care clinics
• Explore the development and implementation
of women’s integrated health care
• Recruit additional physicians and advanced
practice providers
• Consider expanding clinic hours of operation
• Building and equipment renovation and
expansion
• Improved tools for managing referrals. (A
referral is instructions from one provider to see
a dierent provider who has special training in
a specific area)
• Improvements in scheduling eciency
• Redesign clinic workflows to reduce scheduling
delays and referral backlogs
• Add sta to increase the number of providers
• Increase availability of primary care physicians,
with particular focus for hard to reach
populations
• Use panel management to improve continuity
of care and increase access for hard-to-reach
populations (A panel is a list of patients
assigned to individual providers or clinics)
• Other specialty-specific strategies are included
in the implementation plan
Snapshot above serves as a summary of strategies only. See full description in the UNM Hospitals Community Health
Implementation Plan 2020.
2020 Community Health Needs Assessment and Implementation Strategy
6
Focus 3: Increase Access to Medical and Financial Assistance
• Increase sta from Patient Financial Services at
UNMH clinics
• Improve messaging about financial services
• Update public-facing materials
• Provide trainings to community organizations
about financial assistance programs
• Hold financial assistance information meetings
• Update UNMH website to make sure it has the
same message across the board
• Promote awareness of Patient Financial
Services’ programs available to immigrant
patients
• Establish a universal contacts list for UNMH
financial services sta
• Explore ways to give patients a better
understanding of what their costs will be and
provide financial counseling
Focus 4: Reduce Inequities that Lead to Disparities in Health Outcomes
• Embed community health workers in clinics
to screen for and assist patients in addressing
adverse Social Determinants of Health
• Increase awareness of interpreter services
• Participate in community outreach and
support programs
• Provide care coordination and health care
delivery at the Westside Shelter
• Increase awareness of community resources
available to patients who face adverse social
determinants
• Provide training to community organizations
on programs available through the Oce of
Diversity Equity and Inclusion (DEI)
• Monitor quality outcomes data to identify and
address racial/ ethnic disparities, then work
with Diversity, Equity and Inclusion (DEI) to
address issues
• Make sure that patients leave the hospital
understanding at-home instructions
• Have fewer patients leave the Emergency
Department without getting care
• Create environment where patients feel they
can submit complaints
• Work to reduce the number of gendered
spaces (male or female) for patients and sta
• Create a DEI educator position
• Explore the addition of sensitivity training
specific to DEI
Snapshot above serves as a summary of strategies only. See full description in the UNM Hospitals Community Health
Implementation Plan 2020.
7
UNM Hospitals
About UNM Health System
and UNM Hospitals
The University of New Mexico Hospital is
an academic hospital in Albuquerque, New
Mexico. UNMH serves all New Mexicans,
but most patients getting primary services
are residents of Bernalillo County. As the
state’s only academic medical center and
Level I Trauma Center, UNMH is the primary
source of specialty care for patients from
across the state. UNMH is part of the UNM
Health System.
Primary care means care given
by providers who have training
in day-to-day health care needs,
including preventive care. They
often help coordinate other
kinds of care the patient may be
getting. Specialty care means
care provided by doctors who
have training in certain areas of
medicine, like certain diseases, or
certain parts of the body.
Less than 400
791 - 4,000
7,601 - 11,000
401 - 790
4,301 - 7,600
Figure 2
Source: SG2 State Data Analysis- Health Intelligence Company, LLC; OptumInsight, IQVIA, Analysis, 2020. Time period of analysis
2015Q4-2018Q
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2020 Community Health Needs Assessment and Implementation Strategy
Less than 400
491 - 2,400
2,601 - 7,000
401 - 490
2,401 - 2,600
Figure 2 UNMH inpatients by zip code of
residence. Colors indicate the number of
patients, with yellow indicating the fewest
patients and dark olive indicating the most.
UNMH serves the entire state of New Mexico
and also serves patients from northeast
Arizona referred by the Indian Health Service.
Figure 3 UNMH inpatients by zip code
of residence for Bernalillo county. Colors
indicate volume counts ranging from yellow
(fewest) to dark olive (most).
Figure 3
Source: SG2 State Data Analysis- Health Intelligence Company, LLC; OptumInsight, IQVIA,
Analysis, 2020. Time period of analysis 2015Q4-2018Q
9
UNM Hospitals
UNMH, the medical services arm of the UNM
Health System, New Mexico’s only academic
health center, is the state’s only Level 1
Trauma Center (Figure 4). The UNM Health
System also includes the following:
• UNM Comprehensive Cancer Center,
only NCI designated cancer center in NM
• Comprehensive stroke and
neuro-trauma services
• A comprehensive burn center
• A pediatric cardiothoracic
surgery program
• Advanced women’s health care services
• Adult and children’s psychiatric services
• Bariatric and orthopaedic programs
The Health System also includes dozens of
other specialty lines. With over 8,000 team
members and 1,290 faculty, the UNM
Health System is also the state’s fourth
largest employer.
The health system is made of the following:
• University of New Mexico Hospital
• Sandoval Regional Medical Center, which
combines the personal attention of a
community hospital with the expertise
and resources of an academic health
care facility
• UNM Children’s Hospital and UNM Carrie
Tingley Hospital, which oer the widest
range of pediatric services in the state
• UNM Comprehensive Cancer Center,
where 60 percent of adult cancer
patients and almost all pediatric cancer
patients in New Mexico receive care
• UNM Clinical Neurosciences Center,
the only comprehensive neurology,
neurosurgery and pain management
center in the Southwest
• UNM Psychiatric Center and UNM
Children’s Psychiatric Center, which
provide the full spectrum of behavioral
health care
• Dozens of outpatient care oces,
including facilities strategically located
in historically underserved areas in and
around Bernalillo County; and outreach
throughout New Mexico through
mobile clinics, hosted specialty clinics
and telehealth
• The University of New Mexico Medical
Group, Inc., a network of more than 1,100
practitioners in more than 150 specialties
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2020 Community Health Needs Assessment and Implementation Strategy
All together the hospitals handle 22,000
surgical cases, 100,000 emergency room
visits and nearly 900,000 outpatient visits
per year.
As a major component of the UNM Health
System, UNMH cares for a large, diverse
population with complex and urgent health
needs, providing more than $135 million
of unpaid care each year. Each year, UNM
hospitals and clinics:
• Provide care for more than 200,000
New Mexicans
• Serve as training sites for students of
medicine, nursing, pharmacy and other
health professions
• Play an important role in The UNM’s
community-based health research
Figure 4
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UNM Hospitals
UNM Hospitals Awards
and Designations
UNM Hospitals has received awards for
excellence in the care of Stroke, Trauma/Burn,
Lifeguard Air Emergency Services, Women’s
Care, Behavioral Health, and Comprehensive
Cancer Care. In addition, the hospital
consistently achieves top marks for diversity
and inclusive services to name a few.
A Cancer Center Designated by the
National Cancer Institute
Comprehensive
Cancer Center
UNM Hospital
Level 1 Trauma Center
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2020 Community Health Needs Assessment and Implementation Strategy
Collaborating With the
Community to Improve Access
and Care
The 2020 CHNA is one of many ways
UNMH gathers and responds to input
from the community. Other avenues of
community input are described in the
following paragraphs.
The UNMH Patient Family Advisory Council
(PFAC) is a volunteer committee made up
primarily of UNMH patients and caregivers.
The PFAC supports patient-centered care
at UNMH by making sure that patients
and caregivers have a voice in hospital
planning processes and decision-making.
Patient family advisors partner with UNM
sta to put in place patient-centered
improvements and best practices.
PFAC members are chosen through an
application process that helps to make
sure that Council membership reflects the
diversity of the communities served by
UNMH. The PFAC meets monthly.
UNMH CEO, Kate Becker, makes quarterly
presentations to the Bernalillo County
Commission on topics that include
hospital data on quality, access to care,
and financial services. The presentations
give commissioners and county residents
an update on recent developments
at UNMH as well as an opportunity to
provide feedback directly to hospital
leadership. Between meetings, hospital
sta hear directly from commissioners
and their constituents about a broad
range of issues and concerns.
The Bernalillo County Community Health
Council (BCCHC) is another key source of
community input for UNMH. The BCCHC
is a 501(c)(3) non-profit organization
Patient-centered care is “based on
deep respect for patients as unique
living beings, and the obligation to
care for them on their terms.”
Dr. Ron Epstein
https://catalyst.nejm.org/doi/
full/10.1056/CAT.17.0559
Patient centered care shifts the
focus of decision-making from the
health care system to the individual
patient in order to provide care
that is respectful of, and responsive
to, individual patient preferences,
needs and values. The PFAC is an
example of patient-centered care in
action. UNMH uses information and
ideas from patients to improve and
redesign practices so they center on
individuals more than on a checklist
of services.
13
UNM Hospitals
with a board of directors that includes
community members, health and social
service providers, educators, and other
private and public entities that serve county
residents. The Council works to improve
the health and well-being of all Bernalillo
County residents by focusing on healthy and
sustainable communities, improved health
and educational outcomes for children and
youth, and increased access to high-quality
health care for the county’s uninsured and
indigent residents.
UNMH CEO, Kate Becker and members
of her leadership team meet every other
month with members of the Bernalillo
County Healthcare Task Force to report
on progress toward health care goals
established by the task force and formalized
in the Memorandum of Understanding
(MOU) that governs the funding relationship
between the County and the Hospital.
The task force includes community health
experts and advocates and was convened in
2014 by the Bernalillo County Commission
to establish county-wide health system
planning goals and provide guidance on
development of the MOU.
The Community Engagement Committee
of the UNMH Board of Trustees meets
monthly. Members of the public are
encouraged to attend. Committee
priorities include making the most of
community input by identifying gaps and
adding to strengths in existing channels
for feedback.
UNMH also partners with other
governmental entities including
Bernalillo County and the City of
Albuquerque to address community
needs. The UNM Health System plays
a major role in the Bernalillo County
Behavioral Health Initiative.
1
BERNALILLO COUNTY BEHAVIORAL
HEALTH INITIATIVE
The Bernalillo County Behavioral Health
Initiative (BHI) is a joint eort of Bernalillo
County, the City of Albuquerque and
University of New Mexico Hospitals to
develop a comprehensive sequence of
behavioral health care for residents of
the Albuquerque metro area. The region’s
under-resourced behavioral health safety
1
https://www.bernco.gov/health-and-public-safety/behavioral-health-overview.aspx
14
2020 Community Health Needs Assessment and Implementation Strategy
net is dicult to navigate and riddled
with gaps, often resulting in not enough
treatment, public safety concerns, and a
revolving door for behavioral health patients
at the Metropolitan Detention Center and
the UNMH ER.
In 2014, Bernalillo County voters
overwhelmingly approved a tax to fund
improved and expanded behavioral health
services county-wide.
2
The County, City, and
Hospitals have come together to strengthen
the safety net and confirm that the new
funding is used eectively by coordinating
and adding to existing resources for mental
health and substance abuse treatment. So
far, the BHI has funded over 20 programs,
which run the gamut from permanent
supportive housing to crisis services. UNMH
is actively involved in a number of BHI-
sponsored programs, including the following:
• Expansion of psychiatric
emergency services
• Expanded services at the
Children’s Psychiatric Center
• Transition services for the
Metropolitan Detention Center
inmates prior to and post-release
at the Re-entry Resource Center
• A Crisis Stabilization Center for
patients who are having acute
symptoms of mental illness and
substance use disorders
• Clinical detoxification services
at the Bernalillo County Care
Campus supports for children
and families impacted by
adverse childhood experiences
in the UNMH pediatric ER
• Intensive case management
services for individuals
experiencing both mental illness
and substance use disorders
2
For election results see ‘Advisory Question 2’ at https://www.bernco.gov/uploads/files/Unocial_gen_elec_2014.pdf
15
UNM Hospitals
Growing to Meet the
Community’s Needs
The facility now called UNMH opened in
1954 as Bernalillo County Indian Hospital.
The hospital came into being as the result
of a 1952 contract between the US Bureau
of Indian Aairs (BIA), the Indian Health
Service, Bernalillo County and the State of
New Mexico. The 1952 contract conveyed
land from the BIA to Bernalillo County
for purposes of building and operating a
licensed hospital with at least 100 beds set
aside for priority use by Native American
patients. In the late 1960’s, the facility
became part of the University of New
Mexico, and in 1979, the hospital took its
current name.
UNMH built an emergency/critical care
addition in 1984. The facility’s most
recent major upgrade, the Barbara and
Bill Richardson Pavilion, opened in spring
2007. The pavilion added nearly 500,000
square feet of space, including an expanded
emergency department, UNM Children’s
Hospital, and other areas designed for
eciency, safety and the latest technology.
Despite facilities growth and improvements,
for a number of years UNMH has operated
well above the 85 percent average capacity
threshold considered optimal for hospital
eciency. The shortage of beds has
meant that patients share rooms or wait
on gurneys for rooms to become available.
It has also reduced the hospital’s ability
to accept transfers from other hospitals
in New Mexico. Currently, UNMH is ready
to begin a five-year expansion project to
address critical needs for additional beds
and improved facilities. The addition,
which will be built on 6.7 acres west of
the hospital near Lomas Blvd. NE and Yale
Blvd. NE, will include 96 inpatient beds, 18
operating rooms, diagnostic services and
other additions.
Care management means working
to coordinate appointments and
follow-up care. Follow-up care may
mean services that are not medical,
like transportation and food
resources that help patients stay
healthy and out of the hospital.
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2020 Community Health Needs Assessment and Implementation Strategy
Partnering with Native
American Communities
The original federal contract that laid the
groundwork for what is now UNMH has been
amended several times, but the hospital’s
commitment to serving native populations
remains unwavering and is evident in day-
to-day operations as well as governance,
administration, and collaborations.
NATIVE AMERICAN SERVICES AT UNMH
UNMH Native American Health Services
(NAHS) provides Native American patients
with priority admissions and outpatient
clinic appointments, while taking into
consideration the medical needs of all
patients. NAHS sta includes patient care
coordinators and community liaisons
(people who act as contacts between the
Hospital and the community—see below.)
They serve as patient advocates and help
with care management.
The NAHS team also coordinates with
organizations that refer patients to UNMH
and is available to help resolve concerns
voiced by Native American patients.
The hospital’s financial assistance team
helps tribal members enroll in federal and
state programs like insurance through
the Aordable Care Act and New Mexico
Medicaid and in the hospital’s in-house
financial assistance program, known as
UNM Care.
NATIVE AMERICAN REPRESENTATION
AND CONSULTATION
To make certain of native representation
in hospital oversight and policymaking,
the UNMH Board of Trustees includes
one member appointed by the All
Pueblo Council of Governors (APCG).
A representative at large appointed
by the UNM Board of Regents is a
Pueblo community member. The Board
of Trustees also meets with a Native
American sub-committee every other
month. Community liaisons work with
NM Pueblos, Tribes and Nations in
their home communities throughout
the year, providing information about
UNM, understanding specific health-
related concerns experienced by that
specific tribal community, helping
with access to services at the hospital,
and attending community events and
17
UNM Hospitals
health fairs. Community liaisons build
connections between tribal communities
and University of New Mexico educational
pipeline programs that prepare and
encourage young people to enter health
care professions. In addition, hospital
administrators meet with tribal leadership
twice a year and with the Indian Health
Service quarterly.
The Children’s Hospital of
New Mexico
The University of New Mexico Children’s
Hospital, New Mexico’s only dedicated
Children’s Hospital, is an academic
medical center with health care providers
expertly trained to deliver the most
advanced neonatology and pediatric care
in New Mexico. In addition, UNMH Carrie
Tingley Hospital (CTH), founded in 1937,
provides compassionate, coordinated
health care to children and adolescents
with complex musculoskeletal and
orthopedic conditions, rehabilitation
needs, developmental issues and long-
term physical disabilities. CTH includes
more than 21 specialized outpatient clinics
ranging in focus from juvenile arthritis to
clinical genetics to brain and spinal cord
injuries to development and neurological
conditions. Through CTH, thousands
of pediatric patients receive access to
advanced treatments in clinical trials.
18
2020 Community Health Needs Assessment and Implementation Strategy
UNM HOSPITALS CLINIC MAP
UNM Hospitals Clinics are located throughout Bernalillo County. To make sure everyone
can get there, each UNM Hospitals Clinic is located on a major bus line.
To Rio Rancho
Ellison
New Ellison
Corrales Rd.
Hwy. 528
Alameda Rd.
Hwy. 85
Paseo del Norte Rd.
Academy Rd.
Candalaria Rd.
Carlisle Blvd.
San Pablo
Yale Blvd.
Louisiana Blvd.
Wyoming Blvd.
Tramway Blvd.
Montgomery
Indian School Rd.
Gibson Blvd.
Alamo
Central Ave.
Menaul Rd.
Lomas Rd.
Tramway Blvd.
Coors Rd.
Rio Grande Blvd.
4th St.
2nd St.
Osuna Blvd.
Montaño Blvd.
Montaño Blvd.
Bridge Blvd.
Rio Bravo Blvd.
S. Coors Rd.
Isleta Blvd.
Broadway
Atrisco Dr.
40
40
25
H
H
Figure 5
21
19
UNM Hospitals
A comprehensive Community Health Needs
Assessment is a systematic process that
gathers information on health needs and
priorities from community members and
leaders. This data is analyzed along with
epidemiologic data and strategies are
developed to address the priority needs.
These strategies, once put into action, are
evaluated and the results are reported
back to the community. The process then
begins again, with each successive CHNA
building on the insight and outcomes of
the preceding CHNA. The present report
represents the first two steps in the five
step CHNA process shown in Figure 6.
The Aordable Care Act requires that
501(c) 3 hospitals conduct a CHNA every
three years. As a governmental hospital,
UNMH does not have to, but has chosen
to do the CHNA process as a way to
engage with and become more responsive
to the communities it serves.
Part 1. Gathering Data:
Listening Sessions
The University of New Mexico
Hospital began conducting the 2020
comprehensive Community Health Needs
Assessment in the spring of 2019. Part
1 of the process was to hold listening
sessions with community leaders and
residents from Bernalillo County’s diverse
neighborhoods and population groups
(a complete listing of Community Health
Needs Assessment listening session
regions in Bernalillo County is
provided as Appendix 3). During
the summer and
fall of 2019, UNMH
held 21 community
listening sessions
at locations
Gather
Information
Compile
Assessment
& Prioritize
Develop
Plan &
Strategies
Evaluate,
Report and
Repeat
Implement
Figure 6
CHNA Methodology:
How the CHNA Process Works
Epidemiology is the study of things
that determine the causes, the
distribution (the who, when and
where patterns) and the frequency
of health and disease conditions in a
specific population.
20
2020 Community Health Needs Assessment and Implementation Strategy
throughout Bernalillo County to find out
answers from community partners to the
following questions:
Seventeen community listening sessions
open to the public were held in 11
neighborhoods across Albuquerque
and unincorporated Bernalillo County.
Information was also gathered at four
meetings held by the leadership teams of
community-based social and health care
organizations. Particular focus was placed
on gathering information from communities
located south of I-40 and west of I-25, due
to the high occurrence of unmet health
care needs in these areas. Two sessions
were conducted entirely in Spanish and
interpreters were available during most of
the other public meetings.
UNMH sta compiled and analyzed the
feedback obtained from the listening
sessions to identify common themes and
cross-cutting priorities. Input is added
on an on-going basis from numerous
other sources including the PFAC,
County Commissioners, Bernalillo County
Community Health Council, and the All
Pueblo Council of Governors and further
added with community-specific data on
health care, health outcomes, and the
social determinants of health to produce
the most comprehensive possible picture
of each community’s health strengths
and challenges.
The next step in the UNMH 2020 CHNA
is to develop a plan and implementation
strategy to address the county’s most
important unmet health needs. UNMH
received a wide range of comments and
suggestions from the listening session on
how to improve the community’s ability
to thrive. Every comment was noted and
considered carefully to test whether or
not it could be practically used. Data from
the listening sessions was strengthened
with community-specific data on health
care, health outcomes, and the social
determinants of health to produce the
most comprehensive possible picture
1. What are your health needs?
2. How are these needs being met
(or not met)?
3. What issues aect your ability
to thrive?
4. How can UNM Hospitals help
address these issues?
21
UNM Hospitals
of each community’s health strengths and
challenges. All of this information was
distilled to fit within a four- focus approach.
Ultimately, UNMH is committed to working
with community members, social service
providers, public health agencies, local
governments and health care providers to
develop a roadmap towards better, more
equitable health outcomes using information
from the CHNA.
Part 2. Gathering Data:
Facts and Figures about the
Health of Bernalillo County
THE SOCIAL DETERMINANTS OF HEALTH
The health care community and the
community at large are becoming
increasingly aware of the monumental
role that factors outside of the health
care system play in determining health
outcomes. The many economic and social
conditions that aect health outcomes are
together called the Social Determinants
of Health (SDoH). SDoH include factors
like income and employment, educational
levels, access to health care, language and
literacy, personal and public safety, and
environmental hazards at work and in the
community. Unequal access to SDoH-related
resources like safe and aordable housing,
educational opportunity, public safety,
and community-based social support,
contribute to health disparities between
dierent population groups.
In the following sections, we will provide
some of the facts and figures about the
social determinants of health in
Bernalillo County.
EXAMPLES OF SOCIAL DETERMINANTS
OF HEALTH
Adverse (harmful) childhood experiences,
or ACEs, are traumatic events that
happen in childhood like experiencing
violence or abuse in the home, the death
or imprisonment of a parent, untreated
mental health problems, and housing
instability or homelessness. ACES are
a public health issue because they can
interfere with healthy child development.
They can have negative impacts that
last well into adulthood, undermining
an individual’s ability to succeed in
education, employment, and relationships.
ACEs are also linked to chronic illness
like heart disease and behavioral health
problems like mental illness and substance
use. The impact of ACES is cumulative,
22
2020 Community Health Needs Assessment and Implementation Strategy
meaning that the more adverse experiences
a child has, the greater their risk of negative
short and long-term consequences.
Although the exact means by which ACES
influence health are not fully understood,
toxic stress - the eects on the brain of
repeated exposure to high levels of stress
hormones - is likely a major contributor.
Awareness of ACES helps health care
providers better meet the needs of their
adult patients, support parents in reducing
the ACES experienced by their children, and
help children going through trauma to learn
resiliency (the ability to withstand or adjust
to challenges) through the use of trauma-
informed approaches.
Economic hardship and divorce or separation
of parents or guardians are the most
common ACEs. New Mexico has one of the
nation’s highest rates of ACES. One-in-four
New Mexico children have experienced one
adverse childhood experience, and 18 percent
have experienced three or more ACES, a rate
almost twice the national average.
Trauma-informed care,
an example of SDoH
Trauma-informed Care (TIC)
is a treatment framework that
acknowledges the impact of
trauma, recognizes its symptoms,
responds to its eects through
appropriate practices and
policies, and seeks to prevent
further trauma. Programs that
use a trauma-informed approach
recognize that many of their
patients have histories that
include physical, sexual, and/or
emotional abuse as well as past
negative experiences in the medical
setting. Program sta are trained
to be aware of the ways culture,
community, and identity impact a
patient’s experience of health care
and ability to access resources and
to be sensitive to the heightened
need for safety and a sense of
control in the health care setting
that past trauma can engender.
TIC is a critical component of
health care access.
Source: Sacks, V. and Murphey, D. The prevalence of adverse childhood experiences, nationally, by state, and by race/ethnicity.
2018. Child Trends. Retrieved from:
https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity
Sources: Tello, M. “Trauma-informed care: What it is, and why it’s important.” Harvard Health Blog. March 23, 2019
https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562 and Substance
Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
23
UNM Hospitals
Description of Community
DEMOGRAPHIC CHARACTERISTICS
Demographic characteristics, like age and gender, make a dierence in health status and
health care needs. One-in-three New Mexico residents, almost 680,000 people, live in
Bernalillo County. Table 1 shows the age distributions of both Bernalillo County and New
Mexico residents.
Bernalillo County and NM
Residents by Age Group
Bernalillo County New Mexico
Under 5 years 40,559 131,062
5 through 19 129,174 422,712
20 through 64 406,010 1,202,372
65 through 84 87,632 292,365
85 an 85 and older 11,480 36,317
Total 674,855 2,084,828
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
Table 1
24
2020 Community Health Needs Assessment and Implementation Strategy
Like the rest of New Mexico, Bernalillo
County has a large Hispanic and White
non-Hispanic populations. Bernalillo County
includes Isleta, Laguna, and Sandia Pueblos
as well as To’Hajiilee, a separate part of
the Navajo Nation. Native Americans
make up just over 4 percent of Bernalillo
County residents and 9 percent of residents
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
statewide. As the state’s most densely
populated urban area, Bernalillo County
is somewhat more diverse than the
state overall, with larger shares of Asian
and African American residents (Figure
7). Bernalillo County is also home to
immigrants and refugees from around
the world.
4.4%
2.9%
3.0%
50.3%
39.4%
9.1%
1.8%
2.2%
49.1%
37.9%
0%
10%
20%
30%
40%
50%
60%
Native American Asian African American Hispanic White Non-Hispanic
Race & Ethnicity of Bernalillo County and NM Residents
Bernalillo County New Mexico
Figure 7
Race and Ethnicity of Bernalillo and NM Residents
25
UNM Hospitals
Language
Language is a key social determinant of health because it is the primary way people
communicate their health needs and receive health information. Individuals who have
trouble communicating in English often find it dicult to make their way through the
increasingly complex health care system and get the care they need. Thirty percent of
Bernalillo County residents speak a language other than English at home (Figure 8).
444444,,777766
115555,,115588
99,,665566
1100,,116622
1144,,554444
Bernalillo County Residents: Language Spoken at Home
English Spanish Other Indo-European languages Asian languages Other languages
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
Figure 8
Bernalillo County Residents - Language Spoken at Home
26
2020 Community Health Needs Assessment and Implementation Strategy
In Bernalillo County, the percentage of people who speak a language other than English
at home ranges from 13 percent in the East Mountain area to 53 percent in the South
Valley (Figure 9).
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
Figure 9
Percent of County Residents Who Speak a Language other than English at Home
13%
19%
21%
22%
23%
24%
26%
27%
30%
31%
35%
35%
49%
53%
0% 10% 20% 30% 40% 50% 60%
East Mountain
Far NE Heights
NE Heights
UNM
NW Mesa and Southern Bernalillo Cnty
N NE Heights
Four Hills
North Valley
Bernalillo County
Downtown
SE Heights
New Mexico
SW Mesa
S. Valley
Percent of County Residents Who Speak a Language other than English at Home
27
UNM Hospitals
Immigration and Citizenship
Bernalillo County is home to almost 69,000 immigrants. Over two-thirds of the county’s
immigrant population is from Central and South America, but the county is also home
to a significant population of immigrants from a number of Asian countries (Figure 10).
Immigrants in general face many barriers to health care, including low incomes, lack of
insurance, language and cultural barriers. Nationally, per person health care expenses for
immigrants are less than half that of US-born citizens.
7%
20%
3%
68%
2%
Bernalillo County Immigrants by Continent of Origin
Europe Asia Africa Latin America Northern America
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
Figure 10
Bernalillo County Immigrants by Continent of Origin
3
Sarita A. Mohanty, Stee Woolhandler, David U. Himmelstein, Susmita Pati, Olveen Carrasquillo, and David H. Bor. “Health Care
Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” American Journal of Public Health 2005;
95
28
2020 Community Health Needs Assessment and Implementation Strategy
4
Estimated using data from American Community Survey 2017 5 Year Public Use Microdata and methodology from Pew Research
Center See: https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state/
5
Sarita A. Mohanty, Stee Woolhandler, David U. Himmelstein, Susmita Pati, Olveen Carrasquillo, and David H. Bor. “Health Care
Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” American Journal of Public Health 2005;
95
Approximately 19,000 of the 41,606 non-citizen immigrants residing in Bernalillo County
are not legally authorized to be in the US
4
. Undocumented immigrants are at an especially
great disadvantage when it comes to getting health care for themselves and their children,
even when those children are US citizens. Research has found that undocumented
Hispanic immigrants are far less likely than US citizens to have a usual source of health
care or receive regular health screenings, two key markers of health care access. Further,
even though over 70 percent of the children of undocumented immigrants are US citizens
by birth and qualify for support like Medicaid coverage, they still receive 74 percent less
health care than the children of US citizens.
5
Foreign-Born Residents of
Bernalillo County
Foreign-born population 68,646
Naturalized U.S. citizen 27,040
Not a U.S. citizen 41,606
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
Table 2
29
UNM Hospitals
Poverty
Poverty is a strong and well-documented
determinant of health outcomes. Poverty
undermines health in many ways, including
not enough or uncertain access to
nourishing food and shelter, lack of access
to health care and health information,
negative or unfair beliefs about poverty,
acute and chronic stress, limited educational
opportunities, unsafe neighborhoods and
working conditions, and exposure to poisons
in the environment . Poverty has been linked
to a higher rate of many health conditions,
including chronic diseases, some cancers,
developmental delays, injury, depression
and premature death.
6
New Mexico has one of the nation’s
highest poverty rates.
7
Bernalillo County’s
poverty rate is below that of the state
overall, but it remains higher than the
national average (11.8%).
8
More troubling
still, over one-quarter of the county’s
children are growing up in poverty.
Childhood poverty can have long term
results and has been linked to health
problems throughout the lifespan. Figure
11 shows poverty and child poverty in
New Mexico, Bernalillo County, and 12
neighborhoods within Bernalillo County.
Poverty rates are highest in Albuquerque’s
Southeast Heights, where 31 percent of
residents and 45 percent of children and
youth live in poverty. In contrast, the 6
percent poverty rate in the East Mountain
area of Bernalillo County is one-fifth that
of the Southeast Heights.
6
Shaw KM, Theis KA, Self-Brown S, Roblin DW, Barker L. Chronic Disease Disparities by County Economic Status and
Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013. Prev Chronic Dis 2016;13:160088. DOI: http://dx.doi.
org/10.5888/pcd13.160088
7
The 2020 poverty threshold for a family of four is $26,200. See: https://aspe.hhs.gov/poverty-guidelines
8
Semega, J et al, U.S. Census Bureau, Current Population Reports, P60-266, Income and Poverty in the United States: 2018, U.S.
Government Printing Oce, Washington, DC, 2019.
30
2020 Community Health Needs Assessment and Implementation Strategy
21%
18%
7%
8%
11%
15%
16%
16%
18%
21%
24%
26%
31%
31%
29%
26%
6%
10%
15%
19%
21%
28%
29%
32%
22%
37%
39%
45%
0% 10% 20% 30% 40% 50%
New Mexico
All Bernalillo County
East Mountain
Far NE Heights
Remainder of Bernalillo County
NE Heights
SW Mesa
North Valley
Four Hills
N NE Heights
UNM
S Valley
Downtown
SE Heights
People Living in Poverty (%)
Child Poverty (%) Poverty (%)
Source: Author tabulation of US Census American Community Survey 2017 5-Year Micro Sample
Figure 11
People Living in Poverty (%)
31
UNM Hospitals
Housing
A safe and stable home is the foundation
of physical and mental wellbeing. Having
a home makes it possible for community
members to access and benefit from other
health interventions and supportive services.
Like many other urban areas in the U.S.,
Bernalillo County has a severe shortage of
aordable housing. Rents and other housing
costs have increased faster than incomes
in recent decades and the government
programs that subsidize (support) housing
for the needy have not kept pace with
the increasing demand. County residents
sometimes wait years for permanent
subsidized housing like a Section 8 voucher
or an income-based aordable rental.
Over 88,000 Bernalillo County households
spend more than 30 percent of income on
housing. Seventy-eight percent of these
“cost burdened” households (68,260
households) are low income. Cost burdened
households frequently give up other
necessities like nourishing food and health
care to avoid eviction or foreclosure. They
may “double up” with other families to cut
costs and experience overcrowding or be
subject to substandard housing conditions
like rats, mice or insects, mold, or lack of
complete plumbing. Overcrowding and
substandard conditions can be a problem
for good behavioral health, making it
hard to manage chronic conditions, and
increase the risk of infectious disease. The
frequent moves that often accompany
housing instability are particularly hard
on children and can get in the way
of their learning and socio-emotional
development.
9
Figure 12 shows the
percentage of households in New Mexico,
Bernalillo County, and 12 Bernalillo
County neighborhoods that are housing
cost burdened.
Homeless New Mexicans have high rates
of chronic (long-term) disease including
mental illness, substance use disorders,
diabetes, HIV/AIDS, and high blood
pressure and are more likely than the
general population to have more than one
chronic condition.
10
Poor health is both
a cause and an eect of homelessness.
Health problems that make it impossible
to work or hurt a person’s ability for self-
care can lead to homelessness. Once
homeless, people are exposed to a variety
of health risks including victimization,
violence, hunger, poor nutrition, exposure,
infectious disease, sleeplessness, and
profound toxic stress.
32
2020 Community Health Needs Assessment and Implementation Strategy
17.1%
20.3%
22.3%
26.3%
26.7%
27.4%
27.7%
29.9%
31%
31.3%
31.5%
32.5%
36.5%
38.3%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
East Mountain
Far NE Heights
Remainder of Bernalillo County
NE Heights
North Valley
Four Hills
Bernalillo County
N NE Heights
New Mexico
UNM
S Valley
SW Mesa
Downtown
SE Heights
Housing Cost Burdened Households
Source: Author tabulation of US Census American Community Survey 2017 5-Year Micro Sample
Figure 12
Housing Cost Burdened Households
9
Oishi S, Schimmack U. Residential mobility, well-being, and mortality. J Pers
Soc Psychol. 2010 Jun;98(6):980-94. doi: 10.1037/a0019389. PubMed PMID: 20515253
10
Albuquerque Health Care for the Homeless. Phase I Needs Assessment January 2014-June 2014
Residents of Bernalillo County come across a number of barriers to finding safe, stable
and aordable housing. The main obstacles to adequate housing include poverty,
inadequate transportation, and personal vulnerability factors like age, disability,
behavioral health problems, domestic violence, imprisonment, and poor credit.
33
UNM Hospitals
Educational Attainment
Higher levels of education are tied to better
health outcomes in part because education
decreases the chances of experiencing
poverty. Higher levels of education improve
the chances of being employed and higher
education levels improve people’s ability
to communicate health needs, obtain
and understand health information, move
through the health care system and speak
up for their health care rights and the
rights of their family members. Figure 13
shows educational levels for New Mexico,
Bernalillo County, and 12 neighborhoods
within Bernalillo County. Bernalillo
County has a higher percentage of
high school and college graduates than
New Mexico overall. Four Bernalillo
County neighborhoods have high school
graduation rates of 95 percent or above
and two - the Southwest Mesa and South
Valley - have rates below 75 percent.
Bernalillo County residents who lack a
high school diploma are twice as likely as
high school graduates to live in poverty
and four times more likely than those with
a bachelor’s degree to be poor.
34
2020 Community Health Needs Assessment and Implementation Strategy
Source: Author tabulation of US Census American Community Survey 2017 5-Year Micro Sample
Figure 13
Educational Attainment of Population 25 and older
73%
74%
84%
85%
85%
88%
89%
90%
90%
93%
95%
95%
95%
96%
11%
12%
33%
27%
34%
33%
36%
37%
27%
58%
34%
46%
39%
55%
0% 20% 40% 60% 80% 100% 120%
S. Valley
SW Mesa
Downtown
New Mexico
SE Heights
Bernalillo County
North Valley
Four Hills
N NE Heights
UNM
NW Mesa and Southern Bernalillo Cnty
East Mountain
NE Heights
Far NE Heights
Educational Attainment of Population 25 and Older
Bachelor's Degree High School Graduate
35
UNM Hospitals
Access to Healthy Food
A healthy diet is essential for overall well-being. It is also important to prevent chronic
diseases and necessary for care if you have a chronic disease. Access to fresh, healthy
food is critical to keeping a healthy diet. The shortage of supermarkets in low income
neighborhoods and rural communities contributes to high rates of obesity and other
diet-related diseases, like diabetes. Low food access is defined as living more than ½ mile
from the nearest supermarket, supercenter, or large grocery store. Twenty-one percent
of county residents and one-third of New Mexicans have low access to healthy food.
Source: US Department of Agriculture, Economic Research Service, USDA - Food Access Research Atlas. 2015
Figure 14
Percent of Population with Low Food Access
21.4%
33.3%
22.4%
0%
5%
10%
15%
20%
25%
30%
35%
Bernalillo County New Mexico United States
Percent of Population with Low Food Access
36
2020 Community Health Needs Assessment and Implementation Strategy
12
Healthy People 2020 [Internet]. Washington, DC: U.S. Department of Health and Human Services, Oce of Disease Prevention
and Health Promotion [January 31, 2020]. Available from: https://www.healthypeople.gov.
Food insecurity means having limited or uncertain access to adequate, nourishing food.
Food insecurity increases the risk of a variety of negative health outcomes including
obesity, chronic disease, behavioral issues and developmental delays in children.
12
Almost 15 percent of Bernalillo County residents experienced food insecurity at some
point during the year.
Food Insecurity
Population Food Insecurity Rate
Bernalillo County 14.9%
New Mexico 15.5%
United States 12.6%
Table 3
Source: Feeding America. https://www.feedingamerica.org/hunger-in-america
37
UNM Hospitals
Access to Care
Many Bernalillo County residents face barriers to getting the health care they need. Not
being able to get timely and appropriate health care puts them at risk of poor health
outcomes and undermines quality of life. Barriers to care take numerous forms, some
of which, like limited English proficiency, uncertain immigration status, and behavioral
health conditions, are addressed elsewhere in this report. This section considers the
impact that three common barriers - inadequate income, lack of health insurance and
the scarcity of culturally aware practitioners - have on health and health care in Bernalillo
County and New Mexico.
Source: Behavioral Risk Factor Surveillance System. Retrieved on January 2, 2020 from New Mexico Department of Health,
Indicator-Based Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 15
Bernalillo County Adults Who Can’t Aord Needed Health Care
1
1
2
2
.
.
9
9
%
%
1
1
2
2
.
.
9
9
%
%
1
1
3
3
.
.
2
2
%
%
1
1
5
5
.
.
5
5
%
%
9
9
.
.
5
5
%
%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
All County Residents Native American African American Hispanic White Non-Hispanic
Bernalillo County Adults Who Can't Afford Needed Healthcare
38
2020 Community Health Needs Assessment and Implementation Strategy
13
David U. Himmelstein, Robert M. Lawless, Deborah Thorne, Pamela Foohey, and Stee Woolhandler, 2019: Medical Bankruptcy:
Still Common Despite the Aordable Care Act
American Journal of Public Health 109, 431_433,https://doi.org/10.2105/AJPH.2018.304901
14
Kaiser Family Foundation. Key Facts About the Uninsured. December 2019. Retrieved from:
https://www.k.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/
15
Bailey, K. The Deadly Consequences of Being Uninsured. 2012. Families USA. Retrieved from:
https://familiesusa.org/wp-content/uploads/2019/09/Dying-for-Coverage.pdf
Inability to aord health care is not just a problem of the poor and/or uninsured. Many
working families and people with health coverage cannot aord the out-of-pocket costs
of health care. Medical bills are currently the number one cause of personal bankruptcies
in the US.
13
Thirteen percent of Bernalillo County adults report having been unable to get
health care in the previous 12 months due to cost. Hispanic adults were more likely than
other county residents to have diculty aording health care (Figure 15).
Health insurance coverage is a primary factor in a person’s ability to access health care.
The insured get, on average, about 50 percent more health care than the uninsured.
14
The uninsured are more likely than those with coverage to go without preventive care
and to delay or give up necessary medical treatments until they have no choice but to
use the emergency room. In fact, it is estimated that approximately 250 New Mexico
adults die prematurely every year due to lack of coverage.
15
Source: US Census American Community Survey 2017 5-Year Public Use Micro Sample
Table 4
Health Insurance Coverage of Bernalillo County
and New Mexico Residents
Bernalillo County New Mexico
Number Population Number Population
No health insurance coverage 72,353 11% 256,162 12%
With health insurance coverage 595,488 89% 1,793,939 88%
Private health insurance 397,319 59% 1,121,442 55%
Public coverage 272,631 41% 921,057 45%
39
UNM Hospitals
The expansion of access to aordable
health coverage brought about by the
Aordable Care Act dramatically reduced
the percentage of New Mexicans who
lack insurance; but it did not get rid of
the problem entirely. 11 percent of county
residents and 12 percent of New Mexicans
have no health insurance coverage (Table 4).
Most of New Mexico’s uninsured are low
income, and many are unable to pay
their medical bills. The cost of providing
health care to uninsured New Mexicans is
absorbed, in large part, by the other New
Mexico residents in the form of higher costs
for health insurance and health care as well
as higher state and local taxes.
The availability of health care practitioners
also impacts access to care. Primary care
providers (PCPs) - doctors, advanced
16
2016-2018 age-adjusted. Source: New Mexico Behavioral Risk Factor Surveillance System
practice nurses, and physician assistants
- play a critical role in the prevention and
management of disease and serve as
most patients’ first point of contact with
the health care system. Sixty-nine percent
of adults in Bernalillo County and New
Mexico have a primary care provider.
16
The ratio of primary care physicians to
county residents is an important measure
of access to care (Figure 16). In 2014,
there were about 104 primary care
physicians for every 100,000 Bernalillo
County residents. Nationally, there were
about 157 primary care physicians for
every 100,000 US residents. Primary
care services like coordination between
health care providers and eective
communication with patients are essential
to ecient health service delivery.
40
2020 Community Health Needs Assessment and Implementation Strategy
Source: US Department of Health and Human Services, Health Resources and Services Administration, Area Health Resource File.
Figure 16
Primary Care Physicians, Number per 100,000 Pop.
103.7
74.4
157
0
20
40
60
80
100
120
140
160
180
Bernalillo County New Mexico U.S.
Primary Care Physicians, Number per 100,000 Pop.
41
UNM Hospitals
Behavioral Health
Behavioral health is a blanket term that includes mental health promotion and treatment,
marriage and family counseling, and substance use treatment as well as support
for patients who experience or are in recovery from one or more behavioral health
conditions. It is not uncommon for patients to have more than one behavioral health
condition at the same time. Individuals who have both mental illness and substance use
disorder are at especially high risk for poor health outcomes.
Source: New Mexico Behavioral Risk Factor Surveillance System. Retrieved on February 1, 2020 from New Mexico Department of
Health, Indicator-Based Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 17
Adults Diagnosed with Depression by Income Level
21%
42%
23%
23%
16%
17%
19%
32%
21%
18%
16%
14%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
All Income Levels $0-$15k $15k-$24k $25k-$50k $50k-$75k $75k or more
Adults Diagnosed with Depression by Income Level
Bernalillo County New Mexico
42
2020 Community Health Needs Assessment and Implementation Strategy
Behavioral health issues impact people from every walk of life. Timely and appropriate
behavioral health services and access to social and community support is critical to
managing behavioral health conditions. For many New Mexicans, access to behavioral
health resources is limited by factors like income, geography, and social isolation.
Poverty and other SDoH are also stressors in their own right that can make behavioral
health conditions worse. Based on these challenges, it is not uncommon for members
of lower income households to feel a sense of helplessness often leading to depression
(Figure 18).
Source: New Mexico Behavioral Risk Factor Surveillance System. Retrieved on February 1, 2020 from New Mexico Department of
Health, Indicator-Based Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 18
Bernalillo County Youth, Feelings of Sadness or Hopelessness, 2013-2017
34%
39%
33%
32%
36%
32%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
All County Youth Native American Asian African American Hispanic White Non-Hispanic
Bernalillo County Youth, Feelings of Sadness or Hopelessness, 2013-17
43
UNM Hospitals
Social Determinants of Health, like poverty and domestic instability, also contribute to
feelings of sadness and hopelessness among youth. Substance use and addiction can
add on to the behavioral health challenges experienced by youth. Many New Mexico
communities, particularly those in rural and tribal areas, lack the resources and social
services to meet the behavioral health needs of their youth.
The suicide rates in Bernalillo County (20.4 deaths per 100,000) and New Mexico (21.3
deaths per 100,000) are quite a bit higher than the national average of 13.5 deaths per
100,000 and speak to the lack of mental health resources in many communities. New
Mexico’s elevated levels of drug and alcohol use coupled with the impact of adverse
childhood experiences, lack of social service support and higher poverty rates contribute
to the feelings of depression and hopelessness that can lead to suicide.
Source: Suicide Deaths by County. Retrieved on October 25, 2019 from New Mexico Department of Health, Indicator-Based
Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 19
Suicide Death Rate, Bernalillo County and NM, 2008-2018
18.2
11.2
10.1
15.5
25.7
22.6
12.1
12
15.3
26.8
0
5
10
15
20
25
30
Native American Asian African American Hispanic White Non-Hispanic
Suicide Death Rate, Bernalillo County & NM 2008-18
Bernalillo County New Mexico
44
2020 Community Health Needs Assessment and Implementation Strategy
Suicide rates also demonstrate racial and ethnic disparities. Native American and White
non-Hispanic residents of both Bernalillo County and New Mexico have significantly
higher suicide mortality than other racial and ethnic groups.
Source: Suicide Deaths by County. Retrieved on October 25, 2019 from New Mexico Department of Health, Indicator-Based
Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 20
Youth Suicide Attempts by Sexual Orientation
10.1%
7.1%
28.3%
15.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
Overall Straight Gay, lesbian, or
bisexual
Not sure
Youth Suicide Attempts by Sexual Orientation
45
UNM Hospitals
LGBTQ youth face many barriers that may lead to attempted suicide including unstable
housing, being bullied, sexual exploitation, and drug use. Suicide rates among LGBTQ
youth are more than double those of other groups. This alarming statistic speaks to the
need for increased access to culturally-aware behavioral health services for LGBTQ youth.
Notes: Numbers and rates per 10,000 for emergency room visits by age group with diagnoses of prescription opioid overdose,
by New Mexico Small Area over the 57 month period Jan 2011 to Sep 2015. Total visits = 6092 (1015.3 per year). Updated 4/8/19.
Source: Custom tabulation of data from New Mexico Department of Health, Indicator-Based Information System for Public Health
website: http://ibis.health.state.nm.us/
Figure 21
ED Visits for Drug Overdose, Age-Adjusted Rate per 10,000, 2011-2015
5.9
6.8
7.4
7.9
10.0
10.2
10.5
10.7
11.0
12.8
13.5
14.4
22.1
3.7
3.3
3.6
4.2
5.5
5.4
5.8
6.0
6.8
8.2
7.2
7.6
14.9
0.0 5.0 10.0 15.0 20.0 25.0
East Mountain
Far NE Heights
UNM
NW Mesa
NE Heights
Four Hills
SW Mesa
Bernalillo County
North Valley
S. Valley
N NE Heights
SE Heights
Downtown
ED Visits for Drug Overdose, Age-Adjusted Rate per 10,000 2011-15
Prescription Opioid All Drugs
17
Marcus SC, Olfson M. National trends in the treatment for depression from 1998 to 2007. Arch Gen Psychiatry. 2010;67(12):
1265–1273
46
2020 Community Health Needs Assessment and Implementation Strategy
Behavioral health disorders are leading
causes of disability, lost productivity, and
health care spending in the United States.
17
Individuals with mental illness and/or
substance use disorders have worse health
outcomes, use more health services, and die
younger than the general population.
18
They
also account for a larger share of health care
costs than might be expected.
19
Between 2013 and 2017, 902 Bernalillo
County residents died from drug
overdoses.
20
During that period, Bernalillo
County’s rate of death due to drug overdose
(26.3 deaths per 100,000 residents) was the
state’s 15th highest. The rate of overdose-
related visits to hospital emergency rooms
is several times the overdose death rate.
21
Figure 21 shows rates of drug overdose ED
visits by Bernalillo County neighborhood
18
de Oliveira C, Cheng J, Vigod S, Rehm J, Kurdyak. (2016) Patients With High Mental Health Costs Incur Over 30 Percent More
Costs Than Other High-Cost Patients. P.Health A (Millwood). Jan;35(1):36-43
19
Clarke RM, Jerey J, Grossman M, Strouse T, Gitlin M, Skootsky SA. (2016) Delivering On Accountable Care: Lessons From A
Behavioral Health Program To Improve Access And Outcomes. Health A (Millwood). 2016 Aug 1;35(8):1487-93
20
New Mexico Department of Health. New Mexico Substance Use Epidemiology Profile, 2018
21
Bernalillo County Community Health Council Opioid Accountability Initiative 2017-2018 Impact Report. Retrieved from:
http://www.bchealthcouncil.org/resources/Documents/OAI%20Impact%20Report%20-%202018.pdf
22
Source: University of Wisconsin Population Health Institute, County Health Rankings. 2018
Mental health providers are defined as psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and
family therapists, and mental health providers that treat alcohol and other drug abuse, as well as advanced practice nurses
specializing in mental health care.
and type of drug. New Mexico is among
the states hit especially hard by the opioid
epidemic with increased overdose from
prescription opioids as well as heroin.
Increasing the availability of Narcan to
prevent overdose fatalities has been a
large statewide initiative. New Mexico has
also seen a return of methamphetamine
use, driven by relatively low costs and
easy access.
Bernalillo County has roughly 2,970
mental health practitioners, or about one
practitioner per 230 county residents.
22
While this ratio is slightly lower than that
of New Mexico (one practitioner per 260
residents), significant service gaps exist
and the need for behavioral health services
is much larger than the available supply.
47
UNM Hospitals
Seniors
Almost 94,000 residents of Bernalillo
County are age 65 or older. Seniors currently
make up roughly 14 percent of the county’s
non-institutionalized population but this
percentage is expected to rise dramatically
in the coming years as increasing numbers
of baby-boomers and Gen-Xers reach age
65. By 2040, Bernalillo County’s senior
population is expected to more than double.
Growth in the absolute and relative number
of senior citizens will greatly increase
demand for health care services.
27 percent of Bernalillo County households
include at least one person over 65. Over 40
percent of these households, over 29,000
people, are seniors living alone (Table 5).
People over age 65 who live alone are at
risk for social isolation and may have limited
access to supportive services or help in
emergency situations. As a result, lone
23
Burns E, Kakara R. Deaths from Falls Among Persons Aged ≥65 Years — United States, 2007–2016. MMWR Morb Mortal Wkly
Rep 2018;67:509–514
24
Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb
Mortal Wkly Rep 2016;65:993–998
25
Dionyssiotis Y. Analyzing the problem of falls among older people. Int J Gen Med. 2012;5:805–813. doi:10.2147/IJGM.S32651
26
National Council for Aging Care. Fact Sheet Falls: The Biggest Threat to Senior Health and Safety. Retrieved from:
https://www.aging.com/falls-fact-sheet/
seniors often lose their independence or
enter assisted living or other institutional
forms of care earlier than seniors who
live with someone else. Because they
live longer, on average, than men, older
women are more likely than older men to
live alone.
Falls are the leading cause of unintentional
injury death among the elderly.
23
Even
when falls are non-fatal, they can
necessitate long hospital stays and
produce long-term complications that
undermine independence and decrease
well-being (Figure 22).
Most falls in the elderly result from the
interaction of multiple risk factors. As
many as half are at least partly caused by
environmental risk factors.
25
The majority of
falls occur at home.
26
Reducing household
hazards like loose carpets and exposed
appliance cords can help prevent falls.
48
2020 Community Health Needs Assessment and Implementation Strategy
Source: US Census American Community Survey 2017 5-Year Sample
Table 5
Senior Households in New Mexico and Bernalillo County
Households
with Seniors
Percent of HH
with Seniors
Seniors
Living Alone
Bernalillo County 70,856 27% 29,344
New Mexico 231,889 30% 90,827
Source: New Mexico Bureau of Vital Records and Health Statistics, New Mexico Department of Health Retrieved on October 30,
2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health website:
http://ibis.health.state.nm.us/
Figure 22
Fall Death Rate per 100,000 Seniors
- 20.0 40.0 60.0 80.0 100.0 120.0 140.0
East Mountain
Remainder of Bernalillo County
SE Heights
S. Valley
New Mexico
UNM
Bernalillo County
SW Mesa
North Valley
N NE Heights
Four Hills
Far NE Heights
NE Heights
Downtown
Fall Death Rate per 100,000 Seniors
49
UNM Hospitals
Vaccines are critical to disease prevention and one of the most eective and ecient
ways to protect public health. The CDC recommends that all adults 65 years or older be
vaccinated against pneumococcal disease. Seventy three percent of Bernalillo County
seniors have been vaccinated for pneumonia, a rate that exceeds that of New Mexico and
the US overall.
Percentage of Seniors
Who Have Ever Received
A Pneumonia Vaccine
Bernalillo County 73.3%
New Mexico 68.2%
United States 67. 5%
Table 6
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the Health
Indicators Warehouse. US Department of Health and Human Services, Health Indicators Warehouse
50
2020 Community Health Needs Assessment and Implementation Strategy
Maternal and Infant Health
Roughly 7,000 babies are born in Bernalillo
County each year. Regular prenatal care
beginning in the first trimester reduces the
risk of pregnancy-related complications
for the mother and infant and increases a
woman’s chances of having a healthy, full
term baby.
The first twelve weeks, or trimester, is one
of the most critical periods of pregnancy.
Prenatal care that begins in the first
trimester is important because it helps
to identify medical problems and risk
factors early, helps to establish healthy
habits, and connects parents with support
and educational resources that can
benefit them throughout pregnancy.
The benefits of early prenatal care are
greatest for women at risk for poor birth
outcomes including low income women
and teenagers. Just over two-thirds of
mothers in Bernalillo County and New
Mexico receive prenatal care in the
first trimester.
Breastfeeding protects babies against
a variety of diseases and conditions by
providing them with the ideal balance
of nutrients, enzymes, immunoglobulin,
anti-infective and anti-inflammatory
substances, hormones, and growth factors
(Figure 23).
51
UNM Hospitals
Source: New Mexico Behavioral Risk Factor Surveillance System. Retrieved on February 1, 2020 from New Mexico Department of
Health, Indicator-Based Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 23
Maternal and Infant Health
69.3%
92.4%
66.8%
89.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Percent of mothers with 1st trimester prenatal care
(2017) (1)
Percent of mothers who initiate breastfeeding (2)
Maternal and Infant Health
Bernalillo County New Mexico
52
2020 Community Health Needs Assessment and Implementation Strategy
Source: New Mexico Birth Certificate Database, Bureau of Vital Records and Health Statistics, New Mexico Department of Health
Retrieved on October 25, 2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health
website: http://ibis.health.state.nm.us/
Figure 24
Bernalillo County Infant Deaths per 1,000 Births, 2013-2018
3.9
4.6
5.8
6.7
9.6
0
2
4
6
8
10
12
Native American White Non-
Hispanic
Asian Hispanic African American
BBeerrnnaalliilllloo CCoouunnttyy IInnffaanntt DDeeaatthhss//11,,000000 BBiirrtthhss
Infant mortality, the death of infants under one year of age, is one of the most frequently
used measures of population health. The infant death rate for African American residents
of Bernalillo County is over twice that of Native American and White non-Hispanic
residents (Figure 24). Congenital malformations, chromosomal abnormalities, disorders
related to short gestation and low birth weight, and sudden infant death syndrome are
leading causes of death in the post-neonatal period.
53
UNM Hospitals
Source: New Mexico Department of Health, Indicator-Based Information System for Public Health website:
http://ibis.health.state.nm.us/
Figure 25
Neonatal Abstinence Syndrome Rates, 2015-2017
14.2
14.2
19.1
10.3
12.3
14.0
0.0
5.0
10.0
15.0
20.0
25.0
2015 2016 2017
NNeeoonnaattaall AAbbssttiinneennccee SSyynnddrroommee RRaatteess
Bernalillo County New Mexico
Neonatal abstinence syndrome (NAS) is a group of temporary withdrawal symptoms
including irritability, seizures, vomiting, diarrhea, fever, and poor feeding that happen
in newborns who have been exposed during pregnancy to opioid drugs like heroin,
oxycodone (Oxycontin), and methadone. The number of babies born dependent on
drugs in New Mexico more than tripled between 2008 and 2017, paralleling the increase
in opioid misuse observed both locally and nationwide. The Albuquerque metro area
accounts for 55 percent of NAS cases in New Mexico.
27
27
Saavedra, L.G. “Neonatal Abstinence Syndrome Surveillance in New Mexico.” The New Mexico Epidemiology Report. New
Mexico Department of HealthNovember 30, 2018. 2018:10. Retrieved from: https://nmhealth.org/data/view/report/2194/
54
2020 Community Health Needs Assessment and Implementation Strategy
Figure 26
Bernalillo County’s teen birth rate of 18.8 births per 1,000 girls ages 15 through 19 is
lower than the statewide average (25.2 births/1,000). Over the last two decades, teen
birth rate has become dramatically smaller for all racial and ethnic groups in Bernalillo
County (Figure 26). Increased access to and awareness of sexual health information
and birth control are among the factors contributing to the decline, which has also been
observed at the state and national levels.
Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2016
Bernalillo County Adolescent Births per 1,000, Girls Age 15-19
0
20
40
60
80
100
120
1992-1994
1993-1995
1994-1996
1995-1997
1996-1998
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
2005-2007
2006-2008
2007-2009
2008-2010
2009-2011
2010-2012
2011-2013
2012-2014
2013-2015
2014-2016
2015-2017
2016-2018
BBeerrnnaalliilllloo CCoouunnttyy AAddoolleesscceenntt BBiirrtthhss ppeerr 11,,000000,, GGiirrllss AAggee 1155--1199
Native American Asian African American Hispanic White Non-Hispanic
55
UNM Hospitals
Adult Health Behaviors and Risk Factors
Most injury and disease is preventable, or at least manageable, through behavior
changes, early discovery, improved diet, and exercise. Lack of physical activity and poor
nutrition are associated with obesity, diabetes, and poor cardiovascular health. Drinking
too much alcohol is associated with serious health issues that include injuries, cirrhosis,
cancers, and untreated mental health conditions. Adults in Bernalillo County and New
Mexico have lower rates of high alcohol consumption and are less inactive, on average,
than US adults overall (Figure 27).
(1) Two or more drinks per day on average for men and one or more drinks per day on average for women (2) Less than 5 servings
of fruits and vegetables daily (3) No physical activities or exercises outside of work
Source: Center for Applied Research and Engagement Systems (CARES) at the University of Missouri
Figure 27
Adult Health Behavior and Risk Factors
13.3%
76.8%
16.7%
14.2%
77.6%
19.1%
16.9%
75.7%
22.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Excessive Drinking (1) Inadequate Fruit/Vegetable
Consumption (2)
No Leisure/Time Physical
Activity (3)
Adult Health Risk Factors
Bernalillo County New Mexico United States
56
2020 Community Health Needs Assessment and Implementation Strategy
Figure 28
Adult obesity (being overweight) has tended to increase in Bernalillo County and across
the country over the past two decades. Obesity increases the risk of numerous diseases
including cancer, heart disease, stroke and Type 2 Diabetes. It is second only to smoking
as the leading cause of preventable death in the United States. The percentage of
Bernalillo County adults who are obese increased from 16 percent in 2004 to over 23
percent in 2016 (Figure 28).
Source: New Mexico Birth Certificate Database, Bureau of Vital Records and Health Statistics, New Mexico Department of Health.
Retrieved on October 25, 2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health
website: http://ibis.health.state.nm.us/
Adult Obesity Rates, 2004 - 2016
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
AAdduulltt OObbeessiittyy RRaatteess,, 22000044--1166
Bernalillo County New Mexico United States
57
UNM Hospitals
Figure 29
Cigarette Smoking by Bernalillo County Adults
55.6% 65.9%
28.7%
22.6%
5.7%
3.4%
10.0%
8.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Males Females
CCiiggaarreettttee SSmmookkiinngg bbyy BBeerrnnaalliilllloo CCoouunnttyy AAdduullttss
Never smoked Former smoker Now smoke some days Now smoke everyday
Smoking continues to be the leading preventable cause of death in the US and
worldwide.
28
Nevertheless, 8 percent of Bernalillo County women and 10 percent of
Bernalillo County men are daily smokers. (Figure 29)
28
Centers for Disease Control and Prevention. Retrieved from:
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
58
2020 Community Health Needs Assessment and Implementation Strategy
Youth Health Behaviors and
Risk Factors
13 percent of Bernalillo County residents are
between the ages of 10 and 19. The behavior
patterns that are set during adolescence
and young adulthood impact both current
and long-term health and influence the
risk for developing chronic diseases during
adulthood. Preventing risky health behaviors
like smoking and binge drinking from
starting, and encouraging the development
of healthy habits during youth can have
lifelong health benefits.
29
Youth Risk and Resiliency Survey Retrieved on October 30, 2019 from New Mexico Department of Health, Indicator-Based
Information System for Public Health website: http://ibis.health.state.nm.us/
Adolescence is a developmental period
marked by quick physical and emotional
change. For many, it is also a time of
experimentation and reckless behavior.
The eects can last a lifetime. Sixteen
percent of Bernalillo County youth say
they have used prescription drugs without
a prescription and 3.5 percent say they
have tried heroin.
29
Figure 30 shows some
additional risk factors experienced by
Bernalillo County youth.
59
UNM Hospitals
Bernalillo County Youth Risk Factors
18%
17%
30%
20%
15%
30%
50%
41%
40%
42%
22%
18%
19%
21%
18%
32%
24%
33%
36%
26%
0%
10%
20%
30%
40%
50%
60%
Native American Asian African American Hispanic White Non-
Hispanic
BBeerrnnaalliilllloo CCoouunnttyy YYoouutthh RRiisskk FFaaccttoorrss
Sports-related concussion Texted or emailed while driving
Rode with a drinking driver Current use of tobacco or e-cigarettes
Unintentional injuries, suicide, and homicide are the three leading causes of death among
adolescents. The most common causes of unintentional injuries are vehicle crashes,
violence, falls and sports. Injuries are also the top cause of nonfatal morbidity (states of
un-wellness) among youth.
Source: Youth Risk and Resiliency Survey. Retrieved on October 28, 2019 from New Mexico Department of Health, Indicator-Based
Information System for Public Health website: http://ibis.health.state.nm.us/
Figure 30
60
2020 Community Health Needs Assessment and Implementation Strategy
Chronic Disease
Chronic diseases are diseases that are long
term. They cannot be spread from person
to person, and are rarely cured completely.
Seven of the nine leading causes of
death in Bernalillo County – cancer, heart
disease, lower respiratory disease, diabetes,
Alzheimer’s disease, stroke and liver disease
– are chronic diseases.
Some chronic diseases are unavoidable,
but most result from the complex interplay
between multiple factors including lack of
physical activity, poor diet, smoking and/or
drinking alcohol. Chronic diseases often
set in motion other health problems or
make them worse.
As people age their chance of having
more than one chronic disease increases.
Twenty eight percent of Bernalillo
County adults and 31 percent of New
Mexico adults age 45 and over have been
diagnosed with two or more chronic
diseases. Multiple chronic conditions tend
to be more common in communities and
individuals with more risk factors and
adverse social determinants of health.
61
UNM Hospitals
Bernalillo County Adults Who Have Been Diagnosed with Diabetes, 2014 - 2018
5.6%
12.1%
13.9%
17.9%
20.3%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
White Non-Hispanic Hispanic Native American Asian African American
BBeerrnnaalliilllloo CCoouunnttyy AAdduullttss WWhhoo HHaavvee BBeeeenn DDiiaaggnnoosseedd wwiitthh DDiiaabbeetteess
DIABETES
Just over 9 percent of Bernalillo County adults have been diagnosed with diabetes
(Figure 31). Diabetes can make life shorter and increase the risk of heart disease. It is the
leading cause of kidney failure, surgical removal of the foot or leg, and blindness that
happens to adults.
Source: New Mexico Behavioral Risk Factor Surveillance System, New Mexico Department of Health. Retrieved on October 30,
2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health website:
http://ibis.health.state.nm.us/
Figure 31
62
2020 Community Health Needs Assessment and Implementation Strategy
Bernalillo County Youth With Asthma
24.5%
21.8%
22.1%
37.3%
24.1%
24.4%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
All county
youth
Native
American
Asian African
American
Hispanic White
BBeerrnnaalliilllloo CCoouunnttyy YYoouutthh WWiitthh AAsstthhmmaa
ASTHMA
15 percent of county adults and almost one-in-four county youth have been diagnosed
with asthma at some point. Asthma is a chronic condition in which the airways become
inflamed, causing coughing, wheezing and shortness of breath. Asthma can usually be
managed with good primary health care, the right medicines, and lifestyle changes that
help asthma patients avoid the situations and substances that trigger their attacks.
Source: New Mexico Youth Risk and Resiliency Survey. New Mexico Department of Health. Retrieved on October 29, 2019 from
New Mexico Department of Health, Indicator-Based Information System for Public Health website:
http://ibis.health.state.nm.us/
Figure 32
63
UNM Hospitals
Leading Causes of Death
Tracking the leading causes of death helps policymakers understand the impact of
deaths from a certain cause so they can spread out public health resources in the most
eective way. The leading causes of death in New Mexico and Bernalillo County are heart
disease, cancer, and unintentional injury.
Source: New Mexico Death Certificate Database, Oce of Vital Records and Statistics, New Mexico Department of Health.
Retrieved on December 1, 2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health
website: http://ibis.health.state.nm.us/
Figure 33
15 Leading Causes of Death in Bernalillo County and NM, 2017
0 20 40 60 80 100 120 140 160
Hypertension and hypertensive renal disease
Septicemia
Parkinson's disease
Kidney Disease
Homicide
Influenza and pneumonia
Diabetes mellitus
Chronic liver disease and cirrhosis
Suicide
Alzheimer's disease
Cerebrovascular disease (stroke)
Chronic lower respiratory diseases
Unintentional injuries
Cancer
Heart disease
Leading Causes of Death in Bernalillo County and New Mexico
New Mexico Bernalillo County
64
2020 Community Health Needs Assessment and Implementation Strategy
HEART DISEASE
Heart disease is the leading cause of death
in Bernalillo County, New Mexico, and the
US. Heart disease is related to high blood
pressure, high cholesterol, and heart attacks.
Three percent of Bernalillo County adults
(about 15,000 county residents), 4 percent
of New Mexico adults, and 4.4 percent of US
adults have been told by a doctor that they
have coronary heart disease or angina.
30
CANCER
Cancer is a collection of related diseases,
all of which involve the uncontrolled
division of cells that are not normal.
Cancer is the second leading cause
of death in Bernalillo County, New
Mexico and the US. Risk factors for
cancer can include: older age, tobacco
use, environmental exposure to
carcinogens, genetics and family history,
and conditions/diseases like a weak
immune system, diabetes, and human
papillomavirus (HPV) infection.
Breast cancer is the most commonly
diagnosed cancer among women in New
Mexico and the second leading cause
of cancer deaths. The (age-adjusted)
incidence of breast cancer in Bernalillo
County (126 per 100,000) is roughly
comparable to that in New Mexico and the
U.S. overall.
31
30
Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System.
31
National Institutes of Health. State Cancer Profiles. 2012-16. Retrieved from: https://statecancerprofiles.cancer.gov
65
UNM Hospitals
Source: National Institutes of Health. State Cancer Profiles. 2012-16. Retrieved from: https://statecancerprofiles.cancer.gov
Table 7
Lung Cancer Incidence Rate
(Per 100,000 Pop.) by Race / Ethnicity
African
American
White,
Non-
Hispanic
Hispanic Asian
Native
American
Bernalillo County 47. 2 38.4 33.3 27.7 16.6
New Mexico 46.4 41.4 32.2 28.3 13.2
United States 60.9 60.1 30.2 34.4 42.6
Lung cancer is one of the most common and deadliest cancers. African Americans
are at higher risk for lung cancer even though they smoke less, on average, than white
Americans (Table 7).
32
Male smokers are 23 times more likely to develop lung cancer
than men who have never smoked and women who smoke are 13 times more likely than
never-smokers to develop cancer.
32
American Lung Association. Too Many Cases, Too Many Deaths: Lung Cancer in African Americans. Retrieved from:
https://www.lung.org/assets/documents/research/ala-lung-cancer-in-african.pdf
66
2020 Community Health Needs Assessment and Implementation Strategy
Unintentional Injury
Unintentional (accidental) injury is the third leading cause of death in Bernalillo County.
The most common causes of unintentional injury deaths are poisoning (including drug
overdose), motor vehicle crashes, and falls. Rates of death from unintentional injury in
New Mexico and Bernalillo County exceed the national average. Significant racial and
ethnic disparities exist in rates of unintentional injury deaths. (Figure 34)
Source: New Mexico Death Certificate Database, Oce of Vital Records and Statistics, New Mexico Department of Health.
Retrieved on December 20, 2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health
website: http://ibis.health.state.nm.us/
Figure 34
Unintentional Injury Mortality by Race/Ethnicity
56.4
71.8
67.2
59.6
101.2
65.0
49.8
51.5
29.3
0.0
20.0
40.0
60.0
80.0
100.0
120.0
White, Non-Hispanic Native American Hispanic
Unintentional Injury Mortality by Race/Ethnicity
Bernalillo County New Mexico United States
67
UNM Hospitals
Figure 34 shows unintentional injury mortality rates by age and sex. Males die from
unintentional injuries at higher rates than females across the range of ages. The
elderly of both sexes, particularly those 85 and older, have the highest rate of death
from unintentional injury. It is also important to note that even though young people
die at lower rates than older community members, more people under 40 die from
unintentional injury than any other cause (Figure 35).
Source: New Mexico Death Certificate Database, Oce of Vital Records and Statistics, New Mexico Department of Health.
Retrieved on December 20, 2019 from New Mexico Department of Health, Indicator-Based Information System for Public Health
website: http://ibis.health.state.nm.us/
Figure 35
Bernalillo County Unintentional Injury Death Rate per 100,000 by Age and Sex
9.5
55.7
88.3
98.6
107.7
107.1
101.7
203.4
681.6
4.4
19.3
38.8
43.2
41.4
41.2
39.7
158.4
596.1
0 100 200 300 400 500 600 700 800
0-14 years
15-24 years
25-34 years
35-44 years
45-54 years
55-64 years
65-74 years
75-84 years
85+ years
Bernalillo County Unintentional Injury Death Rate per 100,000 by Age and Sex
Female Male
68
2020 Community Health Needs Assessment and Implementation Strategy
UNMH’S PROCESS FOR SELECTING
HEALTH CARE PRIORITY NEEDS
The University of New Mexico Hospitals held
internal stakeholder meetings to review all
of the data developed for the assessment
and select the health care needs to focus on
over the next three years. The stakeholder
group included the hospital’s Ambulatory
Executive Committee, clinic and outpatient
directors, financial managers, and leadership
from the Health System’s Oce of Diversity,
Equity and Inclusion, among others.
Hospital leadership also helped develop
strategies that strengthen and/or use to
maximum advantage existing hospital
resources and current UNMH programs to
address the four focus areas. In addition,
UNMH sta also met with external
community leaders and residents of
the community to identify and discuss
potential community-wide solutions for
each of the identified health needs.
The next step in the process is to work
with community partners to put these
strategies in place. We will publish yearly
reports that track the progress of the
plan and document the ways in which it
impacts the community.
Putting the Pieces Together:
Identifying Top Health Needs
69
UNM Hospitals
APPENDIX 1 - FIGURES
Figure 1 -
CHNA Process
Figure 2 -
UNMH Patient Origin State Map
Figure 3 -
UNMH Patient Origin Bernalillo
County Map
Figure 4 -
UNM Health System
Figure 5 -
UNM Hospitals Clinics Map
Figure 6 -
CHNA Process
Figure 7 -
Race & Ethnicity of Bernalillo and
NM Residents
Figure 8 -
Bernalillo County Residents:
Language Spoken at Home
Figure 9 -
Percent of County Residents Who
Speak a Language other than English
at Home
Figure 10-
Bernalillo County Immigrants by
Continent of Origin
Figure 11-
People Living in Poverty (%)
Figure 12 -
Housing Cost Burdened Households
Figure 13 -
Educational Attainment of Population
25 and Older
Figure 14 -
Percent of Population with Low
Food Access
Figure 15 -
Bernalillo County Adults Who Can’t
Aord Needed Health Care
Figure 16 -
Primary Care Physicians, Number per
100,000 Pop.
Figure 17 -
Adults Diagnosed with Depression by
Income Level
Figure 18 -
Bernalillo County Youth, Feelings of
Sadness or Hopelessness, 2013 - 2017
Figure 19 -
Suicide Death Rate, Bernalillo County
& NM, 2008 - 2018
page page
1
7
8
10
18
19
24
25
26
27
30
32
34
35
37
40
41
42
43
2020 Community Health Needs Assessment and Implementation Strategy
70
Figure 20-
Youth Suicide Attempts by
Sexual Orientation
Figure 21 -
ED Visits for Drug Overdose, Age-
Adjusted Rate per 10,000, 2011 - 2015
Figure 22 -
Fall Death Rate per 100,000 Seniors
Figure 23 -
Maternal and Infant Health
Figure 24 -
Bernalillo County Infant Deaths/1,000
Births, 2013 - 2018
Figure 25 -
Neonatal Abstinence Rates,
2015 - 2017
Figure 26 -
Bernalillo County Adolescent Births
per 1,000, Girls Age 15-19
Figure 27 -
Adult Health Behaviors & Risk Factors
Figure 28 -
Adult Obesity Rates, 2004 - 2016
Figure 29 -
Cigarette Smoking by Bernalillo
County Adults
Figure 30 -
Bernalillo County Youth Risk Factors
Figure 31 -
Bernalillo County Adults Who Have
Been Diagnosed with Diabetes,
2014 - 2018
Figure 32 -
Bernalillo County Youth With Asthma
Figure 33 -
15 Leading Causes of Death in
Bernalillo County and NM, 2017
Figure 34 -
Unintentional Injury Mortality by
Race/Ethnicity
Figure 35 -
Bernalillo County Unintentional
Injury Death Rate per 100,000 by
Age and Sex
44
45
48
51
52
53
54
55
56
57
59
61
62
63
66
67
page page
71
UNM Hospitals
Table 1 -
Bernalillo County and NM Residents
by Age
Table 2 -
Foreign-Born Residents of
Bernalillo County
Table 3 -
Food Insecurity
Table 4 -
Health Insurance Coverage
of Bernalillo County and
New Mexico Residents
Table 5 -
Senior Households in New Mexico and
Bernalillo County
Table 6 -
Percentage of Seniors Who Have Ever
Received a Pneumonia Vaccine
Table 7 -
Lung Cancer Incidence Rate
(Per 100,000 Pop.) by Race/Ethnicity
23
28
36
38
48
49
65
APPENDIX 2 - TABLES
page
2020 Community Health Needs Assessment and Implementation Strategy
72
COMMUNITY HEALTH
IMPLEMENTATION PLAN
2020
2
UNM Hospitals
1
2020 Community Health Needs Assessment and Implementation Strategy
Table
of Contents
Community Health Implementation Plan
Focus 1: Increase Access to Behavioral Health Services
• Strategies
• Internal Resources
• Community Resources
Focus 2: Increase Access to Medical Services
• Strategies
• Internal Resources
• Community Resources
Focus 3: Increase Access to Medical Coverage and Financial Assistance
• Strategies
• Internal Resources
• Community Resources
Focus 4: Reduce Inequities that lead to Disparities in Health Outcomes
• Strategies
• Internal Resources
• Community Resources
Conclusion
Appendix 1 - Community Health Implementation Plan Contributors
Appendix 2 - Figures
Appendix 3 - CHNA Listening Session Regions
1
2
3
5
10
12
13
16
25
27
28
29
31
32
35
37
41
45
46
47
48
1
UNM Hospitals
Community Health Implementation
Plan
The University of New Mexico Hospitals
(UNMH) identified the following priority
health needs for residents within the UNMH
service area:
The University of New Mexico Hospitals
implementation plan, outlined on the
following pages, describes how the hospital
will address the community’s health care
needs by:
• Continuing and strengthening existing
UNMH programs and services
• Exploring new strategies
• Working with community organizations
to put evidence-based strategies into
action across the service area
Each focus section is followed by
examples of internal resources and
community resources that support the
needs in Bernalillo County. Internal
resources include UNMH departments
or programs which contribute the
goals of the focus they are listed under.
Community resources are external
programs or organizations which
contribute to the goals of the focus
they are listed under. Some community
resources are partnered with, or
supported by UNMH or sta, while others
are not. This listing does not represent
a comprehensive inventory of such
resources. We are listening all the time.
For any ongoing feedback, contact us. If
you would like to add your organization
or initiative to the list compiled for the
2023 UNMH CHNA, please contact:
UNMHCommunityRelati[email protected]m.edu.
• Increase Access to Behavioral
Health Services (page 2)
• Increase Access to Medical Services
(page 12)
• Increase Access to Medical
Coverage and Financial Assistance
(page 27)
• Reduce Inequities that lead to
Disparities in Health Outcomes
(page 32)
2
2020 Community Health Needs Assessment and Implementation Strategy
Focus 1: Increase Access to
Behavioral Health Services
Community members who attended the
listening sessions said that it needed to be
easier to get counseling services, drug and
alcohol recovery programs, and mental
health services.
UNM Hospitals currently operates one of
the largest behavioral health continuums
of care in the Southwest. (Continuum
of care means care at every stage of a
person’s journey through treatment from
the beginning throughout the cycle of
recovery.) These services include inpatient
services for geriatric, adult, adolescent and
youth populations as well as a variety of
outpatient and community-based services.
UNMH also has the state’s only dedicated
psychiatric emergency department. Despite
the existing range of services, care gaps
remain and the supply of services does not
meet demand.
The following are examples of strategies,
internal resources, and community
resources, which contribute to access.
3
UNM Hospitals
Strategies
Over the last few years, UNM Hospitals has
worked with a wide range of community
partners including Bernalillo County, the
City of Albuquerque, health care providers,
and community-based social assistance
providers to expand and strengthen the
system of care for mental health and
patients with addictions in Bernalillo County.
There are still care gaps in behavioral
health services. To close these gaps, we
will continue to build upon a range of new
program activities.
• Explore bringing behavioral health
services into obstetrics and gynecology
clinics to increase access to care,
support a model of women’s health
care that brings all health care needs
into close relationship (this is called a
fully integrated model), and support the
growing segment of patients with pelvic
floor disorders and chronic pelvic pain.
• Continue service development at the
Bernalillo County Care Campus. UNMH
has assumed clinical direction of the
Medical Observation Treatment Unit
from Bernalillo County and is working
to enhance medical programing within
the detoxification program. UNMH has
also worked with Bernalillo County to
open the Crisis Stabilization Unit at the
UNM Psychiatric Center (page 9).
1
• Expand programming for forensic
patients (patients in prison because
of mental illness) through the
operation of the Resource Reentry
Center (RRC) with Bernalillo County,
enhance discharge planning activities
for behavioral health patients being
released from the Metropolitan
Detention Center, and continue to
support Albuquerque’s Westside
Emergency Housing Shelter (see:
Forensic Services under “Internal
Resources” page 6 and Resource
Reentry Center under “Community
Resources” page 11).
1
Formerly known as the Metropolitan Assessment and Treatment Services facility (MATS)
4
2020 Community Health Needs Assessment and Implementation Strategy
• Currently UNM Hospitals is working
with a national consultant to forecast
behavioral health service delivery needs
over the next ten years. This process will
lead to:
• The development of a strategic plan
for behavioral health services
• The development of addictions
services capacity for adolescents
and adults
• Other intermediate levels of
behavioral health care
• Expansion of crisis services through
capital improvements (improvements
in buildings and equipment) at the
UNM Psychiatric Center (page 9). An
expansion of Psychiatric Emergency
Services is also happening in
Spring 2020.
• Further development of the CareLink
Behavioral Health Home (page 10) to
provide improved care coordination
for high needs adult and adolescent
behavioral health patients
UNMH operates the Resource
Re-entry Center (RRC)
(page 11) in Downtown
Albuquerque in collaboration
with the County and Oce
of Community Health at the
UNM HSC. Since opening in
July 2018 the RRC has had
over 27,000 people come
through the facility however
many of these choose not to
engage with services.
5
UNM Hospitals
Internal Resources
ADDICTION AND SUBSTANCE ABUSE
PROGRAM (ASAP) FOR ADULTS
AND TEENS
ASAP oers a range of outpatient programs
for adults. It has a targeted program for
adolescents with addiction issues called
STAR (Substance Use Treatment for
Adolescents and Young Adults in Recovery).
Programming includes individual and group
sessions with a counselor, women-only
groups, an outpatient detox program, and
an extensive opioid replacement therapy
program using methadone and suboxone
to stabilize patients while providing
therapeutic support services. The ASAP
primary care clinic is nationally recognized
as a Level 3 Patient-Centered Medical
Home (PCMH).
CAMINANTE SUPPORT EMPLOYMENT
PROGRAM (CSEP)
The CSEP helps people who are at a point
in their recovery where they are able to
look for employment. This program helps
with resume writing, finding employment,
improving interview skills and provides
ongoing support to keep a job.
COMPREHENSIVE ASSESSMENT AND
RECOVERY THROUGH EXCELLENCE
(CARE)
The CARE Campus provides a short-
term social model program designed
to address alcohol and substance
abuse issues. The program oers care
coordination and follow up services to
link patients with ongoing treatment.
UNMH operates programming on the
CARE Campus at 5901 Zuni Rd. SE in
collaboration with the Bernalillo County
Behavioral Health Division. The campus
oers a variety of services including a
detox program and recently opened the
Crisis Stabilization Unit.
6
2020 Community Health Needs Assessment and Implementation Strategy
FORENSIC SERVICES
Limited access to behavioral health services
increases the frequency with which county
residents who have serious and/or multiple
behavioral health problems are arrested
and/or imprisoned. The “revolving door”
for behavioral health patients at Bernalillo
County’s Metropolitan Detention Center
(MDC) undermines their recovery and
is a drain on public resources. UNMH’s
jail diversion program links patients with
criminal justice involvement to resources
like psychiatric treatment, substance abuse
treatment, medical care, education, job
training, government programs, and other
community-based support programs that
can help them build productive lives outside
of jail.
MILAGRO PROGRAM
This program started in 1989 as New
Mexico’s first comprehensive prenatal
care program for pregnant women with
substance abuse and addiction issues.
The Milagro program brings together
behavioral health, prenatal and obstetric
services with transitions into other
appropriate programs. Women who take
part in the program receive prenatal care
from UNM Health System providers in the
family medicine clinics. Medication-assisted
treatments are available to women with
opioid addictions. In addition to medical
services, the Milagro program provides
counseling and case management.
NATIVE AMERICAN BEHAVIORAL
HEALTH PROGRAM (NABHP)
The mission of UNM Health System’s
NABHP is to improve access to high
quality, culturally aware behavioral
health services for Native Americans
in New Mexico. UNMH partners with
native communities on local projects and
initiatives. NABHP also conducts culturally
relevant training and educational initiatives
for behavioral health care workers.
7
UNM Hospitals
NEUROMODULATION SERVICES
In psychiatry, neuromodulation involves
stimulating the brain with electrical or
magnetic currents to treat mental illness
that has not responded well to other
therapies. Neuromodulation services
including Electroconvulsive therapy (ECT)
and Transcranial magnetic stimulation
(TMS) are available at UNM Psychiatric
Center and the UNM Outpatient Surgical
and Imaging Services. ECT delivers small
doses of electricity to the brain over a series
of treatments and is most commonly used
in patients with severe major depression,
bipolar disorder or schizophrenia. TMS uses
magnetic energy to stimulate an area of the
brain that regulates mood. It is an eective
option for treatment-resistant depression.
TMS is done in an oce, and unlike ECT,
does not require anesthesia.
PSYCHOLOGY INTERN POSITION (PIP)
The addition of a PIP increases access to
behavioral health care by encouraging
interns to stay in the area after they finish
their internship and providing additional
sta which helps to reduce appointment
wait times.
PSYCHOSOCIAL REHABILITATION (PSR)
PROGRAM
UNM Health System’s PSR program is
guided by the philosophy of rehabilitation,
which holds that people with disabilities
need chances to identify and choose for
themselves what they want their roles in
the community to be. The PSR provides
skills classes that oer support in acquiring
basic skills crucial to mental health
recovery and personal empowerment.
8
2020 Community Health Needs Assessment and Implementation Strategy
UNM CHILDREN’S PSYCHIATRIC CENTER
UNM Children’s Psychiatric Center (CPC)
provides inpatient mental health treatment
for pediatric patients from ages 5 to 18. The
campus includes four inpatient acute care
units that are staed by a multidisciplinary
team led by a child psychiatrist. The Center
also operates a behavioral intensive care
unit designed for patients who have not
been successful in more traditional program
settings. The CPC is New Mexico’s only
public provider of treatment for children
with serious emotional disturbances.
• The Early Program
This program is for individuals ages 15
through 30 who have experienced a
first episode psychosis within the past 12
months. Program services are provided at
the UNM Psychiatric Center.
In addition to inpatient psychiatric care,
UNMH oers a range of outpatient
behavioral health services for children and
adolescents including community-based care
through the multisystemic therapy teams
and community family teams, individual and
group counseling, and case coordination
services. The CareLink Behavioral Health
Home provides a higher level of care
coordination for higher needs patients.
• Cimarron Clinic
The Cimarron Clinic is the primary
behavioral health outpatient clinic for
children. It provides evaluation and
case management services for youth
experiencing significant emotional
disturbances as well as medication
management with linkages to other
needed services.
• Neuropsychiatric Testing
Psychological tests and evaluations
enable psychologists and psychiatrists
to understand the nature of a youth’s
challenges and properly manage
complex psychiatric conditions. This
helps patients receive proper care.
• The Collaborative Interdisciplinary
Evaluation and Community Treatment
Program (CONNECT)
CONNECT is one of two UNMH
programs that focus on treating young
people for symptoms, like worrisome
changes in thoughts, experiences or
feelings, that may lead to the onset
of a serious mental health disorder.
CONNECT is for patients ages 12 to 25.
9
UNM Hospitals
UNM PSYCHIATRIC CENTER
The UNM Psychiatric Center is a public
facility providing the full range of behavioral
health care for thousands of New Mexicans
annually. Established in 1967, the center
oers 47 beds for adults and seniors and
has become the state’s largest community
mental health care provider. Telehealth
technology extends access to high-quality
behavioral health services in schools,
corrections facilities and other locations
throughout New Mexico.
• Senior Clinic
The UNM Hospitals operates the senior
clinic at the UNM Psychiatric Center.
Patients in the unit are often medically
fragile with significant behavioral and
physical health needs. Patients are
treated by a team led by a geriatric
psychiatrist. Senior center sta focus on
recovery and work to help individuals
address their mental health needs while
reconnecting with their personal hopes
and motivations.
• Geriatric Inpatient Unit
The 15-bed geriatric inpatient unit
located at the UNM Psychiatric Center
at 2600 Marble NE serves patients sixty
and older. Programming addresses
unique needs of older patients.
10
2020 Community Health Needs Assessment and Implementation Strategy
Community Resources
ASSERTIVE COMMUNITY TREATMENT
(ACT)
ACT provides treatment, rehabilitation and
support services for people living with
severe mental illness. The multidisciplinary
mental health team fans out through the
city to help people who come often to
emergency departments, jails and other
institutions and delivers counseling and
other community services to patients
in their homes. The team includes case
managers, peer specialists, nurses,
therapists and prescribing providers. ACT
is supported by a contract with the City of
Albuquerque to serve community members
who have struggled with traditional
outpatient care and as a result over-use
emergency or inpatient care, or who are
jailed often.
CARELINK NM
The CareLink NM Health Home is a
community-based program that provides
additional care coordination for high
needs adult and adolescent behavioral
health patients who are eligible for New
Mexico Medicaid. The CareLink program
coordinates medical services and helps
patients get social services like housing
and food assistance.
COMPREHENSIVE COMMUNITY
SUPPORT SERVICES (CCSS)
CCSS is a recovery-based model that
forms a partnership with patients to help
them reach their individual goals so that
they can live as independently and fully
as possible. CCSS knows that people can
and do recover from mental illness. CCSS
services are provided by referral.
11
UNM Hospitals
PATHWAYS
Pathways is designed to reduce unmet
needs, address health inequities, and
improve the overall health of the residents
of Bernalillo County. It focuses on positive
health outcomes by using community
health navigators as care coordinators who
connect at-risk residents to resources and
follow their progress toward improved
health outcomes.
RESOURCE REENTRY CENTER
Services at the RRC are designed to move
people away from the criminal justice
system by connecting them to community-
based services, like employment and
housing assistance, that will help them stay
out of jail. This program is separate from,
but works with, the Bernalillo County jail
recidivism program (a program to help
people who tend to be rearrested). The
RRC also works with law enforcement
agencies, criminal justice professionals,
health care professionals, patients and their
families to promote positive outcomes for
people who participate.
Community health navigators
and patient advocates are
people who act as links between
health care professionals and
patients or caregivers in order
to help people make their way
through the complex health
system. Meaningful outcomes
for the clients are reached by
following a step-by-step approach
(Pathways). While individual
clients achieve improved health,
common systems issues are also
brought to light and result in
stronger service coordination.
Pathways is funded by UNMH with
revenue from a voter-approved
property tax dedicated to hospital
operations and maintenance.
2
2
Details about this funding mechanism are available at:
https://www.bernco.gov/county-manager/university-of-new-mexico-hospital-mill-levy.aspx
12
2020 Community Health Needs Assessment and Implementation Strategy
FOCUS 2: INCREASE ACCESS TO
MEDICAL SERVICES
Diculty scheduling appointments and
accessing care was a major concern of
people at the listening sessions. From the
Southwest Mesa to the Northeast Heights,
limited access to both primary care and
specialty services were seen as barriers to
a healthy community.
UNM Hospitals provides access to
programs that are not available
anywhere else in New Mexico. Without
these programs, patients would have
to travel out-of-state to get services,
an alternative that is both inconvenient
and expensive. Due to the small number
of providers in these fields, wait times
for non-emergency clinic appointments
can be long. On the other hand, clinic
appointments are generally available
within two weeks for women’s services,
adult and children’s orthopedics, and
optometry. Family medicine oers same
day and next day acute services for
established patients.
The following are examples of strategies,
internal resources, and community
resources, which contribute to access.
13
UNM Hospitals
Strategies
UNMH is pursuing a number of strategies
that improve access to timely care. The
initiatives listed below are examples of
these eorts and do not constitute a
comprehensive inventory:
• Co-locate specialty services, like
psychiatry, within primary care clinics
• Consider expanding clinic hours
of operation
• Recruit more physicians, physician
assistants, nurse practitioners, and
other advanced practice providers in
many specialties including Cardiology,
Pulmonology, and Nephrology
• Improve tools for submitting, receiving
and following up on referrals
• Improve scheduling eciency
• Increase appointment availability to make
certain care is provided in a timely manner
• Continue partnership with health care
consultants to help simplify guidelines for
schedulers to increase clinic volume and
eciency and support a patient-centered
process for access to care
• Redesign clinic workflows to reduce
scheduling delays and referral backlogs
• Improve stang to increase the
numbers of providers
• Increase availability of primary care
physicians, with particular focus on
hard to reach communities
STRATEGIES UNIQUE TO
WOMEN’S HEALTH
• Explore the development and
implementation of women’s integrated
health care (page 24)
• Continue to provide and expand
support groups that enable women
to share their experiences and learn
from each other as a component of
treatment and care
• Explore opportunities for expansion
in obstetrical, gynecological, and
urogynecological care
14
2020 Community Health Needs Assessment and Implementation Strategy
STRATEGIES UNIQUE TO ORTHOPEDICS
• Develop agreements with primary care
clinics for ease of moving patients between
specialty and primary care clinics
• Simplify the clinic referral process
• Increase the number of appointment
slots per subspecialty
• Collaborate with Radiology to prioritize
MRI scheduling for quicker turnaround
• Add a diabetes educator in the Center
for Healing in the Lower Extremities,
(page 17). An educator can help manage
diabetes and improve the likelihood that
surgery will be successful
• Recruit more physicians and advanced
practice providers
• Start a physiatry residency program,
increasing access for non-operative
orthopaedic pain management and
rehabilitation (Physiatry is a branch of
medicine that uses physical therapy,
physical agents like water, light and
electricity and mechanical devices to
prevent, treat and diagnose diseases)
• Train nurses for foot care and start foot
care clinics
• Expand the Fracture Liaison Service
(page 19) to manage osteoporosis and
prevent fractures
• Remodel the General Orthopaedic
Clinic to include a procedure room with
an advanced x-ray machine
STRATEGIES UNIQUE TO PEDIATRICS
• In collaboration with Harvard
University, create biomarkers of toxic
stress with the ultimate goal of being
able to look at ways to lessen the
eect of childhood trauma and to see
a decrease in the biomarkers of stress.
• Facilitate parent support groups in a
variety of languages including Swahili,
Spanish, Arabic and Farsi, through
UNMH’s home visiting program.
15
UNM Hospitals
STRATEGIES UNIQUE TO
OPHTHALMOLOGY
• Make the best use of appointment slots
• Complete renovation at the Eye Clinic to
double exam rooms, allowing for more
ophthalmologists and optometrists
• Recruit more full time ophthalmology
physicians focusing on pediatric,
glaucoma, cataract and teleretina needs
• Recruit optometrists
• Implement Pediatric Fluorescein
Angiography (FA) surgeries, allowing the
doctor to get more information about
the health of the retina (back layer of
the eye) and the optic nerve so pediatric
patients do not have to leave New
Mexico for surgery
• Add hours in the evening and
possibly Saturdays
• Explore expanding current part-time
ophthalmology residency program into
a full-time residency program
STRATEGIES UNIQUE TO SENIOR HEALTH
• Build UNM Movement Disorders Center
and Senior Health Center (page 23)
• Recruit a full-time multiple sclerosis
(MS) specialist in the departments
of Neurology and Ophthalmology
to further increase access to care
and enable patients to get otherwise
unavailable services including therapies
through participation in clinical trials
• Increase registered nurse positions
dedicated to performing Medicare
B Annual Wellness visits. These
positions will improve access to this
valuable service available at no cost to
Medicare B recipients. Annual Wellness
Visits include many aspects of an
annual check-up as well as a Health
Risk Assessment that includes social
determinants of health, assessment
of cognitive function and behavioral
health risk factors, a written schedule
of recommended screenings, health
education and referrals.
16
2020 Community Health Needs Assessment and Implementation Strategy
Internal Resources
The resources listed below contribute to
better access either by addressing one
or more common barriers to care for
disadvantaged populations or by being
the only service of its type available in
New Mexico.
• In addition to these resources, UNMH
is contracted with a national health
care consulting group to identify
opportunities to improve access to care
and reduce the number of patients
waiting to be established with a provider.
Initiatives being considered include
financial incentives for providers to
spend more time seeing patients in the
clinics and increasing the number of
paneled patients assigned to advanced
practice providers like nurse practitioners
and physician assistants.
ADULT AND CHILDREN’S IMMUNOLOGY
Doctors specializing in allergy and
immunology diagnose and treat conditions
like food allergies, asthma, autoimmune
disorders and recurring infections. Oering
these services contributes to access as UNMH
is the only service provider in New Mexico.
ADVANCED PRACTICE PROVIDERS
Advanced practice providers like nurse
practitioners (NPs) and physician
assistants (PAs) increase access to
care by providing some services
traditionally provided only by physicians
This helps physicians to use their time
more eciently and eectively. The
UNM Advanced Practice Provider
(APP) Hospital Medicine Fellowship is
a postgraduate fellowship program. It
supports early career development of NPs
and PAs during their first year of practice
in the specialty of Hospital Medicine.
AMBULATORY CARE DIABETIC CLINIC
AND CENTER FOR DIABETES AND
NUTRITION EDUCATION
The nationally certified Center for Diabetes
and Nutrition Education uses certified
diabetes educators and registered
dietitians to educate patients about how
to monitor and manage their disease.
This program stands out as diabetes care
as well as nutrition education is strongly
needed in Bernalillo County.
17
UNM Hospitals
APPOINTMENT CENTER
UNM Health System Appointment Center
serves as a single point of contact for
patient appointments within the UNM Health
system, including UNM Hospitals Ambulatory
Clinics, Sandoval Regional Medical Center
Ambulatory Clinics, and our Medical Group
Clinics. The Appointment Center promotes
access because it is a single point of contact
for patients; that is, UNMH provides a single
phone number (272-IUNM) making it easier
for patients to schedule appointments.
The Appointment Center also helps the
patient connect with the appropriate UNMH
service(s). The center keeps data about
access for leadership which helps them to
address bottlenecks, and contributes to
reporting appointment availability.
CENTER FOR DEVELOPMENT AND
DISABILITY (CDD)
The CDD identifies, develops, and
strengthens opportunities and choices for
all persons with disabilities and their families
throughout their lives so that they are
included in all aspects of society.
CENTER FOR HEALING IN THE LOWER
EXTREMITY (CHILE)
CHILE is the only service in New
Mexico focusing on reducing lower
extremity amputations due to diabetes
complications. This program is not
available anywhere else in New Mexico.
Without the program, patients would have
to travel out-of-state to get these services
and without the program, the rate of
amputation would increase.
CENTERING FOR DIABETICS
This prenatal education for diabetic
patients is oered in an unhurried and
understandable fashion. Centering
support groups allow women to
participate in their care and benefit from
sharing each other’s experiences while
learning from one another.
18
2020 Community Health Needs Assessment and Implementation Strategy
CHILDREN’S AND ADULT
CYSTIC FIBROSIS
The UNM Cystic Fibrosis Center is the
only facility in the state accredited by the
Cystic Fibrosis Foundation (CFF). CFF
accreditation means that the clinic has
been nationally recognized for providing
specialized care that leads to improved
length and quality of life for children and
adults living with cystic fibrosis.
CHILDREN’S GENETICS
Physicians, genetic counselors and other
professionals provide guidance and
treatment to children and families aected
by abnormal genes or other biological
factors. Without UNMH support, these
services would not be available anywhere in
New Mexico.
CHILDREN’S RHEUMATOLOGY
The UNM Health System has the state’s only
board-certified pediatric rheumatologist.
This much-needed specialty cares for the
joints, soft tissues and connective tissues of
patients under 18.
COGNITIVE BEHAVIORAL
THERAPY (CBT) GROUP FOR
CHRONIC PELVIC PAIN
CBT for Chronic Pain is a limited-
time, evidence-based, and active, a
psychotherapy that has been shown to
improve the wellbeing and functioning of
individuals with chronic pain. The goal of
the group is to have this evidence-based
intervention in locations where women are
already being seen for medical treatment.
This reduces barriers to care.
DEPARTMENT OF SURGERY
UNM’s Department of Surgery provides
surgical education and patient
care including bariatric, colorectal,
cardiothoracic, plastic, ear nose and
throat, and trauma surgery, as a part of
state’s only Level I Trauma Center.
19
UNM Hospitals
DIVISION OF OPHTHALMOLOGY
This division provides state-of-the-art care
and helps patients overcome barriers to
care by coordinating services and ensuring
open dialogue with patients, families and
providers. Continuity of care includes
medicine management, participation in visits
with primary care providers and patient
assessments. Ophthalmologists provide a
variety of services including eye screenings
for premature infants and teleretinal care for
diabetics. (Teleretinal care means that retinal
images can be obtained in primary care clinics
and read remotely by eye care specialists.)
FRACTURE LIAISON SERVICE (FLS)
The FLS is designed to identify patients
at increased risk for secondary fractures
(fractures that are caused by a weakening
of the bone, instead of a fall or a blow)
The FLS helps patients start the right
treatment via improved care coordination
and communication. FLS oers a
multidisciplinary team approach to reduce
secondary fractures by promoting
prevention and oering additional care.
HIGH RISK PRENATAL CARE PROJECT
This project provides outpatient high risk
pregnancy care for New Mexico patients
with obstetrical or medical complications
who do not have health care coverage.
Services provided include ultrasound,
maternal fetal medicine consults, genetic
counseling and genetic testing services
to qualified patients who receive services
through UNM Health System’s Women’s
clinics. Patients who qualify for this fund
may also receive at the same time primary
prenatal care through certain providers,
including the University of New Mexico
Hospital’s Maternal and Fetal Medicine
clinics in Albuquerque or providers within
the outreach communities.
INTERSTITIAL CYSTITIS/BLADDER PAIN
SYNDROME (IC/BPS) GROUP
This Peer Education/Learning based
care focuses on decreasing isolation
and improving coping skills through the
sharing of other people’s experiences
and skills.
20
2020 Community Health Needs Assessment and Implementation Strategy
NATIVE AMERICAN HEALTH SERVICES
UNMH Native American Health Services
(NAHS) helps tribal members and their
families to sign up for health care insurance
and with appointment needs. NAHS patient
care coordinators and community liaisons
serve as patient advocates, assist with
care management and work with UNM
Health System departments to coordinate
appointments and follow-up care for Native
American patients.
OBSTETRICAL CENTERING GROUPS
Group medical visits that help to lower
the risk of preterm birth, reduce racial
disparities in preterm birth, increase rates
of breastfeeding, and improve both visit
adherence and patient satisfaction. The
integration of mental health and social
services with obstetric care provides an
opportunity to identify and lessen risk
factors that could potentially jeopardize a
woman or her family’s well-being in the
long term.
ORTHOPAEDIC FOOT AND
ANKLE CLINIC
This clinic specializes in treating a number
of dierent injuries and conditions dealing
with the foot, ankle and toes including
diabetic foot care, wound care, fractures
and skin diseases. The clinic has expanded
access to podiatry (foot care), which is
a scarce resource in the state. UNMH
continues to actively recruit to oer
needed services to patients.
PAIN MANAGEMENT CLINIC AND
UNM PAIN CONSULTATION AND
TREATMENT CENTER (PCTC)
PCTC is the only interdisciplinary pain
clinic of its kind in New Mexico oering
the widest range of pain management
techniques for pain due to many dierent
conditions. PCTC cares for almost any
condition associated with persistent pain.
The department uses strategies outside
of medicine to help patients, including
physical therapy, rehabilitation, and
chiropractic care.
21
UNM Hospitals
PANELS MANAGEMENT
A panel is a specific group of patients
assigned to a single care team. Managing
small groups of patients on an ongoing
basis, rather than treating individual
patients on an event-by-event basis
emphasizes the health of the entire panel.
Instead of focusing on just those patients
who consistently show up for care, panel
management makes it possible for care
teams to monitor how eectively they are
delivering needed services to everyone in
their panel. UNM Hospitals evaluates the
number of patients assigned to a provider or
care team in order to improve and expand
access to care.
PATIENT-CENTERED
SPECIALTY PRACTICE
The National Committee for Quality
Assurance (NCQA) is an organization
that creates standards and guidelines
to measure the performance of health
care organizations. The NCQA Patient-
Centered Specialty Practice (PCSP)
Recognition Program aims to improve
the quality of patient outcomes as well as
the overall patient experience. The PCSP
mission is to increase coordination and
sharing of patient health information
between Physicians and Advanced
Practice Providers (APPs), and to reduce
ineciencies in access to care and referral
management. Everyone in the PCSP
practice works at the top of their license
as a high-functioning team. The PCSP is
committed to health interventions that
are organized around the patient in all
aspects of care.
THE PEDIATRIC CANCERS TEAM
The Pediatric Cancers Team is the only
pediatric hematology/oncology program
in New Mexico that oers access to
NIH-sponsored cancer clinical trials.
These clinical trials oer the children
of New Mexico the chance to be part
of cutting-edge treatments that may
improve outcomes and quality of life.
The team also oers care for children
with complex blood disorders and
works with oncologists in all of the other
multidisciplinary teams at UNM Cancer
Center to help each child with his or her
treatment needs.
22
2020 Community Health Needs Assessment and Implementation Strategy
PRIMARY CARE / INTERNAL MEDICINE
The Internal Medicine division prevents,
diagnoses, and treats a wide range of adult
diseases, while providing in-depth care for
people living with chronic illnesses. Primary
care physicians are specially trained to
solve diagnostic problems and can handle
severe chronic illnesses and situations where
several dierent illnesses occur at the same
time. Primary care practitioners serve as the
gateway to the health care system as the first
point of contact for most patients. Making
sure people have access to primary care is
critical to ensuring health care access overall.
PROJECT ECHO
A program of the UNM Health Sciences
Center, Project ECHO is an internationally
recognized and replicated model that
uses video conferencing to connect rural
practitioners with experts from UNM and
around the state for mentoring, support,
and continuing professional education.
Practitioners can care for patients in their
own communities, instead of requiring them
to travel to UNM for specialty services.
THE UNM COMPREHENSIVE CANCER
CENTER (CCC)
The CCC strives to make sure that all
New Mexicans have access to world-class
cancer care and benefit from advances
in cancer research. Sta at the CCC
provide outstanding cancer diagnosis and
treatment, conduct world-class cancer
research, educate the next generation of
cancer health care professionals. The CCC
works to overcome the serious disparities
among dierent groups in how often
cancer occurs and what the outcomes are
through community-based outreach.
UNM HEALTH SCIENCES DEPARTMENT
OF NEUROSURGERY
New Mexico’s only provider of full-service
neurosurgery care oers the expertise of
board-certified specialists with access to
advanced surgical tools and technology.
Neurosurgery Services include the full
range of neurological surgeries, including
brain surgery, deep brain stimulation for
movement disorders, epilepsy surgery,
skull base surgery, spine surgery, and
pediatric neurosurgery.
23
UNM Hospitals
UNM HEALTH SYSTEM’S TELEHEALTH
NETWORK
Access to UNM’s telehealth network gives
New Mexico’s rural communities audio
and video access to the expertise of UNM
providers. The telehealth network makes
it possible for patients to get treatment
close to home and avoid the medical risks
and financial cost of unnecessary travel.
Telehealth patient care is currently available
for the following specialties:
• Adolescent medicine & Envision
• Behavioral health
• Cancer care
• Carrie Tingley orthotics, prosthetics and
behavioral health services
• Center For Developmental Disabilities
• Children’s Psychiatric Center
• Continuum of Care
• Dermatology
• Emergency care
• Heart care
• Kidney
• Neurology
• Neuropsychology
• Neurosurgery
• Pediatrics
• Primary care
• Sleep disorders
• Speech pathology
• Transdisciplinary evaluation
and support for persons with
developmental disabilities HIV/AIDS
• Women’s health
UNMH MOVEMENT DISORDER CENTER
The UNMH Movement Disorder Center
provides diagnostic consultation and
expert treatment for multiple sclerosis
patients, a large percentage of whom
are elderly. It is the only such program
in New Mexico. A Movement Disorder
Center and Senior Health Center currently
underway will improve access for patients
in Bernalillo County. Addition of a full-time
MS specialty provider in the departments
of Neurology and Ophthalmology
will further improve access to care.
Some patients will have access to
otherwise unavailable therapies through
participation in clinical trials.
24
2020 Community Health Needs Assessment and Implementation Strategy
UNMH WOMEN’S HEALTH
UNMH Women’s Health oers many
dierent services including the following:
• Maternity care
• Prenatal and postpartum care
• Personalized labor and delivery
experience
• Gynecological services
• Annual well-woman exam
• Pap smears
• HPV vaccines
• STD testing
• Minimally invasive surgery
• Chronic pelvic pain clinic
• Urogynecological services
• Treatment of pelvic floor conditions,
including incontinence and organ
prolapse
• Breast health
• Mammograms
• Diagnostic procedures
• Surgery and second opinions
The department also oers Midwifery and
Family Planning. The service has expanded
access and UNMH continues to actively recruit
to oer the services needed to patients.
WOMEN’S INTEGRATED CARE
A high degree of collaboration
and communication among health
professionals is what makes integrated
care special. The health care team creates
a broad treatment plan that addresses
the patient’s biological, psychological and
social needs.
YOUNG CHILDREN’S HEALTH CENTER
The Young Children’s Health Center
provides primary care to pediatric patients
in Albuquerque’s Southeast Heights.
The Center also oers specialty clinics,
including dermatology, allergy, pediatric
& adolescent gynecology and specialized
developmental care as well as speech
language pathology and feeding clinics.
The Young Children’s Health Center also
works with the City of Albuquerque
to provide an array of social services
including early intervention, home visiting
to families of children 3 and under and
services to address trauma and adverse
childhood experiences (ACEs).
25
UNM Hospitals
HELPING HANDS FOR SENIORS
The Helping Hands for Seniors project
is a collaboration between UNMH, City
of Albuquerque Senior Aairs and
Albuquerque Fire & Rescue with the goal
of helping our elderly age in place. UNMH
home health nurses identify patients who
have non-medical needs that get in the way
of their health. Social workers visit seniors at
homes and pull resources in the community
to help with social determinants of health.
Services provided by the Home Services
Program within Senior Aairs are tailored
to the patients’ needs but include anything
from yard safety to fall prevention measures
like ramps, grab bars and shower benches.
NEW MEXICO HEALTH RESOURCES, INC.
(NMHR)
NMHR is a private, non-profit, no-fee agency
organized to support eorts to recruit and
retain health care personnel for communities
including rural and medically underserved
areas around New Mexico.
Community Resources
FIRST CHOICE
First Choice Community Healthcare
is a Federally Qualified Health Center
(FQHC) system with nine health centers
in three counties, including one school-
based health center. First Choice provides
primary medical care, dental care and
WIC services and integrated behavioral
health care in the primary care setting.
First Choice partners with UNMH to
deliver high quality, cost eective,
accessible care.
FIRST NATIONS
This clinic provides a culturally aware
comprehensive health delivery system
integrating traditional values to take care
of the physical, social, emotional and
spiritual needs of American Indian/Alaskan
Native families and other underserved
populations living in Albuquerque and the
surrounding areas.
26
2020 Community Health Needs Assessment and Implementation Strategy
PATHWAYS
Resource definition on page 11.
SHARE NM
SHARE is an up-to-date and
comprehensive community information
website for individuals and organizations
who are working to improve the quality
of life for New Mexicans. Built by and for
New Mexicans to share information and
resources and support collaboration for
change, SHARE is a trusted resource
for information.
27
UNM Hospitals
FOCUS 3: INCREASE ACCESS
TO MEDICAL COVERAGE AND
FINANCIAL ASSISTANCE
Participants in nearly every listening session
voiced concern about the cost of medical
care. Many were surprised to learn about the
range of financial assistance options already
available to UNMH patients. Community
feedback showed the need for better
communication about the financial services
and support available through UNMH.
Community members expressed a need for
a concise, accessible road map of financial
options to patients at all UNMH sites.
Feedback suggested that sensitivity training
for sta who interact with patients could
make financial services more accessible.
The following are examples of strategies,
internal resources, and community
resources, which contribute to access.
28
2020 Community Health Needs Assessment and Implementation Strategy
Strategies
The University of New Mexico Hospitals seek
to increase access to medical coverage and
financial assistance through the following
strategies and activities:
• Improve messaging about the financial
services available to patients by
enhancing sta orientation and training
• Hold financial assistance meetings to
share information and answer questions
about the services available
• Update public-facing materials to make
information about financial assistance
resources more accessible
• Make sure that the information on
the UNMH website is consistent with
other sources of information about
patient financial services, including
printed material
• Meet with Pathways navigators (page
11) to provide training on current
programs available through Patient
Financial Services (page 29)
• Collaborate with UNMH Marketing to
promote awareness of Patient Financial
Services’ programs available to
immigrant patients
• Establish a universal contacts list for
UNMH sta providing information on
patient financial services
• Increase sta from Patient Financial
Services (page 29) at UNMH clinics
• Provide sensitivity training for Patient
Financial Services sta
• Explore ways to provide pricing
transparency and financial counseling
for the surprise billing initiative
29
UNM Hospitals
Internal Resources
NATIVE AMERICAN HEALTH SERVICES
UNMH Native American Health Services
(NAHS) will help tribal members and their
families with enrollment in coverage and
with appointment needs. NAHS patient
care coordinators and community liaisons
serve as patient advocates, help with
care management and work with UNM
Health System departments to coordinate
appointments and follow-up care for Native
American patients.
PATIENT FINANCIAL SERVICES
Patients who want to get care at UNMH
should not have to miss treatment and
continued care of their health because they
cannot pay. UNM Hospitals has programs
and services available to help patients find
the resources they need to aord good care.
Financial services representatives help
patients apply for Centennial Care 2.0,
New Mexico’s Medicaid program, and/
or get aordable coverage through the
New Mexico Health Insurance Exchange
(HIX). Some patients may also qualify for
secondary coverage through UNM Care
(Secondary coverage means insurance
that will pay after your primary insurance
has paid as much as it can towards
a health care cost). Patient Financial
Services can also help patients set up
aordable payment plans to cover out-
of-pocket health care expenses (payment
plans are when you agree to pay the
amount you owe over time instead of
paying the full amount all at once).
TALKING TO PATIENTS ABOUT
DOLLARS AND CENTS
This financial literacy training helps sta
become aware of technical insurance and
finance-related terms that may confuse
patients. Activities and practice help sta
come up with new ways of saying those
terms and using them in conversation
with patients. Each class will contribute to
an on-going glossary of plain language
terms and phrases, available to hospital
sta through the hospital intranet.
30
2020 Community Health Needs Assessment and Implementation Strategy
UNM CARE
Bernalillo County residents who meet
certain income guidelines may qualify for
medical assistance through UNM Care. UNM
Care covers expenses for the underinsured
and provides secondary insurance for those
patients with Medicare and/or commercial
insurance coverage who have outstanding
balances at UNMH.
SELF-PAY DISCOUNT
Patients who do not qualify for insurance
or UNM Care and who are paying out of
their own pockets may qualify for the self-
pay discount program. This program can
reduce hospital and physician charges
by 45 percent for residents of Bernalillo
County who meet the program guidelines.
Residents of other New Mexico counties
may also qualify depending on the medical
services needed. Eligibility for the self-pay
discount is figured out every year.
ONE-TIME 45 PERCENT DISCOUNT
Patients who do not qualify for any UNMH
financial assistance programs may get a
one-time 45 percent discount on charges
for hospital and physician services
provided at UNM Hospitals.
31
UNM Hospitals
Community Resources
In addition to programs and services
available through UNMH, Patient Financial
Services also provides patients with
information about insurance plans and
financial services outside the UNMH system
that can help pay for their care.
BEWELLNM
New Mexico’s Health Insurance Exchange,
known as BeWellnm, allows individuals
and small businesses to shop and compare
health insurance options and access
premium assistance. These choices are
made possible through the 2010 federal
Patient Protection and Aordable Care Act.
EMERGENCY MEDICAL SERVICES FOR
ALIENS (EMSA)
EMSA is for patients who are ineligible
for Medicaid because of their immigration
status. EMSA pays for emergency medical
services, including labor and delivery.
NEW MEXICO MEDICAID
New Mexico Medicaid, also known as
Centennial Care, is a health insurance
program administered by the New Mexico
Human Services Department and available
to most low and some moderate income
New Mexicans. Centennial Care is publicly
subsidized which means the program has
some support from public (government)
funds.
NEW MEXICO MEDICAL INSURANCE
POOL (NMMIP)
The NMMIP provides health insurance
coverage to residents of New Mexico who
are ineligible for other forms of coverage
and considered uninsurable. NMMIP
provides a Medicare carve-out plan for
individuals with a disability who are
under 65. NMMIP also oers low income
premium programs that have discounts
ranging from 25 percent to 75 percent.
PATHWAYS
Resource definition on page 11
32
2020 Community Health Needs Assessment and Implementation Strategy
Focus 4: Reduce Inequities
that Lead to Disparities in
Health Outcomes
Racial and economic disparities in health
outcomes are well-documented in Bernalillo
County as well as at the national level.
3
UNMH feels strongly about addressing
the need to reduce inequities that lead to
disparities in health outcomes. Many factors
including unequal access to health care
and the clustering of social, economic, and
environmental health risks in low-income
and nonwhite neighborhoods contribute to
health disparities.
As New Mexico’s largest public hospital
and only academic medical center, UNMH
plays a critical role in lessening disparate
health outcomes by increasing access to
medical services, improving health literacy,
and delivering culturally sensitive care.
UNMH works to make sure that hospital
stang reflects the racial and ethnic
make-up of the community (Figure 2).
3
2018 National Health care Quality and Disparities Report. Content last reviewed October 2019. Agency for Health care Research
and Quality, Rockville, MD. Retrieved from: https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html
The Rock at Noon Day
- feeding Albuquerque’s
homeless population
Photo credit:
Roberto E. Rosales
33
UNM Hospitals
urged health care providers to think
dierently about how they deliver
on commitments to health equality.
Attendees encouraged more access to
language interpreter services. They asked
us to promote humanism in our approach
to delivering care.
UNMH is committed to meeting the needs
of vulnerable and underrepresented
communities. Despite improvements,
disparities in health outcomes continue for
people of color and low income county
residents. Listening session attendees
Source: UNMH Interpreter Services, 2020. The size of the colored box indicates the overall interpretation occurring in that
language.
Figure 1
UNMH Interpreter Services, Average Monthly Requests by Language, 2019
UNM Interpretation Services
Arabic
Farsi
Swahili
American Sign Lanugage
Navajo
Vietnamese
Chinese (Mandarin & Cantonese)
Spanish
All Other
American Sign Language
Arabic
Chinese
(Mandarin & Cantonese)
Farsi
Navajo
Spanish
Swahili
Vietnamese
All other
84.2%
10.7%
1.5%
1.0%
.9%
.5%
.8%.8%
1.1.%
34
2020 Community Health Needs Assessment and Implementation Strategy
Community members asked UNM
Hospitals to help increase the awareness
of community resources available to
patients who face diculties like housing
insecurities. As an immediate response to
the needs identified by those facing housing
insecurities, UNMH has followed up with
those in leadership to help address their
needs, including connecting patients with
social services when they are discharged
during late hours, and supporting programs
like The Blue Wrap Project (page 37).
Source: Bernalillo and Sandoval County projected 2018 Census and UNMH Human Resources 2019
Figure 2
Local Population and Sta Demographics, 2019
Bernalillo & Sandoval Counties
Bernalillo & Sandoval
Counties
Hispanic
White
Black or African
American
Native Hawaiin or
Pacific Islander
Asian
American Indian or
Alaskan Native
Two or More Races
UNM Hospital Staff
UNM Hospital Staff
Hispanic
White
Black or African
American
Native Hawaiin or
Pacific Islander
Asian
American Indian or
Alaskan Native
Two or More Races
Bernalillo & Sandoval Counties UNM Hospital Sta
Attendees also asked UNMH to participate
in community outreach and support
programs that celebrate diversity and
inclusivity and empower and support
underrepresented groups. Thanks to the
feedback from listening sessions, UNMH
will commit to working to meet the needs
of under-represented individuals.
The following are examples of strategies,
internal resources, and community
resources, which contribute to access.
American Indian or
Alaskan Native
Asian
Black or
African American
Hispanic
Native Hawaiian or
Pacific Islander
White
Two or more races
35
UNM Hospitals
Strategies
The following are examples of strategies
and possible strategies to reduce health
disparities:
• Embed community health workers
in clinics to screen for and assist
patients in addressing harmful social
determinants of health
• Increase access to interpreter services
for Limited English Proficient (LEP)
patients, families, and caregivers
• Work with community Pathways
navigators to share education on the
complexities of emergent vs urgent
care services
• Provide care coordination and
health care delivery at the Westside
Emergency Housing Center (page 44)
• Increase awareness of community
resources available to patients who
face adverse social determinants like
housing instability
• Participate in community outreach
and support programs that celebrate
diversity and inclusivity and/or create
opportunities to empower and support
under-represented groups
• Monitor quality outcomes data to
identify and address racial/ethnic
disparities, and work with Oce of
Diversity, Equity and Inclusion (DEI)
to address issues
• Work with DEI (page 40) to reduce
identified health disparities and
improve the care provided to an
increasingly diverse patient population
• Make sure that patients from all
racial and ethnic groups, regardless
of language, leave the hospital
understanding discharge instructions
• Decrease the number of patients who
leave the Emergency Department
without receiving care and work to make
sure that this does not happen more
often to economically disadvantaged
patients, regardless of their race,
ethnicity, language, age, or gender
identity
Quality data shows how well the
hospital achieves desired health
outcomes, like safety of care or
reduction of infections patients get
while staying in the hospital.
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2020 Community Health Needs Assessment and Implementation Strategy
• Make sure that all patients, regardless
of their race, ethnicity, language, age,
gender identity, or ability to pay feel
comfortable making a complaint about
their care
• Create a Diversity Equity and Inclusion
Educator position under the Oce of
Diversity Equity and Inclusion to support
the provision of exceptional and inclusive
care to all UNMH patients
• Explore the addition of sensitivity
training specific to diversity, equity,
and inclusion, beginning in the UNMH
Emergency Department
• Provide training to Pathways navigators
and other community organizations
on current programs available
through DEI
• Work to reduce the number of
gendered spaces for both patients and
sta by updating signage across the
organization
37
UNM Hospitals
Internal Resources
BLUE WRAP PROJECT
This project works to make use of unused
clean operating room wraps and convert
them into sleeping bags for the homeless
population. This program works to meet
the needs of those who face adverse social
determinants like housing insecurities.
HEALTH LITERACY
Health care organizations have a
responsibility to make sure patients
can find, understand, and use health
information to make decisions about
their care. The Health Literacy Oce
at UNMH improves the way written
and spoken health information is
communicated. The Oce reviews and
revises for reader-friendliness an average
of 150 patient-facing documents a year
in consultation with medical sta and
works with Interpreter Language services
on translation of these documents
into other languages. The Oce also
provides training for sta on patient-
centered communication skills and is
piloting community-based programs
that increase adult health literacy for
speakers of languages other than English.
The Health Literacy Task Force works
towards improvements in the Hospital’s
ability to provide useful accessible health
information to all community members.
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2020 Community Health Needs Assessment and Implementation Strategy
INTERPRETER LANGUAGE SERVICES
To make sure there is clear communication
between care teams, patients and families,
UNM Health System provides quality
language services at no cost to patients.
The use of professional medical interpreters
helps to make sure that patients get
accurate, fair and confidential interpretation
of all information given during their visit.
In addition to sta interpreters, nearly
200 bilingual hospital employees have
undergone medical interpreter training
and are qualified to provide medical
interpretation throughout the health system
(Figure 1).
LGBTQ COLLABORATIVE
The UNM Health System LGBTQ
Collaborative is an employee resource
group formed in 2011 under the Oce of
Diversity, Equity and Inclusion. It is open to
the entire UNM Health System and includes
community partner representation from
the UNM LGBTQ Resource Center and
the Transgender Resource Center of New
Mexico. The LGBTQ Collaborative works
on initiatives that create an environment
that supports LGBTQ employees, patients,
families, friends and allies.
MIMBRES SCHOOL EXPANSION
The Mimbres School is a state-accredited,
year-round elementary and high school
in a hospital setting. Caring sta develop
general and special education plans that
address each student’s unique academic,
behavioral and social needs in a safe,
structured environment. In response
to requests from UNMH’s patients and
families, Mimbres school expanded from
beyond the Child Psychiatric Center to
the main hospital. The ability to stay on
track with school and not fall behind while
handling the disruptions to family that
come with a chronic/debilitating diagnosis
is gigantic. The school also allows siblings
to enroll and/or take advantage of regular
open tutoring hours open each day.
NATIVE AMERICAN HEALTH SERVICES
Resource definition on page 20
39
UNM Hospitals
NAVAJO WORKING GROUP
The mission of the Navajo Working Group
is to provide quality support services for
Navajo patients and the UNMH personnel
who serve and interact with them. The
working group strives to build awareness of
the need for culturally aware care for Navajo
patients and their families.
NM CARES HEALTH DISPARITIES CENTER
The New Mexico Center for the
Advancement of Research Engagement and
Science on Health Disparities (NM CARES)
is funded by the National Institutes of Health
and National Institute for Minority Health
and Health Disparities. UNM Health Sciences
does research aimed at finding new answers
to the complex problems that contribute to
health disparities in New Mexico.
PROJECT SEARCH
Project SEARCH is a business-led
collaboration that provides young
adults with disabilities the chance to
have experience for future employment
through training and career exploration.
Project SEARCH is a one-year, post high
school transition program which provides
both training and education, and potential
employment. Project SEARCH participants
are on-site at UNM Hospital to learn about
the health care field.
THINKFIRST INJURY PREVENTION
FOR YOUTH
Youth of color are at higher risk of
being injured or killed from injury.
This program’s mission is to prevent
brain, spinal cord and other traumatic
injuries through education, research and
advocacy. Health care professionals from
UNM Health System visit classrooms and
youth organizations, like the Boys & Girls
Club, to make engaging, age-appropriate
presentations that help children and
teenagers understand prevention topics.
40
2020 Community Health Needs Assessment and Implementation Strategy
THE UNIVERSITY OF NEW MEXICO
PREVENTION RESEARCH CENTER (UNM
PRC) AND COMMUNITY ADVISORY
COUNCIL (CAC)
Prevention Research Center and the
Community Advisory Council (CAC) work
to make sure that communities are involved
in the Center’s activities. CAC members are
chosen for their experience, involvement
with, and commitment to health promotion,
disease prevention and other health
issues of New Mexicans. The CAC includes
representatives from tribal organizations,
schools, state and federal health
organizations, community members, and
university faculty and sta. The community-
engaged prevention research assists
programs addressing nutrition, physical
activity, teen pregnancy and violence
prevention and will include surveillance
projects, social marketing initiatives, and
dissemination and implementation research.
UNM HOSPITALS OFFICE OF DIVERSITY,
EQUITY & INCLUSION (DEI)
Through community collaboration,
diversity and cultural humility training,
consultation, advocacy, data collection
and analysis, the DEI enriches the
UNM Health System’s ability to provide
exceptional and inclusive care to all
patients. All individuals who hold a
leadership position at UNMH are required
to participate in a diversity training
designed specifically for leaders.
41
UNM Hospitals
Community Resources
ALBUQUERQUE HEALTH CARE FOR THE
HOMELESS (AHCH)
AHCH is the only health care organization in
Central New Mexico dedicated exclusively
to providing services to homeless people,
AHCH provides critical services to over
7,000 men, women and children every
year. By addressing the health-related
causes of homelessness, AHCH makes it
possible for people to find solutions to end
their homelessness.
BARRETT HOUSE
Barrett House provides shelter and
supportive services to women and children
experiencing homelessness. Barrett House
provides homeless women and children the
stability they need to start their journey
toward having a permanent home.
BEST BUDDIES NEW MEXICO
Best Buddies serves people with
intellectual and developmental disabilities
with programs that include integrated
employment, leadership development, and
inclusive living.
HEADING HOME
This New Mexico non-profit provides
emergency housing, permanent
supportive housing services and
focuses on street outreach to people
experiencing homelessness.
HELPING HANDS FOR SENIORS
The Helping Hands for Seniors project
is a collaboration between UNMH, City
of Albuquerque Senior Aairs and
Albuquerque Fire and Rescue with the
goal of helping Albuquerque’s elderly age
in place. Patients with non-medical needs
that get in the way of their health can get
home visits, navigation services, and home
safety modifications like the installation of
ramps, grab bars and shower benches.
42
2020 Community Health Needs Assessment and Implementation Strategy
HEALTHY NEIGHBORHOODS
ALBUQUERQUE
This program works to improve the
community’s health beyond providing
medical care by addressing the other
factors that play into a person’s health,
like employment and education. UNMH’s
collaboration has resulted in reduced
cubic feet to landfills, reduced CO2 tons,
savings in terms of gallons of water, trees,
and energy. This program also works to
source certain goods and services locally
when available and possible to do so,
with emphasis on hiring locally, buying
locally and supporting the startup research
and growth of local businesses in the
communities that need them the most.
PATHWAYS
Pathways is designed to reduce unmet
needs, address health inequities, and
improve the overall health of the residents
of Bernalillo County. It focuses on positive
health outcomes by using community
health navigators as care coordinators who
connect at-risk residents to resources and
follow their progress toward improved
health outcomes. Meaningful outcomes
for the clients are reached by following
a step-by-step approach (Pathways).
While individuals attain improved health,
common systems issues are also brought
to light and result in stronger service
coordination. Pathways navigators are
embedded in grassroots community
organizations. These organizations
receive grants from Pathways to fund
the navigators’ work. Recent Pathways
grantees include:
• Casa de Salud - interweaves traditional
and conventional medicines to meet
the physical and spiritual health needs
of the community in a welcoming, just,
creative, and inclusive environment.
• Crossroads for Women - provides
comprehensive, integrated services
to empower women emerging from
prison to achieve safe, healthy, and
fulfilling lives in the community, for
themselves and their children.
• East Central Ministries - assists those
living in Albuquerque’s International
District by providing healthy food
resources, holistic care programs, and
services for youth.
43
UNM Hospitals
• Encuentro - engages Latino immigrant
families in educational and career
development opportunities that build
skills for economic and social justice.
• Enlace Comunitario - transforms lives of
individuals and their families experiencing
domestic violence by working to decrease
gender inequity and intimate partner
violence in the central New Mexico’s
Latino immigrant community.
• Juntos - organizes Latino families to
advocate for environmental justice,
including clean air and water
• La Plazita Institute - is designed around
the philosophy of “La Cultura Cura” or
culture heals. La Plazita Institute provides
cultural healing services to Albuquerque’s
vulnerable youth and their families.
• New Mexico Asian Family Center -
oers mental health services to Pan-
Asian, Middle Eastern and African
immigrants and refugees who have
experienced trauma due to war in their
home countries, displacement at refugee
camps and resettlement.
• PB & J Family Services - Provides
intensive wrap-around services to at-
risk children and families.
• TenderLove - helps students learn
to follow directions, take projects
from beginning to end, design their
own projects, think and create
independently. Students also learn
basic financial skills, and basic
employment etiquette, like on-time
arrivals, calling when late, scheduling
time o with supervisor’s approval.
• United Voices for Refugees - is a
community led organization that
advocates for refugee resettlement
policies that promote well-being
and independence.
44
2020 Community Health Needs Assessment and Implementation Strategy
THE UNM ADOBE PROGRAM
The ADOBE Program provides wrap-
around services for youths that have been
imprisoned in the Bernalillo County Youth
Services Center(YSC). The services include
medical and mental health, legal advice,
home navigators and education support.
The program’s primary goal is to lower the
risk of the youth repeating in delinquent/
criminal behavior.
WESTSIDE EMERGENCY HOUSING
CENTER
A project of Heading Home, the
Westside Shelter provides emergency
housing to men, women, and families
experiencing homelessness. UNM
Health System participated, along with
many local organizations to bring the
Westside Emergency Housing shelter in
to being. UNM rotates with other care
delivery systems to provide acute health
visits.UNMH has care navigators on-site.
45
UNM Hospitals
CONCLUSION
UNMH is committed to improving the
health of Bernalillo County by making the
highest quality health care as accessible
as possible to all community members.
This commitment means dierent things
to dierent people, as we learned during
21 listening sessions we held throughout
the county’s diverse neighborhoods.
Residents of the South Valley emphasized
an opportunity for UNMH to deliver more
compassionate care in health outcomes,
while respondents from the North East
Heights said they would like to see a
reduction in appointment wait times and a
larger availability of specialists. Several core
themes were consistent throughout. Themes
included improved access to medical and
behavioral health care, greater transparency
and better communication about the many
forms of financial assistance available
through UNMH. Another theme was the
need to better address the racial and socio-
economic health disparities that arise from
unequal access to resources and other
adverse (harmful) social determinants of
health, like poverty and language barriers,
that aect in greater numbers the
county’s most diverse and economically
vulnerable residents.
As New Mexico’s largest public hospital
and only academic medical center,
UNMH has been striving, through the
development of its own resources and
the creation of community partnerships,
to address these and other critical
health needs for years. Some progress
has been made, but solutions to large
systemic issues like provider shortages
and economic inequality are only possible
through collaboration with the many
other government entities, community
organizations, and New Mexico residents
that share our concern and commitment
to the health and health care of all
New Mexicans. As we move into the
implementation phase of the 2020 UNMH
CHNA, we look forward to partnering
with the many groups and individuals who
generously stepped up to share with us
their needs, concerns, and visions for a
healthier New Mexico.
46
2020 Community Health Needs Assessment and Implementation Strategy
LEADERS AND FACILITIES INVOLVED
UNM Hospitals would like to thank the following individuals and organizations for their
contributions toward the successful completion of the UNM Hospitals 2020 Community
Health Needs Assessment:
APPENDIX 1 - COMMUNITY HEALTH
IMPLEMENTATION PLAN CONTRIBUTORS
• Los Vecinos Community Center
• First Choice Community
• Erna Fergusson Library
• Paradise Hills Community Center
• UNMH SW Mesa Family Clinic
• Barelas Community Center
• UNMH SE Heights Clinic
• Jewish Community Center
• South Valley Economic Development
Center in conjunction with
Coorperativa Korimi
• Oce of African American Aairs
• Cherry Hills Library
• NM Black Mental Health Coalition
• UNMH NV Family Clinic
• First Nations
• All Nations Wellness and Healing Center
• Albuquerque Health Care for the
Homeless
• UNM School of Public Administration
• Pathways to a Healthy Bernalillo County/
Bernalillo County Re-entry Resource
Center
• UNM Health Sciences Center Oce of
Community Health, Health Extension
Regional Ocers (HEROS)
• Centro Savila
• ACCESS - Arts Community Culture
Education Sports Science
• EleValle
• Bernalillo County Community Health
Council
• UNM Oce for Community Health
• New Mexico Black Mental Health
Coalition
• UNM HSC Marketing
• UNM Hospitals Health Literacy Oce
• UNM Hospitals Oce of Diversity Equity
and Inclusion
• UNM Hospitals Interpreter Language
Services
• UNM Hospitals CEO, Kate Becker and
the Hospitals’ Chief Ocers, Clinical
Executives, and all Clinical and Financial
Operations teams
• UNM Hospitals Business Development
Oce
47
UNM Hospitals
APPENDIX 2 - FIGURES
Figure 1 -
UNMH Interpretation Services
Figure 2 -
Local Population & Sta
Demographics 2019
33
34
page
48
2020 Community Health Needs Assessment and Implementation Strategy
APPENDIX 3 - CHNA LISTENING
SESSION REGIONS
BERNALILLO COUNTY
• East Mountain
• Far NE Heights
• UNM Area
• NW Mesa
• NE Heights
• Four Hills
• SW Mesa
• North Valley
• S Valley
• N NE Heights
• SE Heights
• Downtown
SW Mesa
S Valley
NE Heights
N NE Heights
Far NE Heights
East Mountain
NW
Mesa
SE
Heights
Four
Hills
UNM
Kirtland
AFB
Downtown
North
Valley