Presbyterian Healthcare Services

BERNALILLO COUNTY HEALTHY HERE: COMMUNITIES LEADING HEALTHY CHANGE

TRACK 3 OF ACCOUNTABLE HEALTH COMMUNITIES. ACCOUNTABLE COMMUNITIES FOR HEALTH SERVING MEDICAID/MEDICARE ENROLLEES IN UNDERSERVED AREAS OF BERNALILLO COUNTY: A COMMUNITY DRIVEN DESIGN (BERNALILLO-ACH)

ADVANCING HEALTH EQUITY THROUGH WHOLE PERSON CARE FOR DIABETES PREVENTION AND MANAGEMENT IN NEW MEXICO - COMPONENT B APPLICANT, PRESBYTERIAN HEALTHCARE SERVICES ALONG WITH PROJECT PARTNERS, WILL ADDRESS HIGH DIABETES LEVELS IN FIVE NEW MEXICO COUNTIES: DOÑA ANA, OTERO, QUAY, CURRY, AND SAN MIGUEL. THIS SERVICE AREAS HAS A COMBINED POPULATION OF 373,850 AND INCLUDES URBAN, RURAL, AND FRONTIER COUNTIES. THE PROJECT WILL USE A WHOLE PERSON APPROACH AND FOCUS ON FOUR POPULATIONS EXPERIENCING HEALTH AND SOCIOECONOMIC DISPARITIES: HISPANIC/LATINO, AMERICAN INDIAN/ALASKA NATIVE, LOW-INCOME, AND PRE-NATAL/PERI-NATAL POPULATIONS. THE FIVE-YEAR EFFORT WILL IMPLEMENT CDC STRATEGIES 1, 5, 10, AND 13. THIS INCLUDES BRINGING DIABETES RECHARGE, AN ADCES-ACCREDITED DIABETES SELF-MANAGEMENT PROGRAM, THE NATIONAL DIABETES PREVENTION PROGRAM, AND THE MEDICARE DIABETES PREVENTION PROGRAM TO UNSERVED AND UNDERSERVED AREAS. PARTNERS WILL INCREASE PARTICIPATION AND RETENTION THROUGH TWO COMPLIMENTARY DIABETES SUPPORT PROGRAMS FOCUSED ON COOKING, NUTRITION, AND HEALTHY FOOD ACCESS: KITCHEN CREATIONS, BY PARTNER NEW MEXICO STATE UNIVERSITY, AND A PRODUCE PRESCRIPTION SERVICE BY PRESBYTERIAN WITH LOCAL FOOD PANTRIES AND FOOD SECURITY AGENCIES. THROUGH A NETWORK OF COMMUNITY HEALTH WORKERS, COMMUNITY-BASED SOCIAL SERVICES AGENCIES, AND LOCAL HEALTH PROVIDERS, PARTNERS WILL RECRUIT, REFER, AND SUPPORT PARTICIPANTS USING CULTURALLY-RESONANT PRACTICES AND AN ELECTRONIC REFERRAL SYSTEM TO CONNECT INDIVIDUALS WITH SOCIAL SUPPORTS AND EVIDENCE-BASED INTERVENTIONS. PROJECT OUTCOMES ARE AS FOLLOWS (1) INCREASE THE NUMBER OF ORGANIZATIONS AND SITES IMPLEMENTING EVIDENCE-BASED DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT (DSMES), DIABETES SUPPORT PROGRAMS AND SERVICES, AND DIABETES PREVENTION PROGRAMS (DPP) SERVING FIVE HIGH-NEED COUNTIES IN NEW MEXICO; (2) INCREASE PARTICIPATION IN EVIDENCE-BASED COMMUNITY BEHAVIORAL CHANGE PROGRAMS, INCLUDING DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT (DSMES), DIABETES SUPPORT PROGRAMS AND SERVICES, AND DIABETES PREVENTION PROGRAMS (DPPS) IN FIVE HIGH-NEED COUNTIES IN NEW MEXICO; (3) INCREASE ADAPTATION/TAILORING OF EFFECTIVE DSMES, NATIONAL DPP, MEDICARE DPP AND DIABETES SUPPORT PROGRAMS AND SERVICES FOR PRIORITY POPULATIONS OF HISPANIC/LATINO, AMERICAN INDIAN/ALASKA NATIVE, LOW-INCOME, AND PRE-NATAL/PERI-NATAL POPULATIONS; (4) INCREASE THE NUMBER OF INDIVIDUALS (PATIENTS, HEALTH PLAN MEMBERS) IN FIVE HIGH-RISK NEW MEXICO COUNTIES WHO ARE SCREENED FOR SOCIAL DETERMINANTS OF HEALTH (SDOH) AND REFERRED TO COMMUNITY RESOURCES; (5) INCREASE MULTI-DIRECTIONAL COMMUNICATION BETWEEN COMMUNITY RESOURCE PROVIDERS, CLINICAL PROVIDERS, AND OTHER HEALTH SYSTEM RESOURCES (HEALTH PLAN, COMMUNITY HEALTH) WITHIN FIVE HIGH-NEED COUNTIES IN ORDER TO SUPPORT PARTICIPATION IN DIABETES MANAGEMENT AND PREVENTION PROGRAMS AND TO HELP INDIVIDUALS OVERCOME SOCIAL DETERMINANTS OF HEALTH (SDOH) BARRIERS; AND (6) INCREASE DIABETES WORKFORCE CAPACITY TO ADDRESS SOCIAL DETERMINANTS OF HEALTH AND PATIENT/MEMBER CONTACT WITH TRAINED COMMUNITY HEALTH WORKERS (CHWS) AND PROMOTORAS (SPANISH SPEAKING CHWS) TO SUPPORT PARTICIPATION AND RETENTION IN EVIDENCE BASED CHRONIC DISEASE SELF-MANAGEMENT PROGRAMS IN FIVE HIGH-NEED COUNTIES IN NEW MEXICO.

BERNALILLO COUNTY COMMUNITY HEALTH COUNCIL - COMMUNITIES LEADING HEALTHY CHANGE PROGRAM: REDUCING HEALTH DISPARITIES AMONG AMERICAN INDIAN AND HISPAN

HEALTHY HERE: COMMUNITIES LEADING HEALTHY CHANGE

ANE - NURSE PRACTITIONER RESIDENCY PROGRAM

BERNALILLO COUNTY COMMUNITY HEALTH COUNCIL - COMMUNITIES LEADING HEALTHY CHANGE PROGRAM: REDUCING HEALTH DISPARITIES AMONG AMERICAN INDIAN AND HISPAN

HEALTHY HERE BERNALILLO COUNTY COMMUNITY FOOD PROJECTS AND MOBILE FOOD MARKET

BERNALILLO COUNTY IS NEW MEXICO'S MOST POPULOUS COUNTY (662,564 RESIDENTS, ONE-THIRD OF THE STATE POPULATION) AND IT CONTAINS THE STATE'S LARGEST CITY, ALBUQUERQUE (POPULATION 545,852). THE COUNTY HAS SOCIO-GEOGRAPHIC CONTRASTS IN EXTREME POVERTY AND WEALTH, AREAS WITH ABUNDANT GROCERIES AND FOOD DESERTS, CUTTING-EDGE MEDICAL FACILITIES AND FEDERALLY DESIGNATED HEALTHCARE SHORTAGE AREAS, NEIGHBORHOODS PEPPERED WITH ADVANCED DEGREE PROFESSIONALS AND OTHERS WHERE HAVING AS MUCH AS A HIGH SCHOOL DIPLOMA PUTS ONE IN THE MINORITY. WHEN IT COMES TO HEALTH, LIFE EXPECTANCY VARIES BY MORE THAN 22 YEARS ACROSS CENSUS TRACTS WITHIN BERNALILLO COUNTYPARTNERS, PRESBYTERIAN HEALTHCARE SERVICES (APPLICANT AND BACKBONE AGENCY), THREE SISTERS KITCHEN, ENCUENTRO, AND MEALS ON WHEELS ALBUQUERQUE WILL BRING A COMPREHENSIVE APPROACH TO COMMUNITY FOOD PROJECTS BY CONNECTING ELDERLY RESIDENTS WITH LOCAL PRODUCE, NUTRITIOUS MEALS, AND SUPPORT IN PREPARING AND ENJOYING HEALTHY FOODS. THOSE CONNECTIONS WILL BE CREATED BY HOME HEALTH AIDES (HHAS) WHO HAVE SUPPLEMENTAL NUTRITION/COOKING TRAINING, MEDICAL PROVIDERS ASSESSING NEEDS OF ELDERLY PATIENTS, AND VIA HOME MEAL DELIVERY SERVICE. CONNECTING HARVEST TO HEALTH/CONECTANDO COSECHAS CON LA SALUD WILL IMPROVE SENIOR NUTRITION, REDUCE LANGUAGE ACCESS DISPARITIES, INCREASE LOCAL FOOD ACCESS, INCREASE CONSUMPTION OF NUTRITIOUS FOODS, ENHANCE WORKFORCE DEVELOPMENT, SUPPORT ENTREPRENEURSHIP, AND STRENGTHEN THE SUPPORT STRUCTURES FOR AGRICULTURAL PRODUCERS. THE PROJECT WILL TRAIN 135 HHAS (MOST SPANISH SPEAKING OR BILINGUAL), SUPPORT PURCHASE OF OVER 63,000 POUNDS OF PRODUCE FROM 10+ LOCAL GROWERS, AND PROVIDE MEAL DELIVERY TO 540 LOW-INCOME SENIORS. OVERALL, 1,620 SENIORS AND WILL DIRECTLY BENEFIT FROM HHA AND MEALS ON WHEELS PROGRAM SERVICES DURING THE FOUR-YEAR PROJECT PERIOD.

CENTRAL NEW MEXICO THRIVE FOR LIFE: EMPOWERING OLDER ADULTS IN CENTRAL NEW MEXICO TO ADDRESS CHRONIC PAIN