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Helping clients find the help they need

SANTA FE, N.M. — Sabrina Esquibel, four months pregnant, appeared calm for her prenatal appointment recently at La Familia Health Clinic on Alto Street.

That’s despite gently directing her son, 4-year-old Xavier, on how to push the stroller carrying his 18-month-old sister, Milaya, who wanted to walk more than ride, and managing a large diaper bag, Xavier’s backpack and her own purse.

She had help.

Ana Morelos, as a “navigator” with the ¡Que Cute! program, helps a pregnant woman get to and from the La Familia clinic. A new Santa Fe County effort plans to use the program’s “navigator” to help people get help across various networks of health care and social services. (Eddie Moore/Albuquerque Journal)

¡Que Cute! Healthy Baby program “navigator” Ana Morelos was beside her, watching busy Milaya and a smiling Xavier while Esquibel dealt with all the preliminaries of a medical appointment. Morelos would be going into the medical appointment with Esquibel, as well.

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Morelos’ work entails assisting moms identified as at high risk for giving birth to low birth weight babies to find the assistance they need from various medical and social help networks. Going it alone can cause stress, and stress in pregnancy is one of the risk factors for low birth weight babies.

The structure of Las Cumbres Community Services’ ¡Que Cute! “navigation” program has served as a model for a much broader initiative launched recently in Santa Fe County, organizers say.

The new effort, funded by county government, will provide human navigators offering hands-on help for indigent or under-insured people with persistent and expensive health care problems, directing them toward assistance in such areas as housing, food, transportation, pregnancy-related care and behavioral health care.

The navigator role is intended to prevent ineffectual efforts, or those that don’t last due to stilted, “siloed” delivery, said Kyra Ochoa, Health Care Assistance manager with the county’s Health Services Division.

“A lot of work has been piecemeal. This will align providers and create agreements on how we can do it together,” said Ochoa.

For example, an indigent person sick enough to end up in the emergency room several times a year may also be homeless and hungry. A navigator would help recognize all the issues that may be contributing to a long-term, and expensively treated, illness.

The three-year, $3.3 million program – dubbed Accountable Health Community, or AHC – includes $360,000 worth of contracts with seven community organizations.

The contracts will pay for a total of six navigators and one clinical social worker. They are expected to reach 270 clients.

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The participating organizations are: the Santa Fe Public Schools Teen Parent Program; the school district’s Adelante Program (for families facing homelessness); the Santa Fe Fire Department Mobile Integrated Health Office (MIHO) program; St. Elizabeth’s Shelter; the Interfaith Shelter (Pete’s Place); The Life Link; United Way of Santa Fe County; and the First Born Home Visiting Program.

The county is also in negotiation with an eighth program, Christus St.Vincent Regional Medical Center, for information-sharing between navigators and the Christus system, Ochoa said in an email.

The program is being funded with balances from Santa Fe County’s indigent fund and its general fund, including recurring and non-recurring revenue.

Organizers from the Health Services Division program within the county Community Services Department will pay for screening of clients’ social service needs and navigation, along with additional primary care, dental and behavioral health treatment at federally qualified health centers, including the La Familia Medical Center in Santa Fe and El Centro in Española, that serve uninsured and under-insured county residents.

A request for proposals for $975,000 in services is expected to be issued, under which the health centers would provide additional screening to help their clients access a navigation system and more kinds of services.

A ‘gap analysis’

After a year of preparation and study – including town hall meetings that drew more than 200 people – and the funding of a “gap analysis” to determine where health care services, including behavioral health services, are needed for indigent people and seniors, the county is close to bringing all the pieces together, said Rachel O’Connor, director of the Health Services Division.

The gap analysis includes an “inventory of what we have in Santa Fe County,” O’Connor said.

The study should be complete in September with up-to-date information on housing, health care and other programs that are providing support.

Taking an “upstream” approach by addressing two or more needs – like homelessness and behavioral health care – at once may slow down other rising costs, such as those attached to the revolving door at the county jail, Ochoa said.

The “accountable” part of the title of the Accountable Health Community name is derived from the human chain the program is hoping to strengthen. It’s a remodel of the county’s Health Care Assistance program, she said.

“It’s relationship-based,” she said.

Elizabeth Peterson, project manager for the AHC program, said the project is intended to support the entire community by developing networks that support anyone in the county. “It’s about building community and we all share in this community,” she said.

The existing indigent program has paid claims for health care from providers and will continue to do so, and the indigent program also will ask clinics to connect patients to a navigator.

Baby health model

The strategy and goals behind the AHC aren’t just a shot in the dark at social problems – it got some of its structure from ¡Que Cute! Healthy Baby, a successful La Cumbres Community Services program to bring healthy babies into the world.

With a 9.9 percent rate for babies born underweight – roughly those below 5½ pounds and at risk for an early life of health problems and developmental struggles – the county started a program in 2015 targeting pregnant women with risks associated with low birth weight babies.

Following screening funded by the county at La Familia Medical Center, pregnant women who showed risk factors were directed to navigators at Las Cumbres and were asked to enroll in its special program, ¡Que Cute!.

“The program’s objective is to lower the stress, which is a risk factor, for the moms,” said navigator Morelos.

Mom Esquivel said the support provided by the program has helped in many ways. Getting a ride to a doctor’s appointment is just one of many. Emotional support offered by navigator Morelos has been important.

“I never really liked asking for help, even when it would have been good to have it with them,” she said, indicating her first two children.

Working with Morelos, her identity as a “private person,” has expanded a little.

“I’ve grown out of it,” she said.

If a mom can’t find transportation to a medical appointment and misses the appointment, the stress of uncertainty burdens the baby, Morelos said.

“A person’s life begins at conception and everything can influence them. We’re organic beings – you can’t disconnect anything in a human being, but we tend to separate each one,” Morelos said.

Providing a “warm hand-off” of personal introductions and standing by when a mom needs housing, food, behavioral health services or even more flexible doctor appointments, are some of the goals of the program.

A homeless mom may find her navigator talking with a housing services coordinator for a shelter and feel like she’s got someone she can depend on, Morelos said.

Meanwhile, the program also offers parenting and education classes – including prenatal lessons in talking gently, consistently and positively to babies, she said.

From June 2015 to June 2017, the rate of babies born below 5½ pounds dropped to 8 percent among 477 mothers screened and connected to services, Ochoa said. Further, of the 40 babies born to mothers who engaged in ¡Que Cute! services, 36 babies were born at a healthy rate of 5½ pounds or higher.


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