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University of New Mexico Community Health Worker Model: CHW LEADS


The University of New Mexico Community Health Worker model (CHW LEADS) targets difficult-to-reach, marginalized populations in Bernalillo County and elsewhere in New Mexico. Patients are admitted to the program two ways: by screening patients enrolled in primary care clinics participating in the program and referring them to a CHW; or through Medicaid managed care organizations (MCOs), which refer hard-to-reach, high-risk members to CHWs at attributed clinics. In participating federally qualified health center (FQHC) clinics, all patients are screened for social needs using a standardized instrument. Those who screen positive for a social need are then asked if they wish to see a CHW at the clinic to discuss the need. If the patient needs and wants help to deal with adverse social determinants, the medical assistant refers the patient to a CHW colocated at the clinic. CHWs provide education, advocacy and social support. To complement the services of in-clinic CHWs, other CHWs in the Pathways to a Healthy Bernalillo County Program are embedded in the community in social services agencies that specialize in addressing particular needs, such as housing, domestic violence, legal assistance, and workforce training. These CHWs act as community health navigators: they receive referrals from clinics and identify and recruit difficult-to-reach clients in their community or service population, build a relationship of trust with them, and assess their risks and needs, referring clients to appropriate clinical and social services. CHW LEADS links all these CHW programs into an integrated network.


CHW LEADS has screened more than 50,000 patients since it launched as a pilot program in select clinics of an urban FQHC, in collaboration with the University of New Mexico (UNM) Health Sciences Center’s Office for Community Health and Medicaid MCOs. The model is being disseminated throughout the state of New Mexico. Based on results achieved in the pilot, the UNM Health Sciences Center’s Office for Community Health estimates that the program generates a 4:1 return on investment in high-need, high-cost patients served by the program, through decreased emergency department and hospital visits for primary care sensitive diagnoses, lower prescription drug costs, and increased use of primary care.


For providers. In primary care clinics with CHWs, patients reporting social needs are referred to a CHW, who provides a variety of services. The program created a new role for CHWs: they serve as frontline public health workers, who are trusted members of the community or have an unusually close understanding of the community. CHWs help improve patients’ health literacy, help them choose goals they wish to achieve, and guide them step-by-step until their goals are achieved. Clinic-based CHWs are colocated with primary care teams and engage in weekly huddles with clinicians to discuss clients’ clinical and social needs. CHWs address patients’ social needs while physicians address patients’ clinical needs. CHWs from different programs in the network meet monthly to share problems, approaches, and latest updates in the best ways to address social needs in their community. The network attempts to address recurrent barriers by working on health policy changes, such as expanding housing vouchers and subsidies for payment of utilities and increasing public funding for CHW work.

For patients/caregivers. CHWs use motivational interviewing to help patients define their goals. They seek to empower patients to gain the skills, capacity, and confidence to navigate the health and social care systems, access resources on their own, and manage their health. To reach a broader community population, these programs are open to friends and family members who may not be current patients at the clinic. CHWs help address social determinants of health, while continuing to help address clinical issues.


The UNM Health Sciences Center’s Office for Community Health leads the hiring, training, and deployment of CHWs in collaboration with the state Medicaid program, Medicaid MCOs, FHQCs, and others. CHWs work in rural as well as urban communities. In Rural Hidalgo County, Hidalgo Medical Services created a new chief support officer position to give equal organizational priority to family and social needs.


CHWs are paid in different ways. Medicaid MCOs pay a capitated fee of $2.19–$5.75 per member per month for members who are empaneled with a participating provider in the CHW LEADS program. In addition, MCOs pay $321 per member per month for select high-risk members referred to the clinic. Bernalillo County supports the Pathways program with a designated tax levy, negotiated through an arrangement with the University of New Mexico. These funds are dispersed to participating community-based organizations based on the staged completion of Pathways and used to fund the salaries of CHW navigators. The county also pays the salaries of CHWs to staff the Re-entry Resource Center, which addresses the social needs of inmates released from the county jail to reduce recidivism. The county also pays the salaries of CHWs to screen for and address social needs of children and families seen in the University Hospital Pediatric Emergency Department to reduce risk of child abuse. UNM aggregates data on social needs from the patient-screening instruments, shares them with the community, and works on policy or systems issues to address the root causes of social needs at a community level. CHW LEADS also played a significant role in the development of the state certification process for CHWs; in a Medicaid mandate that all MCOs fund CHWs; and in disseminating the model to hospital clinics and wards, providers of care to immigrants, and providers serving people with co-occurring mental health and substance abuse disorders.

Publication Details

Publication Date: November 9, 2018