Report Type: Community Forum/Survey Data Profile
Community Health Assessment
YEAR
2023
AUTHOR / ORGANIZATION
Presbyterian Healthcare Services
GEOGRAPHIC SCOPE
Bernalillo County, Multi-jurisdictional
What is this?
This is a Community Health Assessment (CHA) conducted by Presbyterian Healthcare Services for its Central New Mexico delivery system, covering Bernalillo, Sandoval, Torrance, and Valencia counties. The assessment fulfills IRS requirements for nonprofit hospitals and informs Presbyterian's community health implementation plan for 2023-2025. The assessment was conducted collaboratively with University of New Mexico, New Mexico Department of Health, and other partners to minimize community burden. The methodology included quantitative secondary data analysis from sources including BRFSS, YRRS, and the American Community Survey; qualitative data collection through community forums, focus groups, and key informant interviews; community surveys administered through Google and health council distribution (n=1,153); and stakeholder engagement with health councils, community advisory boards, and Presbyterian leadership. The assessment employed an equity lens throughout, with particular attention to racial, geographic, and population-specific disparities.
Summary
This assessment provides foundational data for behavioral health systems change in Bernalillo County and surrounding areas. Key findings reveal that behavioral health remains a top priority, with community members identifying access to healthcare, substance use, and mental health as critical concerns. The assessment documents significant provider shortages, with the ratio of population to providers remaining too high for adequate access. Community forums identified specific barriers including stress and isolation, lack of providers, stigma, provider turnover, inadequate resources for drug rehabilitation or substance use treatment, limited internet access, and lack of childcare to attend appointments. The report notes that deaths of despair, substance use, and drug overdose are rising while life expectancy is decreasing. Presbyterian has implemented peer support specialists in emergency departments for patients experiencing overdose or alcohol-related emergencies, expanded community health worker programs, and is participating in the five-year Partnerships for Success-PFS20 project to address polysubstance use. The assessment emphasizes the need for trauma-informed and culturally competent care, particularly for Native American communities served by multiple pueblos across the four-county region. Focus group findings specifically call for treatment and harm reduction services accessible locally in multiple languages, including navigation and Medication Assisted Treatment (MAT), along with support for families of people who use substances.
BH Systems Change Recommendations
How This Report Informs Systems Change The assessment identifies specific system-level gaps that should guide behavioral health systems change in Bernalillo County: 1. Workforce Development: The provider-to-population ratio is inadequate across the region, requiring expansion of peer support specialists, community health workers, and behavioral health providers. The assessment documents Presbyterian's successful model of embedding these workers in emergency departments and care teams. 2. Polysubstance Use Infrastructure: Through the Partnerships for Success-PFS20 project, Presbyterian is building dedicated infrastructure to reduce polysubstance misuse using the Strategic Prevention Framework. This coalition model across six high-burden counties provides a template for regional coordination. 3. Treatment Access Gaps: Focus groups with persons with lived experience specifically identified needs for locally accessible treatment and harm reduction services in multiple languages, navigation support, MAT access, and family support services. 4. Stigma Reduction: Community forums identified stigma as a persistent barrier, particularly in smaller communities. Systems change efforts should address both provider attitudes and community-level stigma. 5. Social Determinants Integration: Universal SDOH screening with referral to community resources has connected patients to services for over 115,000 identified needs, demonstrating the value of clinical-community linkages. 6. Youth-Focused Services: Youth mental and physical health is in sharp decline according to focus groups, requiring targeted interventions including resilience education, peer spaces, and navigation support. 7. Cultural Responsiveness: Native American and Hispanic/Latinx populations require trauma-informed, culturally tailored approaches, with services available in multiple languages including Spanish and Indigenous languages.
How to Use for Systems Planning
What this report IS useful for: - Understanding population-level behavioral health needs across the four-county Central New Mexico region - Identifying priority populations for targeted interventions (LGBTQ+, youth, Native Americans, Hispanic/Latinx, men, pregnant women, people living in poverty) - Learning about existing Presbyterian behavioral health programs and partnerships that could be scaled or replicated - Documenting community-identified barriers to behavioral health services including stigma, provider shortages, and access issues - Understanding the intersection of social determinants with behavioral health needs in this region What this report DOES NOT provide: - Detailed provider or service inventories for behavioral health in Bernalillo County - Specific funding amounts or budget allocations for behavioral health initiatives - Clinical outcome data for Presbyterian's behavioral health programs - Analysis of the existing behavioral health workforce or training pipelines - Detailed geographic mapping of service gaps within Bernalillo County - Assessment of telehealth or crisis services capacity
Key Facts & Data Points
- Four-county service area covering Bernalillo, Sandoval, Torrance, and Valencia counties with total population of approximately 916,391 - Bernalillo County is most populous in New Mexico; Sandoval County encompasses seven pueblos and six tribal entities - 19% of population primarily speaks Spanish at home - Life expectancy is decreasing while deaths of despair, substance use, and drug overdose are rising - Community survey collected 1,153 responses across priority topics - Presbyterian has invested more than $8.7 million in operational community health funds and leveraged $19.8 million in grants since 2013 - Over one million SDOH screenings conducted and patients connected to resources for over 115,000 identified needs since SDOH screening implementation - 64% of all New Mexico overdoses occur within the six-county Partnerships for Success coalition area (Bernalillo, Sandoval, Valencia, Santa Fe, Doña Ana, San Juan) - Sandoval County has 12.2% Native American population, about double the statewide percentage - Valencia County has highest percentage living with disability at 44.7% (2020) - Priority populations identified: LGBTQ+, youth, Native Americans, Hispanic/Latinx, men, pregnant and post-partum women, people living in poverty, and Black/African Americans
Priority Services & Findings
**Mental Health / Crisis Care** - Behavioral health identified as top community concern across all four counties - Significant provider shortages with ratio of population to providers too high for adequate access - Stigma remains a barrier (equating behavioral health issues with weakness, small town gossip) - Community forums identified stress and isolation, lack of providers, provider turnover as key challenges - Presbyterian Kaseman Hospital provides inpatient psychiatric and substance abuse services for adult, child, and geriatric patients - Mental health treatment resources identified as major gap in community surveys across all counties **SUD Organizations** - Deaths of despair and drug overdose on the rise across the region - Peer support specialists embedded in emergency departments for overdose and alcohol-related emergencies - Peer support expanded to NICU for babies with neonatal abstinence syndrome - Partnerships for Success-PFS20 five-year federal project addresses polysubstance use in Central New Mexico - Focus groups identified needs for: MAT access, harm reduction services in multiple languages, support for families, reduction of stigma - Inadequate resources for drug rehabilitation identified as community barrier - Easy access to prescription drugs identified as primary intervention concern **School-Based / Youth Services** - Youth identified as priority population across all four counties - Youth focus groups report mental and physical health in sharp decline - Need for more mental health and resilience resources specifically for youth - Youth report fear of consequences of substance use on friends and family - Youth need more activities and spaces to connect with peers and caring adults - Transportation and financial barriers impact youth access to education, mental health, nutrition, and physical activity **Integrated Primary Care** - Universal SDOH screening implemented across all Presbyterian hospitals, emergency departments, urgent cares, and clinics - Community health workers embedded in care teams in emergency departments and clinics - Presbyterian has expanded peer support to 24-hour virtual services for all Regional Delivery System hospitals - Food Farmacy program provides weekly produce and shelf-stable items for patients in need - Diabetes Recharge program combines dietician-led education with skill-building for newly diagnosed patients - Spanish-speaking focus group identified need for culturally tailored communication about seeking and navigating care
Immediate Actions for Systems Planners
-Review the substance use focus group findings to understand barriers and facilitators to treatment from persons with lived experience and service providers in Bernalillo, Sandoval, and Valencia counties. -Examine Presbyterian's peer support specialist model in emergency departments as a potential template for expanding crisis response workforce across the county's behavioral health system. -Coordinate with the Partnership for Success-PFS20 coalition to align county-level polysubstance use prevention efforts with existing regional infrastructure. -Engage the Community Wellness Council and other local health councils as established community proxies for ongoing behavioral health planning and implementation input. -Use the identified priority populations (LGBTQ+, youth, Native Americans, Hispanic/Latinx, men, pregnant/post-partum women, people in poverty, Black/African Americans) to target outreach and ensure equity in service delivery. -Review the SDOH screening data and referral patterns to identify high-need areas where behavioral health and social supports intersect. -Access the accompanying Community Health Implementation Plan (CHIP) at www.phs.org/community for Presbyterian's specific intervention strategies and committed resources for 2023-2025.
Key Contacts
**/ - Leigh Caswell, MPH, Vice President, Community Health, Presbyterian Community Health **/ - Sharz Weeks, MPH, Community Health Epidemiologist **/ - Meredith Root-Bowman, MPH, MPA, Director of Community Health Improvement **/ - Albuquerque Area Southwest Tribal Epidemiology Center = - Community Wellness Council = - Sandoval County Health Council = **/ - Partnership for a Healthy Torrance Community = - NM Alliance of Health Councils = - Albuquerque Area Southwest Tribal Epidemiology Center = **/ - Health Equity Council = - Healthy Here Coalition = - Together for Brothers initiative