Report Type: Plan Recommendations
Community Health Implementation Plan
YEAR
2025
AUTHOR / ORGANIZATION
Presbyterian Healthcare Services
GEOGRAPHIC SCOPE
Bernalillo County, Multi-jurisdictional
What is this?
This is a Community Health Implementation Plan (CHIP) required by IRS regulations for non-profit hospitals. Presbyterian Healthcare Services developed this plan for its Central New Mexico hospitals—Presbyterian Hospital, Presbyterian Kaseman Hospital, and Rust Medical Center—to address community health priorities identified through a comprehensive Community Health Assessment process. The plan was developed using community stakeholder engagement including forums, surveys, focus groups with 201 participants, and key informant interviews with populations including maternal/child health providers, substance use treatment providers, Spanish-speaking adults, and Native Americans. Internal Presbyterian stakeholders also provided input through management retreats, feedback sessions, and advisory committees. The methodology applies the Socio-Ecological Model of Health and a Collective Impact/Asset-Based approach to maximize alignment with existing community resources and partners.
Summary
This implementation plan presents Presbyterian Healthcare Services’ comprehensive strategy for behavioral health systems change in Central New Mexico. The behavioral health priority focuses on improving prevention and treatment of substance use disorders and increasing access to mental health services while reducing stigma. Key strategies include expanding peer support specialist programs across hospitals, emergency departments, NICUs, and primary care settings; implementing virtual peer support models; deploying SBIRT and emergency department buprenorphine distribution; and increasing harm reduction through naloxone distribution. The plan commits to workforce development through Mental Health First Aid training, trauma-informed care education, and building a robust Community Health Worker infrastructure. Presbyterian explicitly partners with the Bernalillo County Behavioral Health Addiction Treatment Advisory Board and supports the 988 crisis lifeline implementation. The social health strategies address housing, food insecurity, and transportation barriers through universal SDOH screening with closed-loop referrals to community organizations. The plan’s health equity framework, commitment to addressing structural racism, and focus on LGBTQ+ populations and perinatal health equity provide a foundation for reducing behavioral health disparities. These strategies align directly with Senate Bill 3 workforce development goals and county-level behavioral health coordination efforts.
BH Systems Change Recommendations
The report contains explicit behavioral health systems change recommendations: 1. Expand and sustain Peer Support Worker model in hospitals and clinics to identify substance use and mental health disorders and navigate individuals to services 2. Develop Virtual Peer Model to deliver peer support services to regional hospitals using technology 3. Implement SBIRT (Screening, Brief Intervention, and Referral to Treatment) across care settings 4. Implement Emergency Department Buprenorphine distribution and education 5. Deploy Opioid Stewardship across the Presbyterian enterprise 6. Increase harm reduction through naloxone distribution and community education 7. Implement anti-stigma campaigns addressing negative attitudes about mental health and substance use 8. Support 988 crisis lifeline awareness and coordination 9. Train workforce in Mental Health First Aid, trauma-informed care, and adverse childhood experiences 10. Implement Pilot ECHO for Community Health Workers, Peer Support Specialists, and Substance Use Prevention Specialists 11. Prioritize polysubstance use and harm reduction among men, Hispanic, Native American, and LGBTQ+ populations in Bernalillo, Sandoval, and Valencia Counties 12. Partner with Bernalillo County Behavioral Health Addiction Treatment Advisory Board and Albuquerque Celebrates Recovery Advisory Board 13. Support policies that remove barriers and increase access to behavioral health services
How to Use for Systems Planning
What this report IS useful for: - Identifying Presbyterian's specific behavioral health strategies, workforce investments, and partnership commitments for coordination with county initiatives - Understanding Presbyterian's peer support and community health worker expansion plans that align with SB3 workforce development - Locating existing partnerships with county behavioral health coalitions and boards for systems alignment - Identifying Presbyterian's measurable outcomes for behavioral health that could inform regional accountability metrics - Understanding health equity approaches that address disparities among priority populations What this report DOES NOT provide: - Detailed budget allocations or funding commitments for specific behavioral health initiatives - Quantified targets for workforce expansion (number of peer support workers or CHWs to be hired) - Gap analysis of behavioral health services in the community - Assessment of other providers' behavioral health capacity in the region - Crisis system capacity data or coordination protocols - Implementation timelines or phased milestones for individual strategies
Key Facts & Data Points
- Covers Bernalillo, Sandoval, Torrance, and Valencia Counties - Presbyterian Hospital is a 453-bed facility, the largest in New Mexico - Presbyterian Kaseman Hospital provides full continuum of psychiatric and substance abuse services for adult, child, and geriatric patients - Implementation period: Calendar year 2023 through calendar year 2025 - 34 community input forums conducted (2 virtual forums per county) - 1,153 community survey responses collected - 201 participants in focus groups and key informant interviews - Presbyterian has committed to carbon neutrality by 2030 - Rust Medical Center employees provide approximately 150 weekend backpacks of healthy food to children weekly - Presbyterian has an enterprise-wide goal to implement Universal Social Determinants of Health Screening
Priority Services & Findings
**SUD Organizations** - Peer Support Worker model expansion to identify substance use disorders and navigate individuals to harm reduction and treatment - Emergency Department Buprenorphine distribution and education implementation - Naloxone distribution and harm reduction efforts - Partnership with Behavioral Health Human Services Department and Office of Substance Abuse Prevention on SAMSHA's Strategic Prevention Framework - SBIRT (Screening, Brief Intervention, and Referral to Treatment) implementation - Opioid Stewardship deployment across Presbyterian enterprise - Focus on polysubstance use among men, Hispanic, Native American, and LGBTQ+ populations **Mental Health / Crisis Care** - Presbyterian Kaseman Hospital provides inpatient psychiatric services and outpatient psychiatric clinics - Support for 988 crisis lifeline implementation and community awareness - Mental Health First Aid and Youth Mental Health First Aid training expansion - Anti-stigma campaigns addressing negative attitudes about mental health - Partnership with Bernalillo County Behavioral Health Addiction Treatment Advisory Board - Behavioral health services available across inpatient, outpatient, and primary/specialty care settings - Virtual behavioral health services for adults and teens through telehealth investment **Integrated Primary Care** - Primary Care Collaborative Care Model implementation - Community Health Workers integrated into Presbyterian Medical Group care teams - Universal SDOH screening implementation across PHS system covering food insecurity, housing, transportation, financial instability, safety, substance use, alcohol use, and mental health - Integration of peer support and CHW roles with behavioral health department and care teams - Chronic disease self-management programs including Diabetes ReCHARGE **School-Based / Youth Services** - Positive youth development strategies to build resiliency and reduce toxic stress - Youth mentorship opportunities - Investment in youth-oriented community-based programming - Youth Mental Health First Aid training - Partnership with Rising Together and Together4 Brothers youth initiatives - Backpack food program serving children at Martin Luther King Jr. Elementary School
Immediate Actions for Systems Planners
-Coordinate with Presbyterian's Community Health team to align peer support worker expansion with county behavioral health workforce development initiatives under SB3 -Establish formal partnership with Presbyterian's SDOH screening initiative to ensure closed-loop referrals connect to county behavioral health navigation resources -Engage Presbyterian leadership on the Bernalillo County Behavioral Health Addiction Treatment Advisory Board to strengthen health system-county coordination -Partner with Presbyterian on 988 crisis lifeline community awareness campaigns to ensure coordinated messaging -Align county harm reduction strategies with Presbyterian's naloxone distribution and opioid stewardship efforts -Explore opportunities to integrate county mobile crisis services with Presbyterian's emergency department behavioral health protocols -Coordinate with Presbyterian's Virtual Peer Support Model development to extend crisis and recovery support to underserved areas -Connect Presbyterian's Mental Health First Aid training expansion to county workforce development initiatives for consistency
Key Contacts
**/ Presbyterian = - Community Health Dept - Community Health Advisory Committee - Community Health Steering Committee - Health Equity Committee - LGBTQ+ Committee - Perinatal Health Equity Committee **/ - Albuquerque Celebrates Recovery Advisory Board = - BernCo Behavioral Health Addiction Treatment Advisory Board = - Health Equity Council = - NM Dept of Health = - NM VA Medical Center = - NM Farmers' Marketing Association **/ - Partnership for a Healthy Torrance County = - RoadRunner Foodbank = - Sandoval County Behavioral Health Coalition = - Sandoval County Health Collaborative = - United Way of Central NM = - UNM Hospital = - Valencia Community Wellness Council