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Assessments and Reports

Community Health Assessments

In support of the patients, members and communities we serve, and as part of a requirement of the Patient Protection and Affordable Care Act, Presbyterian completed its first community health assessment in 2013 and updated the community health assessment in 2016, 2019, and 2022. By conducting a community health assessment every three years we identify the priority health issues facing each of our communities. As part of the community health assessment process, Presbyterian partners with local health councils and conducts forums to help us better understand the key drivers of some of the health issues our communities face.

Presbyterian is committed to community health improvement through community engagement, multi-sector partnerships, and sustainable impact. Community Health Implementation Plans and their impact reports accompany the Community Health Assessments. These reports, including the updated CHAs, are available for your review and comment.

To provide feedback on any of these documents or to request a printed or electronic copy, please contact the Community Health Team.

Health Assessments, Implementation Plans, and Impact Reports

Central New Mexico

The central region includes Bernalillo, Torrance, Sandoval, and Valencia counties. As with most of the other areas of New Mexico, some parts of this region demonstrate low need and low barriers to care, while others, such as southern Bernalillo County, and rural parts of Sandoval, Torrance and Valencia counties, have high need and high barriers to care. While the primary contributors to poor health vary slightly from county to county, they include poverty, drug and alcohol use, vaccination rates, nutritional status, and access to mental and behavioral healthcare.

The central region is currently served by Presbyterian Hospital, Presbyterian Kaseman Hospital, and Presbyterian Rust Medical Center, as well as various clinics and Presbyterian Medical Group locations.




Santa Fe County

Santa Fe County is served by Presbyterian Santa Fe Medical Center, as well as affiliated clinics. Some of the barriers to good health in Santa Fe include a higher percent of people who cannot afford medical care because of cost, increasing alcohol-related death rates, increasing drug overdose death rates, and a relatively high percent of high school students experiencing sadness and hopelessness. Some facilitators to good health in Santa Fe County include that the county ranks well overall for general health outcomes and health factors, has relatively more providers to population compared to the rest of the state, low unemployment rates, good rates of physical activity among adults, low percent of adults with high blood pressure, and relatively low infant mortality rates compared to the rest of the state.




Community Health Priority Area Initiatives

Much of our work takes us out of the office and into the community. Our projects, initiatives and programs are supported by various partners and grants that fall into our health priorities including Behavioral Health, Social Health, and Physical Health and drive progress in access and equity. Read below to learn more about how we partner with our communities to impact health at the individual and family levels, through organization and community change, and through policy.

Behavioral Health

The Behavioral Health initiative works to address mental health and substance use to include prevention and treatment.

Long Term Goal: All New Mexicans have access to behavioral health services to improve overall well-being

Peer Support

Learn more about Peer Support on the Community Health Resources and Programs page

Partnerships for Success

Mental Health First Aid

Social Health

The Social Determinant of Health initiatives builds on multi-sector partnerships, policies, and programs to address violence, poverty, education, economic development, built environment, equity, and the root causes of unmet social needs.

Long Term Goal: All New Mexicans live in social conditions that promote attaining the full potential of health and well-being

Health Council Support

We are proud to support both county health councils and the New Mexico Alliance for Health Councils. For 25 years health councils have played a key role in the state’s public health system by identifying local health needs, establishing community priorities and plans, and implementing local solutions. The health councils have also leveraged small investments like ours to attract additional funding to support programs and services to improve the health of their communities. We currently work directly with nine county health councils in the communities where we have hospitals. Together with the health councils we identified needs, heard what the community was asking of us, and developed our plans to address those needs together. This allows us to reduce duplication and promote alignment and collective impact with our community partners. By working together we can be more effective and implement quality, sustainable programs and strategies which lead to better health for our communities.

New Mexico Culture of Health – Funded by the Robert Wood Johnson Foundation

The partnership between Presbyterian, The New Mexico Alliance of Health Councils, UNM Health Science’s Center for Participatory Research, the Center for Health Innovation (New Mexico Public Health Institute), New Mexico Department of Health, New Ventures Community Building supports seven county and tribal health councils across the state as they increase community engagement, improve assessment and develop policy recommendations on important public health issues, with an emphasis on marginalized and underserved communities. The initiative is grateful for assistance from Public Agenda, a non-partisan research and public engagement organization, and Altarum, both of which provide technical expertise.

Read more about the next phase of the project: Centering Equity

Health Related Social Needs Screening and Referrals

To truly improve the health of our patients, members, and communities, Presbyterian must address the non-medical social needs of those we serve. Addressing social needs is an important strategy to achieve health equity.

In 2021 Presbyterian launched a universal screening tool for social needs. Patients are screened during clinical encounters at least every six months for social needs in several areas, including mental health, substance use, food insecurity, access to transportation, and more. Those who are identified as having a social need receive a personalized list of vetted community resources automatically as part of their after-visit paperwork. Some patients will be offered additional support from a Community Health Worker to navigate the process of accessing the resources.

This work is part of a larger strategy to impact the Social Determinants of Health. In partnership with Presbyterian’s Population Health, Community Health is working to make food, transportation, housing needs, and personal safety interventions more accessible. Community Health has developed best practices for training certified community health workers as part of the care team to help screen and navigate high risk patients experiencing social barriers to health. Community Health Workers are on the frontline diagnosing the social aspects of poor health, and service as a crucial bridge between communities and the healthcare system.

Patient Story

Why is it important to identify and address social needs? Data shows that 80 percent of health outcomes for a given population are impacted by health behaviors, social & economic factors, and physical environment. For more information, view the County Health Rankings Model (2022) Collaboration between University of Wisconsin Population Health Institute and Robert Wood Johnson Foundation

Not only is this work the right thing to do for our patients, it is also required by the Centers for Medicaid/Medicare, and the Joint Commission for hospital accreditation.

Food Is Medicine

The Food Farmacy is a prescription-based food pantry for patients in Central New Mexico who have been determined by their healthcare provider as food insecure. The Food Farmacy is referral based only and is not open to the public.

View Infographic

Northern Roots is a comprehensive produce prescription program that offers families healthy food resources in Northern New Mexico. Program Location: Santa Fe Medical Center and Presbyterian Española Hospital.

View Infographic

Healthy Neighborhoods Albuquerque

Healthy Neighborhoods Albuquerque (HNA) is collaborative of anchor institutions created in 2016 to develop partnerships and collaborative projects that leverage anchor institutions in Albuquerque and Central New Mexico. The partners include: Albuquerque Community Foundation, Albuquerque Public Schools, Bernalillo County, Central New Mexico Community College, City of Albuquerque, and Presbyterian Healthcare Services.

The Local Procurement Vision of HNA is that anchor institutions partner with our community to harness purchasing and investment power to strengthen the local food system to purchase locally and sustainably grown and produced food to provide to patients, students, and employees to support health and wellness. This vision will be accomplished through 1) community health and wealth building, 2) inspiring others, 3) educating children and community, and 4) supporting economic development.

  • Local purchasing addresses social determinants of health in our communities by investing in local businesses and farms and supporting economic development
  • Local purchasing can build on multi-sector partnerships, policies, and programs to address poverty, equity, and the root causes of unmet social needs
  • Local purchasing can provide access to and knowledge about healthy local foods

Presbyterian Financial Assistance and Care Coverage

Physical Health

Healthy Eating and Active Living initiatives include a variety of projects designed to improve nutrition and support programs that encourage indoor and outdoor activities.

Long term goal: All New Mexicans have access to health care and healthy environments that promote improved physical health

Healthy Eating and Active Living Classes

Healthy Eating and Active Living classes aim to improve prevention and management of chronic health conditions through healthy eating, cooking, and physical activity while also supporting social and emotional well-being.

To learn more about Healthy Eating and Active Living classes, click below:

Wellness Referral Center

The Healthy Here Wellness Referral Center (WRC) was created by Presbyterian Community Health and is managed by Adelante Development Center. The WRC is responsible for connecting patients to classes and programs related to healthy eating, active living, chronic disease self-management, and more. Healthcare providers submit referrals for patients to the WRC and then the WRC contacts each referred patient to explain the resources available, registering them in programs at a time, location and in a language that is most appropriate for their needs. The WRC makes reminder calls and completes follow-up evaluations to learn about patient satisfaction, any barriers to participating, and to sign up the patient for additional classes and programs if desired. Patients also receive rewards for participating. WRC programs and classes are available for free to participants, in part, through funding by Presbyterian Community Health and Presbyterian Healthcare Foundation. This work is also made possible thanks to funding from the Centers for Disease Control & Prevention.

Connecting Harvest to Health/Conectando Cosechas con la Salud

From 2018 through 2022, Presbyterian Community Health provided a yearly $100,000 match and collaborated with Three Sisters Kitchen, Encuentro, and Meals on Wheels Albuquerque to 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 are made by home health aides (HHAs) who have supplemental nutrition and cooking training or medical providers assessing needs of elderly patients and will be provided 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
  • Strengthen the support structures for agricultural producers

The project trained 98 HHAs (most Spanish speaking or bilingual), supported purchase of over 53,255 pounds of produce from more than 22 local growers, and provided meal delivery to 2,754 low-income seniors. Overall, 2,754 seniors directly benefited from HHA and Meals on Wheels program services during the four-year project period.

This work is funded by the United States Department of Agriculture and Presbyterian Healthcare Services.


COVID-19 and Flu Vaccination Confidence Listening Sessions

Read the full report with recommendations

Healthy Here

We’re working to change systems and environments to make it easier for Hispanic, Latino, and Native American residents of the International District and South Valley to access healthy foods, be physically active, and manage chronic disease. We do this with the help of a large network of partners, all of which have years of experience and expertise working in communities. Collectively our impact is stronger than when we work alone. This work is funded through the Center for Disease Control and Prevention’s REACH (Racial and Ethnic Approaches to Community Health) award and managed by Presbyterian Community Health.

LGBTQIA+ Health Equity

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