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