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					         Doña Ana County
Health and Human Services Alliance
           Action Plan




                         Prepared by
                  Renée T. Despres, Ph.D.
                           For the
    Doña Ana County Health and Human Services Alliance,
Doña Ana County Health and Human Services Department, and the
      Doña Ana County Board of County Commissioners


                        June 8, 2006
DAC HHS Alliance Action Plan                                   2                                                       9/6/2006



                                             Table of Contents


Executive Summary...................................................................... 3
I. Introduction............................................................................... 5
II. Background .............................................................................. 7
  A. Organizational History and Profile ............................................................................ 7
  B. Living in Doña Ana County ..................................................................................... 10
  C. Accessing Health Care in Doña Ana County ........................................................... 12
  D. A Strained Safety-Net .............................................................................................. 13
  E. Why are Some People Healthy and Some People Not? ........................................... 16
  F. Building a Foundation of Prevention........................................................................ 18
  G. Healthy Gente 2010: A Framework for Action ....................................................... 20
III. Methods................................................................................. 23
IV. Findings and Analysis .......................................................... 24
  A. Primary Care ............................................................................................................ 26
  B. Specialty Care .......................................................................................................... 41
  C. Behavioral Health..................................................................................................... 55
  D. Oral Health............................................................................................................... 73
V. Action Plan ............................................................................. 86
  A. Comprehensive Recommendations and Actions...................................................... 86
  B. Blueprint for Action 2006-2007............................................................................... 95
  C. Action Worksheets ................................................................................................... 99
VI. Appendices .......................................................................... 133
VII. References.......................................................................... 141
DAC HHS Alliance Action Plan                3                                      9/6/2006




Executive Summary
In July, 2005, the Doña Ana County Health and Human Services Department (DAC
HHSD) and the Doña Ana County Health and Human Services Alliance (the Alliance)
hosted the first community health forum in a year-long strategic planning process called
Juntos por Cambio. During the next seven months, four additional forums were held.
These forums focused on primary care, specialty care, behavioral health, and oral health.
Input was gathered from healthcare consumers, providers, public health experts, and
political leaders, and many other individuals.

This document summarizes the results of the Juntos por Cambio events. It is both a report
on the state of health care in Doña Ana County and a call to action for community
leaders. The action plan contained in this document offers specific strategies and actions
for addressing healthcare priorities in Doña Ana County and building a sustainable
healthcare infrastructure.

Doña Ana County’s healthcare safety-net system is strained by increasing needs and
limited resources. The county’s location on the United States/Mexico border creates
critical health needs linked to environmental, social, inheritable, and economic factors.
The county’s large rural areas, high poverty rate, and large number of un- and
underinsured residents create challenges for health care delivery and access. These
challenges must be addressed through the development of sound health policy, financial
commitments, recruitment and retention of a stable, skilled, culturally competent
healthcare workforce, and ongoing data collection and evaluation.

This document provides a comprehensive overview of health issues in Doña Ana County,
describes the methods used to collect data, and offers an analysis of the findings. This
report concludes with an action plan that provides long-range recommendations and
specific actions that can be taken to implement those recommendations, as well as a
short-range “blueprint” for actions to begin in fiscal year 2006-2007.

In the ever-shifting ecology of community health, multiple effects can be expected
whenever one factor is altered or one action is taken. Yet the over-arching goal of this
action plan remains consistent: to meet the unmet healthcare needs of Doña Ana County
residents, leading to improved health outcomes, increased well-being of residents, and the
best possible use of county healthcare resources.

The following is a summary of recommendations developed based on data from the
Juntos por Cambio forums and workgroups. A full list of action steps needed to carry out
these recommendations is found in the Action Plan section of this report:

Prevention and Education
   1. Increase and coordinate primary and secondary prevention and education efforts
   2. Create linkages with existing state and federal resources
   3. Increase health outreach through media campaigns
   4. Increase use of existing resources
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Delivery of Care
   1. Expand healthcare services for the uninsured and underinsured
   2. Develop mobile healthcare delivery systems
   3. Develop alternative healthcare delivery systems

Access to Care
   1. Increase use of case management
   2. Increase the number of insured people in Doña Ana County
   3. Increase access to medications
   4. Develop a county transportation system

Healthcare Human Resources
   1. Take advantage of programs designed to alleviate healthcare human resources
       shortages in rural areas
   2. Use incentive programs to attract and retain providers
   3. Expand use of mid-level providers
   4. Coordinate with New Mexico State University to develop local, culturally-
       competent providers

Financing
   1. Increase funding for prevention and education activities
   2. Increase county funding for unmet needs
   3. Explore private and public funding opportunities
   4. Explore alternative methods of financing unmet healthcare needs

Policy
   1.    Ensure implementation and continuity of community-based planning process
   2.    Create and implement policies that emphasize prevention and education
   3.    Ensure that Doña Ana County policies accurately reflect needs of county residents
   4.    Pursue legislative reforms
   5.    Increase effectiveness of Medicaid spending
   6.    Develop policies to increase healthcare workforce

Data Collection and Evaluation
   1. Create an integrated data collection system
   2. Request technical assistance from New Mexico State University, New Mexico
      Department of Health (including the NMDOH Office of Border Health), the
      Centers for Disease Control, the US/Mexico Border Health Commission, and
      other resources
   3. Collect data on current use of the public health safety-net system
   4. Collect baseline data on current health needs to correlate with Healthy Gente 2010
      indicators
   5. Develop staffing for data collection and evaluation activities
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I. Introduction
Doña Ana County, like other public entities around the United States, is struggling to
meet the healthcare needs of its population. The county is mandated by the New Mexico
Indigent Hospital and County Health Care Act to provide care for “indigent” patients –
uninsured and underinsured residents of the county – and to supplement federal funding
for Medicaid. Reliance on these healthcare safety-net services is growing as healthcare
costs spiral upward, rates of chronic disease such as diabetes and obesity climb, and
private insurance rates decrease – not only in Doña Ana County but nationwide.

Doña Ana County spent nearly $9 million dollars to fund healthcare safety net services
during fiscal year 2005-2006. The bulk of those dollars – $6.3 million – went to hospitals
to support indigent care. Two federally-funded healthcare clinics received $1.2 million in
supplemental funding from the county, while $1.5 million was spent on ancillary services
including ambulance transport, hospice care, behavioral health care, and prevention and
health promotion efforts.

The county’s spending on healthcare was supplemented by state and federal funding,
including Medicaid (federal funding matches every county dollar with approximately
three dollars), direct provision of services through the state’s public health department,
and other avenues. The federal government provided $15 million in matching funds to the
county’s Sole Community Provider Hospitals, Memorial Medical Center (leased by the
private for-profit company LifePoint, Inc.) and Mountainview Medical Center, for
indigent care. Private foundations also funded health promotion, education, and provision
through various grants.

All told, the financial investment in meeting the unmet healthcare needs of Doña Ana
County residents is tremendous. Is it enough? Are these dollars well spent? As a result of
the county’s investment, was high-quality healthcare delivered to all eligible residents in
the most efficient, cost-effective, coordinated way possible? Did the county’s investment
improve the health of Doña Ana County residents who rely on safety net service? Will
there be enough healthcare resources to meet the county’s critical healthcare needs next
year? Five years from now? Ten years from now?

In an effort to answer these and other questions about the future of healthcare in Doña
Ana County, the Doña Ana County Health and Human Services Department (DAC
HHSD), at the behest of its advisory committee, the Doña Ana County Health and
Human Services Alliance (“the Alliance) and Doña Ana County Commissioner Bill
McCamley, implemented a strategic planning process in July of 2005. The strategic
planning process included a series of community forums and stakeholder work sessions.
Input was gathered from healthcare consumers, providers, public health experts, and
political leaders, and many other individuals. The process was facilitated by DAC HHSD
staff and Dan Reyna, MPH, of the New Mexico Department of Health Office of Border
Health.
DAC HHS Alliance Action Plan                 6                                       9/6/2006


Forum participants emphasized the need for provision of services today and the need to
build a sustainable healthcare infrastructure to ensure that services are there tomorrow.
They were keenly aware of the difficult context in which healthcare safety-net services
are delivered in Doña Ana County, including the county’s lengthy shared border with
Mexico, large geographic region, large rural population, and high poverty rate. They
recognized that responsibility for health and for health care is shared between citizen,
local, state, and federal entities, and private providers.

Healthcare resources are limited while the need for healthcare is unlimited and growing –
a dynamic that affects not only Doña Ana County, but healthcare providers, payers, and
consumers worldwide. This document is proof that county residents are acutely aware of
the growing gap between resources and demand. By thinking strategically about the
future of healthcare in Doña Ana County, county leaders can ensure the best use of
available resources and the sustainability of programs.

The planning efforts described in this document are both immediate and long-range.
Some of the goals can be quickly accomplished through actions described in this plan;
some are already underway and the actions outlined here will simply support and enhance
those initiatives. Other goals are based on broad visions of systemic change and will not
be completed in a few months, a year, or even several years. Along the way, community
leaders, healthcare consumers and providers, and all other stakeholders will need to
revisit the health status indicators, priorities, goals, and recommendations described in
this plan, evaluate the efficacy of actions undertaken, and continue to develop innovative,
effective systems to improve health and well-being in Doña Ana County.

The steps to systems change outlined in this plan are designed to ensure that healthcare is
available to all Doña Ana County residents across their lifespans. When a mother
receives prenatal care and gives birth to a healthy child, when that child receive
immunizations that protect her from infectious diseases, when the toddler learns to care
for her teeth, when she learns how to eat nutritious foods, when as an adult she gives
birth to her own healthy children, when as a senior she lives an active life free of chronic
disease, one can truly say that healthcare access across a lifespan has made a difference.

Systems change does not happen overnight. It happens priority by priority, when people
work together and funding and other resources are coordinated. As DAC HHSD Director
Silvia Sierra so aptly put it, “When we all work together in addressing one thing, we can
do systems change. I don’t think anybody wants to be sick. Everybody wants to be
healthy. For that to happen, they need access to the best healthcare possible for them and
their families. This process is not new to Doña Ana County. It’s exactly what we did with
the Colonias Initiative, and now we can do it with healthcare throughout our county.”
DAC HHS Alliance Action Plan                 7                                      9/6/2006




II. Background

A. Organizational History and Profile
Although this plan focuses on the work of one year, it was made possible by many years
of planning and collaboration between healthcare providers, consumers, community
leaders, and other stakeholders who have worked diligently to improve healthcare in
Doña Ana County. The foundation for this project was laid by the Doña Ana County
Community Health Council (DACHC) which, in turn, grew out of the Doña Ana County
Maternal Child Health Council (DAC MCH). The DAC MCH was created in 1991 when
the New Mexico Legislature passed the County Maternal Child Health Plan Act. The act
provides funding to New Mexico counties for the development of comprehensive,
community-based maternal and child health services.

These earlier healthcare planning efforts identified several needs that are echoed in the
current plan, including a need to for infrastructure, coordination of services, benchmark
data. The theme of scarce resources relative to growing need is not a new one to Doña
Ana County. Planning documents that emerged out of those initiatives include the
Maternal-Child Health Plan, which is updated annually, and the report “Community-
Based Planning for Effective, Cost-Efficient Health Care Delivery: Doña Ana County,
New Mexico,” prepared by Joel A. Diemer and Caroline Willingham, IIRM-CAHE, New
Mexico State University.

Infrastructure provides the support system within which all healthcare services operate,
either individually or collectively. As Diemer and Willingham wrote:
Whether specialized or comprehensive, virtually all programs of any consequence require
supporting infrastructure. Such support infrastructure is likely to have many dimensions
depending on the scope and complexity of the problem(s) being addressed. In terms of
scope and complexity, few issues can compare with health care. This is true at almost any
scale for which the issue can be considered (29).

A major step toward creating that healthcare infrastructure occurred in 2001, when the
Doña Ana County Board of Commissioners created the Doña Ana Health and Human
Services Department (DAC HHSD) with support from the previous health council. The
mission of the DAC HHSD is “to improve the quality of life of residents of Doña Ana
County by identifying and addressing unmet health and human service needs.” When the
BOCC created the DAC HHSD, it institutionalized the efforts of the county health
council. In addition, it secured permanent resources to address issues identified by the
previous health council.

The department has grown into a multi-division organization. The department heads up
the Colonias Initiative for the entire county, making sure that core infrastructure needs
are met for county residents. Department divisions are the Health Care Division,
Behavioral Health Division, and the Community Outreach Division.
DAC HHS Alliance Action Plan                 8                                     9/6/2006


 •   The Health Care Division administers sole community provider funds for the
     county’s two hospitals, external agency contracts for health car and ancillary
     service providers, and manages the indigent claims fund for all of Doña Ana
     County.
 •   The Behavioral Health Division focuses on the implementation of behavioral health
     programming for the county. These services are primarily preventive in nature and
     focus on the development of life skills for program participants. This division also
     oversees the Local DWI Grant as well as DOH/BHD grants and Federal SAMHSA
     Grants.
 •   The Community Outreach Division works as a liaison with communities in the
     county. The Community Outreach Division has developed community coalitions,
     which are guiding the Colonias Initiative for the county by providing advice for
     capital outlay requests and implementing projects using previous year's allocations.
     The division also serves to forward other county department activities through
     resource fairs and outreach mechanisms for information dissemination through out
     the county. This division has traditionally been responsible for Maternal Child
     Health funding as well as the county's AmeriCorps VISTA Program.

In January, 2005, the Doña Ana County Board of Commissioners created the Doña Ana
County Health and Human Services Alliance (the Alliance). The creation of the Alliance
was an important step toward coordination of health-planning efforts in the county, for it
brought together all existing county-level health-focused councils and created liaisons
with regional health-planning groups. The Commissioners’ purpose in authorizing the
Alliance was to create an advisory body for the DAC HHSD that would “improve
coordination and collaboration, nurture public understanding, strengthen accountability,
promote informed policy-making, and provide an opportunity for effective community
input.”

The Alliance has incorporated the duties of several councils including the Driving While
Intoxicated (DWI) council and the Health Council for Doña Ana County. For example,
with approval from the New Mexico Department of Finance and Administration, the
Alliance serves as the legislatively mandated Local DWI Council. In addition, the
Alliance serves as the health council by identifying health needs and resources in Doña
Ana County and developing this action plan.

The creation of the DAC HHSD and the Alliance represent important steps toward
creating a viable healthcare infrastructure to support the work of many dedicated
community leaders who devote a tremendous amount of time, expertise, and energy to
health planning in Doña Ana County. DAC HHSD staff provides technical and
administrative support to the Alliance as part of the department’s role in meeting the
county’s responsibilities for improving the core public health functions of assessment,
policy development, and service provision.

The Alliance integrates several advisory bodies to “create a common sense of purpose
and shared understanding of methods and perspectives, while promoting new channels of
communication.” Alliance membership is not based on representation from specific
DAC HHS Alliance Action Plan                  9                                      9/6/2006


organizations. The membership of the Alliance includes representation of key public,
private, voluntary and not-for-profit stakeholders and community-based representation to
assure fairness, geographic balance, and life-cycle representation. This diverse base of
community stakeholders affords a far-reaching perspective beyond that of a limited
healthcare “vacuum.” For the complete Alliance Operating Guidelines, please see
Appendix A.

The Alliance provides direction to the DAC HHSD, which, in turn, implements programs
based on Alliance direction, fiscal responsibilities, and DAC BOCC directives. Thus,
Doña Ana County no longer has organizations working in isolation. The DAC HHSD has
the support and resources of the DAC BOCC and the validity of a community-based
process through the Alliance. This structure brings government resources and
community input together to develop, implement, and evaluate this action plan.

During its first year, the Alliance developed the community-based strategic planning
process that led to this report and action plan. Data for this action plan were gathered
during the "Juntos Por Cambio" health forums, which identified needs in primary care,
specialized care, behavioral health, and oral health for Doña Ana County. Providers,
consumer, and advocates participated in the process. The priorities reflected in this plan
were developed during a series of five community and stakeholder forums and
subsequent work sessions. A complete description of the planning process is found in the
methods section of this document.

This plan documents the ability of the Alliance to lead a cooperative, community-based
healthcare planning effort and demonstrates the clear benefits of the Alliance/DAC
HHSD structure and relationship. This plan, which was made possible by that
relationship, represents a major step toward providing the DAC HHSD with a
comprehensive profile of the county’s health status, leading to more informed-decision
making. It provides guidance to the DAC HHSD to maintain effective and efficient
methods for using county resources to provide services.

Finally, this report uses Healthy Gente 2010 as the framework for measuring the
improvements in health status anticipated from the actions described in this plan. Healthy
Gente 2010 is a set of indicators of health status for residents on the United States side of
the US/Mexico border. These evidence-based benchmarks provide the foundation for
developing measurable outcomes and objectives for health status in Doña Ana County,
thus increasing the DACHHSD’s ability to leverage state and federal program funding
and technical assistance.

As a result of the establishment of the DAC HHSD and the Alliance as its advisory body,
available resources can be coordinated to address the needs, gaps, and priorities identified
in this comprehensive healthcare action plan. Successful implementation of this plan will
have long-lasting influence on the coordination, monitoring, and evaluation of the health
and human service delivery system in Doña Ana County.
DAC HHS Alliance Action Plan                  10                                       9/6/2006


B. Living in Doña Ana County
Geography, political boundaries, and associated socio-economic factors strongly affect
the health status and unmet health needs of Doña Ana County’s population. The county
includes 3,807 square miles of land in south central New Mexico, bordered on the south
by Chihuahua, Mexico and on the east by the Texas. Doña Ana’s location on the United
States/Mexico border gives it a dual identity as both a county in New Mexico and part of
a cluster of border counties.

According to United States Census Bureau estimates, the population of Doña Ana County
was 186,095 in 2004. Of that population, 63.4 percent were of Hispanic or Latino
descent, 1.5 percent were Native-American, 1.5 percent African-American, and .8 percent
Asian-American. Most of the remaining 35 percent were of Anglo descent. Of the
Hispanic population in Doña Ana County, the vast majority are of Mexican descent.

If you live in Doña Ana County, you enjoy warm weather, beautiful views, and sunshine-
filled days. You live in an area with a rich cultural heritage, a large university, an array of
restaurants, desert beauty, and the backdrop of a dramatic mountain range. You probably
speak at least a smattering of Spanish, and there’s a 54.4 percent chance that Spanish is
the language you speak at home.

There’s a one-in-four chance that you’re one of the 24.5 percent of Doña Ana County
residents who live below the federal poverty (FPL) line of $15,735 for a family of two
adults and one child. The New Mexico poverty rate is 17.7, and the United States rate is
12.5 percent. If you’re under 17 and live in Doña Ana County, the probability that you’ll
live in poverty rises to 35.1 percent, compared to 25.9 percent for the entire state and 17.6
percent for the nation as a whole. The state of New Mexico is the second poorest in the
nation, with only Mississippi having a lower median income. The median family income
in Doña Ana County in 1999 was $29,808, compared to a statewide median of $34,133
and a nationwide median of $41,994.

One in three people in the county don’t have health insurance of any sort, and if you work
for a small business, there’s a good chance that you’re one of those people, especially if
you’re an adult. Your children, however, are more likely than you are to have health
insurance. About three in four children are covered, most by Medicaid or the State
Children’s Health Insurance Plan.

You don’t have to be unemployed not to have health insurance – only 51 percent of
businesses in southwestern New Mexico offer health insurance to their employees. If you
make less than $30,000 a year, there’s a good chance that your employer is one of the
other 49 percent. Statewide, only one-third of companies that pay employees less than
$30,000 per year offer health insurance options.

There’s a good chance you never planned to have those children. About 50 percent of
pregnancies in Doña Ana County are unintended. Fewer than 7 out of 10 pregnant
women of all ages will start receiving prenatal care during their first trimester. That’s a
DAC HHS Alliance Action Plan                 11                                      9/6/2006


little better than the state proportion of 71 percent, but far below the national rate of 80
percent, and even further below the Healthy People 2010 objective of at least 90 percent.

The low rate of prenatal care is partly a result of a high rate of unintended pregnancies.
Unintended pregnancies are strongly associated with poorer preconception health,
including abuse by a partner, unhealthy maternal lifestyle during pregnancy, including
cigarette smoking, use of alcohol and other drugs, and poor nutrition. Birth outcomes if
unintended pregnancies include higher rates of premature delivery, low birth-weight, and
small size for gestational age. Later in life, these children may experience lower
cognitive, behavioral, and emotional development, as well as child abuse and neglect.

Your kids, however, are probably immunized against major childhood diseases.
Increasing rates of health insurance coverage for children, coupled with a mandatory
school entrance immunization requirement passed in the early 1980s and state-sponsored
free vaccine programs, have dramatically increased the statewide percentage of children
immunized by school age. Childhood immunization rates reached a low in New Mexico
of about 63 percent in 1999-2000, but had climbed to their highest level ever – about 71
percent – by 2001. This rate is still well below national rates of 78 percent and the 90
percent needed according to epidemiological studies to eliminate the potential for disease
outbreak and achieve appropriate population-level immunity. Current state immunization
objectives are to focus on each child receiving a full complement of the 20-plus
recommended immunizations by the age of two. Both Healthy People 2010 and Healthy
Gente 2010 also identify 90 percent as objectives for the nation and the border area.

Even if your children are immunized, there’s a good chance that they’ll have dental caries
(cavities) and possibly periodontal disease by the age of five, and that it will negatively
affect their health for the rest of their lives. Those oral diseases increase your kids’
chances of developing diabetes, heart disease, and possibly even cancer.

If you’re a female teenager, look around at your peers. Nearly half (48 percent) of you
will be pregnant before you reach 17. More than 12 percent chance of you will be
physically hurt by a boyfriend over the course of a year, and 8.8 percent of you will be
physically forced to have sexual intercourse during that same time period. If you’re a
male teen, you’re susceptible to violence, too, but it’s likely to come in the form of
fighting – half of male teens get in a physical fight over the course of a year. Regardless
of gender, too many teens (37.3 percent, compared to a state rate of 34.9 percent) will
ride with a drinking driving over the course of a month; 17.5 percent of them, compared
with a state rate of 19.1 percent, were themselves the drinking drivers.

If you live in one of Doña Ana County’s 37 colonias – settlements in unincorporated
areas that lack access to a sanitary water supply, wastewater treatment processes, and
paved roads – your health is likely to be poorer than most other residents of the county.
Public health advances that have been established since the early 1900s in other parts of
the United States, such as wastewater treatment, access to potable water, and
immunizations, have not reached the colonias. Both children and adults in these
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settlements have increased rates of preventable infectious diseases including tuberculosis,
pertussis, and gastrointestinal infections.

If you live in Doña Ana County, your life is most likely to end because of heart disease.
In 2004, the leading causes of death in Doña Ana County were diseases of the heart,
which caused 292 out of 1,206 total deaths in the county. Malignant neoplasms caused
258, unintentional injuries 88, and diabetes mellitus 87 deaths. Diabetes is the fifth
leading cause of death in New Mexico, but the fourth (barely) leading cause of death in
Doña Ana County. If you have diabetes, there’s a good chance that you’ll also develop
heart disease, so even though your death may be listed as cardiac-related, diabetes may
have been the underlying culprit. More than six percent of New Mexicans have diabetes.
If you’re a Hispanic/Latino American and your ethnic roots are in Mexico, you have
twice the chance of developing diabetes as a non-Hispanic white, according to the
Centers for Disease Control.


C. Accessing Health Care in Doña Ana County
There are healthcare services available to Doña Ana County residents. You just need to
know how to access them. You can sign up for some of the health education programs
offered at the county’s six community resource centers. If you’re savvy – or if you’ve
received assistance from a community health advocate, or promotora – you may know
that health care isn’t out of reach. If your family’s income falls below the federal poverty
level, you’re female and you’re pregnant, or if you’re a child, you probably qualify for
Medicaid. Whether you’ll be able to find providers who accept Medicaid is another
question.

Whether or not you have insurance, you can access primary health care, including some
oral health and behavioral health services, through one of two federally qualified health
centers (FQHCs) – Ben Archer Health Center or La Clinica de Familia. Both FQHCs
have clinics in remote areas of the county. You may be able to find health care through
other private and public sources. If your income is less than $800 a month and you don’t
qualify for other services, you can get at least basic primary care and screening at Saint
Luke’s Health Care Clinic. Two hospitals receive county funding to provide emergency
and specialty care, which you can access if you qualify as indigent or if you’re eligible
for Medicaid or Medicare. Women and children can receive reproductive health services
and early childhood care through the First Step program.

In fact, so many services are available that you may find yourself confused about when,
where, and how you can get health care – and how much you’ll need to pay. You may not
know when and where your children can get immunizations, how to protect yourself from
sexually transmitted infections, or that you can transmit cavities to your baby by tasting
her food then using the same spoon to feed her. Even if you know that eating a
nutritionally balanced diet and exercising regularly are ways to maintain good health,
those precautions might be impossible for you to follow if you're a single mother living in
Anthony and working two low-wage jobs to make ends meet. Fresh fruits and vegetables
might not be easily available to you if you live in a low-income neighborhood.
DAC HHS Alliance Action Plan                 13                                      9/6/2006




Despite the wide array of services available, you might fall through one of the many gaps
that exist in the healthcare system. You might have private health insurance but a high
deductible, leaving you responsible for most of your own healthcare costs. If you’re older
than 65 and on Medicare, you’ll have about 43 percent of your medical expenses covered.
The other 57 percent will come out of your own pocket. And Medicare doesn’t cover oral
health care costs, so if you start having problems with your teeth, your only resource will
be the sliding fee scales at one of the FQHCs, where you can get basic dental work done.
If you need specialty dental care, well, that’s another story. If, like about 50 percent of
the county’s population, you live in a rural area and want health services, you’ll need a
reliable vehicle to access those services. While limited public transportation services
exist, most serve only the Las Cruces area.

Faced with these and other barriers to accessing health care, you may not do anything at
all until you have a health crisis. Then you may end up calling an ambulance to transport
you to an emergency room. You may have developed a chronic disease – diabetes, heart
disease, cancer, asthma – which probably could have been prevented if you’d received
some preventive care and education along the way. But at this point, your disease may be
so advanced that you require specialty care, surgery, life-time medications, and even
assistance with the activities of daily living. After you leave the emergency room, you
may get “lost” again, falling back into the gap until the next time you have a health crisis.



D. A Strained Safety-Net
Doña Ana County offers a wide range of safety-net services to low-income residents,
including prevention and education, primary care, oral health, behavioral health, and
specialty care services. Funding for safety net services comes from a complex mixture of
federal, state, local, and private foundation funding, as well as individual payers. Yet
public funding for health insurance and health care is not keeping up with the demand,
including Medicaid and Medicare, community health centers, public health clinics, public
health infrastructure, and services for people with special needs.

Under the New Mexico Indigent Hospital and County Health Care Act, 30 of New
Mexico’s 33 counties – Doña Ana County among them – provide hospital care and
ambulance transport for “indigent” patients and supplement federal funding for Medicaid.
The Indigent Hospital and County Health Care Act defines indigent patients as persons
who receive healthcare, can normally support themselves and their families, but cannot
pay the cost of care. The act designates “the individual county” as responsible for paying
for ambulance transportation, hospital care, and the provision of health care to indigent
patients. Counties must provide “local revenues to match federal funds for the state
Medicaid program, including the provision of matching funds for payments to sole
community provider hospitals and the transfer of funds to the county-supported Medicaid
fund pursuant to the Statewide Health Care Act.” Countywide health planning is also
encouraged under the act, as it “can improve the provision of health care to indigent
patients.”
DAC HHS Alliance Action Plan                 14                                     9/6/2006




In 2004, counties statewide collected $38.8 million for financing of health care, primarily
through gross receipt taxes. All counties spent $41.2 million for safety-net medical
services, exceeding revenues by 5.0 percent. In 2003, expenses exceeded revenues by 6.5
percent. The decline was mostly due to an increase in gross receipts taxes. Still, while
county revenues increased from $25.49 million in 2000 to $38.8 million in 2004 (a 52.2
percent increase), expenditures on health care financing increased 68.4 percent from
$24.17 million in 2000 to $40.7 million in 2004. Doña Ana County was one of 16
counties to provide safety-net healthcare services to its residents that exceeded its annual
gross receipt revenues.

Clearly, such a level of expenditure cannot be sustained. Despite this significant funding,
essential health services are still not being provided to many county residents. To ensure
that all residents have access to health care – and that the county is getting the “most
bang for its buck” – the county, like other public entities, must think strategically about
healthcare needs now and in the future.

The current situation is part of a national picture that has more to do with the way
healthcare financing has evolved over the years than with any mismanagement or errors
on the part of an individual provider, state, or county. A full discussion of healthcare
financing policy is beyond the scope of this report. However, it is important to note that
healthcare systems in the United States have evolved to provide an “all or nothing” type
of situation. While some people cannot access care, others receive too much, often
unnecessary, and costly care (Bodenheimer 1). Healthcare resources tend to be broken
into “silos” with little communication between providers in different areas.

A decline in employer-sponsored health insurance coverage is one of the major stresses
on the publicly-funded healthcare system. As fewer and fewer people are covered by
traditional employer-sponsored private insurance, many are turning to public sources to
help pay for healthcare. According to the Kaiser Commission on Medicaid and the
Uninsured, the number of uninsured people in the United States increased by nearly six
million between 2000 and 2004. During the same period, employer-sponsored insurance
dropped from 68.9 percent to 65.1 percent. The majority of growth in uninsured adults
has been among those with incomes below federal poverty level (46 percent) or those
whose incomes fall between 100 and 199 percent of the federal poverty level (22
percent). People in southern states have been most affected. Minorities and non-citizens,
while more likely to be uninsured, do not account for the majority of the grown in the
uninsured over these four years.

Nationally, four out of five (81 percent) people who are uninsured live in working
families. Nearly 70 percent of them live in households with at least one full-time worker,
while 13 percent have a part-time worker. People most likely to be uninsured are low-
wage workers, those employed in small businesses, service industries, and blue-collar
jobs.
DAC HHS Alliance Action Plan                 15                                      9/6/2006


Children are as likely as adults to lose employer-sponsored insurance, but because of
expanded eligibility for public insurance programs, largely Medicaid and the State
Children’s Health Insurance Program, children did not lose coverage as dramatically as
adults. Children covered by public insurance increased from 17 percent to 22 percent,
resulting in a slight decrease in the share of children without coverage.

Rates of employer-sponsored insurance in New Mexico are below the national average.
In January 2005, the New Mexico Health Policy Commission/NMSU reported that
statewide, 59 percent of New Mexico employers provide health insurance to their
employees. Rates in the southern part of the state were lower, at 51 percent. The smaller
the business, the less likely it was to provide health insurance to its employees (with the
exception of the self-employed). Of those who did provide insurance, only 37 percent
statewide and 36 percent in the south/southwest paid 100 percent of their employee
premiums.

For those who provide, fund, and administer safety-net healthcare services, dropping
rates of employer-sponsored health insurance present a dual challenge. Not only are the
actual numbers of individuals who qualify for publicly-funded health increasing, but their
healthcare needs tend to be greater and more costly. The uninsured are less likely to
receive preventive care, such as immunizations, screening exams for cancer, diabetes, or
heart disease, and routine checkups. When they do access the health system, it is often
only after chronic mild illness has become a serious disease or an acute emergency.

Even among those whose jobs pay a living wage, a healthcare crisis can negatively and
seriously impact financial stability. According to the Kaiser Family Foundation, more
than a third of the uninsured “have a serious problem” paying their medical bills, and
nearly a fourth are pursued by collection agencies for medical bills (Kaiser, Why Are So
Many Americans Uninsured? 2). In some cases, the healthcare crisis may lead to loss of
employment, increasing financial duress – and the load on publicly-funded healthcare
systems. The following table illustrates barriers to health care access faced by people
with and without health insurance.
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The decrease in employer-sponsored health insurance can be attributed to many factors,
including rising insurance rates, increasing rates of chronic disease, rapidly rising
healthcare costs, an entire system that’s fraught with inefficiencies, and the need for
employers to reduce overhead costs.

People with health insurance tend to be healthier, partly because they are more likely to
be able to afford to seek health care when – and sometimes before – they need it. Insured
adults in poor health seek care from a physician 70 percent more often than uninsured
adults in poor health (Newacheck et al, 1998, qtd in Bodenheimer 20). Insured adults
receive 90 percent more hospital services than the uninsured (Hadley et al, 1991 qtd in
Bodenheimer 20).


E. Why are Some People Healthy and Some People Not?
Because health insurance affects the ability to access health care, it is an important
influence on health outcomes. Yet lack of access to care is only one reason why the
health of Doña Ana County residents is much poorer than the rest of the nation. To build
an effective safety-net healthcare system, stakeholders must recognize the other factors
that determine health outcomes, called the “determinants of health.”

Traditionally, public health literature has identified the four major determinants of health
as socio-environmental factors, bio-physiological factors, individual psychosocial and
behavioral factors, and access to healthcare. These determinants interact to create the
entire context of a person’s life – and health status.
DAC HHS Alliance Action Plan                  17                                      9/6/2006




The World Health Organization identifies several additional determinants of health,
which can be seen as sub-categories of the four major determinants:
   • Income and social status - higher income and social status are linked to better
       health. The greater the gap between the richest and poorest people, the greater the
       differences in health.
   • Education – low education levels are linked with poor health, more stress and
       lower self-confidence.
   • Physical environment – safe water and clean air, healthy workplaces, safe houses,
       communities and roads all contribute to good health. Employment and working
       conditions – people in employment are healthier, particularly those who have
       more control over their working conditions
   • Social support networks – greater support from families, friends and communities
       is linked to better health. Culture - customs and traditions, and the beliefs of the
       family and community all affect health.
   • Genetics - inheritance plays a part in determining lifespan, healthiness and the
       likelihood of developing certain illnesses. Personal behavior and coping skills –
       balanced eating, keeping active, smoking, drinking, and how we deal with life’s
       stresses and challenges all affect health.
   • Health services - access and use of services that prevent and treat disease
       influences health
   • Gender - Men and women suffer from different types of diseases at different ages.
                               (World Health Organization: The Determinants of Health)

Because gender, race, ethnicity, education or income, disability, geographic location, and
sexual orientation all affect the determinants of health, they can lead to great inequities in
the health status of populations. Differences in health status because of gender, race,
ethnicity, education or income, disability, geographic location, or sexual orientation are
called health disparities. Health disparities are defined by the United States National
Institutes of Health as “differences in the incidence, prevalence, mortality, and burden of
diseases and other adverse health conditions between specific population groups.”

The NMDOH report Health Status Disparities in New Mexico, published in March 2003,
provides a comprehensive look health disparities in the state based on gender, ethnicity,
education level, and income. After collecting a decade’s worth of data, researchers
identified, categorized, and analyzed nearly 40 health indicators. Overall, health
disparities in New Mexico were greatest for Native American populations; Hispanics had
the poorest perception of health and the highest rates of teen birth, drug-related death,
firearm injury death, chlamydia, and binge drinking. They experienced the greatest
disparity increases for teen births and hepatitis B, and the greatest disparity decrease for
smoking. Education and income were closely related to health disparities. Those with the
highest education levels and highest incomes experienced the least disparities.

Males experienced higher rates than females for almost every indicator, including all
death indicators. Females had higher rates of pertussis (whooping cough), shigellosis, and
chlamydia, and a poorer perception of health than males. The greatest decrease in
DAC HHS Alliance Action Plan                 18                                      9/6/2006


disparity by gender was seen for motor vehicle injury death, while the greatest increase in
disparity by gender was seen for suicide. (NMDOH March 2003)

Access to healthcare and the quality of healthcare received is also affected by ethnicity,
income level, gender, and other factors. The 2005 National Healthcare Disparities
Report focuses on health disparities in access to medical care throughout the United
States. The report contains both good and bad news regarding healthcare disparities. The
good news: some healthcare disparities are diminishing, while information about
disparities is improving. The bad news: healthcare disparities still exist. The bad news for
Doña Ana County: healthcare disparities are growing among Hispanics, and among
people living below the poverty line.

From a healthcare planning perspective, understanding the determinants of health and
patterns of healthcare disparities can help to target the causes of Even the best healthcare
plan can’t change some things – for example, the genetic predisposition to diabetes
among Hispanics. But other things can be changed, including lifestyle factors, access to
care, and environmental factors such as second-hand smoke. About 70 percent of all
premature deaths in New Mexico and the United States are caused by individual
behaviors and environmental factors – two determinants of health that can be affected by
interventions.


F. Building a Foundation of Prevention
How can healthcare planners change the things that can be changed? Focused prevention
and education programs are cost-effective ways prevent disease and improve health
outcomes at the population level. Childhood immunization programs are one of the most
cost effective. However, planners must be aware that not all prevention activities have the
same potential cost effectiveness. For instance, a smoking cessation costs, on average,
$1000 per year of life gained; medications to control $100,000; surgery for cardiac
disease $500,000 per year of life gained. The earlier prevention intervention happen, the
greater the efficiency, and the better the health outcomes.

In Understanding Health Policy: A Clinical Approach, Thomas Bodenheimer, M.D. and
Kevin Grumbach, M.D. of the Department of Family and Community Medicine at the
University of California, San Francisco provide a useful framework for understanding
disease prevention. According to this model, disease prevention has three components:
primary, secondary, and tertiary prevention:
    • Primary prevention, or efforts to avoid a disease or injury before it happens (for
       instance, childhood immunizations, banning smoking in public places)
    • Secondary prevention, or screening to detect disease processes during early stages
       and intervention to slow or stop the progress of the disease (for instance, Pap
       smears to detect cervical cancer, blood cholesterol level checks and blood
       pressure checks to detect heart disease risk)
    • Tertiary prevention, or efforts to minimize the effects of disease and disability
       (for instance, the use of home oxygen to allow someone with chronic obstructive
DAC HHS Alliance Action Plan                 19                                      9/6/2006


       pulmonary disease (COPD) to live as normal a life as possible, or physical
       therapy to increase strength and balance in someone with muscular dystrophy)

Likewise, prevention strategies can occur at three systemic levels:
   • Address social determinants of disease, especially poverty. Income and social
      status are directly proportional to health status, a correlation that is well-
      established even in countries where universal health care is available. Economic
      development may have a greater impact on health than targeted public health
      programs. However, economic development is impossible if a population is in
      poor health. For an extreme example, consider African countries ravaged by
      HIV/AIDS, where a large proportion of the population never reaches the age to
      enter the labor force.
   • Provide public health interventions to reduce overall incidence of illness.
      Examples include wastewater treatment, banning cigarette smoking in public
      places, health education programs on diabetes, depression, and other prevalent
      diseases, smoking cessation and substance abuse programs, and sex education
      programs in schools. In 2002, of the $1.6 trillion that the United States spent on
      healthcare, 3 percent went to public health activities such as these.
   • Preventive healthcare services performed by providers. These services can include
      both primary prevention, such as childhood immunizations, patient counseling on
      smoking cessation or reducing risk of sexually transmitted infections, and
      secondary prevention, such as cancer screening. Recommendations for regular
      schedules for preventive medical care services have been established by the U.S.
      Preventive Services Task Force, an independent panel of experts in primary care
      and prevention that systematically reviews the evidence of effectiveness and
      develops recommendations for clinical preventive services. These
      recommendations can be accessed online at
      <http://www.ahrq.gov/clinic/uspstfix.htm>

At the same time that healthcare planners must recognize that individual behaviors can
dramatically affect health, they must also avoid blaming individuals for poor health. As
the World Health Organization states, “blaming individuals for having poor health or
crediting them for good health is inappropriate.” Whether a person's health is poor or
good is largely situational. Even behavioral factors that could be directly controlled, such
as cigarette smoking, driving while intoxicated, and accessing prenatal care, are often
determined by cultural norms and expectations. For those who live in poverty, dangerous
neighborhoods, and have little motivation for, there may be little motivation to change
behaviors. In this case, environmental factors – most notably socio-economic ones –
contribute to behavioral factors, creating a snowball effect. Prevention strategies must
address the entire community.

Secondary prevention activities such as providing Pap smears to detect cervical cancer
are useless if follow-up services are not available. There is an ethical and practical
imperative to provide services such as radiation and chemotherapy treatment to those
who screen positive to cancer, as well as appropriate follow-up care and education for
DAC HHS Alliance Action Plan                 20                                     9/6/2006


those who test positive for diabetes mellitus or others conditions such as hypertension or
high cholesterol levels.

Prevention and health education activities provide the foundation for an integrated
healthcare system that provides access to all services. Adequate, effective, and culturally-
responsive primary, secondary, and tertiary prevention services can avert disease, detect
chronic diseases at early, treatable stages, and reduce the cost of end-of-life care. It is
predicted that in the long-term, prevention and education activities reduce the need for
more expensive specialized services, ensuring that those services will be available to
those who need them.


G. Healthy Gente 2010: A Framework for Action
Healthy Gente is a health promotion and disease prevention agenda that draws on the
national health indicators defined in Healthy People 2010. Healthy Gente 2010 indicators
are a set of health status indicators developed for U.S. communities that border Mexico.
It identifies 25 of the most important preventive health goals, indicators, and strategies,
resulting in a strategic management tool that can be used by the four US border states,
communities, and other public and private sector partners. The goals of Healthy Gente
2010 are to increase quality and years of healthy life and eliminate health disparities.

Healthy Gente grew out of preparatory work for the U.S.-Mexico Border Health
commission’s Healthy Border 2010 agenda. The US-Mexico Border health Commission
serves as a forum for addressing critical health issues in the border region. Healthy Gente
indicators were developed by members of the Design Team, the support group for the
Border Health Commission, including the directors of the four U.S. state border health
offices. The team used four principles to guide the selection of indicators: 1) they should
address key health issues on the border; 2) they should be limited in number; 3) to the
extent possible, the objectives should be measurable; and 4) they should be compatible
with federal and state indicators. The goal was to develop a set of indicators that will
resonate with the border population will be easily understood, and will help to coordinate
further public and private health programs.

The Healthy Gente indicators are not objectives, but a framework for each responsible
county, municipality, or region to develop its own objectives based on current status,
available resources, and time available. The 25 indicators cover the majority of the focus
areas identified by Healthy People 2010. The indicators, grouped according to topic, are:

Access to Care
   • Reduce by 25% the population lacking access to primary care

Cancer
   • Reduce female breast cancer death rate by 20% (per 100,000 women)
   • Reduce cervical cancer death rate by 30% (per 100,000 women)
DAC HHS Alliance Action Plan              21                                   9/6/2006


Diabetes
   • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
   • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)

Environmental Health
   • Reduce to zero the proportion of households without complete bathroom
   • Reduce to zero the percent of the population residing in counties exceeding EPA
       air quality standards
   • Reduce the number of hospital admissions for acute poisoning by 25%
   • Reduce HIV incidence by 50% (per 100,000 inhabitants)

Immunization and Infectious Diseases
   • Achieve 90% immunization coverage in children aged 10-35 months
   • Reduce incidence of Hepatitis A by 50% (per 100,000 inhabitants)
   • Reduce incidence of Hepatitis B by 50% (per 100,000 inhabitants)
   • Reduce incidence of tuberculosis by 50% (per 100,000 inhabitants)

Injury and Violence Prevention
    • Reduce motor vehicle crash death rate by 25% (per 100,000 inhabitants)
    • Reduce childhood death rate due to unintentional injuries by 30% (per 100,000
        children age 0-4)

Maternal, Infant, and Child Health
   • Reduce infant mortality by 15% (per 1,000 live births)
   • Increase percent of women beginning prenatal care in 1st trimester to 85% (per
      100 women)
   • Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
      women 15-17 years of age)

Mental Health
  • Reduce suicide mortality rate by 15% (per 100,000 inhabitants)

Nutrition and Overweight
   • Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)

Oral Health
   • Increase to at least 75 percent the proportion of the population served by
      community water systems with optimally fluoridated water
   • Increase percent of people using oral health care system annually to 75% (per
      100,000 inhabitants)

Respiratory Diseases
   • Reduce asthma hospitalization rate by 40% (per 10,000 inhabitants)

Substance Abuse
DAC HHS Alliance Action Plan              22                                       9/6/2006


   •   Reduce the rate of alcohol-related motor vehicle crash deaths by 50% (per
       100,000 inhabitants)
   •   Increase to 89% the proportion of adolescents not using:
           o alcohol in the past 30 days
           o marijuana in the past 30 days
           o cocaine use in the past 30 days

Tobacco Use
   • Reduce by 33% the proportion of adults and adolescents currently using tobacco
DAC HHS Alliance Action Plan                23                                     9/6/2006




III. Methods
Data for this report was gathered primarily through Juntos por Cambio, the community-
based strategic planning process led by the DAC HHSD from July 2005 to March 2006.
Additional data was gathered through interviews, literature searches, reviews of existing
county health plans, and additional workgroup sessions.

The strategic planning process was carried out in the following manner:
   • A Community Forum was held Wednesday, July 27, 2005. Representatives from
       seven main providers of medical care in Doña Ana County gave brief
       presentations about their organizations and the services they provide. A question
       and answer session was then held. Participants were given the opportunity to ask
       questions and raise issues verbally, write their questions down on paper, and/or
       complete surveys distributed at the registration table. Translation was provided, as
       was dinner, childcares, and transportation from the northern and southern regions
       of the county.
   • About 275 issues were raised by attendees during the forum. Alliance members
       and DACHHSD staff consolidated these into a list of six topic areas: 1) access to
       care 2) healthcare human resources 3) priority health issues 4) undocumented
       immigrants 5) costs of care and insurance, and physician reimbursement and 6)
       behavioral health issues.
   • Worksheets were developed to standardize the process of analyzing strengths,
       weaknesses, opportunities, barriers, current efforts, data/statistics, resources
       (needed or current), goals/aims, objectives/strategies, responsible parties, other
       recommendations, and evaluation measures including outcome measures,
       individual health status indicators, and systems indicators. See Appendix Y for a
       sample worksheet. Facilitators were identified and trained.
   • A Stakeholders’ Forum was held on Saturday, July 30, 2005. The Community
       Forum was briefly reviewed and a presentation about strategic planning was
       given. Attendees then divided into workgroups using identified topic areas for an
       hour of strategic planning about issues within those areas.
   • Four forums followed: primary care, specialty care, behavioral health, and oral
       health. During each forum, presentations were given to the entire group. Break-
       out sessions were then held. A trained facilitator assisted groups in completing the
       strategic planning worksheets and identifying issues and goals for each topic.
       During subsequent work sessions, the pertinent ad hoc committee distilled the
       information gathered during the forum into priority goals and recommendations.

Data retrieved from the Juntos por Combio events were then analyzed and collated into
significant findings and issues. Follow-up research was conducted to recognize gaps and
duplication in resources, identify other available resources, list other appropriate
healthcare delivery systems, and develop and organize recommendations, goals, and
objectives.
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IV. Findings and Analysis
Findings of the participants echo those found by healthcare planners nationwide and
statewide. Like those who developed the State of New Mexico Comprehensive Plan,
Doña Ana County participants found that “prevention strategies, redeployment of
existing health care resources or savings from efficiencies” are the key steps to ensuring
that resources are available. In every forum, discussion, and interview, participants
focused on the need to transform health care safety net services into an integrated
continuum of care.

The public burden of health care is not likely to lessen in the near future. Federal
spending on healthcare faces severe cutbacks. Healthcare costs are likely to continue to
spiral upwards in coming years, leaving the county unable to fulfill even minimum
mandates for providing care to low-income populations.

The flow of humanity across the U.S.-Mexico border also takes its toll. According to the
US-Mexico Border Health Commission report, Medical Emergency: Costs of
Uncompensated Care in Southwest Border Counties, “state and local governments and
local healthcare providers absorb a large portion of the costs of providing uncompensated
emergency medical care to undocumented immigrants. These costs impose a significant
financial burden on southwest border hospitals and emergency medical services (EMS)
providers, and account for an estimated 25 percent of hospitals’ uncompensated costs.”

Doña Ana County is home to a complex network of high-quality health resources, yet
many gaps still exist. Most of these gaps are in the areas of access, coordination of
services, delivery, case management, and health care structure and financing. The major
providers of safety-net healthcare services in Doña Ana County are described below.

The county is served by two federally-qualified health center (FQHC) systems, Ben
Archer Health Center (BAHC) and La Clinica de Familia (LCDF). Both community
health centers provide primary medical care, primary dental care, behavioral health
services, pharmacy services, limited laboratory services, transportation, and social
services including case management, health education, outreach, and eligibility. Both
centers serve people regardless of their ability to pay. BAHC clinics are located in Hatch
and Doña Ana, while LCDF has clinics in Las Cruces, Chaparral, Mesilla, San Miguel,
Anthony, and Sunland Park. LCDF also offers a mobile site, which was added in 2005.
Mental and dental health services are provided at four of LCDF’s clinics.

Two hospitals offer inpatient and specialized care: Mountain View Regional Medical
Center and Memorial Medical Center. The latter is currently managed by Lifepoint, Inc.
Both hospitals serve patients with private insurance or Medicaid/Medicare and receive
sole provider community hospital funding to provide care to indigent patients.

MMC also partially funds the First Step Center, a women’s health clinic providing
prenatal care, deliveries, postnatal care, gynecological services. First Step Pediatrics
offers newborn baby well checks, pediatric acute care, well-child care and
DAC HHS Alliance Action Plan                 25                                     9/6/2006


immunizations. Approximately half of all babies born in Doña Ana County are delivered
by First Step. Other funding for First Step programs comes from federal and private
sources.

It is costly to provide health care for uninsured and underinsured residents of Doña Ana
County. Yet the dollars spent on health care have far-reaching impact, not only on the
quality of life of county residents, but on workforce development, economic
development, community safety and security, and more.

Medicaid expenditures provide one example of leveraging county health care dollars with
far-reaching impact. Data on the county’s “return on investment” of Medicaid matching
dollars is not currently available. However, state and national data indicate that it is
significant.

According to the New Mexico State Comprehensive Plan, in New Mexico, the Medicaid
program drives one of the biggest financing issues in the state. Medicaid expenditures
alone result in $5.68 in economic activity for every $1.00 in General Fund spent. The
yield is approximately 24 cents on the dollar returned to the State General Fund from tax
revenues. In addition, Medicaid expenditures created almost 30,000 jobs in New Mexico.
Nationally, Medicaid spending accounts for more than 20 percent of total state spending
and has become the second-largest item in most state budges, after elementary and
secondary education. More than 22 percent of New Mexico’s population receives health
care through the New Mexico Medicaid program, a total of 425,000 residents, 275,000 of
them children. More than half (55 percent) of the programs expenditures go to the two-
thirds of those people who are in managed care.

As the county’s population grows and the sheer number of people needing healthcare
increases, the most effective strategy for the county will be to gradually increase
emphasis on low-cost interventions including prevention education, primary and
preventive care. This is a long-term public health strategy to reduce the need for high-
cost medical treatment and improve the overall health status of the population. It is not
one that will succeed overnight. Yet this approach must be implemented gradually. While
shifting the emphasis to primary care and prevention, the county must still meet its
responsibility to care for the uninsured person in a diabetic crisis, the pregnant teen, the
victim of an alcohol-related motor vehicle collision.
DAC HHS Alliance Action Plan                26                                      9/6/2006




A. Primary Care
1. Background
Major issues identified during the primary care forums were a need for better access to
services, a need to increase and coordinate prevention and education activities, a need for
a continuum of high-quality care, and growing demand in face of stagnant resources.
Although services are available, they are often uncoordinated, with little communication
between providers and minimal follow-up and case management, partly because of the
transient nature of the population served. At the same time that some resources are being
overtaxed, other existing resources, such as the DAC Community Resource Centers, are
being underused.

Even with federal, state, and county funding, private foundation grants, third-party
reimbursements, and some paying clients, available resources for primary care are not
sufficient to meet demand. How can those resources best be allocated for the good of all?
How does the county coordinate services, reach an ethnically and socio-economically
disparate, geographically remote population?

These are a few of the questions raised and addressed by the primary workgroup. Some
of the interventions they propose are medical and focus on the provider/patient
relationship; others are public health interventions with widespread implications for
improving the health status of Doña Ana County residents.

What is Primary Care?
The Institute of Medicine defines primary care as “the provision of integrated, accessible
health care services by clinicians who are accountable for addressing a large majority of
personal health care needs, developing sustained partnerships with patients, and
practicing in the context of family and community” (Institute of Medicine, 1996).
Primary care includes preventive services, comprehensiveness, and coordination of
services.

Most health care needs can be taken care of at the primary care level. However, this does
not mean that most health care resources do or should go to primary care (see the results
of the specialty care forums for an explanation of resource use versus need). Primary and
preventive care forms the foundation of the healthcare system.

A key strength of the primary care model is the concept of a sustained relationship
between clinician and client. The primary care provider becomes the medical “home” for
the client, familiar with his or her healthcare needs, and can better refer that client to
specialty care when needed. In this sense, the primary care clinician acts as a
“gatekeeper,” not a “gate-shutter” (Bodenheimer 54). In this role, the primary care
provider acts as a patient advocate helping them to make the appropriate use of health
care services. The primary care provider acts as “gatekeeper,” assuring that each patient
gets “the right service at the right time and in the right place.”
DAC HHS Alliance Action Plan                27                                      9/6/2006


Community-oriented primary care focuses not on the individual but on target populations
within a community. Using this approach, the primary care provider first determines the
health needs of that particular population – for instance, Spanish-only speakers with
diabetes – and then develops community-based interventions to address those needs. For
example, Doña Ana County could build a database of all Spanish-only speakers who are
diagnosed with diabetes and use this database to provide extra assistance, through a
promotora or other outreach worker, to patients who are not managing their disease well.


Priority Health Issues in Doña Ana County
The primary care workgroup identified diabetes, cardiac disease, asthma, and depression
as the four priority health issues in Doña Ana County.
    • Cardiac disease was the leading cause of mortality in 2004, causing 292 out of
        1,206 total deaths in the county
    • Asthma prevalence across all ages in Doña Ana County is 11.1 percent, compared
        to 10.8 percent across New Mexico according to the New Mexico Health Policy
        Commission.
    • Depression affects both children and adults. One third of 9-12 graders in Las
        Cruces Public Schools reported feeling sad and hopeless in the 2003 New Mexico
        Youth Risk and Resiliency Survey
    • Diabetes prevalence among adults in Doña Ana County is 9.4 percent, compared
        to 6.3 percent nationally. Diabetes-related death rates are 45 per 100,000
        population in Doña Ana County, compared to 25 per 100,000 population
        nationally.

All of these health priorities are of critical importance for the health status of Doña Ana
County residents. In terms of health planning, both long and short-term priorities must be
established. Diabetes has been chosen as the priority health issue to address in FY 2006-
2007; however, this does not mean that other priority health issues will go unaddressed.

The rationale for choosing diabetes to focus on is threefold. First, the greatest
discrepancies exist between diabetes rate, hospitalizations, and mortality and the rest of
New Mexico and the United States in general. According to the CDC, diabetes is the
sixth leading cause of death nationwide. The New Mexico Health Policy Commission
reports that diabetes is the fifth leading cause of death in New Mexico, and in Doña Ana
County, it almost matched unintentional injury as the third leading cause of death.
Doña Ana County residents exhibit a cluster of risk factors, including ethnicity –
Hispanic Americans of Mexican descent are twice as likely to develop diabetes as whites
– age, lifestyle, and poverty. These factors combine to predict a rapid increase in
prevalence of an already epidemic and costly disease.

Second, type 2 diabetes is the most prevalent form of diabetes, and it can be prevented, or
at least delayed, and in most cases managed with exercise and diet. Pre-diabetes, a cluster
of factors that indicate a person is likely to develop diabetes, can be detected and
managed through exercise and diet. Tertiary prevention activities among people already
diagnosed with the disease are of critical importance. These activities include education,
DAC HHS Alliance Action Plan                 28                                        9/6/2006


active blood glucose monitoring, medications, and support groups. Because people who
manage their diabetes are less likely to experience complications, tertiary prevention can
have enormous impact on health status. Complications of diabetes include heart disease
and stroke, high blood pressure, eye disease and blindness, renal failure, nervous system
disease, amputation, oral disease, and complications during pregnancy. Mothers with
diabetes are more likely to have pre-eclampsia, babies with major birth defects, and
excessively large babies, causing danger to both mother and child.

Emphasizing diabetes as the first of four priority goals does not mean the other priorities
go unaddressed. Prevention interventions for diabetes include dietary changes and
physical activity, both of which also target cardiac disease, hypertension, and many other
chronic illnesses associated with poor diet and sedentary lifestyle. Diabetes is also linked
to depression. For instance, a study published in the April 3, 2006 issue of Pediatrics
found that poor blood sugar control and frequent emergency room visits may indicate that
children and adolescents with diabetes are suffering from symptoms of depression.

Third, baseline data on diabetes currently exists, providing the means to develop clear
objectives and to measure progress as a “case study” before addressing other health
priorities. Other low- and no-cost, effective, culturally-appropriate resources are available
for diabetes prevention and intervention, including the New Mexico Diabetes Prevention
and Control program and the CDC’s diabetes tools.

A note on asthma: Asthma needs to be addressed at the level of environmental health and
community infrastructure. Education and treatment are effective in helping people to
manage asthma, and these efforts must be continued and improved by the healthcare
community. However, both Healthy People 2010 and Healthy Gente 2010 identify
improving air quality to meet EPA standards as the most effective primary prevention
program for asthma. Such an undertaking must be a multi-dimensional project that
involves the county, businesses, individuals, and public resources including not only
healthcare but economic development, environmental protection agencies, and leveraging
other county resources.

Barriers to Primary Care
There are many reasons why people do not access primary care, ranging from the
straightforward to the not-so-obvious. Poverty is the primary barrier to accessing care,
often preventing people from seeking services even at clinics that offer sliding-fee scales.
For those with no income, even 10-dollar co-pay can be too much. Fear also comes into
play, especially for undocumented workers who must pass through border checkpoints
and risk being reported to Immigration and Naturalization Services. Transportation forms
a major barrier, especially for residents in rural areas of the county. Other barriers include
lack of childcare, limited clinic hours, language, and lack of knowledge about health care.
Not knowing when or how to access primary or preventive care services, residents often
end up not seeking care until they are seriously ill.

A full description of barriers to primary care access identified by the primary care
workgroup can be found in the list of gaps that follows.
DAC HHS Alliance Action Plan                29                                     9/6/2006




Healthy Gente 2010 Indicators
Ten of the 25 Healthy Gente 2010 indicators apply to primary care priorities in Doña Ana
County. These indicators are:

 •   Reduce by 25% the population lacking access to primary care
 •   Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 •   Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
 •   Achieve 90% immunization coverage in children aged 10-35 months
 •   Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
      women 15-17 years of age)
 •   Increase percent of people using oral health care system annually to 75% (per
      100,000 inhabitants)
 •   Reduce asthma hospitalization rate by 40% (per 10,000 inhabitants) (1998-2000
      aggregated data)
 •   Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)
 •   Reduce by 33% the proportion of adults and adolescents currently using tobacco
 •   Reduce to zero the percent of the population residing in counties exceeding EPA air
      quality standards

These indicators provide a basis for the development of health objectives in Doña Ana
County. However, baseline data is only available for some of the indicators (for instance,
baseline data is available for both diabetes indicators). Development of objectives will
depend on baselines, available resources, and realistic timelines.


2. Forum Results
The Primary Care Forum was held on July 30, 2005 at the Hilton of Las Cruces. It was
the first of four forums held. About 70 people participated in the event, including
providers, consumers, and elected officials.

Once the information had been presented the participants broke into working groups to
analyze the issues and develop possible solutions to the problems the groups chose to
address. The work groups were given approximately one hour and forty-forty five
minutes to list issues they would like to address under the given topic. A designated note
taker and facilitator gathered the information from each group, using SWOB analysis
sheets.

The workgroups identified four issues and 10 goals/recommendations. Groups then
presented their issues and ideas for recommendations to the audience, and submitted their
SWOB sheets to DAC HHSD staff. A follow-up meeting was conducted, during which
the goals and recommendations developed during the forum were prioritized.

The following section provides a verbatim summary of the forum results, including the
issues and topics identified and the priority goals and recommendations developed by the
forums. These are raw data and have been used as the basis for the above analysis, the
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recommendations that follow, and the action worksheets found in Section II of this
document.

Topics and Issues
The following topics and issues were identified during the community and stakeholders
forums:

Topic: Access to Care
Issues:
    • Access to primary care for uninsured, low-to-medium income residents
    • Lack of information about what services are available where
    • Outreach and difficulties in understanding how to get services for Spanish
        speakers
    • Transportation for rural, low-income, and elderly residents to get to services

Topic: Priority Health Issues
Issues:
    • Elder care for an aging population

Topic: Healthcare Human Resources
Issues:
    • Nursing shortage due to aging of nurses and nurses moving to other states,
        seeking better pay

Topic: Undocumented immigrants
Issues:
    • Fear preventing many from seeking services
    • Resource centers for farm workers that used to exist


Priority Goals and Recommendations
The following priority goals and recommendations were identified by the primary care
workgroup. They are listed as prioritized:

   1. Increase access to primary care/prevention services for un- and underinsured
   2. Educate public on appropriate use of public resources and personal responsibility
   3. Establish/coordinate county-wide prevention activities/campaigns/model
      (prevention/education)
   4. Identify resources to increase access to prescriptions for uninsured and
      underinsured
   5. Develop and implement standardized protocols and delivery systems for
      coordinated care and chronic care self management for uninsured and
      underinsured residents with diabetes, asthma, cardiovascular disease, and
      depression
   6. More research is needed for payment sources form federal, state, and county
   7. Determine reasons why people don’t access health care
DAC HHS Alliance Action Plan               31                                     9/6/2006


   8. Increase coordination between healthcare providers and community
   9. Determine resources lacking and determine how we can cost-effectively and
       clinically address gaps
   10. Transportation



3. Resources
Many primary care resources are available to uninsured and underinsured residents of
Doña Ana County. The major resources are as follows.


3.1 Prevention and Education
A wide array of disease prevention and healthcare education programs exist in Doña Ana
County. The following are a few examples:
    • Almost all providers participate in community health fairs.
    • Ben Archer Health Center and La Clinica de Familia emphasize health education
       and outreach through many channels, including:
    • Promotoras (community health workers) provide education on a variety of topics
       including maternal child health
    • Health educators
    • Dentists and dental hygienists
    • Social workers
    • Therapists
    • The NMDOH Diabetes Prevention and Control Program provides technical
       assistance and other resources through both FQHCs
    • The NMDOH offers a wide range of disease prevention programs
    • Camino de Vida provides HIV prevention and education services
    • Immunizations are provided through community resource centers, both FQHCs,
       and the NMDOH public health department.
    • US/Mexico border initiatives to increase physical activity levels, such as “Step It
       Up,” offer culturally-responsive health promotion models.
    • The Southern Area Health Education Center (SOAHEC) works with families
       throughout Doña Ana County to inform them about home hazards and resources
       available to address them. SOAHEC offers outreach through a variety of
       presentations done at community agencies and in private homes in regards to
       possible hazards. Community health workers (promotoras) also perform home
       visits, during which they go through a checklist of home hazards and provide
       information and referrals.
    • Community Action Agency provides pregnancy prevention education for teen
       mothers, Medicaid enrollment, education for people in poverty so they can
       become self-sufficient (e.g. budgeting, life-skills)
    • Both hospitals provide health education for the community within their facilities
    • NMSU Cooperative Extension Service provides nutrition education,
       environmental education, and a wide range of printed health literacy materials.
DAC HHS Alliance Action Plan                32                                     9/6/2006


   •   First Step clinic provides education on prenatal care within their care
   •   Emergency response organizations provide fire prevention, injury prevention, and
       safety information, including cardiopulmonary resuscitation training



3.2 Delivery of Care
A wide array of primary care and disease prevention programs exist in Doña Ana County.
These providers offer geographic dispersion of resources, bring multiple other resources
– including healthcare human resources and state, federal, and private funding – into the
community, create jobs, provide a base of primary care services, eligibility, primary and
secondary prevention programs, and provide support and outreach services for Doña Ana
County residents.

Providers of healthcare to the uninsured and underinsured include:
   • La Clinica de Familia Health Center (LCDF) is a Federally Qualified Health
       Center (FQHC) that provides primary medical, dental, and behavioral health
       services, as well as outreach and health education services to the uninsured and
       underinsured in the central and southern regions of the county. LCDF has been
       certified by the Joint Commission on Accreditation of Healthcare Organization
       (JCAHO). The center operates seven full-time sites in Doña Ana County and a
       mobile health clinic. In 2004 LCDF provided care to12,788 un/underinsured
       county residents at an uncompensated cost exceeding $2 million. La Clinica
       participates in all entitlement (Medicaid, State Children’s Health Insurance
       Program [SCHIP], County Indigent, etc.) and insurance (Medicare, private
       insurance, etc.) programs. LCDF is a Migrant Farmworker Health Center.
   • Ben Archer Health Center (BAHC) is a FQHC that provides primary medical,
       dental, behavioral health, outreach and health education services to the
       un/underinsured in the northern region of Doña Ana County. BAHC operates
       seven clinics in four counties; two of those clinics are in northern Doña Ana
       County. BAHC administrative offices are at the Hatch facility, located in Doña
       Ana County. BAHC has been certified by JCAHO. In 2004, BAHC served more
       than 11,000 un/underinsured Doña Ana County residents at an uncompensated
       care cost exceeding $1.5 million. BAHC participates in all entitlement (Medicaid,
       SCHIP, County Indigent, etc.) and insurance (Medicare, private insurance, etc.)
       programs. BAHC is a Migrant Farmworker Health Center.
   • St. Luke’s Health Center is a free healthcare clinic serving the homeless
       population, located within the Las Cruces city limits. St. Luke’s provides medical,
       pharmacy and referral services to the homeless population. It is staffed by
       volunteer nurses, physicians, and support personnel. Many of its pharmaceuticals
       are donated. St. Luke’s only provides services to homeless residents who are not
       eligible for entitlement or insurance programs.
   • The Family Medicine Residency Program is the only freestanding community-
       based residency program in New Mexico. The program’s dual mission is to train
       physicians for the southern New Mexico areas and provide high-quality care to
       clients regardless of their ability to pay. The program provides full-service family
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       medicine, which includes pediatric, adult, geriatric, and obstetrical care. The
       Family Medicine Residency Program also provides deliveries for pregnant
       patients of Ben Archer Health Center. In 2004, the program provided care for an
       estimated 7500 un/underinsured residents at an uncompensated cost of
       approximately $250,000. The Family Residency Medical Program participates in
       all entitlement (Medicaid, SCHIP, county Indigent, etc.) and insurance (Medicare,
       private insurance, etc.) programs.
   •   New Mexico Department of Health, Public Health Division, District 3 (DOH)
       provides services in eight southwestern New Mexico counties, including Doña
       Ana County. NMDOH provides outreach and clinical services for immunizations,
       sexually transmitted disease, tuberculosis, family planning, adult wellness
       checkups, and a special supplemental nutrition program for women, infants, and
       children (WIC). NMDOH also provides case management services for perinatal
       care and for children and youth with chronic medical conditions. NMDOH
       operates the Public Health Resource Center (PHRC) in Las Cruces, where persons
       with chronic illness (diabetes, asthma, obesity/overweight, hepatitis C, arthritis,
       and depression) may receive one-on-one counseling and small group classes for
       better self-management of chronic conditions. The PHRC also serves as the
       Access to Recovery Central Intake for the substance abuse assessment and
       referral system. Surveillance systems for communicable, environmental, and
       occupational diseases are part of DOH responsibility.
   •   First Step Center and First Step Pediatrics offer prenatal care, labor and delivery,
       gynecological care, newborn baby well checks, pediatric acute care, well-child
       care and immunizations.
   •   School-based clinics at Las Cruces and Oñate High School provide primary care
       services to youth. LCDF also serves the Gadsen School district through its mobile
       clinic


3.3 Access to Care
    • BAHC and LCDF each have a formalized system to provide information to
       patients and assist them in obtaining payment assistance, including enrollment in
       the indigent program
    • BAHC, LCDF, Covering Kids, Families and Youth Incorporated, Memorial
       Medical Center, Mountain View Regional Medical Center, and other agencies
       with trained personnel provide Presumptive Eligibility/Medicaid Onsite
       Application Assistance (PE/MOSAA) to eligible clients.
    • The most promising step toward improving access to health care in Doña Ana
       County is the implementation of the Healthy Communities Access Program
       (HCAP) county-wide management information system (MIS), scheduled for
       August 2006. The Community Action Agency is the fiscal agent for the project.
       By consolidating information within a single database, the program will improve
       continuity of care and provide valuable information for research and trend
       identification. After initial implementation, the current database will be expanded
       to include social and economic modules to consolidate efforts and maximize
       shrinking financial resources. The goals of the HCAP MIS program include:
DAC HHS Alliance Action Plan                34                                     9/6/2006


   •   coordinate healthcare and ancillary services among Doña Ana County providers
       via a single database program;
   •   standardize and streamline eligibility assessment and enrollment processes across
       providers;
   •   help uninsured and underinsured persons find a payer source for medical care;
   •   decrease inappropriate utilization of emergency rooms;
   •   increase preventative care through referrals to primary care clinics;
   •   promote, monitor, and track self-management of diabetes, cardiac-related
       hypertension, asthma, and depression; and
   •   Educate the community on available programs to increase access to and
       appropriate use of the health care system.
   •   The successful HCAP grant application grew out of the collaborative work of the
       Access to Care Consortium, a group of more than 23 health and ancillary service
       providers in Doña Ana County. The Consortium has been actively meeting for
       more than 2.5 years to identify and address health care and health access issues in
       the community.
   •   Doña Ana County’s Community Resource Centers offer physical spaces for
       education and prevention activities, health-screenings, and networking for
       community members in rural areas. They will be included in the HCAP MIS
       system
   •   NMDOH nurses provide services in community resource centers.
   •   Senior programs provide transportation, food (meals on wheels, etc.), mostly
       through volunteer commitment.
   •   Transportation programs exist throughout the county, although not all residents
       are able to take advantage of them due to geographical constraints. These include
       BAHC’s transportation services, Safe Ride, private sector transportation,
       Workforce Investment Act, TANF, and other programs. The South Central
       Council of Governments can provide an overview of transportation programs in
       Doña Ana County.


3.4 Healthcare Human Resources
    • Doña Ana County has a strong core of outreach workers known as promotores/as.
      In Doña Ana County, almost all are promotoras – this is a predominately female
      workforce. Promotoras are members of a community who act as a liaison between
      community members and health and social services systems. Because they are
      community members, they are culturally competent and able to navigate the
      border issues. Their roles range from Medicaid enrollment to health education and
      case management.
    • VISTA volunteers are part of the Americorps program. They are trained and
      provide community organizing leadership for rural communities through the
      community resource centers. They serve for a period of one year.
    • Health providers including physicians, dentists, social workers, nurses, nurse
      practitioners, physician assistants, etc. are encouraged to work in rural areas
      through the National Health Service Corps and other loan repayment programs.
DAC HHS Alliance Action Plan               35                                    9/6/2006


   •   NMSU’s fast-track nursing program offers training opportunities for nurses in
       southwest New Mexico.
   •   The Doña Ana Branch Community College (DABCC) offers an associate’s
       degree in community health, trains certified nurse assistants (CNA’s), and an
       associate degree in nursing.
   •   NMSU recently received funding to build the infrastructure for its Southwest
       Center for Health Disparities. The Center promises to be a hub of research and a
       resource the county can draw on for student interns, a long-term public health
       workforce, and technical assistance including data collection and evaluation and
       grant applications.


3.5 Financing
    • Federal dollars are available for transportation but require a local match
    • Federal, state, and local funding is provided to the FQHCs, however, funding is
       limited
    • County funding for indigent care is drawn from gross receipts taxes
    • The City of Las Cruces is currently funding some healthcare activities. During
       fiscal year 2006-2007, the City will provide supplemental funding to St Luke’s
       Health Center ($30,745) for primary care. La Piñon will receive $17,069 for
       sexual assault services; La Clinica de Familia will receive $25,102; Southwest
       Counseling will receive $31,083 for medication assistance); and Mesilla Valley
       Hospice will receive $33,108 to help pay for hospice care for low-income city
       residents.
    • Some private foundation funding is available for health care
    • Medicare, Medicaid, the State Healthcare Coverage Initiative, and private
       insurance companies reimburse primary care providers


3.6 Policy
    • The sale of the Memorial Medical Center to a private company resulted in
       additional available funding for primary care and allows the county and city to
       invest additional resources in primary care.
    • The Indigent Act provides the underpinning for funding healthcare the county’s
       indigent population
    • Regional transportation groups are addressing transportation issues and
       coordinating with the city and county
    • Senator Bingamen is sponsoring a study of transportation issues in the region.
       Based on projected need, recommendations for additional funding are expected
    • Presumptive eligibility for Medicaid provides immediate access to care for
       selected, qualified enrollers.
DAC HHS Alliance Action Plan                 36                                      9/6/2006


3.7 Data Collection and Evaluation
    • The Border Epidemiology Office at NMSU is contracted with HCAP to perform
       analysis for data collected through the HCAP MIS system
    • Baseline data exist for several Healthy Gente 2010 indicators, including diabetes
       hospitalization, diabetes mortality, teen pregnancy, percent of women beginning
       prenatal care in first trimester, and asthma hospitalization
    • NMSU Department of Business has indicated that they will provide technical
       assistance in mapping Medicaid spending in Doña Ana County




4. Gaps
Despite the wide range of existing resources, many gaps remain in around the delivery of
primary and preventive care in Doña Ana County. Gaps are of two types: gaps in services
and gaps in access. An example of a gap is service is a lack of primary care after-hours
clinics. An example of a gap in access is Medicaid enrollment. While Medicaid
enrollment has increased in the past decade, many eligible pregnant women and children
are not enrolled. They may not enroll because they do not know they are eligible, because
of the stigma associated with enrollment in a public aid program, or because
caseworkers’ existing workloads are overwhelming, which inhibits their desire to inform
the public if they qualify for enrollment.


4.1 Prevention and Education
    • Uncoordinated delivery of prevention, education, and outreach means that it’s
       difficult to track who is receiving services, services may be duplicated, and it’s
       difficult to evaluate prevention and education programs for effectiveness
    • Public health infrastructure issues are significant in rural areas, especially in the
       colonias. Lack of wastewater treatment causes many preventable diseases

4.2 Delivery of Care
    • Community Resource Centers are not fully utilized
    • Undocumented workers have few resources where they feel safe.
    • Inadequate access to pharmaceuticals (for instance, medications for diabetes or
       for controlling hypertension) and inadequate access to home health services such
       as oxygen lead to an increased number of preventable emergency room visits

4.3 Barriers to Care
    • While the HCAP MIS program holds great promise for integration, coordination,
       and streamlining of healthcare services in Doña Ana County, the project is funded
       only through August 2006. The HCAP grant was initially a two-year grant with
       the second year funding projected at $780,000. In late 2005, HRSA advised the
       Access to Care Consortium that the second year of funding had been cut. While
DAC HHS Alliance Action Plan                37                                     9/6/2006


       the budget has been modified to sustain the project over two years, additional
       funding will be needed to sustain the project. Potential cost-savings are
       tremendous but not likely to be realized within the funded period, so it may be
       difficult to win additional grant awards.
   •   Poverty is the primary barrier to accessing care in Doña Ana County. More than
       half – 53.4 percent – of county residents live at or below 200 percent of federal
       poverty level (annual income of $36,800 for a family of four), and 27.1 percent
       live at or below 100 percent of federal poverty guidelines (annual income of
       $18,400 for a family of four). Poverty leads to:
   •   Lack of health insurance. The uninsured rate in Doña Ana County is more than 24
       percent, compared to 21.3 percent for New Mexico and 15.6 percent nationally.
       About 33 percent of county residents are medically indigent (uninsured or
       underinsured). Of Doña Ana County’s Hispanic population, 40 percent are
       uninsured.
   •   Difficulty meeting even nominal co-pays for those with no income
   •   Lack of knowledge of availability of healthcare resources forms another key
       barrier. There is a general lack of information about what services are available
       where, even among the provider community. Eligibility requirements are
       complex, and filling out paperwork is time-consuming. Duplication occurs when a
       client visits a second provider. HCAP will address these issues; however, they
       remain a problem as of this writing.
   •   Lack of information-sharing among providers creates a significant barrier to care.
       Patients may be denied access to care because they have no documentation of
       their eligibility for a source of payment, even though they have enrolled at another
       facility. HCAP will address this issue.
   •   Lack of transportation forms a major barrier to care for many residents, especially
       in rural areas of the county.
   •   More than 90 percent of healthcare services in the county are located within Las
       Cruces city limits, yet 48 percent of county residents live outside those limits
   •   Most colonias lack paved roads.
   •   Many residents do not own a reliable vehicle
   •   The only public transportation system is in Las Cruces
   •   Federal funding for transportation is available, but it requires a local match of
       funds
   •   Fear is a significant barrier to accessing services for undocumented workers.
       Border checkpoints within the county and the fear of being reported to
       Immigration and Naturalization services make it difficult for these residents to
       access care
   •   Many county residents do not have telephones
   •   Limited service hours at the clinics mean that people who work full-time may not
       be able to access care. (However, both LCDF and BAHC offer some extended
       evening hours. Some LCDF dental clinics are open until 6 p.m. weeknights.
       LCDF’s Las Cruces and Anthony clinics are open from 8 a.m. to 2 p.m. on
       weekends. BAHC clinics are open two weeknights; the BAHC Doña Ana Clinic
       is open on Saturdays.
DAC HHS Alliance Action Plan                38                                      9/6/2006


   •   Language and cultural differences form a primary barrier to accessing care.
       Spanish speakers often have difficulty understanding how to get services.
       Providers may not be able to communicate with them clearly, leaving both patient
       and provider frustrated and negatively impacting the quality of care. Both FQHC
       clinics have many bilingual (English/Spanish) staff; however, hospitals,
       physicians’ offices, and ancillary services sites often lack this resource.
   •   Behavioral health issues may interfere with a person’s ability to access primary
       healthcare
   •   Some forum participants felt that racial discrimination and attitudes about
       providing services to rural areas of the county create another set of barriers


4.4 Healthcare Human Resources
    • Doña Ana County has a designated Medically Underserved Population (MUP)
    • Northern and Southern Doña Ana County are designated Health Professional
       Shortage Areas (HPSAs) for primary care
    • While NMSU offers a fast-track nursing program, enrollment in the program is
       limited to 78 students per year. Many graduating nurses go on to work in other
       communities, often to seek larger paychecks available in cities so they can pay
       back student loans
    • VISTA volunteers are a great asset, however, their longevity is very short since
       they only serve for one year
    • There is a high turnover of physicians
    • It is difficult to attract physicians to Doña Ana County because of social, cultural,
       and economic factors
    • Providers need training in cultural competence. Many providers do not speak
       Spanish, and fewer are truly knowledgeable about the belief systems and
       traditions of Doña Ana County’s culturally-diverse population


4.5 Financing
    • While services are available through the FQHCs and other publicly-funded
       healthcare systems, need is growing quickly while resources are remaining “flat.”
    • Federal dollars for health grants have been cut in recent years


4.6 Policy
    • Medicaid does not provide reimbursement for promotoras, health education, and
       other outreach services
    • Title X (family planning services) is only available to a limited number of
       providers due limited funding
    • County indigent policies have not been reviewed and updated since 1992
    • Federal poverty level (FPL) guidelines need to be reviewed and updated. The FPL
       are used to determine eligibility for Medicaid, SCHIP, and other entitlement
       programs.
DAC HHS Alliance Action Plan                39                                      9/6/2006


   •   Barriers exist to Medicaid enrollment and recertification, resulting in large gaps in
       access


4.7 Data and Evaluation
    • Specific data needs to be collected on geographic areas within the county,
       populations, services not available, and services underutilized
    • Baseline data for all Healthy Gente 2010 indicators needs to be collected and
       evaluated
    • HCAP funding expires August 31, 2006 (a no-cost, six-month extension has been
       submitted and is pending approval by HRSA)


5. Action Steps
5.1 Prevention and Education
    • Establish/coordinate county-wide healthcare prevention and education
       activities/campaigns/model.
    • Leverage funding from non-healthcare sources to improve air quality, living
       conditions, and install water treatment systems in rural areas of the county
    • Focus prevention and education efforts on diabetes during FY 2006-2007.
    • Use ongoing community-based planning to determine the next health priority
       issue to be addressed: cardiac disease, depression, or asthma


5.2 Delivery of Care
    • Expand existing healthcare services for the uninsured and underinsured by
       providing additional financial resources, recruiting additional human resources,
       improving access, and exploring innovative ways to increase capacity.


5.3 Access to Care
    • Support the creation of a sustainability plan for the HCAP MIS
    • Expand use of the DAC HHSD Healthcare Helpdesk
    • Increase emphasis on enrollment in funding programs such as Medicaid, SCHIP,
       State Health Insurance Coverage Initiative, and other alternative healthcare
       coverage
    • Develop a county transportation program.
    • Apply for funding from federal sources
    • Identify matching funds from county resources


5.4 Healthcare Human Resources
    • Provide education and career ladder opportunities to current healthcare workers
       (e.g. support promotoras to become licensed practitioners, RN’s to become
DAC HHS Alliance Action Plan               40                                   9/6/2006


       CFNPs). Leverage federal and state workforce development training dollars to
       provide training.
   •   Take advantage of loan-repayment programs such as the National Health Service
       Corps to recruit healthcare providers to rural areas of the county
   •   Increase recruitment of mid-level providers such as nurse practitioners,
       physician’s assistants, etc.


5.5 Financing
    • Increase funding for prevention and education activities
    • Seek private and public funding through grant opportunities for primary care and
       prevention

5.6 Policy
    • Approach elected officials about the need to revisit the formula by which federal
       poverty guidelines are determined
    • Review and update county policies for implementing the New Mexico Indigent
       Healthcare Act
    • Explore reimbursement options through Medicaid, state rural health initiative, and
       other funding sources for promotoras/community health workers and health
       educators
    • Investigate options for bringing a nurse practitioner program to the Family
       Residency Program by the University of New Mexico


5.7 Data Collection and Evaluation
    • Request assistance from NMSU to map indigent care funding for major clinics
       and hospitals
    • Determine percentage of emergent versus non-emergent calls to 911 system and
       by whom (chief complaint, privately insured, indigent, undocumented, age, etc.)
    • Determine percentage of emergent versus non-emergent emergency room visits
       and by whom (chief complaint, privately insured, indigent, undocumented, age,
       etc.)



6. Sources of Information on Primary Care
   •   HRSA Bureau of Primary Care http://bphc.hrsa.gov/
   •   CDC Diabetes Program http://www.cdc.gov/diabetes/
   •   New Mexico Diabetes Prevention and Control Program
DAC HHS Alliance Action Plan                41                                     9/6/2006




B. Specialty Care


1. Background
The overriding theme of the specialty care forum was the lack of resources to keep up
with demand. Specialty care is expensive because it requires technology to keep up with
standards of care. Current funding is inadequate for the amount of care needed by the
uninsured and underinsured population in Doña Ana County. Because specialty care
often involves high-risk procedures and high-risk patients, malpractice insurance is
expensive. Many specialty care providers either leave the area or do not accept low-
income patients because of low and slow reimbursement.

Access to specialty care in Doña Ana County is limited. The 1999 New Mexico
Household Survey conducted by the New Mexico Health Policy Commission found that
within Doña Ana County only 50 percent of those needing specialty services were able to
receive them.

What is Specialty Care?
Specialty care is care that requires specialized clinical expertise. It includes secondary
care – for instance, hospital care for a patient with acute renal failure. Providers of
secondary care include physicians in such specialties as internal medicine, pediatrics,
neurology, psychiatry, obstetrics and gynecology, and general surgery. Specialty care
also includes tertiary care, which involves the management of rare and complex disorders
such as pituitary tumors and congenital malformations. Providers of tertiary care include
cardiac surgeons, immunologists, endocrinologists, and pediatric hematologists
(Bodenheimer 47).

For purposes of the specialty care forum, specialty care was divided into obstetrics and
gynecology, surgical specialties, and non-surgical specialties.

Areas of Need in Doña Ana County
Several areas of acute need were identified by the specialty care forum.

Financing
Lack of funding for specialty care was a primary concern of all forum participants. Many
innovative ideas for long-term financing of primary care were developed during the
forums. Complicated eligibility processes for indigent care, slow Medicaid
reimbursement, and other factors often lead specialists to use their own resources for
indigent care.

Specialty care is costly to provide. Most health needs can be met at the primary care
level. However, this does not imply that most health care resources should be devoted to
primary care. Even though patients with severe or complicated conditions requiring
secondary or tertiary care are in the minority, their care will command a much larger
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share of health care resources per capita than the majority of people with less dramatic
health care needs (Bodenheimer).

In addition, specialty care often involves high-risk patients and high-risk procedures,
leaving physicians open to malpractice suits. Malpractice insurance is costly, and many
plans only allow one lawsuit. Only physicians working at federally-qualified healthcare
centers (FQHCs) are covered under federal tort law, leaving private providers vulnerable
to lawsuits.

Obstetrics and Gynecology
Approximately 40,300 women of childbearing age reside in Doña Ana County, about
23.1 percent of the county population. According to the National bureau, the birth rate in
Doña Ana County in 2000 was 17.3 births per 1000 females 15 to 44 years of age,
compared to the New Mexico birthrate of 15.3. The birthrate for teens ages 15 to 19 was
19.1, compared to a statewide birthrate of 17.8.

Of women who gave birth in Doña Ana County during 2000, 45.6 percent were
unmarried. More than half (50.5 percent) of those births were paid for by Medicaid,
compared to a state average of 46.8 percent. There are approximately 150 births to
underinsured and uninsured residents per year.

However, Doña Ana County’s infant mortality rate of 5.0 is one of the lowest in New
Mexico, including New Mexico border counties, and the United States. Infant mortality
rates for these areas are 6.6, 6.8, and 6.9 for the United States as a whole.

Diabetes mellitus
Diabetes mellitus affects 9.4 percent of the adult population of Doña Ana County. While
diabetes management is usually treated at the primary care level, the many complications
of diabetes often lead people with the disease to specialty care (see the findings and
analysis from the primary care forum for a more details discussion of diabetes
complications). In 2002, there were 2,456 hospital admissions in New Mexico in the
diagnostic categories directly related to diabetes, including diabetic emergencies, kidney
and urinary tract diagnoses, cranial and peripheral nerve disorder, amputation, peripheral
vascular disease, skin grafts and wound debridement, and other antepartum diagnoses.
However, when all inpatients with diabetes-related conditions (not only those admitted
primarily for a diagnosis of diabetes) are counted, an additional 24,001 patients were
identified as diabetics. Similar statistics are not currently available for Doña Ana County.

Cardiac Disease
Cardiac disease is the leading cause of death in the United States, in New Mexico, and in
Doña Ana County. Heart disease is also the leading cause of death for women in the
United States. In 2004, 3,161 New Mexicans, including 292 Doña Ana County residents,
died because of diseases of the heart.

According to the American Heart Association, Doña Ana County’s Hispanic residents of
Mexican descent are especially vulnerable to diseases of the heart. In the United States,
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diseases of the heart and stroke claim the lives of 29.3 percent of the more than 117,000
Hispanics or Latinos who die each year. Cardiovascular disease affects 29.2 percent of
men and 29.3 percent of women among Mexican-American adults. For every 100,000
Hispanics in the United States in 2002, 138.3 died from coronary heart disease (CHD),
including heart attack.

Chronic Obstructive Pulmonary Disease (COPD)
COPD affects more than 14 million US residents. Of diseases, COPD is the fourth
leading cause of death in the United States and in New Mexico and Doña Ana County.
Between 1996 and 2000, on average, 226 Doña Ana County residents died each year as a
result of COPD. COPD is a costly disease. Nationwide, total expenditures for COPD in
2004 were $37.2 billion, and increase of more than $5 billion since 2002.

Cancer
Malignant neoplasms (cancers) were the second leading cause of death in Doña Ana
County in 2004, causing 258 deaths among county residents. While malignant neoplasms
were also the second leading cause of death statewide, more Hispanics died because of
cancer than any other cause of death, including diseases of the heart, unintentional
injuries, diabetes, and cerebrovascular disease.

According to the American Cancer society, 8,150 new cases of cancer will be diagnosed
in New Mexico and 3,290 people will die of cancer in 2006. New Mexico’s cancer death
rate from 1998-2002 was 209.5 per 100,000 males and 144.1 per 100,000 females, with
lung cancer being the leading cause of mortality for both males (51.1) and females (29.0).
Breast cancer was the second leading cause of female cancer mortality, with a death rate
of 23.0, and prostate cancer the second leading cause of male cancer mortality, with a
death rate of 29.4.

The following figures, taken from the New Mexico Cancer Plan 2001-2006, provide
graphic illustrations of the prevalence of cancers in New Mexico:
DAC HHS Alliance Action Plan   44   9/6/2006
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Cancer rates in Doña Ana County are slightly less than the state average. The aggregate
rate for all cancers among males in Doña Ana County from 1994-1998 was 362.5
compared to a statewide rate of 392.7; for females, it was 263.9 compared to a statewide
rate of 301.4.

Pertinent Healthy Gente 2010 Indicators
   • Reduce female breast cancer death rate by 20% (per 100,000 women)
   • Reduce cervical cancer death rate by 30% (per 100,000 women)
   • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
   • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
   • Reduce infant mortality by 15% (per 1,000 live births)
   • Increase percent of women beginning prenatal care in 1st trimester to 85% (per
       100 women)
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   •   Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)
   •   Reduce by 33% the proportion of adults and adolescents currently using tobacco


2. Forum Results
The Specialty Care Forum was held on October 22, 2005 at the Hilton of Las Cruces. It
was the second of four forums held. About 50 people participated in the event, including
providers, consumers, and elected officials.

The CEOs of Memorial Medical Center and Mountain View Regional Medical Center
gave brief overviews of specialty care issues in Doña Ana County. Presentations by
providers followed the overviews. These presentations focused on specific issues
pertaining to obstetrics and gynecology, surgical, and non-surgical specialties.

Once the information had been presented the participants broke into six working groups,
two groups per topic, to analyze the issues and develop possible solutions to the problems
the groups chose to address. The work groups were given approximately one hour and
forty-forty five minutes to list issues they would like to address under the given topic. A
designated note taker and facilitator gathered the information from each group, using
SWOB analysis sheets. The workgroups identified 15 issues and 16
goals/recommendations. Groups then presented their issues and ideas for
recommendations to the audience, and submitted their SWOB sheets to DAC HHSD
staff. A follow-up meeting was conducted, during which the goals and recommendations
developed during the forum were prioritized.

This following is a verbatim summary of the forum results, including the issues and
topics identified and the priority goals and recommendations developed by the forums.
These are raw data and have been used as the basis for the above analysis, the
recommendations that follow, and the action worksheets found in Section II of this
document.

Issues from the Specialty Care Forum
The following issues were retrieved from the guided discussions at the specialty care
forum:

Obstetrics/Gynecology
   • Financing
   • Malpractice

Medical Specialties (Group 1)
  • Malpractice (insurance and lawsuits)
  • Reimbursement
  • Physicians (recruitment and working hours)
  • Indigent Care (all uncompensated care versus only Doña Ana County Indigent
      Health Care)
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Medical Specialties (Group 2)
  • Benefit eligibility assessment
  • Funding allocation

Surgical Specialties
   • Tort reform
   • Redistribution of current resources sponsored by city/county
   • Gross receipts taxes – state
   • Malpractice costs – state
   • Multi-service specialty clinic sponsored by city/county
   • Ensure New Mexico funds are used to augment city/county funds
   • Streamline/education on indigent fund
   • Funding needs to come back from University of New Mexico because very little
       emergency care goes there

Surgical Specialties (Group 2)
   • Mil Levy
   • Gross Receipt Taxes

Priority Goals and Recommendations

The following priorities were identified by workgroup participants. They are listed as
prioritized:

   1.  Streamline indigent program eligibility process (HCAP)
   2.  Create mil levy to fund malpractice costs or support healthcare
   3.  Review and analyze distribution of funds
   4.  Create multi-specialty indigent clinic and restructure of income criteria eligibility
       for indigent clients
   5. Develop community involvement and education
   6. Simplify forms to determine eligibility, flow chart (HCAP)
   7. County will establish a cost of service on healthcare and increases annually
   8. Look at Medicaid schedules regarding reimbursing providers for what they
       actually do
   9. Survey to show money versus indigent
   10. Create single payer system
   11. Promote personal responsibility
   12. County or state insure practitioners (pay for policy or some other coverage) –
       malpractice
   13. Reallocate funds
   14. Create Doña Ana County Salud plan
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3. Resources
Doña Ana County offers an array of specialty care services to its uninsured and
underinsured residents, including:


3.1 Prevention and Education
    • Maternal Child Health Both Ben Archer Health Clinic and La Clinica de Familia
       offer promotora programs focused on prenatal and perinatal care and early
       childhood wellness. Components of these programs include Medicaid enrollment,
       culturally-competent counseling for pregnant women, home visits before and after
       delivery, and family planning education. LCDF also operates the Doña Ana
       Health Start Program, which provides case management, health education,
       breastfeeding support, and outreach services to pregnant women and families with
       children up to the age of two.
    • Chronic disease Medical specialties equipment services are available in Doña
       Ana County, including home oxygen. The use of home oxygen by COPD patients
       can improve quality of life, decrease hospitalizations, and decrease the length of
       hospital stays that do occur. Primary prevention is the most cost-effective way to
       decrease COPD. However, for those patients already diagnosed with COPD,
       tertiary prevention measures such as home oxygen can be very effective.
    • Cancer The NMDOH offers the Breast and Cervical Cancer Early Detection
       Program and the Comprehensive Cancer Program. The Breast and Cervical
       Cancer Early Detection Program (B&CC Program) is a federally-funded program
       that provides free breast and cervical cancer screening to low-income women in
       New Mexico. Healthcare providers throughout the state screen women who
       qualify for the program and are reimbursed by the program for their professional
       services. During the B&CC Program’s first 10 years, 144,240 Pap tests and
       87,630 screening mammograms were funded. During that time, 883 women were
       diagnosed with cervical cancer and 505 women were diagnosed with breast
       cancer through the B&CC Program. The Comprehensive Cancer Program (CCP)
       is funded by the State of New Mexico and the Centers for Disease Control. The
       CCP’s mission is to promote the health of New Mexicans through comprehensive
       cancer prevention and control efforts. Projects include skin cancer prevention
       education; prostate cancer education on early detection and treatment, and support
       for patients and their families; support and education for cancer survivors with
       any type of cancer and their families; cancer patient housing; and colorectal
       cancer early detection education.


3.2 Delivery of Care
    • Memorial Medical Center (MMC) is a Class A, 280-bed hospital that is charged
       with primary responsibility for the emergency and inpatient care of
       un/underinsured residents of Doña Ana County. MMC receives county and
       federal funding for the care of indigent residents, which will exceed $23 million
       in 2005/2006. Previously a county (public) hospital, the hospital is now operated
       by Lifepoint, a private hospital system serving rural communities throughout the
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       United States, under a 40-year lease agreement with the City of Las Cruces and
       Doña Ana County. MMC states that it provided in excess of $30 million in
       uncompensated care in 2004. It is estimated that 7500 un/underinsured residents
       were served by MMC during that period. The hospital participates in all
       entitlement (Medicaid, SCHIP, County Indigent, etc.) and insurance (Medicare,
       private insurance, etc.) programs.
   •   Mountainview Regional Medical Center (MVRMC) is a Class A, 168-bed
       hospital that provides emergency and inpatient care to un/underinsured residents.
       MVRMC receives county funding for care of indigent patients and will be
       receiving additional federal matching funds for an estimated total of $1.5 million
       in FY 2005/2006. MVRMC states that it provided more than $7 million in
       uncompensated cared in 2004 to an estimated 1,200 un/underinsured residents.
       The hospital participates in all entitlement (Medicaid, SCHIP, County Indigent,
       etc.) and insurance (Medicare, private insurance, etc.) programs.
   •   Southwest Ambulance of New Mexico is the contractual provider of emergency
       and non-emergency advanced life support response for the citizens of Doña Ana
       County. In 2004 Southwest Ambulance responded to more than 17,500
       emergency (911) calls and transported more than 11,000 residents to appropriate
       medical care facilities
   •   Hatch Ambulance provides emergency and non-emergency advanced life support
       response in the northern area of Doña Ana County. In 2004 Hatch Ambulance
       responded to more than 424 emergency (911) calls
   •   First Step Center provides prenatal care, deliveries, and pediatric care to
       un/underinsured residents. Approximately half of all babies born in Doña Ana
       County are delivered by First Step. First Step receives some federal and county
       funding and depends heavily on local fundraising efforts. The county has a
       $250,000 external agency contract with First Step, targeted to direct services for
       pregnant women who are qualified for the County Indigent Program. All medical
       staff at First Step is under Memorial Medical Center and paid by them; none are
       under Mountainview Regional.
   •   The Family Medical Residency Program is the only freestanding community-
       based residency program in New Mexico (see the primary care findings and
       analysis for a complete description of the program). In addition to its primary care
       components, the program provides deliveries for pregnant patients of Ben Archer
       Health Center. The Family Medical Residency Program participates in all
       entitlement (Medicaid, SCHIP, County Indigent, etc.) and insurance (Medicare,
       private insurance, etc.) programs.
   •   Mesilla Valley Hospice provides end-of-life care to patients with a life-limiting
       illness and a prognosis of six months or less. Hospice teams work with patients
       and families to develop individual plans that include physical, spiritual, and
       emotional goals. The program also provides a free-standing inpatient unit for
       patients without a home or who have insufficient care at home. County funding
       allows Mesilla Valley Hospice to provide care to patients who have few
       resources. Doña Ana County is unique in New Mexico in recognizing the end-of-
       life needs of all residents and providing funding for those needs.
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3.3 Access to Care
    • Obstetrics
           o Ben Archer Health Center’s county-funded maternal child health program
               also transports women with high-risk pregnancies to Memorial Medical
               Center for care
           o Two out-of-state hospitals subsidize emergency obstetrics care
           o Two tertiary hospitals pay for air transport for emergency obstetrics care
    • Memorial Medical Center has a dialysis unit that provides services to
       un/underinsured patients. Only inpatient services are offered.
    • Local specialty-care physicians provide a significant amount (up to 20-30 percent
       of their practice) of free care to indigent persons in health crises. However, this is
       not a systemic and sustainable solution.


3.4 Healthcare Human Resources
    • Las Cruces has a strong network of dedicated specialty-care providers
    • Hospitals are actively and creatively recruiting specialty-care providers


3.5 Financing
    • Forum participants felt that the existing primary care indigent funds should be
       available for specialty care as well
    • Funding from LifePoint, Triad, and private corporations assists with specialty-
       care needs

3.6 Policy
    • Forum participants did not identify policy resources that specifically support
       specialty care in Doña Ana County


3.7 Data and Evaluation
4 Implementation of the HCAP system will allow the county to collect and evaluate
    baseline data on specialty-care needs and outcomes
5 NMSU’s Border Epidemiology Center can provide technical assistance in data
    evaluation


4. Gaps
Many gaps in specialty-care services exist in Doña Ana County. Forum participants were
especially concerned about the following gaps
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4.1 Prevention and Education
    • Lack of coordination between prevention programs
    • Tertiary prevention (after care, prescriptions, and equipment) is not covered by
       insurance or the indigent fund


4.2 Delivery of Care
    • The cost of specialty-care services is only reimbursed by the indigent fund if care
       is provided at one of the two hospitals in the county
    • Free-standing dialysis clinics in the county are for-profit facilities that require full
       insurance to provide care


4.3 Barriers to Care
    • Complex eligibility processes for indigent eligibility, Medicaid enrollment, and
       other programs reduce access by acting as a deterrent to both providers and
       patients
    • Forum participants expressed concern that undocumented immigrants were being
       turned away from emergency rooms because of their inability to pay
    • Lack of transportation for rural residents creates a significant barrier to care. All
       specialty-care services are located within Las Cruces city limits
    • A lack of stretcher vans and flexible transport hours by existing non-emergency
       health transport providers leads to inappropriate, non-emergent transport by
       ambulance. If the transportation is not reimbursed by Medicaid/Medicare or
       private insurance, the family is held responsible


4.4 Healthcare Human Resources
    • There are few incentives for specialty-care providers to remain in Doña Ana
      County.
    • Regional medical residency participation often does not include opportunities in
      Doña Ana County. For instance, University of Texas El Paso sends their residents
      to rural areas in other states.
    • There is a lack of orthopedic surgeons in the county
    • Midwives have performed vital obstetrics services for uncomplicated pregnancies
      in Doña Ana County for many years. However, the midwife population is aging
      and more and younger midwives are needed.


4.5 Financing
    • Resources do not currently meet demand. There is an immediate need for a
       feasibility study of alternative funding methods proposed by forum participants,
       including a Doña Ana County Salud program tailored to local needs so that profit
       margin goes back into the community. Other funding ideas developed during the
       forums included a mil levy, an increase in the gross receipts tax, and a "sin" tax
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       on cigarettes, alcohol, and other products with negative impact on public health.
       Other models should also be investigated, such as the UNM Cares health
       insurance program for low-wage workers.
   •   There is no mechanism to address ongoing increases in cost of care
   •   Malpractice insurance is expensive and provides limited coverage for specialty-
       care providers working with high-risk patients
   •   There is no current mechanism for direct billing from physicians to county
   •   More money is needed to cover midwives
   •   Medicaid reimbursement of obstetrics providers is limited and often does not
       cover costs


4.6 Policy
    • Only physicians practicing at Federally Qualified Health Centers are covered by
       federal tort law
    • State and federal legislation is needed to fund malpractice insurance for
       obstetricians who provide services to uninsured and underinsured populations
    • Local physicians are not part of the federal system and thus are not protected by
       tort law.
    • The County Indigent program only provides partial reimbursement for specialty
       care costs for un/underinsured residents of Doña Ana County. This partial
       reimbursement is available only if services are provided at one of the two
       hospitals.


4.7 Data and Evaluation
    • While the implementation of the HCAP program holds much promise for
       collecting and evaluating data about specialty care, many gaps remain. Specific
       and immediate needs for data collection and evaluation include:
    • Number and percent of non-emergent emergency room visits and 911 calls
    • Number of emergency room visits and 911 calls for unmanaged chronic disease,
       including cardiac disease, diabetes, asthma, depression, and COPD
    • There is a need for a feasibility study of providing malpractice insurance to
       providers. How much would be saved by covering providers? Would that provide
       additional incentives for providers to move to/remain in Doña Ana County?
    • An analysis of supply and demand for obstetrics services needs to be completed



5. Action Steps


5.1 Prevention and Education
    • Increase and coordinate primary and secondary prevention and education efforts
       for chronic diseases (diabetes, cardiac disease, COPD, and cancer).When
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       available and culturally-appropriate, use existing resources such as the New
       Mexico Cancer Program’s prevention materials.
   •   Explore funding options for tertiary prevention (after care, prescriptions, and
       equipment)
   •   Create linkages with existing state and federal resources


5.2 Delivery of Care
    • Create a mechanism to provide follow-up care for un/underinsured residents who
       receive screening services such as Pap smears, mammograms, and Coordinate
       delivery of specialty-care services with primary care, behavioral and oral health
       care
    • Coordinate delivery of specialty-care services with primary care, behavioral and
       oral health care with case management


5.3 Access to Care
    • Support implementation and sustainability of HCAP MIS system through
       partnerships with public and private providers


5.4 Healthcare Human Resources
    • Create incentives for specialty-care providers to remain in Doña Ana County
    • Approach medical school residency programs to recruit participation in southern
       New Mexico


5.5 Financing
    • Conduct a feasibility study of healthcare financing options (e.g. mil levy, property
       tax, income tax, “sin” tax [a tax on cigarettes, alcohol, and other substances
       shown to be detrimental to public health], DAC Salud, UNM Cares, TriCare
       [military] model, other means of financing specialty care)
    • Pursue public and private grant funding opportunities for specialty care
    • Ensure adequate funding for obstetrical and gynecological care


5.6 Policy
    • Pursue legislative support and state and federal funding for medical malpractice
       insurance for providers
    • Review county indigent policies for funding of specialty care


5.7 Data and Evaluation
    • Collaborate with NMSU to create a database of information about healthcare
       needs in Doña Ana County
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   •   Map current distribution of public funds for health care
   •   Collect and evaluate data on potential cost savings associated with use of home
       care and home-based medical equipment



6. Sources of Information on Specialty Care
   •   American College of Obstetricians and Gynecologists (ACOG)
       http://www.acog.org
   •   American Heart Association http://www.americanheart.org
   •   American Cancer Society http://www.cancer.org
   •   University of New Mexico Health Sciences Center, Epidemiology and Cancer
       Prevention Program and the New Mexico Tumor Registry
       http://hsc.unm.edu/epiccpro/
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C. Behavioral Health


1. Background
Several overriding concerns arose during the behavioral health forum and subsequent
work sessions. These were the need for appropriate interventions for people with
behavioral health needs, the need for effective, community-wide, evidence based
substance abuse prevention programs, the need for integrated case management, and the
need to reduce violence, specifically domestic violence, sexual assault, and bullying/gang
violence.

Because behavioral health spans many dimensions, from mental illness to domestic
violence to high-risk behaviors to substance abuse disorders, even the best statistical
analyses can provide only a portion of the need for mental health services. The most
comprehensive portrait of behavioral health services statewide is the 2002 study,
Behavioral Health Gaps and Needs in New Mexico. The report was the result of a
collaboration of state agencies and managed care organizations. It was produced at the
direction of the New Mexico legislature and executive branch.

According to the 2002 study, more than 500,000 New Mexicans have mental disorders or
substance abuse/dependence disorders. Mental disorders affect about 368,721 individuals
in New Mexico. More than 150,000 New Mexico residents have substance abuse
problems, ranging from abuse to addiction. Of those with mental disorders, 70,766 adults
have serious mental illness, 18,594 children and adolescents ages 9 through 17 have
severe emotional disturbance, 242,438 adults have other mental disorders, and 36,923
children and adolescents have other mental disorders. In 2002, only 19 percent of adults
and 52 percent of children and adolescents needing public sector mental health services
were being served.

The study also estimated that untreated mental health and substance abuse disorders,
including tobacco use and addiction, cost employers, taxpayers, and families more than
$3 billion annually. This amount could be drastically reduced with appropriate prevention
and treatment programs. For every dollar spent on alcohol and other drug treatment,
$7.14 is saved by reductions in other social, governmental, and economic costs. For every
dollar spent on mental health services, as much at $10 is saved.

In 2002, the state of New Mexico was not investing adequately in substance abuse
prevention, treatment, and research. For every dollar spent on substance abuse
prevention, treatment and research, $41.43 is spent by the state of New Mexico on the
consequences of substance abuse on intervention and treatment programs.

The picture has changed somewhat since 2002, although much work remains to be done
to create a workable mental healthcare system in New Mexico, including Doña Ana
County. In Grading the States 2006, the National Alliance for the Mentally Ill (NAMI)
described New Mexico’s mental healthcare system as “anything but enchanting.” The
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most significant positive step that has happened in New Mexico, according to NAMI, is
the “experiment known as the Behavioral Health Purchasing Collaborative (BHPC)
which has the potential to become a national model.” On the other hand, New Mexico
residents struggle with serious behavioral health problems. The state ranks fifth-highest
in suicide rates, and second-lowest in per capita spending for state-directed mental health
services. Poverty, large rural areas, and lack of health insurance also contribute to the
problem.

What is Behavioral Health?
Behavioral health includes mental health disorders, from mild to severe, substance abuse
disorders, and risky behaviors. Behavioral health has many dimensions. From acute
illness to mild depression, from incapacitating substance addiction to alcohol poisoning
from a one-night binge, from risky behaviors to teen pregnancy, HIV, and Hepatitis C
infection, from the violently mental ill to suicidal depression, behavioral health
encompasses both the physical and mental, both the individual and community.
Increasingly, practitioners are beginning to recognize that behavioral health is not
separate from primary care or the community one lives in.

Major Behavioral Health Issues in Doña Ana County
The following brief descriptions highlight some of the major behavioral health issues
identified by the behavioral health forum and workgroup as well as secondary research:

Lack of Resources for Chronically Mentally Ill Adults
Few resources are available for chronically mentally ill adults who have been diagnosed
using Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) as having a
major mental disorder, developmental disorder, or learning disability (Axis I disorders).
Mental illness is a lifelong, incurable condition. Funding to provide holistic care for the
mentally ill is not available. Most are uninsured and not qualified for indigent care. They
lack housing, medical care, medications, and case management.

Detention Instead of Treatment for the Mentally Ill About 20 percent of inmates at the
Doña Ana County Detention Center have mental disorders, most with co-occurring
substance abuse and addiction disorders. Limited or non-existing community resources
leave little choice for law enforcement agencies to divert individuals whose infractions
often suggest alternative placements. With no coordinated and funded public programs to
care for them, the jail has become the inadvertent “safety net” for the mentally ill.

Domestic Violence
Statewide, three-fourths of victims of domestic violence are female. In 2004, nearly one-
third of domestic violence cases involved alcohol and/or drug use. In 95 percent of those
cases, suspect was using alcohol and/or drugs, and in 16 percent the victim was using of
alcohol and/or drugs. These statistics include the 10 percent of cases in which both
suspect and victim were using substances. Of cases reported by law enforcement, 95
percent involved suspected drug and/or alcohol abuse by the offender; of those reported
by domestic violence service providers, 64 percent involved suspected substance abuse.
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Current or former intimate partners were offenders in 65 percent of law enforcement-
reported cases and 89 percent of shelter-reported cases.

Doña Ana County ranks fourth in the state for rates of domestic violence, with the Las
Cruces Police Department reporting 20.4 domestic violence calls per 1000 population.
Trends in domestic violence are soaring upward in Doña Ana County. Domestic violence
providers in Doña Ana County served 934 percent more clients in 2004 than in 2003, a
total of 1137 during the year. Of 207 cases that went to district court, 139 (67 percent)
resulted in convictions; 597 cases went to magistrate court, 229 (38 percent) of which
resulted in convictions.

Sexual Assault
In 2004, 348 sex crimes were reported to law enforcement and 168 to service providers in
Doña Ana County. Of those, 270 involved complete sexual penetration (CSP) and 23
involved criminal sexual contact (CSC) with a minor. Doña Ana County ranked first of
New Mexico’s 33 counties in the rate of law-enforcement reported CSP incidents.

Statewide, females were victims in 85 percent of CSP cases reported by law enforcement,
83 percent of CSC cases, and 88 percent of those who sought help from service providers
and Sexual Assault Nurse Examiner (SANE) programs. Most CSP offenders reported by
law enforcement were between the ages of 13 and 35; most non-CSP offenders were
between the ages of 7 and 25.

Most sexual assaults are perpetrated by a boyfriend, acquaintance, or family member.
Strangers were offenders in only 14 percent of cases reported by service providers and
law enforcement and 21 percent of those reported by SANE programs. The remainder
were known to the victim. Acquaintances and boyfriends comprised the greatest
proportion of known offenders as reported by both law enforcement and service providers
(26 percent and 42 percent), while parents (6 percent) and step-parents ( 8 percent) as
reported by law enforcement and fathers (24 percent), uncles (14 percent), and step-
fathers (14 percent) as reported by service provides, comprised the greatest proportion of
related offenders.

Since SANE began providing services in 1997, successful prosecution rates have
increased by 60 percent. This includes plea bargains. Because of the length of time
required in the judicial process, the effects of sexual assault services may not be seen
immediately.

Hate Crimes, Bullying and Gang Violence
Hate crimes, bullying and gang violence are serious problems among Doña Ana County
youth. The 2003 New Mexico Youth Risk and Resiliency Survey (NMYRRS) showed
that more than 35 percent of youth (slightly less than the state average) in grades 9 to 12
reported being in a physical fight during the last year, while 20 percent (slightly more
than the state average) reported being in a physical fight at school. About 20 percent had
carried a weapon in the past 30 days, and for 10 percent, that weapon had been a gun.
Ten percent had carried a weapon while at school in the previous 30 days.
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Males were significantly more likely to engage in violent behavior than females, with 50
percent of males in grades 9 to 12 reporting having been in a physical fight during the
previous year compared to about 25 percent of females. More than 26 percent of males
had been in a fight at school; 14.2 percent of females had done so. Almost a third – 31.6
percent – of males had carried a weapon in the previous 30 days, and for 17.3 percent of
all males, that weapon was a gun. Among females, 10.3 percent had carried a weapon,
2.2 percent carried a gun, and 4.8 percent carried a weapon at school during the previous
30 days.

In addition, 10 percent of students, compared to 8.2 percent statewide, reported skipping
school because they felt unsafe during the previous 30 days. Nearly 12 percent reported
having been threatened or injured with a weapon at school during the previous year.

While these statistics reveal a significant violence problem among youth in Doña Ana
County, they also probably underestimate the full problem, since they only include youth
enrolled in and attending school. They do not include violent behaviors among youth who
drop out of high school.

Teen Pregnancy Prevention
Teen pregnancy prevention crosses all service areas. It is a primary care issue, for
sexually active teens must have access to low- or no-cost birth control and be taught how
to use it. It is a specialty care issue, for teens who become pregnant require obstetrical
care and are more likely to experience complications than women in their twenties and
early thirties. It is an oral health issue, for oral disease has been linked with birth defects.

But teen pregnancy prevention is fundamentally a behavioral health issue. In 2003,
according to the NM YRRS, 42.3 percent of youth in grades 9 to 12 in Doña Ana County
reported that they had ever had sexual intercourse, 26 percent said they were currently
sexually active, and 16.8 percent reported not using a condom at last sexual intercourse.
Alcohol or drugs were used before last sexual intercourse by 11.7 percent of teens.

In 2003, the teen birth rate per 1000 females ages 15 to 19 in Doña County was 79.9,
compared to the New Mexico rate of 61.1. New Mexico’s rate is third in the nation,
behind Nevada, Arizona, and Mississippi. Doña Ana County had the fifth-highest teen
birth rate of 33 counties. On average, state and national teen birth rates declined during
the late 1990s and early 2000s. However, in Doña Ana County the teen birth rate has
risen significantly and steadily since its 1999 rate of 66.2.
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Source: NM Kids Count 2005 Data Book


About 50 percent of all pregnancies in Doña Ana County are unintended, mirroring the
national percentage of unintended pregnancies. Teens are most likely to experience an
unintended pregnancy. The Alan Gutmacher Institute reports that nationwide,
approximately 900,000 to one million teenage girls have unintended pregnancies.
Nationwide, half of those pregnancies end in abortion. In New Mexico, 65 percent of teen
pregnancies end in live births and 20 percent in abortion.

Teens are more likely to give birth to low birth-weight infants, partly because teen
mothers are less likely to eat a nutritious diet, more likely to smoke and use recreational
drugs, and less likely to get early and adequate prenatal care. Teen mothers are more
likely to have serious complications during pregnancy, labor, and delivery. Infants born
to teen mothers are more likely to have childhood health problems that require
hospitalization. As they grow up, they are more likely to be physically abused,
abandoned, or neglected; do poorly in school; spend time in jail; and become teen parents
themselves.

Teen mothers and fathers are less likely to graduate high school, more likely to live in
poverty, and more likely to rely on social support systems. The cost of teen childbearing
to New Mexico taxpayers is more than half a billion dollars per year. Nationally, the cost
reaches 38 billion dollars annually.
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Pertinent Healthy Gente 2010 Indicators
   • Reduce motor vehicle crash death rate by 25% (per 100,000 inhabitants)
   • Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
       women 15-17 years of age)
   • Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
   • Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per
       100,000 inhabitants)
   • Increase to 89% the proportion of adolescents not using
          o alcohol in the past 30 days
          o marijuana in the past 30 days
          o cocaine use in the past 30 days
   • Reduce by 33% the proportion of adults and adolescents currently using tobacco

These indicators provide the basis for the development of behavioral health objectives in
Doña Ana County. However, baseline data is currently available for only some of the
objectives. For objectives to be developed, baseline data, available resources, and a
realistic timeline must be established.

2. Forum Results
The Behavioral Health Forum was held on December 3, 2005 at the Hilton of Las Cruces.
It was the third of four forums held. About 45 people participated in the event, including
providers, consumers, and elected officials.

Presentations were given by a panel of experts that included representatives from Value
Options, the Doña Ana County Behavioral Health Collaborative, the New Mexico
Department of Health, Mesilla Valley Hospital, Southwest Counseling, and the National
Alliance for the Mentally Ill (NAMI). Presentation topics included access to recovery,
inpatient care, outpatient care, and the role of consumer, family and advocates. A fifteen-
minute question and answer session was held after the presentations were given, during
which participants asked questions of the presenters.

From the initial forum results, six topics were drawn by the behavioral health ad hoc
committee. These topics were teens, substance abuse, suicide, behavioral health
education, capacity, and violence. During the subsequent work group sessions,
participants completed Strengths, Weaknesses, Opportunities, and Barriers (SWOB)
sheets, formulated goals and recommendations, and established priorities.

This following is a verbatim summary of the forum results, including the issues and
topics identified and the priority goals and recommendations developed by the forums.
These are raw data and have been used as the basis for the above analysis, the
recommendations that follow, and the action worksheets found in Section II of this
document.
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Topics and Issues

Topic: Behavioral Health Education
Issues
    • Cultural Proficiency

Topic: Capacity
Issues:
    • Legislation
    • Crisis Service
    • Medication

Topic: Substance Abuse
Issues:
    • Lack of effective, evidence-based prevention community wide
    • Lack of continuity in prevention, intervention, treatment and aftercare for
        Alcohol, Tobacco, and other Drugs (ATOD), including dual diagnosis populations
        (i.e. those with both mental health/developmental disabilities and substance abuse
        disorders)

Topic: Suicide
Issues:
    • Legislative changes
    • Intervention
    • Prevention/Awareness

Topic: Teens
   • Parenting
   • Prevention

Topic: Violence
Issues:
    • Domestic Violence
    • Sexual Assault
    • Hate, bullying, and gangs


Priority Goals and Recommendations
The following priority goals and recommendations were developed by the behavioral
health workgroup. They are listed as prioritized:

   1.   Establish and utilize mobile crisis team
   2.   Increase links between services with effective case management
   3.   Reduce violence in Doña Ana County
   4.   Increase education in schools and decrease early use and availability of drugs and
        alcohol
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   5. Develop culturally-relevant programs for Doña Ana County
   6. Partner with law enforcement
   7. Develop a plan to define responsibility of providers
   8. Get medications to un/underinsured population
   9. Improve environmental strategies (PSA’s, funding for public access messages)
   10. Target five biggest employers, e.g. WSMR, for drug-awareness training



3. Resources
3.1 Prevention and Education
    • The Doña Ana County Behavioral Health Division of the DAC HHSD offers
       multiple behavioral health prevention and education programs, including:
    • The Strengthening Families curriculum, a program for parents to learn how to
       teach their children social learning skills. Parents learn skills and techniques to
       improve their relationships with their children and create a more positive family
       environment. Parents can share their parenting stories, skills, and express any
       concerns about their children.
    • Creating Lasting Family Connections, a comprehensive family strengthening,
       substance abuse, and violence prevention program targeted toward families with
       youth ages 11-17. The program is designed for families to improve self-esteem
       and communication skills and to help youth learn to stand up for themselves and
       avoid alcohol and drugs, violence and other health-threatening behaviors.
    • The Doña Ana County DWI Program, also operated by the DAC HHSD,
       addresses root issues of drinking and driving using a multifaceted approach
       including community education, prevention, intervention, treatment, and
       enforcement activities and services. The program’s three goals are to: 1) decrease
       incidence of DWI in Doña Ana County, 2) reduce repeat offenses of DWI, and 3)
       to assure compliance with court sanctions for the crime of Driving While
       Intoxicated. The vision of the Doña Ana County DWI Program is a community
       free of the ills associated with driving while under the influence of alcohol.
    • Mesilla Valley Hospital has a longstanding education program called "Psyche
       Quizzine," which consists of free monthly luncheon presentations on mental
       health and substance abuse issues, and an extensive suicide prevention program
       for teens under the auspices of the Jason Foundation.
    • NAMI-DAC chapter is the affiliate of the National Alliance for the Mentally Ill of
       Doña Ana County through the state organization, NAMI-NM. NAMI started as a
       grass roots organization, and is now present in all fifty states. NAMI's mission is
       to provide support, education, and advocacy for the consumers of the mental
       health system and their families. NAMI-DAC programs include:
           o A monthly family support group,
           o A family-to-family education course twice yearly, designed to help family
               members understand and support their ill relative.
           o “The Warm Line,” a consumer run friendly phone line, through which
               consumers can find support, share concerns, and have a peer who is
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               willing to listen and talk. The Warm Line is available every day from 5:00
               PM to 9:00 PM.
           o NAMI-DAC also offers the Treatment Guardian Program. Through this
               program, a trained treatment guardian is available to advocate for and
               make decisions regarding mental health care for a client who may not be
               able to make these decisions.
   •   The Teen Collaborative is a group of agencies and programs that offer awareness
       opportunities regarding teen issues to the community via presentations and health
       fairs. The Collaborative works together to enhance existing information while
       creating networking opportunities for participating agencies. Collaborating
       agencies include La Piñon, NMDOH, CASA, Las Cruces Public Schools,
       Chaparral Community Health Counsel, and Medicaid enrollment.
   •   Other strengths in regards to teens in Doña Ana County:
           o Family activity programs
           o After-school activities
           o Information about prevention is available
           o Schools, churches, community resource centers, and other community
               organizations provide locations for delivery of prevention and education
               programs as well as screening for high-risk behaviors.
           o Presently, KIDTALK warmline has goals and objectives addressing the
               prevention of hate crimes and bullying at an early stage


3.2 Delivery of Care
    • Ben Archer Health Center provides behavioral health services at both of its sites
       in Doña Ana County.
    • Mesilla Valley Hospital is a private psychiatric hospital serving adolescents and
       adults who are seeking treatment for behavioral health issues including
       depression, suicidal behaviors, anxiety disorders, schizophrenia, bipolar disorders,
       alcohol and drug dependency, adolescent behavioral problems, sexual, physical,
       and emotional abuse, and psychosocial and severe psychosomatic problems.
       Assessment and referral services are offered to all individuals, regardless of
       ability to pay. Mesilla Valley Hospital is CYFD accredited and accepts both
       private and public health insurance; however, the agency is not a provider for the
       county indigent fund.
    • Memorial Medical Center (MMC) offers 12 locked, secure inpatient beds for
       persons with behavioral health needs as part of their 40 year lease with the
       County.
    • The Peak Hospital in Santa Teresa has 30 inpatient beds for persons with
       behavioral health needs. The agency accepts both private and public health
       insurance. However, the agency is not a provider for the county indigent fund.
    • Southern New Mexico Human Development offices in Las Cruces, Sunland Park,
       and Anthony offer outpatient services including mental health, alcohol and drug,
       and psychiatric services, case management, psychosocial interventions, education
       and information, and a 24-hour crisis intervention line.
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   •   Southwest Counseling Center has three locations in Las Cruces, which offer
       outpatient mental health, alcohol and drug services, drug court services, peer
       support services, telemedicine, case management, psychosocial interventions,
       supported housing services, education and information, and a 24-hour crisis
       intervention line. SCC also manages a transitional living center, which offers 24-
       hour care, crisis stabilization/23-hour observation, case management services,
       psychosocial interventions, supported housing, and education and information.
   •   Families and Youth Incorporated (FYI) provides a full array of behavioral health
       services to children and youth including prevention education, harm reduction
       services, Medicaid enrollment, outpatient mental health and substance abuse
       counseling, home-based services, residential treatment services, treatment foster
       care, adolescent shelter care, youth employment, and Juvenile Community
       Corrections. Funding includes federal, state, and local sources.
   •   La Casa Domestic Violence Shelter provides comprehensive services to families
       affected by domestic violence, including emergency shelter, counseling, legal
       advocacy, crisis intervention, offenders programs, case management, and
       outreach. In 2004, La Casa served 1,137 adult victims of domestic violence, 458
       children who were victims of or witnessed domestic violence, and 81 offenders.
   •   La Piñon Sexual Assault Recovery Services of Las Cruces offers a comprehensive
       array of services related to sexual assault and abuse to individuals, families and
       the community. La Piñon offers 24-hour hospital and phone advocacy,
       counseling, and community education. La Piñon believes that by offering
       unconditional support, information and a safe environment for change, the person
       who has been sexually assaulted can take steps to regain control of her/his life and
       make the transition from victim to survivor. Services include:
           o Crisis Intervention:
                   • 24-hour 1st response to survivors of sexual assault through phone,
                       face to face and SANE Project. Trained volunteer advocates
                       execute this service after graduating from 40 hours of intensive
                       training in sexual assault advocacy intervention.
                   • 24-hour telephone & hospital emergency room assistance
                   • Crisis intervention for victims, their friends and relatives
                   • Information and advocacy regarding medical treatment
                   • Information and assistance through the legal process
                   • Assistance in applying to Crime Victims Reparation Commission
                       for compensation
           o S.A.N.E. Project. Sexual Assault Nurse Examiner Project is a
               collaborative venture of La Piñon Sexual Assault Recovery Services and
               Memorial Medical Center. Specially trained Nurse Examiners provide
               care with sensitivity, ensuring privacy and timely treatment in a safe
               environment at no cost.
                   • Check injuries
                   • Pregnancy prevention
                   • S.T.D. (Sexually transmitted disease) prevention
                   • Gathering forensic evidence (Criminal Sexual Penetration kit)
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           o Counseling. Outpatient individual and group counseling for sexual assault
               survivors is facilitated by Licensed Professional Clinical Counselors with
               extensive experience in sexual assault and trauma related issues.
           o Community Education. La Piñon offers responsive and flexible
               presentations and professional training concerning sexual assault issues
               and safety. Staff and advocates provide these programs to the community.
               In FY 2005-06, staff will reach more than 19,000 people in Doña Ana
               County.
           o KIDTALK warmline for children provides a safe place to call
   •   The Forensic Intervention Consortium of Doña Ana County (FIC-DAC) seeks to
       contribute to the orderly administration of justice and the protection of the
       community and its citizens by reducing recidivism and undue detention of persons
       with mental illness and/or developmental disabilities. The organization provides
       assistance to chronically mentally ill adults who are faced with misdemeanor and
       minor felony criminal charges. The FIC-DAC seeks to develop a community-
       based service for the mentally ill and integrating the mentally ill back into their
       communities. Programs include:
   •   Jail diversion for the mentally ill, which arose for the purpose of keeping minor
       offenders who have a mental illness out of our prison systems and making
       treatment available to them.
   •   Crisis Intervention Team (CIT) training and certification to law enforcement
       officers. CIT members are trained to assist the mentally ill in confrontational
       situations.
   •   A residential program that includes placement in residential care facilities with
       case management and mental health care support.
   •   Schools throughout New Mexico offer behavioral health assessment and
       interventions for children and adolescents through school counselors,
       psychologists, and social workers. Special education students are assessed and
       receive Individualized Education Plans. Of 21,000 visits to school-based health
       centers in 2001, 29 percent were for behavioral health issues. School-based
       mental health programs are being piloted with additional behavioral health
       specialists in school health centers.


3.3 Access to Care
    • The Access to Care subcommittee of the Local Behavioral Health Collaborative is
       conducting surveys of consumers, family members, behavioral healthcare
       providers and other stakeholders to identify needs, gaps in services, concerns. The
       subcommittee will compile a report and present recommendations based on this
       research to the New Mexico Behavioral Health Purchasing Collaborative to
       incorporate specific needs for Doña Ana County into the state behavioral health
       plan.
    • Medications are available to consumers who are enrolled in Medicaid or
       Medicare. Medication assistance programs that provide free prescription
       medications are also available; however, the individual physician must apply for
       it. It takes about three 3 weeks for approval and delivery of medications. The Jail
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       Diversion program pays for medications for people in its program who fall in the
       funding gaps.
   •   The DAC HHSD Healthcare Helpdesk is designed to assist county residents in
       gaining access to healthcare.
   •   Ben Archer Health Center provides referrals to mental health services through
       primary care clinicians. Promotoras assist in identifying residents at risk of
       depression, anxiety, and other behavioral health problems and provide education
       and prevention services.


3.4 Healthcare Human Resources
    • Doña Ana County’s unique population mix offers opportunities for the
       development of culturally-competent prevention and education materials that
       could set standards for the rest of the state and the nation. The population has the
       capacity for translation and interpretation and has cultural competence that goes
       beyond language but addresses beliefs and behavioral norms.
    • Law enforcement throughout the county has received CIT training
    • New Mexico State University prepares students for careers in behavioral health in
       several departments:
          o The School of Social Work offers both BSW and MSW degrees
          o The Family and Consumer Science Department graduates marriage and
               family therapists and family and child educators
          o The Counseling Education Program trains psychologists (Ph.D.) and
               master’s level therapists
          o The Criminal Justice Department is committed to victimology within their
               required courses
          o The Interdisciplinary Institute on Addiction Studies offers an
               interdisciplinary graduate minor in alcohol and drug counseling
          o The Nursing Department trains nurse practitioners with a focus on
               behavioral health
          o The Health Science Department offers graduate degrees in public health


3.5 Financing
    • Many medications are donated (however, not enough to meet demand)
    • Medicare Part D offers low-cost prescriptions to qualifying members
    • The 17 agencies of the New Mexico Behavioral Health Purchasing Collaborative
       finance behavioral health services through a statewide contract with
       ValueOptions, a for-profit behavioral health provider (see bullet one under
       “Policy” below)
    • The NMDOH Pathways Program is a voucher program for adults with substance
       abuse disorders. Vouchers include substance abuse treatment and support
       services.
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3.6 Policy
    • The Local Behavioral Health Collaborative provides local guidance to the
       statewide Behavioral Health Planning Council, the planning arm of the New
       Mexico Interagency Behavioral Health Purchasing Collaborative. The New
       Mexico Interagency Behavioral Health Purchasing Collaborative consists of 17
       agencies that provide funding for behavioral health care in the state. Currently, the
       statewide contract rests with Value Options, Incorporated, a for-profit behavioral
       health provider. The purpose of the Local Collaborative is to develop strong local
       voices to guide behavioral health planning and services. There is a local
       collaborative for each of New Mexico's 13 judicial districts, plus a limited number
       as makes sense for the state's sovereign tribes and pueblos. Each local
       collaborative is to be identified or formed locally and recognized by the state
       Collaborative to help create and sustain the partnerships among customers, family
       members, advocates, local agencies, and community groups. They will identify
       needs, help develop a range of resources and ensure the responsiveness and
       relevance of behavioral health services and supports to improve the quality of life
       of those affected by behavioral health concerns. In addition, two individuals and
       an alternate from each county are appointed to the Local Collaborative by the
       County Health Council (in Doña Ana County, the Alliance). These individuals
       report back to the Alliance on the activities of the Local Collaborative.
    • The Southwest New Mexico Regional Substance Abuse Committee (SAC)
       facilitates a regional effort to prevent and decrease substance abuse and chemical
       dependency by linking resources to needs in a strategic and shared plan of action.
       Membership is open to any community member or community coalition member
       in NMDOH Region V. In addition, two individuals and an alternate from each
       county are appointed to the Regional SAC by the County Health Council (in Doña
       Ana County, the Alliance). These individuals report back to the Alliance on the
       activities of the Regional SAC.
    • Local legislators are aware of the need for increased behavioral health services in
       Doña Ana County and have introduced legislation supporting increased funding
       for various needs, including inpatient beds,
    • Police are aware of hate crimes, bullying, and gangs, and laws are in place


3.7 Data Collection and Evaluation
    • The Healthy Communities Access Program (HCAP) MIS system, once
       implemented in August 2006, will collect data on depression at participating sites
    • The Access to Care Subcommittee of the Local Behavioral Health Collaborative
       has been tasked with developing a money map showing where the money for
       mental health services is coming from and going to, as well as how much money
       is being used. The Subcommittee is investigating possibilities for technical
       assistance with the money map, including an NMSU graduate student, possibly
       someone already interning with NMDOH Public Health, or Dean Caruthers in the
       Business School. Approximately $15,000 is needed to fund the mapping project;
       the subcommittee will approach ValueOptions for a possible mini-grant.
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   •   The New Mexico Youth Risk and Resiliency Survey provides annual data on risk
       behaviors among youth enrolled in public schools
   •   State of New Mexico Department of Health, Injury and Epidemiology Bureau,
       Office of Injury Prevention provides data on domestic violence and sexual assault
   •   PRAMS provides data on teen pregnancy
   •   The New Mexico Teen Pregnancy Coalition provides county-level data on teen
       pregnancy
   •   SETTLE and NMDOH provide data on suicide
   •   The Border Epidemiology Center provides technical assistance and data
       evaluation services


4. Gaps
Despite the wide array of behavioral health services available in Doña Ana County,
significant gaps in services and access remain. These include:


4.1 Prevention and Education
    • Lack of effective, evidence-based substance abuse prevention programs on a
       community-wide level. Multiple programs exist, but there is little coordination
       between programs and not all populations are served.
    • Many prevention and education programs adopt a “one size fits all” approach that
       does not respect the cultural diversity of Doña Ana County. Even if materials
       have been translated from English to Spanish, this does not guarantee that they are
       culturally-relevant.
    • Lack of activities for children and youth
    • Lack of home education. Parents don’t have good education, knowledge, and
       skills about substance abuse, bullying, gang violence, and how to talk with their
       kids about sex
    • Most worksites do not prioritize prevention of substance abuse
    • Child abuse, poor communication, family violence, substance abuse, and high
       divorce rates may put family members at risk of mental health and substance
       abuse disorders, as well as perpetuating the cycle of violence.
    • Lack of continuity in prevention, intervention, treatment and after care for those
       who abuse Alcohol, Tobacco, and other Drugs (ATOD), including dual diagnosis
       populations (i.e. those with both mental health/developmental disabilities and
       substance abuse disorders)
    • Lack of public awareness about suicide


4.2 Delivery of Care
    • Northern and Southern Doña Ana County are behavioral healthcare shortage areas
    • While the jail diversion program has been effective, mental disorders still affect
       20 percent of Doña Ana County Detention Center inmates. Program expansion,
       additional crisis intervention training, and expanded residential options are needed
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       to provide more choices for those people whose infractions may not merit
       incarceration or whose release pending trail can be accommodated.
   •   There are no mental health services in the detention center and there are no places
       to accept acutely psychotic inmates needing hospitalization. A psychiatric ward is
       needed in the detention center.
   •   Increasingly, emergency responders are being called upon to respond to “welfare
       checks” – calls that fall outside the scope of work of law-enforcement. In 2004,
       the Las Cruces Police Department responded to 424 welfare checks in one month.
       These calls often involve mental health crises. No centralized resources such as a
       telephone response system are available, nor is there a defined response protocol
       for these calls. Mental health crises and criminal violations often overlap,
       including domestic violence and sexual assault. The current situation increases
       liability to county government because appropriate programs and trained
       responders are not available. People are not triaged quickly to appropriate care.
       Escalation and endangerment of consumers and emergency responders is
       common.
   •   More secure inpatient beds are needed at Memorial Medical Center
   •   Mountainview Medical Center has no inpatient beds for patients with behavioral
       health needs
   •   The existing baseline for the average waiting time in the emergency room is 6.5
       hours, far too long for a person having a mental health crisis.
   •   There is no detoxification center in Doña Ana County except the jail
   •   There are no local, state-funded, in-patient rehabilitation centers
   •   Although both FQHCs offer mental health services, mental health is often not
       treated as part of primary care
   •   There is no publicized, local suicide crisis line
   •   Long-term services for people with traumatic brain injury (TBI) are very limited


4.3 Barriers to Care
    • Transportation forms an important barrier to care for those with behavioral health
       problems.
    • The rural nature of the area and lack of infrastructure, especially in the colonias,
       create important barriers to care. There is a discrepancy between services
       available in Las Cruces and in other geographic areas of the county
    • The only long-term inpatient services for adults without insurance are in Las
       Vegas, New Mexico. There is a need for a “Las Vegas South”
    • Fear of going outside the family often discourages people from seeking help when
       they need it
    • Providers are not necessarily culturally competent
    • The time required to procure behavioral health medications is often long
    • A lack of physicians qualified to manage behavioral health medications in the
       rural areas limits patients’ access to these medications
    • St Luke’s Health Center does not provide anti-psychotic medications
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   •   Parents and teens may lack time and knowledge to communicate well. Few
       community incentives exist for parents to develop skills
   •   Imposition of cultural standards on the less dominant culture, leading to
       disempowerment
   •   Many private practitioners do not accept Medicare


4.4 Health Care Human Resources
    • There are not enough behavioral health providers, particularly psychiatrists, to
       meet demand, especially in the rural areas.
    • There are not enough human resources for teen prevention activities
    • Few private practitioners specialize in pediatric behavioral health such as trauma-
       related issues
    • There are not enough registered nurses to adequately staff SANE programs


4.5 Financing
    • No state funding is available for mental health medications
    • The cost of prescription medications is often prohibitive for those with mental
       disorders
    • Salary disparities between Doña Ana County, public school systems, and El Paso,
       Texas contribute to a lack of behavioral health human resources. Behavioral
       health providers often leave Doña Ana County or commute to nearby areas
       because they get better pay and benefits.


4.6 Policy
    • Funding mandates often make it impossible to deliver appropriate care
    • The mentally ill are not eligible for Supplemental Supportive Income (SSI)
       through the Social Security Administration
    • Legislative funding is stagnant.
    • The New Mexico legislature passed a bill in 2006 that would have provided
       funding for a crisis triage inpatient program for assessments and up to 30 day civil
       commitments, a mobile crisis team, a “step up and step down” facility for persons
       transitioning back into the community, and a mental heath court. However,
       Governor Richardson vetoed most of the funds.
    • Doña Ana County Sheriff’s Department and Las Cruces Police Department are
       not linked through a memorandum of agreement (MOA) or memorandum of
       understanding (MOU)


4.7 Data Collection and Evaluation
    • There is a need for data from law enforcement on mental health crisis
       interventions
    • There is a need for baseline data on behavioral health needs
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   •   There is a need for data on self-inflicted injuries from emergency personnel
   •   There is a need for data on self-inflicted injuries from nursing homes


5. Action Steps


5.1 Prevention and Education
    • Enhance existing jail diversion, sexual assault, and domestic violence prevention
       and education activities
    • Develop a culturally-relevant prevention and education media campaign to
       address priority issues of domestic violence, sexual assault, hate
       crimes/bullying/gangs
    • Provide drug-awareness training to five biggest employers in Las Cruces
    • Increase drug awareness education in schools and decrease early use and
       availability of drugs and alcohol
    • Use schools and community resource centers as prevention education and
       screening centers
    • Increase suicide awareness education in the schools


5.2 Delivery of Care
    • Develop and use a mobile mental-health crisis team
    • Increase the number of inpatient beds available to un/underinsured at Memorial
       Medical Center
    • Establish ten 23-hour crisis beds at Memorial Medical Center
    • Establish a detoxification center with mental health services in the Doña Ana
       County Detention Center
    • Establish a psychiatric unit in the Doña Ana County Detention Center
    • Encourage the development of school-based health centers by the NMDOH


5.3 Access to Care
    • Increase links between services with effective case management
    • Include behavioral health medications in efforts to research and implement
       successful prescription drug plan partnerships with the goal of getting medications
       to un/underinsured populations


5.4 Healthcare Human Resources
    • Partner with law enforcement to decrease the number of mentally ill detained in
       the Doña Ana County detention center
    • Continue and increase crisis intervention training (CIT) of all emergency
       responders
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   •   Provide internship opportunities for students enrolled in NMSU’s School of
       Social Work
   •   Explore the use of rural health provider programs and HB2 visas to increase the
       number of psychiatrists in Doña Ana County.


5.5 Financing
    • Increase funding for existing prevention and education programs
    • Seek public and private funding for alternative community-based, in-home and
       non-facility or clinic-based services


5.6 Policy
    • Continue to coordinate Alliance goals and activities with that of the local
       behavioral health collaborative
    • Reevaluate procedures and guidelines for law enforcement to be able to intervene
       in crisis cases
    • Develop a plan to define responsibility of providers


5.7 Data Collection and Evaluation
    • Explore additional ways in which HCAP could serve as a data collection resource
       for information about mental illness and substance abuse in Doña Ana County
    • Request technical assistance and training from, and provide student internship
       opportunities to, the Border Epidemiology Center and other relevant departments
       at New Mexico State University


6. Sources of Additional Information on Behavioral Health
   •   New Mexico Behavioral Health Collaborative Resource list (includes Behavioral
       Health Gaps and Needs in New Mexico, 2002) at
       http://www.state.nm.us/hsd/bhdwg/history.html
   •   National Alliance on Mental Illness http://www.nami.org
   •   Mental Health in the United States: Health Risk Behaviors and Conditions
       Among Persons with Depression – New Mexico, 2003
       http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a4.htm
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D. Oral Health


1. Background
The overriding theme that emerged from the Doña Ana County oral health forums is that
oral health must not be treated as an afterthought to other health care, but as an integral
part of overall health. This theme is in concert with state, national, and global planning
efforts. Over the last decade, healthcare providers, public health workers, researchers, and
other healthcare professionals have come to recognize that oral health cannot be treated
as an afterthought to primary care.

The importance of oral health was acknowledged most explicitly with the publication in
2000 of Oral Health in America: A Report of the Surgeon General. According to the
Surgeon General’s report, the “mouth is a mirror” of health and disease in the rest of the
body. In her introductory statement to the report, Donna E. Shalala, Secretary of Health
and Human Services, wrote “Oral health is integral to general health…oral health means
more than healthy teeth and… you cannot be healthy without oral health.” She went on to
observe that there are “existing safe and effective disease prevention measures that
everyone can adopt to improve oral health and prevent disease.”

Health planners nation- and border-wide recognize oral health as inseparable from overall
health. A Healthy People 2010 goal is to “prevent and control oral and craniofacial
diseases, conditions, and injuries and improve access to related services.” Likewise, the
US/Mexico Border Health Commission includes oral health in its set of 25 bi-national
health indicators. Oral health is included in Healthy Gente 2010 indicators, a set of
suggested health indicators for the United States side of the border region.

Oral health is a strategic priority for New Mexico. The NMDOH Strategic Plan for fiscal
year 2007 identifies oral health as a priority public health issue. A stated objective of the
plan is to “improve access to preventive and restorative oral health services provided to
children.” Specific strategies identified in the plan are to: 1) develop a continuum of oral
health care for children ages 0 to 18 by providing them with fluoride varnish and sealant
application; 2) develop public/private partnerships for the provision of oral health
preventive and restorative care; 3) improve access by expanding the number of dentists in
rural areas; and 4) improve the quality of dental care for people with disabilities.

In addition, the NMDOH is currently developing an oral health surveillance system based
on the indicators used by the Centers for Disease Control (CDC) national oral health
surveillance system. Through this system, the state will gather baseline data on oral
health status of New Mexicans and evaluate the data to determine which actions will have
the greatest impact on improvement of oral health statewide. Currently, the New Mexico
Oral Health Surveillance system is working to produce data specific to Doña Ana
County.
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Oral surveillance indicators are:
   • Percent of the population who visited the dentist or dental clinic within the past
       year
   • Percent of the population who had their teeth cleaned by a dentist or dental
       hygienist within the past year
   • Percent of the population 65+ who have lost all of their teeth
   • Percent of the population on public waters systems who receive fluoridated water
   • Percent of third grade students who have one or more sealants on their permanent
       first molar teeth
   • Percent of third grade students with caries experience (treated or untreated tooth
       decay)
   • Percent of third grade students with untreated tooth decay
   • Percent of oral and pharyngeal cancers detected at the earliest stage

In emphasizing the need for oral health care for residents, Doña Ana County is taking the
lead in promoting an often neglected area of health.

What is Oral Health – and Disease?
While we often think of dental care as only about teeth, oral health extends beyond
perfect molars. Oral health includes the oral and craniofacial structures, such as the teeth,
gums, surrounding soft tissues, bones, palate, lips, and tongue.

Oral health influences a person’s ability to eat, chew, and swallow. It affects food choices
– it’s hard to eat a raw carrot or bite into an apple if your teeth hurt. Oral disease can
impede speech and language development, disrupt sleep, and cause disfigurement. Often,
people with severe oral disease are afraid to smile or laugh. These problems directly
affect overall physical and mental health. In addition, an emerging body of research
shows a direct connection between infections of the oral cavity and systemic disease,
including diabetes, cardiac disease, osteoporosis, and cancer.

The two primary oral diseases are dental caries and periodontitis. Dental caries is the
most common chronic disease, and it usually starts in childhood. Children can acquire
dental caries by age 1. The disease is caused by the bacterium streptococcus mutans. It is
infectious and can be passed from person to person, including parent to child, child to
child in day-care centers, and other routes of transmission. Without treatment, the
infection is progressive and increases the risk for future tooth decay. One-third of
children with dental caries miss school because of the problems caused by dental caries;
one quarter don’t smile or laugh because they are ashamed. Those with advanced disease
often end up in a hospital, and the disease has been associated with poor growth.

Periodontitis, the second most common infectious oral disease, is caused by an anaerobic
bacterium called p. gingivitis. Infection with gingivitis causes damage to the mouth in
two ways. First, the bacteria itself destroys gum tissue. It also causes the immune system
to release byproducts, the chronic release of which causes gingival tissue destruction.
Left untreated, periodontitis can cause destruction of the alveolar bone, gingival
attachment loss, and tooth loss.
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Periodontitis has also been linked to systemic diseases. It is considered the “sixth
complication of diabetes,” and is related to the severity of diabetes. Treating one
improves the other. People with periodontal disease are twice as likely to have coronary
artery disease, and the disease can worsen existing cardiac disease. It has been linked to
osteoporosis – specifically, bone loss in the jaw – and respiratory diseases. Pregnant
women with periodontal disease are seven times more likely to have preterm/low birth-
weight babies.

More than 120 systemic diseases are known to express themselves in the mouth. One of
the most devastating oral diseases is oral cancer. Although easily prevented if detected in
its pre-cancerous state, oral cancer affects 31,000 people in the United States each year
and claims more than 9,000 lives.

Barriers to Oral Health Care
Disparities in oral health care access reflect those in overall health care access. Not
surprisingly, use of the oral health care system is linked to education and income levels,
as well as ethnicity. In 2002, according to the New Mexico Behavioral Risk Factor
Surveillance System, 65.5 percent of adult males and 69.1 percent of adult females in
New Mexico had visited a dentist within the last twelve months. Among Hispanics, that
percentage fell to 61.4 percent. Of those with annual incomes less than $10,000, 51.6
percent had visited a dentist during that time period; of those with annual incomes more
than $10,000 but less than $20,000, 52 percent had received dental care. Slightly less than
half (45.3 percent) of those with less than a high school education had visited a dentist
during those two years.

A 1999 Health Policy Commission Survey found the following barriers in access to oral
health care for New Mexicans:

   •   No way to pay for services (number 1 reason)
   •   Difficulty scheduling appointment (number 1 for Native Americans)
   •   Couldn’t leave work or responsibility
   •   No insurance or wasn’t covered or accepted
   •   Couldn’t get transportation
   •   Medicaid not accepted
   •   Too far away

In Doña Ana County, all of these factors come into in play. However, knowledge, beliefs,
and attitudes about oral health also create significant barriers to accessing oral health
care. A 1999 survey conducted informally in Las Cruces schools found that the primary
reason parents did not take their children to the dentist was because they “didn’t need to.”
Another common attitude is “it’s just my teeth.” The same person who would run to the
clinic for a cold may leave dental caries untreated for years. Likewise, parents may
believe that baby teeth aren’t important and take a “wait until the baby teeth fall out”
approach to accessing oral health care for their children. Cultural barriers also play a role,
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including fear of dentists, language barriers, and, for undocumented workers, fear of
deportation.

Prevention and Education: Does it Work?
The good news: prevention and education programs focused on oral health work, and
they are cost effective. Because oral disease is progressive, failure to provide basic
preventive care results in a need for more complex and expensive care. Some of the most
effective ways to prevent oral disease are early initiation of a preventive oral hygiene
program, fluoride varnishes for infants, dental sealants (current standard is for third
graders), and appropriate fluoride levels in public water systems.

Educating parents about oral health needs of their children could have dramatic impact on
the long-term oral and general health of those children. For instance, few parents know
that they can transmit dental caries to their children simply by tasting their food, then
putting the same spoon in the child’s mouth. Birthing centers, hospitals, and well-baby
checks could be used to educate parents about the importance of initiating dental care by
six months of age. According to the American Academy of Pediatrics, early intervention
education programs are extremely effective. Simply teaching a parent not to let their
infant or toddler suck on a bottle or "sippy" cup of milk or juice for prolonged periods
can dramatically reduce the risk of early childhood caries.

Dental caries is closely correlated with low socioeconomic status, lack of education, poor
oral hygiene, and diet. According to BAHC pediatric dentist Peter Hayes, DDS, initiation
of a strong preventive program by 6 months of age is the most effective way to prevent
early oral disease. The program should include an assessment of the infant’s risk for
dental caries, as well as parent education about bottle feeding, dietary habits, thumb
sucking, and general oral health hygiene.

The AAP recommends that all infants and children have a “dental home” to mirror their
“medical home.” A “medical home” is a primary care physician who provides
“accessible, continuous, comprehensive, family centered, coordinated, compassionate,
and culturally effective” care and who helps to manage and facilitate all aspects of the
child’s care. Likewise, the dental home delivers pediatric primary dental care needs in a
similar manner. According to the AAP, the dental home “is a specialized primary dental
care provider within the philosophical complex of the medical home.”

The AAP recommends that infants who are assessed to be within one of the following
risk groups should be referred to a dentist as early as 6 months of age and no later than 6
months after the first tooth erupts or 12 months of age (whichever comes first) for
establishment of a dental home:
    • Children with special health care needs
    • Children of mothers with a high caries rate
    • Children with demonstrable caries, plaque, demineralization, and/or staining
    • Children who sleep with a bottle or breastfeed throughout the night
    • Later-order offspring
    • Children in families of low socioeconomic status
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Infants who fall in these high-risk categories may benefit from fluoride supplementation,
including professionally-applied fluoride varnishes. According to Dr. Hayes, fluoride
supplements should not be given to a one or two year old unless there is existing decay or
they exhibit other risk factors. Oral health providers differ on the advisability of using
toothpastes containing fluoride for infants (ages 0-12 months).

A dental sealant is a plastic film-like material that is applied to the chewing surfaces of
the back teeth. The plastic material acts as a barrier between the teeth and decay-causing
bacteria. The NMDOH sealant program targets the professional application of dental
sealants among third graders. Optimally, sealants would be applied as soon as the first
molars erupt (6-9 years of age or first through third grades) and then again as second
molars erupt (11-14 years of age or sixth through eighth grades).

The most effective oral disease prevention mechanism at the public health level has been
the introduction of community water fluoridation. Community water fluoridation is the
process of adjusting the fluoride content of public water sources to 0.7 - 1.2 parts fluoride
per million parts water, the recommended level for optimal dental health. Both children
and adults have less dental caries – 50 to 70 percent less – when they live in communities
with optimal water fluoride levels. In 2005, the Las Cruces Municipal Water System had
sixteen wells that tested below 0.7 mg/L (seven of which were below 0.5 mg/L) and eight
wells that tested between 0.7 and 1.19 mg/L.

Healthy Gente 2010 Indicators
The Healthy Gente 2010 indicators for oral health are as follows:
   • Increase to at least 75 percent the proportion of the population served by
      community water systems with optimally fluoridated water
   • Increase percent of people using oral health care system annually to 75%

These indicators provide a basis for the development of oral health objectives in Doña
Ana County. However, before objectives can be developed, the county must establish a
baseline of the percentage of people currently using the oral health care system annually.
Qualitatively, forum participants felt that the current percentage is “nowhere near” 75
percent and that it would be unrealistic to adopt this measure immediately, partly because
the resources are not currently available. A 10 percent increase from the baseline, once
established, over a period of three years was felt to be appropriate for most areas of the
county.

2. Forum Results
The Oral Health Forum was held on January 21, 2006 at the Best Western Mesilla Valley
Inn. It was the fourth of four forums held. About 35 people participated in the event,
including providers, consumers, and elected officials.

Presentations were given by a panel of experts that included Jesūs Carlos Galván, DDS,
Delta Dental of New Mexico, Toby Casci, DDS, La Clinica de Familia, Laurie Gormley,
DDS, Private Practice, and Doris Baker, RDH. Presentation topics included oral-systemic
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connection, general dentistry and access to services, pediatric dentistry, and education
and prevention. A fifteen-minute question and answer session was held after the
presentations were given, during which participants asked questions of the presenters.

From the initial forum results, three topics were identified by the oral health ad hoc
committee. These topics were general dentistry and access, prevention and education, and
the oral-systemic connection. During the subsequent work group sessions, participants
completed SWOB sheets, formulated goals and recommendations, and established
priorities.

The following is a verbatim summary of the forum results, including the issues and topics
identified and the priority goals and recommendations developed by the forums. These
are raw data and have been used as the basis for the above analysis, the recommendations
that follow, and the action worksheets found in Section II of this document.

Topics and Issues
The following topics and issues were identified during the oral health care forum.

Topic: General Dentistry and Access
Access to care
   • Better service in detention centers and for special populations (especially
       geriatrics)
   • Medicaid shortage of professionals

Topic: Prevention and Education
   • Education
   • Communication
   • Special populations (e.g. elderly, special needs children)
   • Oral Systemic Connection
   • Coordination of treatment/services between medical and dental
   • Data on hidden costs and impacts of untreated oral diseases
   • Early dental visits

Priority Goals and Recommendations
The following priority goals and recommendations were identified by the oral healthcare
workgroups. They are listed as prioritized:

   1. Develop effective outlets and referral system for access to oral health services in
      the rural community
          a. Objective 1: Establish a mobile dental clinic
          b. Objective 2: Conduct oral health education at the community resource
              centers
   2. Establish/utilize school-based curriculum to increase prevention education.
          a. Objective 1: Apply standard science based effective curriculum, possibly
              Bernalillo County’s, to provide parents and children information about
              oral health care and encouraging them to become more involved.
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            b. Objective 2: Include the families with children who have special needs.
   3.   Put together comprehensive data analysis study
   4.   Create a policy to require dental hygienists and increase oral health services in
        nursing homes
   5.   Better allocation and sharing of resources
   6.   Expand DOH sealant programs and referrals
   7.   Increase/provide dental care in Detention Center
   8.   Better recruitment of dentists for City and County
   9.   Increase the number of dentists that accept Medicaid
            a. Objective 1: Reimburse dentists in a timely manner.



3. Resources
Doña Ana County has a wide array of resources that are being used and/or could be used
to improve the oral health of its residents. These resources include:


3.1 Prevention and Education
    • The NMDOH sealant program provides services to schools and school districts
       where more than 50 percent of the students are eligible for free lunch programs.
       In 2005, 895 second and third-grader received dental sealants through the
       NMDOH Office of Dental Health. Another 137 children who were screened had
       already had sealants done elsewhere.
    • Head Start screening programs
    • Women, Infants, and Children (WIC) screening programs
    • Dental assistants and certified health educators are effective in assisting with
       pediatric oral disease prevention and in preventing and managing oral health
       diseases associated with diabetes


3.2 Delivery of Care
    • Ben Archer Health Center provides basic oral health services at its Hatch and
       Doña Ana clinics, as well as oral health prevention and education programs.
       Same-day access is available. During FY 2004-2005, oral health providers at
       BAHC saw 868 indigent patients for 3767 encounters. This number represents
       only indigent patients served and not the entire clientele. BAHC is one of the few
       community health centers nationwide to have a pediatric dentist on staff.
    • La Clinica de Familia Health Center provides basic oral health services at four of
       its clinics (Las Cruces, Anthony, Sunland Park, and East Mesa), as well as oral
       health prevention and education programs. Walk-in access to basic oral health
       care is available. During FY 2004-2005, oral health providers at LCDF saw 940
       indigent patients for 3500 encounters. This number represents only indigent
       patients served and not the entire clientele.
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   •   Many providers work with elementary schools to provide free services to children
       with immediate oral health needs. However, this is not a systematic solution to
       pediatric oral health needs.


3.3 Access to Care
    • Community resource centers
    • Community health fairs/convivios
    • Community outreach via promotoras, VISTAs, nurses
    • Public and private schools
    • Ben Archer Health Center provides sealants, oral exams, and prophys in Hatch
       Schools and will begin these services Las Cruces Public Schools during 2006
    • First Step Clinic refers pregnant women and children to appropriate oral health
       care
    • Primary care providers and pediatricians refer clients to appropriate oral care.
       Medicaid guidelines suggest that primary care practitioners perform oral risk
       assessments on all infants by six months to one year of age.


3.4 Healthcare Human Resources
    • Doña Ana County boasts a strong and committed network of private pediatric
       dental providers.
    • Promotoras provide culturally-responsive education and referrals


3.5 Financing
    • No specific financial resources were identified by the oral health workgroup
    • Federal funding for oral health care allows FQHCs to provide basic oral health
       services
    • Private funding sources are available
    • In accordance with a statewide emphasis on oral health needs, the state legislative
       body is a potential financial resource for addressing the county’s unmet oral
       health needs


3.6 Policy
    • Medicaid covers oral health care for children, some pregnant women, and
       developmentally-disabled adults


3.7 Data Collection and Evaluation
    • The Doña Ana County Health and Human Services Department collects data on
       the number of patients who receive oral health care services
    • The NMDOH is developing an oral health surveillance system in accordance with
       CDC guidelines. Oral surveillance indicators include annual visits to a dentist or
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       dental clinic, teeth cleaning, complete tooth loss, public water systems
       fluoridation status, dental sealants for third graders, caries experience of third
       graders, untreated tooth decay among third graders, and oral-pharyngeal cancer.
   •   A report on oral health in the six border counties (Doña Ana ,Grant, Hidalgo,
       Luna, Catron, and Sierra) is currently under development
   •   PRAMS collects data on the number of pregnant women who:
   •   Recall discussion with a prenatal healthcare worker about how to care for teeth
       and gums;
   •   The number who had a dental problem; and
   •   The number who received dental care



4. Gaps
Oral healthcare resources in Doña Ana County are limited, and even when they do exist,
not all county residents have access to them. Major gaps identified by the oral health care
forum, interviews, and research include:


4.1 Prevention and Education
    • The lack of a culturally-responsive, evidence-based oral health prevention
       curriculum
    • The lack of health education and screening programs in middle and high schools
    • The lack of a comprehensive strategy to educate parents, children, general public,
       healthcare professionals including providers, outreach workers, and public health
       professionals. Recommendations for dental care of children under the age of three
       have changed dramatically in the last three years. Continuing education is
       necessary to make sure that current standards are publicized.
    • The lack of coordination between existing oral health prevention and education
       programs
    • Currently, there is no NMDOH dental sealant program in the middle schools. The
       sealant program is only offered to third graders, targeting the first set of
       permanent molars. While NMDOH Office of Dental Health staff members have
       discussed trying to open up program in middle schools, there are no concrete
       plans to expand the dental sealant program to middle school. Nor do parents
       routinely receive education about the need for need another round of sealants
       during the middle school years.


4.2 Delivery of Care
    • The NMDOH sealant program has limited resources and does not serve the Las
       Cruces or Hatch school districts, only Gadsden
    • Emergency rooms do not have the equipment for dentists to provider emergency
       oral health care
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4.3 Barriers to Care
    • Doña Ana County residents face several barriers to accessing dental care,
       including:
    • Transportation
    • Border checkpoints
    • Cost
    • Cultural competence of providers
    • Belief that oral health is not an integral part of health
    • Lack of knowledge about the importance of preventive dental care at all ages
    • Populations not served:
           o Detention centers, especially juveniles
           o Nursing homes do not provide oral health care to residents
           o Indigent populations are only served in Las Cruces
           o It is difficult to reach pre-kindergarten children in the colonias
           o It is difficult to reach adult women, including pregnant women, in the
               colonias



4.4 Healthcare Human Resources
    • Doña Ana County is a designated dental health professional shortage area.
       According to New Mexico Health Resources, 70 dentists have addresses in Doña
       Ana County. This shortage of qualified oral health providers is especially evident
       in rural areas.
    • Lack of dentists serving rural areas. The greatest percentage of oral health care
       providers practice in Las Cruces because of economic reasons.
    • Forum participants identified a lack of culturally-competent oral health providers
    • While both community health centers provide basic oral health care, the need is
       growing more quickly than are resources
    • No oral health specialists (with the exception of pediatric dentists and some
       orthodontists) in Las Cruces accept Medicaid patients; there are no oral health
       specialists in rural areas of the county. Medicaid patients must travel to
       Albuquerque for specialty oral healthcare such as oral surgery
    • Lack of collaborative dental hygienists serving rural areas, secondary to the
       location of dentists because dental hygienist must practice under supervision of a
       dentist.
    • There are no dental schools in New Mexico


4.5 Policy
    • Medicare does not pay for oral health care. Seniors are a high-risk group.
    • Although Medicaid does provide coverage for oral health care, the complexity of
       paperwork, slow and low reimbursement, and high overhead costs for dentists
       means few accept Medicaid patients. Statewide, only 53 percent of dentists accept
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       Medicaid. The percentage of specialty oral health providers who accept Medicaid
       is miniscule.
   •   Medicaid does not cover anesthesia for oral health care
   •   Many privately insured individuals do not have dental health coverage. Dental
       health coverage packages are expensive and often provide low benefits for high
       premiums.
   •   Private dental insurance may not cover dental care for children under the age of
       three.
   •   While dental hygienists are trained to perform oral health screenings and apply
       varnishes and sealants, they are not able to do so without supervision. If the
       statutes were changed, then dental hygienists would be able to provide these
       services independently, thus increasing access to care.


4.6 Data Collection and Evaluation
    • There is no comprehensive baseline data for the number or percentage of people
       accessing oral health care services in Doña Ana County. This data is necessary for
       measurable oral health objectives to be developed and implemented in Doña Ana
       County.
    • The county needs comprehensive data on the systemic/oral health connection to
       provide a basis for grant applications and research opportunities.
    • There is a need for better tracking and case management. Comprehensive data
       needs to be collected on who is getting services where, who is not being served;
       with what types of oral health problems are people entering the system.
    • Healthy Communities Access Program (HCAP) Management Information System
       (MIS) is not currently designed to collect data on oral health
    • Aligning data collection with the New Mexico oral health surveillance indicators
       would provide a chance for collaboration and cooperation with the state of New
       Mexico and the federal Centers for Disease Control.



5. Action Steps


5.1 Prevention and Education
    • Implement an age-appropriate, culturally-relevant, evidence-based oral health
       education curriculum for use in all school districts, including elementary, middle,
       and high schools. Integrate this curriculum into a comprehensive, ongoing health
       education program.
    • Expand use of community resource centers in prevention and education efforts,
       including screening, sealant, and, when appropriate, infant fluoride varnish
       programs.
    • Develop a media campaign to educate the public about oral health care with age-
       specific and culturally-relevant components
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   •   Ensure that maternal child health programs include oral health components,
       including prenatal classes on prevention of oral disease


5.2 Delivery of Care
    • Purchase, staff, and maintain a mobile dental clinic to serve rural areas of the
       county
    • Provide dental care in detention center


5.3 Access to Care
    • Coordinate with the NMDOH Sealant Programs to expand services and to reach
       Las Cruces and Hatch schools (currently being addressed by BAHC)


5.4 Healthcare Human Resources
    • Take advantage of WICHEE and other programs designed to alleviate healthcare
       human resources shortages in rural areas.
    • Train promotoras to recognize oral health problems and refer clients to
       appropriate care.
    • Develop recruitment program to attract dentists and dental hygienists to Doña
       Ana County


5.5 Financing
    • Increase county funding for oral health care services in community health centers
    • Seek private and public grant funding sources


5.6 Policy
    • Collaborate with the NMDOH and the New Mexico Department of Education to
       implement health curricula, including oral health, in schools
    • Allow trained dental hygienists to provide screening, infant varnish, and sealants
       independently
    • Work with the NM HSD Medicaid Office to develop a pilot program to increase
       the number of dentists in Doña Ana County who take Medicaid
    • Alter Medicaid contracts to include dental hygienists on staff at nursing home
    • Explore expansion of oral health-related services for which Medicaid
       reimbursement could apply


5.7 Data Collection and Evaluation
    • Require county contractors to collect and share aggregate data with the state Oral
       Health Surveillance System and the NMSU Border Epidemiology Center
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   •   Create an integrated data collection system. The HCAP MIS system provides the
       vehicle to do so, however oral health surveillance indicators must be integrated
       into the system
   •   Conduct an “open mouth” survey of third-graders in all school districts
   •   Conduct an “open mouth” survey of three-year-olds
   •   Conduct an “open mouth” survey of seniors 65+
   •   Request technical assistance from NMSU, NMDOH, CDC, and other resources


6. Sources of Additional Information on Oral Health
   •   Oral Health in America: A Report of the Surgeon General available online at
       http://www.surgeongeneral.gov/library/oralhealth/
   •   Healthy Gente 2010
   •   NMDOH State Comprehensive Health Plan
   •   NMDOH Strategic Plan 07
   •   New Mexico State Oral Health Surveillance Tool (currently under development
       through the Health Systems Bureau of NMDOH)
   •   Centers for Disease Control Oral Health Resources online at
       http://www.cdc.gov/OralHealth/index.htm
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V. Action Plan
A. Comprehensive Recommendations and Actions
Three overarching themes emerged from the forums and workgroups. First, there is a
pressing need for services to be integrated and coordinated. Rather than looking at
primary care, specialty care, behavioral health, and oral health as separate silos, these
services must be integrated through case management, better communication, and other
means. Second, prevention and education must be emphasized, and people must learn
how and when to appropriately access the healthcare system. Third, resources are strained
in every corridor of health care. Limited financial and human resources create obstacles
to meeting the unmet healthcare needs of Doña Ana County residents.

Thus, the following matrix delineates recommendations and action steps based on topics
that affect all healthcare providers and consumers, rather than on types of health care.
The actions were developed by forum and workgroup participants. However, because
several themes repeated themselves across groups, several of the overarching
recommendations were written to unify these actions.

All of these actions are not expected to be fully implemented during the next year, two
years, or even five years. It is also possible that some of the recommendations and actions
will change as others are implemented. For instance, a diabetes prevention and education
program that addresses obesity, physical activity, smoking cessation, and nutrition might
also result in decreased rates of cardiac disease. These recommendations and related
actions represent a long-range approach to creating a sustainable healthcare infrastructure
in Doña Ana County, making best use of available resources, and addressing the priority
health needs in the county to improve health and well-being of all county residents.
DAC HHS Alliance Action Plan              87                                    9/6/2006




Recommendation                            Action Steps
I. Prevention and Education
Increase and coordinate primary and        •   Establish and coordinate county-wide
secondary prevention and education              prevention activities/campaigns/model
efforts                                         (prevention/education).
                                           •   Focus on diabetes FY 2006-2007
                                           •   Focus first on one priority health issue,
                                                then others identified by the forums:
                                                diabetes, cardiac disease, depression,
                                                and asthma
                                           •   Use community-based process to
                                                determine the next priority health area
Create linkages with existing state and    •   When culturally appropriate, use
federal resources                               existing resources such as the New
                                                Mexico Cancer Program’s prevention
                                                materials
                                           •   Coordinate with the NMDOH sealant
                                                programs to expand oral health
                                                services to reach Las Cruces and Hatch
                                                Schools (currently being addressed by
                                                BAHC)

Increase outreach through media            •   Develop culturally-relevant prevention
campaigns                                       and education media campaigns to
                                                address priority issues of domestic
                                                violence, sexual assault, hate crimes,
                                                bullying/gangs
                                           •   Develop a media campaign to educate
                                                the public about oral health care with
                                                age-specific and culturally-relevant
                                                components
Increase use of existing resources for     •   Enhance existing jail diversion, sexual
prevention and education                        assault, and domestic violence
                                                prevention and education activities
                                           •   Expand use of community resource
                                                centers in prevention and education
                                                efforts for oral health, including
                                                screening, sealant, and, when
                                                appropriate, infant fluoride varnish
                                                programs
                                           •   Implement an age-appropriate,
                                                culturally-relevant, evidence-based oral
                                                health education curriculum for use in
                                                all school districts, including
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                                           elementary, middle, and high schools.
                                           Integrate this curriculum into a
                                           comprehensive, ongoing health
                                           education program.
                                      •   Ensure that maternal child health
                                           programs include oral health
                                           components, including prenatal classes
                                           on prevention of oral disease.
                                      •   Use schools and community resource
                                           centers as prevention, education, and
                                           screening centers for behavioral health
                                           problems
                                      •   Enhance prevention efforts of the
                                           Driving While Intoxicated program
                                      •   Increase drug awareness training in
                                           schools and decrease early use and
                                           availability of drugs and alcohol
                                      •   Provide drug awareness training to the
                                           five biggest employers in Las Cruces
II. Delivery of Care
Expand healthcare services for the    •   Provide additional financial resources
uninsured and underinsured            •   Recruit additional human resources
                                      •   Improve access
                                      •   Explore innovative ways to increase
                                           capacity
                                      •   Provide oral health care in detention
                                           centers
                                      •   Increase number of secure inpatient
                                           beds available to un/underinsured
                                           psychiatric patients at Memorial
                                           Medical Center
                                      •   Establish ten 23-hour mental health
                                           crisis beds at Memorial Medical Center
                                      •   Encourage the development of school-
                                           based health centers by the NMDOH

Develop mobile healthcare delivery    •   Develop and use a mobile mental-health
systems                                    crisis team
                                      •   Purchase, staff, and maintain a mobile
                                           dental clinic to serve rural areas of the
                                           county
C. Develop alternative healthcare     •   Establish a detoxification center with
delivery systems                           mental health services in the Doña Ana
                                           County Detention Center
                                      •   Establish a psychiatric unit in the Doña
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                                               Ana County Detention Center

III. Access to Care
A. Increase use of case management         •   Support implementation and
                                                sustainability of HCAP MIS system
                                                through partnerships with public and
                                                private providers
                                           •   Use case management to coordinate
                                                delivery of specialty-care services with
                                                primary care, behavioral and oral
                                                health care
                                           •   Increase links between behavioral
                                                health services with effective case
                                                management
                                           •   Create a mechanism to provide follow-
                                                up care for un/underinsured residents
                                                who receive screening services such as
                                                Pap smears, mammograms, and
                                                prostate exams
Increase the number of insured in Doña     •   Increase emphasis on enrollment in
Ana County                                      funding programs such as Medicaid,
                                                SCHIP, State Health Insurance
                                                Coverage Initiative, and other
                                                alternative healthcare coverage
                                           •   Support sustainability of the HCAP
                                                MIS system, which will play a huge
                                                role in enrolling people in Medicaid
                                                and the indigent program. This will
                                                increase the number of clients with an
                                                ability to pay and decrease the number
                                                of clients receiving indigent funds.
Increase access to medications             •   Research and implement successful
                                                prescription drug plan partnerships
                                                with the goal of getting medications to
                                                un/underinsured populations
                                           •   Include behavioral health medications
                                                in this effort
                                           •   Include medications to treat chronic
                                                diseases such as diabetes, hypertension,
                                                asthma, chronic obstructive pulmonary
                                                disease, depression, etc.
Develop a county transportation program    •   Apply for funding from federal sources
                                           •   Identify matching funds from county
                                                resources
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IV. Healthcare Human Resources
Take advantage of programs designed to    •   Explore WICHEE as a resource of oral
alleviate healthcare human resources           health providers
shortages in rural areas                  •   Explore the use of rural health provider
                                               programs and HB2 visas to increase the
                                               number of psychiatrists in Doña Ana
                                               County
                                          •   Provide education and career ladder
                                               opportunities to current healthcare
                                               workers (e.g. support promotoras to
                                               become licensed practitioners, RN’s to
                                               become CFNPs). Leverage federal and
                                               state workforce development training
                                               dollars to provide training.
                                          •   Take advantage of loan-repayment
                                               programs such as the National Health
                                               Service Corps to recruit healthcare
                                               providers to rural areas of the county
                                          •   Approach medical school residency
                                               programs to recruit participation in
                                               southern New Mexico
Use incentive programs to attract and     •   Develop an incentive program to reward
retain providers                               providers and agencies who address
                                               gaps and develop effective, innovative
                                               models
                                          •   Create incentives for specialty-care
                                               providers to remain in Doña Ana
                                               County
                                          •   Develop recruitment program to attract
                                               dentists and dental hygienists to Doña
                                               Ana County.

Expand use of mid-level and ancillary     •   License dental hygienists so they can
providers                                      provide screening, infant varnish, and
                                               sealants without supervision of a
                                               dentist
                                          •   Train promotoras to recognize oral
                                               health problems and refer clients to
                                               appropriate care
                                          •   Increase recruitment of mid-level
                                               providers such as nurse practitioners,
                                               physician’s assistants, etc.
                                          •   Partner with law enforcement to
                                               decrease number of mentally ill
                                               detained in detention center
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Coordinate with New Mexico State            •   Request technical assistance from and
University (NMSU) to develop local,              provide student internship
culturally-competent providers                   opportunities to the Border
                                                 Epidemiology Center, the Southwest
                                                 Center for Health Disparities, and other
                                                 relevant departments at NMSU
                                            •   Provide internship opportunities for
                                                 students enrolled in NMSU’s School of
                                                 Social Work
V. Financing
Increase funding for prevention and         •   Increase county funding for prevention
education activities                             and education line items
                                            •   Leverage funding from non-healthcare
                                                 sources such as economic development
                                                 and community infrastructure grants to
                                                 improve air quality, living conditions,
                                                 and install water treatment systems in
                                                 rural areas of the county
                                            •   Explore funding options for tertiary
                                                 prevention (after care, prescriptions,
                                                 and equipment)
Increase county funding for unmet needs     •   Ensure adequate funding for obstetrical
                                                 and gynecological care
                                            •   Increase county funding for oral health
                                                 care services in community health
                                                 centers

Explore private and public funding          •   Develop staffing for grant seeking
opportunities                               •   Seek private and public funding for
                                                 expansion of primary care services
                                            •   Pursue public and private grant funding
                                                 opportunities for specialty care
                                            •   Seek public and private funding for
                                                 alternative community-based, in-home
                                                 and non-facility or clinic-based
                                                 behavioral health services
                                            •   Seek private and public grant funding
                                                 for oral health care services
Explore alternative methods of financing    •   Conduct a feasibility study of healthcare
unmet healthcare needs                           financing options (mil levy, property
                                                 tax, income tax, “sin” tax [a tax on
                                                 cigarettes, alcohol, or other substances
                                                 known to be detrimental to public
                                                 health], DAC Salud, UNM Cares,
                                                 Tricare [military], other means of
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                                               financing specialty care)
                                           •   Leverage funding sources not directly
                                               focused on health care for
                                               infrastructure projects that will directly
                                               impact health
VI. Policy
Ensure implementation and continuity of    •   Ensure that county healthcare RFPs
community-based planning process               address the priority issues identified by
                                               the strategic planning process by
                                               emphasizing prevention and education,
                                               access to care, coordination of services,
                                               and data collection and evaluation
                                               activities
                                           •   Continue to actively seek community
                                               input through forums and other
                                               mechanisms for public input
                                           •   Develop a communications plan to keep
                                               all elected officials and other
                                               stakeholders informed of Alliance
                                               and/or Department activities
                                           •   Continue relationships with the
                                               Behavioral Health Collaborative,
                                               Southwest Regional Substance Abuse
                                               Committee, HCAP, and other relevant
                                               groups
                                           •   Continue to coordinate Alliance goals
                                               and activities with that of the local
                                               behavioral health collaborative
Create and implement policies that         •   Collaborate with the NMDOH and the
emphasize prevention and education             New Mexico Department of Education
                                               to implement health curricula,
                                               including oral health, in schools
                                           •   Explore reimbursement options through
                                               Medicaid, state rural health initiative,
                                               and other funding sources for
                                               promotoras/community health workers
                                               and health educators
                                           •   Reevaluate procedures and guidelines
                                               for law enforcement to be able to
                                               intervene in mental health crisis cases

Ensure that Doña Ana County policies       •   Review and update county policies for
accurately reflect needs of county             implementing the New Mexico
residents                                      Indigent Healthcare Act
                                           •   Review county indigent policies for
                                               funding of specialty care
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                                           •   Develop a plan to define responsibility
                                               of providers

Pursue legislative reforms                 •   Pursue legislative support and state and
                                                federal funding for medical malpractice
                                                insurance for specialty-care providers
                                           •   Approach elected officials about the
                                                need to revisit the formula by which
                                                federal poverty guidelines are
                                                determined
                                           •   Allow trained dental hygienists to
                                                independently provide screening, infant
                                                varnishes, and sealants

Increase effectiveness of Medicaid         •   Work with the NM Human Services
services                                        Department to develop a pilot program
                                                to increase the number of dentists in
                                                Doña Ana County who take Medicaid
                                           •   Alter Medicaid contracts to include
                                                dental hygienists on staff at nursing
                                                homes
                                           •   Explore expansion of services for which
                                                Medicaid reimbursement could apply
Develop healthcare workforce               •   Investigate options for bringing a nurse
                                                practitioner program to the Family
                                                Residency Program by the University
                                                of New Mexico
VII. Data Collection and Evaluation
A. Create an integrated data collection    •   Explore sustainability options for the
system                                          HCAP MIS system
                                           •   Integrate oral health surveillance
                                                indicators into the HCAP MIS system
                                           •   Explore additional ways in which
                                                HCAP could serve as a data collection
                                                resource for collecting information
                                                about mental illness and substance
                                                abuse in Doña Ana County

B. Request technical assistance from       •   Request assistance from NMSU to map
NMSU, CDC, NMDOH, and other                    indigent care funding for major clinics
resources                                      and current distribution of public funds
                                               for health care
                                           •   Collaborate with NMSU to create a
                                               database of information about
                                               healthcare needs in Doña Ana County
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                                              •   Request technical assistance and
                                                  training from the Border Epidemiology
                                                  Center and other relevant departments
                                                  at NMSU
                                              •   Require county contractors to collect
                                                  and share aggregate data with the state
                                                  Oral Health Surveillance System and
                                                  the NMSU Border Epidemiology
                                                  Center

C. Collect data on current use of the         •   Determine percentage of emergent
public health safety net system                   versus non-emergent calls to 911
                                                  system and by whom (privately
                                                  insured, indigent, undocumented, age,
                                                  ethnicity, etc.)
                                              •   Determine percentage of emergent
                                                  versus non-emergent emergency room
                                                  visits and by whom (privately insured,
                                                  indigent, undocumented, age, ethnicity,
                                                  etc.)
                                              •   Collect and evaluate data on potential
                                                  cost savings associated with use of
                                                  home care and home-based medical
                                                  equipment
                                              •   Require county contractors to collect
                                                  and share aggregate data with the state
                                                  Oral Health Surveillance System and
                                                  the NMSU Border Epidemiology
                                                  Center
D. Collect baseline data on current health    •   Collect baseline data on oral health
needs                                         •   Conduct an “open mouth” survey of
                                                  third-graders in all school districts
                                              •   Conduct an “open mouth” survey of
                                                  three-year-olds
                                              •   Conduct an “open mouth” survey of
                                                  seniors 65+
E. Develop staffing for data collection       •   Hire an information specialist for DAC
and evaluation activities                         HHSD Healthcare Helpdesk
                                              •   Contract with the NMDOH/NMSU
                                                  Border Epidemiology Center for data
                                                  evaluation activities
                                              •   Coordinate with the US/Mexico Border
                                                  Health Commission to establish
                                                  baseline data for Healthy Gente 2010
                                                  and monitoring tools for benchmarks
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B. Blueprint for Action 2006-2007
The following blueprint for action has been developed based on the goals and priorities
identified by the workgroups during the strategic planning process guided by the Doña
Ana County Health and Human Services Alliance and the leadership of the Doña Ana
County Board of Commissioners. These actions were identified out of the many long-
range recommendations and action steps designated during the planning process based on
their feasibility, anticipated impact on health, and critical needs. It is recommended that
implementation of these action steps begin during fiscal year 2006-2007.

Not surprisingly, the priorities identified by the workgroups align closely with state and
federal planning efforts. They recognize diabetes mellitus, teen pregnancy, and violence
as priority health issues. Critical service issues include provision of basic dental health,
obstetrics, and specialty care services. Priority infrastructure issues focus on increased
prevention and health education efforts and improved access to care for county residents.
The vision that emerged from the process: a healthcare system that provides a continuum
of high-quality, culturally-responsive health care, emphasizing prevention and wellness
education and integrating primary care, oral health, behavioral health, specialty care, and
long-term care services.


1. Priority Health and Service Issues
Four priority health and service issues were identified for Doña Ana County to address
immediately. The choice of these issues is based on health status compared to other
regions of the United States, how quickly the problem is growing, associated disability
and mortality, and forum input:
  • Type 2 diabetes mellitus
  • Teen pregnancy and parenthood
  • Violence, specifically domestic violence and sexual assault, teen violence, and
      bullying and gangs
  • Lack of access to basic dental services
  • Lack of access to specialty care
  • Lack of access to obstetrics services
  • Lack of case management and coordination for behavioral health services


2. Priority Healthcare Infrastructure Issues
Forum participants identified many gaps that must be addressed at the level of
infrastructure. Based on forum results, additional research, and interviews with DAC
HHSD staff and health policy experts, the following infrastructure priorities have been
developed:
  • Prevention: Develop and implement a county-wide disease prevention strategy
  • Research: Develop and maintain comprehensive data collection and evaluation
      mechanisms
  • Access: Create a system of care that offers seamless access to healthcare services
      without duplication of services or gaps
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 •   Resource Development: Create sustainable and adequate healthcare funding
     mechanisms


3. Goals
The following goals were developed and selected by forum participants:
   1. Identify and coordinate existing prevention and education programs in Doña Ana
       County
   2. Increase access to primary care and prevention services, including oral and
       behavioral health, for uninsured and underinsured populations
   3. Develop effective outlets and referral system for access to oral health services in
       the rural community/colonias
   4. Identify and address service needs not met by indigent program
   5. Streamline indigent program eligibility process
   6. Increase links between services with effective case management
   7. Develop a system for data collection and evaluation
   8. Develop healthcare resources, including healthcare human resources and
       financing
   9. Educate public on appropriate use of public resources and personal responsibility
   10. Keep elected officials and other stakeholders and community informed


4. Health Status Indicators
Objectives for Doña Ana County’s Action Plan are being developed using Healthy Gente
2010 indicators, a set of 25 health status indicators developed by the NMDOH Office of
Border Health for the US side of the US/Mexico border region. These indicators and
percentages reflect a 10 year plan and should not be confused with the percentage ratio or
goals set forth for Doña Ana County in 2006–2007.

Pertinent Healthy Gente 2010 indicators are:
    1. Reduce by 25% the population lacking access to primary care
    2. Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
    3. Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
    4. Achieve 90% immunization coverage in children aged 10-35 months
    5. Reduce childhood death rate due to unintentional injuries by 30% (per 100,000
        children age 0-4)
    6. Increase percent of women beginning prenatal care in 1st trimester to 85% (per
        100 women)
    7. Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
        women 15-17 years of age)
    8. Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
    9. Increase to at least 75 percent the proportion of the population served by
        community water systems with optimally fluoridated water
    10. Increase percent of people using oral health care system annually to 75% (per
        100,000 inhabitants)
    11. Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)
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    12. Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per
        100,000 inhabitants)
    13. Increase to 89% the proportion of adolescents not using:
            o alcohol in the past 30 days
            o marijuana in the past 30 days
            o cocaine in the past 30 days


5. Implementation
The following section describes specific recommendations for actions that Doña Ana
County can begin immediately to improve its healthcare safety net system. Each action
addresses at least one health priority issue, infrastructure priority, and strategic priority.


1: Policy Actions
1.1 Ensure that county healthcare RFPs address the priority issues identified by the
    strategic planning process by emphasizing prevention and education, access to care,
    coordination of services, and data collection and evaluation activities.
1.2 Conduct a feasibility study of alternative healthcare financing options (mil levy, DAC
    Salud, UNM Cares model, other means of financing specialty care)
1.3 Develop an incentive program to reward providers and agencies who address gaps
    and develop effective, innovative models
1.4 Develop a communications plan to keep all elected officials and other stakeholders
    informed of Alliance and/or Department activities


2: Prevention and Education Actions
2.1 Provide an evidence-based, culturally-appropriate oral health education program in
    schools and Community Resource Centers
2.2 Develop a culturally-appropriate prevention and education media campaign to include
    a media campaign on appropriate use of healthcare resources
2.3 Enhance prevention efforts of the Driving While Intoxicated program
2.4 Enhance existing jail diversion, sexual assault, and domestic violence prevention and
    education programs
2.5 Explore funding options for tertiary prevention (after care, prescriptions, and
    equipment)


3: Access to Care/Delivery System Actions
3.1 Ensure compatibility of the Health Communities Access Program (HCAP) MIS
    system with indigent program eligibility requirements
3.2 Develop a mental health mobile crisis team
3.3 Explore funding options for a mobile dental clinic
3.4 Research and implement successful prescription drug plan partnerships
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4: Data Collection and Evaluation Actions
    4.1 Develop staffing for data collection and evaluation activities
    4.2 Add oral health surveillance indicators to HCAP data collection activities
    4.3 Request technical assistance and training from, and provide student internship
        opportunities to, the Border Epidemiology Center and other relevant departments
        at New Mexico State University
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C. Action Worksheets

Guide to Action Worksheets
The action worksheets that follow provide a detailed overview of the recommended
actions developed out of the community healthcare strategic planning process and
identified in the “Blueprint for Action” above. Each worksheet contains the following
information:

Action: What is the major recommendation for action?

Forum Goals Addressed: Which of the overall goals developed by the forums does this
action address?

Action Items: What specific steps need to be taken to accomplish the overall action?

Health and Service Priorities Addressed: Which of the health and service priorities
established by the strategic planning process does the action address?

Healthcare Infrastructure Priorities: Which of the healthcare infrastructure priorities
established by the strategic planning process does the action address?

Healthy Gente 2010 Indicators: Which of the pertinent Healthy Gente 2010 indicators
does the action address?

By when/for how long: When should the action steps be accomplished? For how long
should the overall action go on?

Responsible Parties: Who are the parties responsible for making this action happen?

Short-term measures of success: How will we know, within the next year, that the
action is succeeding?

Long-term measures of success: How will we know, within the next five to ten years,
that the action is effective?
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1: Policy Actions

Action 1.1: Ensure that county healthcare RFPs address the priority issues identified
during the strategic planning process by emphasizing prevention and education, access to
care, coordination of services, and data collection and evaluation activities.

Forum Goals Addressed:
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations
 • Develop effective outlets and referral system for access to oral health services in the
     rural community/colonias
 • Identify and address service needs not met by indigent program
 • Increase links between services with effective case management
 • Develop a system for data collection and evaluation
 • Develop healthcare resources, including healthcare human resources and financing

Action Items:
 • Continue collaborative external RFP process
 • Review and revise existing Doña Ana County strategic plan to incorporate forum
     goals
 • Maintain data collection and evaluation activities

Rationale: Aligning county-funded programs with the goal established by the
community-based planning process allows them to be clarified, disseminated, and
implemented. Two levels of accountability are established. This ensures that the county is
responding to the community healthcare needs identified during the planning process and
that those programs, likewise, respond to those needs.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Prevention
 • Teen pregnancy and parenthood            • Research
 • Violence, specifically domestic          • Access
      violence and sexual assault, teen     • Resource development
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of access to obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services
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Healthy Gente Indicators:
 • Reduce by 25% the population lacking access to primary care
 • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
 • Achieve 90% immunization coverage in children aged 10-35 months
 • Reduce childhood death rate due to unintentional injuries by 30% (per 100,000
     children age 0-4)
 • Increase percent of women beginning prenatal care in 1st trimester to 85% (per 100
     women)
 • Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
     women 15-17 years of age)
 • Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
 • Increase percent of people using oral health care system annually to 75% (per
     100,000 inhabitants)
 • Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)
 • Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per 100,000
     inhabitants)
 • Increase to 89% the proportion of adolescents not using:
          o alcohol in the past 30 days
          o marijuana in the past 30 days
          o cocaine in the past 30 days

By when/for how long:                       Responsible Parties:
 • Annual RFP process                        • DAC HHSD staff
 • Ongoing, with adjustments for each        • County Commissioners
     RFP cycle based on measurable           • County manager and staff
     successes                               • Contractors and subcontractors
                                             • External Agency Review Committee
Short-term measures of success:             Long-term measures of success:
 • RFP’s drafted appropriately               • Number of prevention and education
 • RFP process continued                         programs
 • Forum priorities incorporated into        • Coordination between programs
      strategic plan                         • Data collected and evaluated
 • Data collection and evaluation            • Ongoing adjustments made to data
      systems in place                           collection and evaluation systems
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Action 1.2: Conduct a feasibility study of alternative healthcare financing options (mil
levy, “sin” tax, taxes on non-essential items, DAC Salud, UNM Cares model, other
means of financing specialty care)

Forum Goals Addressed:
 • Develop healthcare resources, including healthcare human resources and financing
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations
 • Identify and address service needs not met by indigent program

Action Items:
 • Review models of healthcare financing programs in other communities
 • Define sub-specialty care
 • Request technical assistance from NMSU business department to evaluate
     healthcare financing options
 • Evaluate community support for “sin tax,” mil levy, and other healthcare tax options
 • Collate data on self-pay and no-pay, “in-kind,” and charity care
 • Compile results of research into feasibility report

Rationale: Several healthcare financing options were recommended by the specialty care
work group. The first step in implementing any of these suggestions is a feasibility study
to determine which options are viable, cost-effective, and sustainable. While these
options were focused on specialty-care services – which are expensive, partly because
providers must rely on advanced technologies to provide high-quality care – a viable
long-term financing strategy could have a positive impact on all sectors.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Resource development
 • Teen pregnancy and parenthood
 • Violence, specifically domestic
      violence and sexual assault, teen
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of funding for obstetrical
      services
 • Lack of case management and
      coordination for behavioral health
      services
DAC HHS Alliance Action Plan              103                                    9/6/2006


Healthy Gente Indicators:
 • None specifically addressed; all will be positively impacted by better healthcare
     financing


By when/for how long:                        Responsible Parties:
 • Feasibility report completed by July       • DAC HHSD Staff
     07                                       • NMSU College of Business
 • Implementation by July 08                  • Physicians
                                              • Clinics
                                              • Hospitals

Short-term measures of success:              Long-term measures of success :
 • Data collected                             • Retention of physicians in community
 • Follow-up meeting with NMSU                • Physician reimbursement for services
 • Feasibility report completed               • Adequate numbers of specialty care
 • Financing options identified and               physicians
      implemented
DAC HHS Alliance Action Plan               104                                    9/6/2006




Action 1.3: Develop an incentive program to reward providers and agencies who address
gaps and develop effective, innovative models

Forum Goals Addressed:
   • Identify and coordinate existing prevention and education programs in Doňa Ana
      County
   • Increase access to primary care and prevention services, including oral health, for
      uninsured and underinsured populations
   • Develop effective outlets and referral system for access to oral health services in
      the rural community/colonias
   • Identify and address service needs not met by indigent program

Action Items:
    • Identify potential resources for incentive program, including donations from area
        businesses, county resources,
    • Develop guidelines for recognition of programs
    • Establish independent review team for recognition
    • Determine when, where, and how incentives will be announced and awarded
Rationale: Doña Ana County’s unique mix of rural and urban environments, geographic
location on the US/Mexico border, demographics, and cultural and social challenges call
for programs that address these needs in innovative ways. By providing incentives to
innovative, effective programs that have significant positive impact on the health and
well being of Doña Ana County residents, the county can encourage the development of
such programs.
Priority Health and Service Issues:           Priority Infrastructure Issues:
• All priority health and service issues      • All priority healthcare infrastructure
    can be addressed by this action:              issues can be addressed by this action:
    • Type 2 diabetes mellitus                    • Prevention
    • Teen pregnancy and parenthood               • Research
    • Violence, specifically domestic             • Access
        violence and sexual assault, teen         • Resource Development
        violence, and bullying and gangs
    • Lack of access to basic dental
        services
    • Lack of access to specialty care
    • Lack of access to obstetrics services
    • Lack of case management and
        coordination for behavioral health
        services
DAC HHS Alliance Action Plan              105                                  9/6/2006


Healthy Gente Indicators:
• All pertinent Healthy Gente Indicators can be addressed by this action:
       o Reduce by 25% the population lacking access to primary care
       o Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
       o Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
       o Achieve 90% immunization coverage in children aged 10-35 months
       o Reduce childhood death rate due to unintentional injuries by 30% (per
          100,000 children age 0-4)
       o Increase percent of women beginning prenatal care in 1st trimester to 85% (per
          100 women)
       o Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per
          1,000 women 15-17 years of age)
       o Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
       o Increase percent of people using oral health care system annually to 75% (per
          100,000 inhabitants)
       o Reduce the proportion of adults who are obese by 15% (per 100,000
          inhabitants)
       o Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per
          100,000 inhabitants)
       o Increase to 89% the proportion of adolescents not using:
              • alcohol in the past 30 days
              • marijuana in the past 30 days
              • cocaine in the past 30 days

By when/for how long:                       Responsible Parties:
• Begin development/planning in             • DAC HHSD Staff
    October 06                              • Guidance of Alliance members
• Implement by July 07                      • Independent review committee
• Ongoing
Short-term measures of success:             Long-term measures of success:
 • Identification of resources               • Increased services for residents
 • Development of review guidelines          • Innovation among service providers
 • Development of independent review         • Increased morale among service
      team                                       providers and employees
 • Incentives awarded                        • Achievement of objectives based on
                                                 Healthy Gente Indicators
DAC HHS Alliance Action Plan               106                                     9/6/2006




Action 1.4: Develop a communications plan to keep all elected officials, consumers, and
other stakeholders informed of Alliance and/or Department activities

Forum Goals Addressed:
 • Educate public on appropriate use of public resources and personal responsibility
 • Increase access to primary care and prevention services, including oral health, for
     uninsured and underinsured populations
 • Develop healthcare resources, including healthcare human resources and financing

Action Items:
 • Develop a newsletter to distribute at community resource centers
 • Use other forms of media – print, radio, and television – to distribute information
     about Alliance/Department activities
 • Develop a website with forms for input
 • Continue community forum process

Rationale: Ongoing community and stakeholder involvement is critical to the success of
any healthcare initiative. All stakeholders, including policy-makers, providers, and
consumers, must be kept informed of the process and have options for offering input.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Resource development
 • Teen pregnancy and parenthood            • Access
 • Violence, specifically domestic          • Prevention
      violence and sexual assault, teen
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of funding for obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services

Healthy Gente Indicators:
 • All Healthy Gente Indicators are addressed by this policy-level intervention.



By when/for how long:                        Responsible Parties:
 • January 07                                 • DAC HHSD Staff
 • Ongoing                                    • Contracted media relations firm
                                              • Alliance members
DAC HHS Alliance Action Plan                107                                 9/6/2006


Short-term measures of success:               Long-term measures of success:
 • Newsletter published and distributed        • Changes in program due to consumer
 • Number of articles published in print,          input
      radio, and television media              • Recognition of Alliance by consumers
 • Website functional                              and stakeholders
 • Number of elected officials contacted       • Number of bills introduced to
 • Annual forum held                               legislature
                                               • Amount of state funding awarded
                                                   based on Alliance priorities
                                               • Other public and private funding
                                                   awarded based on Alliance priorities
DAC HHS Alliance Action Plan               108                                     9/6/2006




2: Prevention and Education Activities

Action 2.1: Provide an evidence-based, culturally-appropriate oral health education
program in schools and Community Resource Centers

Forum Goals Addressed:
 • Develop effective outlets and referral system for access to oral health services in the
     rural community/colonias
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations

Action Items:
 • Assess current status of oral health prevention and education programs in all three
     school districts
 • Identify and/or develop culturally-responsive, evidence-based, age-appropriate
     curricula
 • Identify and train professionals and para-professionals to deliver curricula
 • Establish site-based schedules for instruction
 • Integrate into community resource center monthly programs
 • Increase outreach efforts through media campaign

Rationale: Oral health is of primary importance to overall health. By providing
prevention education in places where children and parents gather, the county can conduct
a relatively inexpensive prevention and education program that will have long-term
impact on overall health and significantly reduce dollars spent on oral disease. Because
oral health has been linked to systemic disease and is recognized as one of the
complications of diabetes, this action also targets diabetes.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Lack of access to basic dental services  • Prevention
 • Type 2 diabetes mellitus                 • Access
                                            • Resource development



Healthy Gente Indicators:
 • Increase percent of people using oral health care system annually to 75% (per
     100,000 inhabitants)
 • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
DAC HHS Alliance Action Plan             109                               9/6/2006


By when/for how long:                      Responsible Parties:
 • Assessment by Dec 06                     • DACHHSD Staff
 • Identification and development of        • NMDOH Public Health Dept
      curricula by Dec 07                   • Ben Archer/La Clinica de Familia
 • Professional and para-professional       • Americorps VISTA volunteers
      instructors trained by March 08       • School health administrators
 • Implementation of curricula by Sept      • Health educators
      08
Short-term measures of success:            Long-term measures of success :
 • Existing efforts identified              • Number of time curricula presented
 • Curricula identified/developed           • Number of adults and children
 • Instructors trained                          receiving service
 • Curricula implemented                    • 10% increase in number of people
 • Evaluation tool developed                    visiting dentist twice a year
                                            • Increased awareness and behavioral
                                                changes
                                            • Decrease in advanced tooth decay and
                                                other preventable problems
DAC HHS Alliance Action Plan               110                                   9/6/2006




Action 2.2: Develop a culturally-appropriate prevention and health education strategy to
include a media campaign on appropriate use of healthcare resources

Forum Goals Addressed:
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations

Action Items:
 • Evaluate prevention plan developed by graduate student for the Alliance
 • Gather data on number of residents who have been involved in health education
     activities
 • Include education about available resources based on community population
 • Contract with a public relations firm to develop television, radio, and internet
     outreach tools
 • Establish coordinated outreach and health education effort across providers by
     creating prevention taskforce

Rationale: Many people enter the healthcare system at an inappropriate – and often the
most expensive – point. Educating the public about available resources and when and
how to use them can help residents to decide whether and when to seek help at a primary
care clinic, urgent care clinic, or in the emergency room. Reducing the burden on
emergency transport and emergency room can help to reduce costs and make the best use
of scant resources.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Prevention
 • Teen pregnancy and parenthood            • Access
 • Violence, specifically domestic
      violence and sexual assault, teen
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of access to obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services

Healthy Gente Indicators:
 • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
 • Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)
DAC HHS Alliance Action Plan            111                               9/6/2006


By when/for how long:                     Responsible Parties:
 • Data gathered and contract awarded      • DACHHSD Staff
     by January 07                         • HCAP staff
 • Implementation July 08                  • BEC staff
 • Ongoing                                 • Contractor

Short-term measures of success :          Long-term measures of success :
 • Cooperation of hospitals and            • 10% increased in people using
      ambulance services                       prevention services
 • Data collection and evaluation          • 10% increase in people accessing
      systems developed                        primary care
 • Data collected and gathered             • Decrease non-emergent visits to
 • Contractor hired                            emergency room by 10%
 • Provider prevention taskforce           • Decrease non-emergent 911 calls by
      developed                                10%
DAC HHS Alliance Action Plan                112                                      9/6/2006




Action 2.3: Enhance prevention efforts of the Driving While Impaired program

Forum Goals Addressed:
• Identify and coordinate existing prevention and education programs in Doňa Ana
   County
• Increase links between services for effective case management

Action Items:
   • Leverage the “Too Good…” curriculum, a model program developed by the
       Melendez Foundation
   • Provide life-skills training regarding ATOD in the schools
   • Provide life skills training in coordination with drivers’ education programs in the
       Las Cruces School District
   • Provide a parenting curriculum to families in rural communities
   • Use a grassroots campaign to change norms in the community using a promotora
       model of education
   • Increase visibility of enforcement activities

Rationale: Alcohol-related vehicle crashes cause death and disability at great expense to
the citizens of Dona Ana County. Between 1998 and 2002, 131 people died in Dona Ana
County as a result of motor vehicle crashes. Nearly half (45%) of those deaths were
alcohol-related. Alcohol played a role in 10.6 percent of injuries sustained during motor
vehicle crashes. About 30 people were permanently disabled by injuries caused by drunk
drivers. In Dona Ana County, the average DWI offender is an Hispanic male between the
ages of 21 and 50 years of age. Specifically, 75% of offenders are Hispanic, the average
age is 22, and 56% live in the greater Las Cruces area.

The mission of the local DWI program is to “reduce the incidence of DWI, alcoholism,
alcohol abuse, drug addiction, drug abuse, and alcohol-related domestic violence.”
Strategies used to enact this mission include planning, coordination, and evaluation;
prevention, screening, and treatment; alternative sentencing, and intensive supervision.
Treatment programs will always be necessary. However, prevention has the most direct
impact on the goal of reducing incidence. Prevention programs also provide a greater
impact, dollar for dollar, than treatment services. Enhanced focus on prevention can bring
about widespread changes in behavioral norms and beliefs about alcohol.

This action also addresses access issues through compliance monitoring, which includes
primary case management and referrals to other agencies. By identifying and addressing
problems that clients are facing, the program can Data collection and evaluation activities
will include focus groups, surveys, and tests administered pre- and post-course during
prevention and education activities. Tracking will include compliance, recidivism, and
reduction in key social indicators for the program. The initial indicator will be a reduction
of DWI crashes within Dona Ana County.

The DWI program also helps to sustain funding through the distribution of available DWI
DAC HHS Alliance Action Plan                 113                                   9/6/2006


funding to Dona Ana County and fee generation. In addition, DFA provides annual
competitive grant funding opportunities for innovative projects.

Finally, the DWI program addresses the Healthy-Gente 2010 indicator for youth suicide
through its holistic approach to behavior. All curricula directed toward youth are life-
skills oriented and resiliency-based. Those programs provide skills not only for alcohol,
tobacco, and other drugs but behavioral health issues across the board.

Priority Health and Service Issues:            Priority Infrastructure Issues:
    • Violence                                 • Prevention
    • Lack of case management and              • Research
        coordination for behavioral health     • Access
        services                               • Resource Development


Healthy Gente Indicators:
• Reduce childhood death rate due to unintentional injuries by 30% (per 100,000
   children age 0-4)
• Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per 100,000
   inhabitants)
• Increase to 89% the proportion of adolescents not using:
       o alcohol in the past 30 days
       o marijuana in the past 30 days
       o cocaine in the past 30 days
• Reduce suicide mortality rate by 15% (per 100,000 inhabitants)

Program-Specific Objectives:
• Reach 90 percent of all students enrolled in the drivers’ education program of Las
   Cruces Independent School District based on attendance logs
• Increase knowledge of DWI issues in youth in Dona Ana County by 10% as
   measured by pre- and post-test scores
• Increase awareness of DWI issues in the community by 10%, as measured by
   attendance at presentation, amounts of information disseminated, and pre- and post-
   test scores
By when/for how long:                        Responsible Parties:
• Implementation in schools Sept 06          • DAC HHSD Staff, specifically DWI
• Community-based campaign January               program
   07                                        • DWI subcommittee of the Behavioral
• Ongoing                                        Health committee
                                             • Contractors and collaborations such as
                                                 southwest counseling, DAC sheriff’s
                                                 dept, DAC teen court
DAC HHS Alliance Action Plan               114                                  9/6/2006


Short-term measures of success               Long-term measures of success (outputs):
(outcomes):                                  • Changed behavioral norms (decreased
• Changes in knowledge regarding                acceptability) regarding use of alcohol
    ATOD                                     • Changes in families’ beliefs (decreased
• Increased parenting skills that enable        acceptability) regarding appropriateness
    family cohesion and communication           of alcohol and substance use
• Increase community awareness of DWI        • Changes in community culture
    issues in the community                     regarding ATOD and DWI
• Provide a visible deterrent to DWI in
    the community
DAC HHS Alliance Action Plan               115                                    9/6/2006




Action 2.4: Enhance existing jail diversion, sexual assault, teen pregnancy, and domestic
violence prevention and education programs

Forum Goals Addressed:
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations
 • Identify and address service needs not met by indigent program
 • Increase links between services with effective case management
 • Develop healthcare resources, including healthcare human resources and financing
 • Identify and implement teen pregnancy prevention programs

Action Items:
 • Provide funding for existing programs to increase service capacity to enhance and
     expand existing programs
 • Seek funding from public and private sectors including state, federal, and private
     foundations
 • Increase public awareness of sexual assault and domestic violence dynamics by
     conducting culturally-responsive media campaign
 • Complete development of the online jail diversion Crisis Intervention Training
     (CIT) program for law enforcement
 • Investigate and test a train-the-trainer program on sexual assault for educational
     institutions and employers

Rationale: Existing programs are effectively serving consumers, but the need is growing
and resources are not. By emphasizing prevention and education programs, care for
consumers and families will be improved, crisis intervention and thus costs will be
reduced, and access to care enhanced.

Priority Health and Service Issues:           Priority Infrastructure Issues:
 • Violence, specifically domestic             • Prevention
      violence and sexual assault, teen        • Access
      violence, and bullying and gangs         • Research
 • Lack of case management and
      coordination for behavioral health
      services
 • Reduce teen pregnancy

Healthy Gente Indicators:
 • Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
 • Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per 100,000
     inhabitants)
 • Increase to 89% the proportion of adolescents not using:
DAC HHS Alliance Action Plan              116                                  9/6/2006


          o alcohol in the past 30 days
          o marijuana in the past 30 days
          o cocaine in the past 30 days
 •   Reduce teen pregnancy rate by 33% (per 1,000 women 15-17 years of age)

By when/for how long:                       Responsible Parties:
 • Funding in next budget cycle              • DACHSSD staff
 • Submit grant applications (ongoing)       • Forensic Intervention Consortium of
 • Sexual assault/domestic violence              Doña Ana County (FIC-DAC)
     prevention media campaign by 18         • La Piñon
     months after funding                    • La Casa
 • Complete CIT online training by June      • National Sheriff’s Association
     07; ongoing                             • NM State Police
 • Train-the-trainer program                 • NMSU
     implemented 18 months from              • Educational institutions
     funding; ongoing.                       • Employers
                                             • Other

Short-term measures of success :            Long-term measures of success :
 • Grant application submitted               • Jail diversion reduction of detention
 • Funding procured                              center bed days
 • Staffing                                  • Increase in reported cases of sexual
 • Programs implemented                          assault by victims and professionals
 • Number trained in CIT                     • Increase number of sexual assault
 • Number of trainers trained in sexual          cases accepted by the DA office
      assault prevention                     • Increase number of successful felony
                                                 convictions in district court
DAC HHS Alliance Action Plan                117                                     9/6/2006




Action 2.5: Explore funding options for tertiary prevention (efforts to minimize the
effects of disease and disability such as follow-up care, prescriptions, and equipment)

Forum Goals Addressed:
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations
 • Identify and address service needs not met by indigent program

Action Items:
 • Establish a baseline based on ER and hospital discharges
 • Select critical needs based on mortality rates
 • Identify Medicare/Medicaid guidelines for eligibility
 • Maximize the number of payer sources for the uninsured and underinsured
 • Assure that patients are enrolled in appropriate funding source
 • Revise county funding guidelines to include critical tertiary prevention needs

Rationale: Tertiary prevention activities such as home-based oxygen, glucose monitors
and strips can provide cost-effective options to in-hospital or nursing home care for those
who need it. Ensuring that medications are available can avert physical or mental health
crises requiring costly emergency transport and treatment.

Priority Health and Service Issues:           Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                    • Prevention
 • Lack of access to specialty care            • Access
                                               • Resource development



Healthy Gente Indicators:
 • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)


By when/for how long:                         Responsible Parties:
 • July 07                                     • DAC HHSD Staff
 • Ongoing                                     • Hospitals
                                               • HCAP Staff
                                               • NMDOH Public Health Nursing
                                               • Clinics
                                               • City of Las Cruces elected officials
                                                   and staff
                                               • County elected officials and staff
                                               • DAC IT
DAC HHS Alliance Action Plan               118                                9/6/2006


Short-term measures of success :             Long-term measures of success :
 • Historical patient data uploaded into      • Decrease of misuse in emergency
      HCAP database/Infocom                       room
 • Top five critical needs identified         • Decrease in preventable
 • Eligibility process streamlined                hospitalizations
 • Use of alternative payer sources           • Increase in primary care visits
      maximized                               • Decrease in percentage of uninsured
 • County funding provided                        population
                                              • Impact mortality rate
DAC HHS Alliance Action Plan               119                                    9/6/2006




3: Delivery of Care/Access to Care Actions
Action 3.1: Ensure compatibility of the Health Communities Access Program (HCAP)
MIS system with indigent program eligibility requirements

Forum Goals Addressed:
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations
 • Identify and address service needs not met by indigent program
 • Streamline indigent program eligibility process
 • Increase links between services with effective case management
 • Develop a system for data collection and evaluation
 • Develop healthcare resources, including healthcare human resources and financing

Action Items:
 • Coordinate with software vendor to develop fields for indigent program
 • Coordinate with software vendor to develop fields for Medicaid program
 • Coordinate with software vendor to pre-populate and print forms
 • Submitted for six-month no-cost extension with HRSA for HCAP funding through
     February 28, 2007
 • Develop strategies to sustain HCAP program after federal funding ends in February
     2007

Rationale: The HCAP access program promises to be a primary tool in creating a
standardized eligibility system, track patient enrollment in public health insurance
programs, facilitating referrals to appropriate healthcare providers, and tracking the
provision of care across providers. A stated goal of the HCAP proposal is to implement
“an integrated healthcare delivery system for the uninsured and underinsured.” For this
goal to be achieved, the HCAP MIS system must be compatible with indigent program
eligibility requirements.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Prevention
 • Teen pregnancy and parenthood            • Access
 • Violence, specifically domestic          • Research
      violence and sexual assault, teen     • Resource development
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of access to obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services
DAC HHS Alliance Action Plan              120                                  9/6/2006




Healthy Gente Indicators:
 • All pertinent Healthy Gente 2010 indicators are addressed by this action.


By when/for how long:                       Responsible Parties:
 • Implementation August 2006                • DAC HHSD Staff
 • Ongoing                                   • HCAP staff


Short-term measures of success :            Long-term measures of success :
 • Fields inserted in software to            • Decrease intake time for indigent
      coordinate with indigent and               patients by 30%
      Medicaid, program requirements         • Decrease eligibility renewal time for
 • Software edited to pre-populate and           indigent patients by 50%
      print forms                            • Decreased costs for eligibility/intake
 • HCAP MIS implemented and tested           • Sustainable funding strategies
 • No-cost extension granted                     developed and implemented,
 • Additional funding secured beyond             including public and private sources
      February 2007
DAC HHS Alliance Action Plan                 121                                     9/6/2006




Action 3.2: Develop a mental health mobile crisis team

Forum Goals Addressed:
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral health, for
     uninsured and underinsured populations
 • Identify and address service needs not met by indigent program
 • Increase links between services with effective case management
 • Develop healthcare resources, including healthcare human resources and financing

Action Items:
 • Design a multi-culturally-appropriate mobile crisis team based on evidence-based
     research to fit DAC environment
 • Determine program host/contractor based on existing resources in the community
     and capabilities through application process
 • Develop training modules
 • Conduct training
 • Establish a 24/7 mobile crisis hotline
 • Determine responsibilities
 • Develop data collection and evaluation tools

Rationale: Increasingly, emergency responders are being called upon to respond to
“welfare checks” – calls that fall outside the scope of work of law-enforcement. In 2004,
the Las Cruces Police Department responded to 424 welfare checks in one month. These
calls often involve mental health crises. There is often overlap between mental health
crises and criminal violations, including domestic violence and sexual assault.

To address this gap, the behavioral health workgroup proposed the development of a
mobile crisis team – a group of trained responders that can accompany law enforcement
and EMS to calls, in addition to the crisis intervention training currently being offered to
law enforcement. A key part of the mobile crisis unit is a telephone response system.
Many of these calls could be defused simply by intervention with a trained professional
on such a hotline.

The establishment of a mobile crisis team will decrease the amount of time law
enforcement spends on welfare checks; reduce liability to county government with
appropriate programs and trained responders; triage people to appropriate care; prevent
escalation and endangerment of consumers and emergency responders; and decrease the
average waiting time in the emergency room (existing baseline is 6.5 hours).
DAC HHS Alliance Action Plan              122                                   9/6/2006


Priority Health and Service Issues:         Priority Infrastructure Issues:
 • Violence, specifically domestic           • Prevention
      violence and sexual assault, teen      • Access
      violence, and bullying and gangs       • Resource development
 • Lack of case management and
      coordination for behavioral health
      services
Healthy Gente Indicators:
 • Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
 • Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per 100,000
      inhabitants)
 • Increase to 89% the proportion of adolescents not using:
           o alcohol in the past 30 days
           o marijuana in the past 30 days
           o cocaine in the past 30 days
By when/for how long:                       Responsible Parties
• Program fully functional within 18        • DACHHSD Staff
    months from effective date of funding • District Attorney
                                            • EMS
                                            • Fire
                                            • Law enforcement
                                            • Central dispatch
                                            • Advocates
                                            • Consumers
                                            • Mental health and other concerned
                                                providers
                                            • Consultants
Short-term measures of success :            Long-term measures of success :
 • Program designed                          • Number of welfare checks conducted
 • Contractor identified                          by law enforcement
 • Training modules developed                • Number of people appropriately
 • Hotline established                            triaged to treatment
 • Number of professionals trained           • Reduction of emergency room
 • Establish standards for collaboration          contacts for suspected mental illness
      and cooperation among existing         • Reduced exposure to risk for Doña
      community providers                         Ana County
                                             • Increased cooperation among mental
                                                  health providers
                                             • Reduce average hours spent in the
                                                  emergency room for mental health
                                                  clients from established baseline by
                                                  10 percent.
DAC HHS Alliance Action Plan                123                                     9/6/2006




Action 3.3: Explore funding options for a mobile dental clinic

Forum Goals Addressed:
 • Develop healthcare resources, including healthcare human resources and financing
 • Increase access to primary care and prevention services, including oral and
     behavioral health, for uninsured and underinsured populations
 • Develop effective outlets and referral system for access to oral health services in the
     rural community/colonias
 • Identify and address service needs not met by indigent program

Action Items:
 • Seek funding from public and private sources
 • Legislature ICIP request
 • Approach area legislators
 • Internet-enabled
 • Investigate long-term staffing options including practicums, WICHE
 • Establish a minimum number of operating hours based on consumer need and
      available resources
 • Develop resources for maintenance of equipment, cost of operating (fuel, etc.)
Rationale: Although the investment in a mobile dental clinic is significant, the potential
cost benefits of providing basic dental services in rural areas are great.


Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Lack of access to basic dental services  • Prevention
                                            • Access
                                            • Resource development



Healthy Gente Indicators:
 • Increase percent of people using oral health care system annually to 75% (per
     100,000 inhabitants)


By when/for how long:                          Responsible Parties
 • Legislation introduced in Jan 07             • DACHHSD Staff
 • Grant applications written according
     to funding cycles, no later than Dec
     06
DAC HHS Alliance Action Plan           124                                  9/6/2006


Short-term measures of success :         Long-term measures of success :
 • Legislation passed and funding         • Increase number of people in rural
      assigned                                areas who use oral health system
 • Public/private foundation funding          annually by 10%
      awarded for Doña Ana County         • Increase number of infants
 • Unit purchased                             countywide receiving fluoridation
 • Staffed                                    treatments by 10%
 • Unit operational                       • Increase number of pregnant women
                                              countywide receiving oral health care
                                              by 20%
                                          • Increase number of seniors 65+
                                              receiving oral health care by 20%
DAC HHS Alliance Action Plan               125                                    9/6/2006




Action 3.4: Research and implement successful prescription drug plan partnerships

Forum Goals Addressed:
 • Develop healthcare resources, including healthcare human resources and financing
 • Increase access to primary care and prevention services, including oral health, for
     uninsured and underinsured populations
 • Identify and address service needs not met by indigent program

Action Items:
 • Develop a taskforce to investigate options for prescription drug partnerships
 • Develop a formulary
 • Finalize partnerships for successful prescription drug plans
 • Educate promotoras and other outreach eligibility workers about partnership
     availability and requirements
 • Provide consumer enrollment opportunities through clinics and community resource
     centers
 • Use existing HCAP resources, which are based on successful national models, to
     develop a comprehensive array of medication assistance programs

Rationale: There are many existing free or low cost medication assistance programs.
Research is needed to determine which ones are most appropriate for Doña Ana County
residents. Major barriers to using these programs include personnel time to apply for the
programs, most of which require frequent recertification. Medicare Part D patients are no
longer eligible for many of these programs. A component for this goal is already built
into the HCAP program. There are several successful models ongoing nationally.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Access
 • Violence, specifically domestic          • Resource development
      violence and sexual assault, teen
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of access to obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services

Healthy Gente Indicators:
 • Reduce by 25% the population lacking access to primary care
 • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
 • Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
     women 15-17 years of age)
DAC HHS Alliance Action Plan              126                                   9/6/2006


 •   Reduce suicide mortality rate by 15% (per 100,000 inhabitants)




By when/for how long:                       Responsible Parties:
 • Taskforce developed by Sept 06            • DAC HHSD Staff
 • Initial Partnerships established by       • Prescription Drug Taskforce Members
      January 07                             • HCAP Staff
 • Implementation by July 07
 • Ongoing
Short-term measures of success: :           Long-term measures of success :
 • At least five prescription drug           • Number of county residents enrolled
      partnerships established                   in drug partnership programs
 • Promotoras and outreach workers           • Reduce emergency room visits and
      trained                                    hospitalization for diabetes crises by
 • Educational information distributed           10%
 • Enrollment activities begun               • Reduce emergency room visits and
                                                 hospitalization for hypertensive
                                                 crises by 10%
                                             • Reduce emergency room visits and
                                                 hospitalization for asthma by 10%
DAC HHS Alliance Action Plan                127                                    9/6/2006




4: Data Collection and Evaluation Activities

Action 4.1: Develop staffing for data collection and evaluation activities

Forum Goals Addressed:
 • Develop a system for data collection and evaluation
 • Develop healthcare resources, including healthcare human resources and financing
 • Develop effective outlets and referral system for access to oral health services in the
     rural community/colonias
 • Identify and address service needs not met by indigent program

Action Items:
 • Hire an information resource specialist for the DAC HHSD Healthcare Helpdesk
 • Contract with the NMDOH/NMSU Border Epidemiology Center for data evaluation
     activities
 • Coordinate with the US/Mexico Border Health Commission to establish baseline
     data for Healthy Gente 2010 and monitoring tools for benchmarks

Rationale: The need for data collection and evaluation was consistently identified by all
forum workgroups as a priority. Better data will allow more targeted planning efforts to
address the unique needs of Doña Ana County residents, increase the county’s ability to
apply for grants and thus leverage federal and state funds, and provide the evidence base
to meet the county’s unmet health needs and improve health outcomes.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Research
 • Teen pregnancy and parenthood            • Resource development
 • Violence, specifically domestic
      violence and sexual assault, teen
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of access to obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services

Healthy Gente Indicators:
 • Reduce by 25% the population lacking access to primary care
 • Reduce deaths due to diabetes by 10% (per 100,000 inhabitants)
 • Reduce hospitalization caused by diabetes by 25% (per 100,000 inhabitants)
 • Achieve 90% immunization coverage in children aged 10-35 months
 • Reduce childhood death rate due to unintentional injuries by 30% (per 100,000
     children age 0-4)
DAC HHS Alliance Action Plan              128                                   9/6/2006


 •   Increase percent of women beginning prenatal care in 1st trimester to 85% (per 100
      women)
 •   Reduce pregnancy rate in adolescents 15-17 years old by 33 percent (per 1,000
      women 15-17 years of age)
 •   Reduce suicide mortality rate by 15% (per 100,000 inhabitants)
 •   Increase percent of people using oral health care system annually to 75% (per
      100,000 inhabitants)
 •   Reduce the proportion of adults who are obese by 15% (per 100,000 inhabitants)
 •   Reduce the rate of alcohol related motor vehicle crash deaths by 50% (per 100,000
      inhabitants)
 •   Increase to 89% the proportion of adolescents not using:
           o alcohol in the past 30 days
           o marijuana in the past 30 days
           o cocaine in the past 30 days

By when/for how long:                        Responsible Parties:
 • January 07                                 • DAC HHSD staff
 • Ongoing                                    • HCAP staff
                                              • Providers, including hospitals and
                                                  FQHCs
                                              • BEC
                                              • US/Mexico Border Commission
Short-term measures of success :             Long-term measures of success :
 • Job description(s) developed               • Baseline data established for Healthy
 • Sustainable funding secured                    Gente Indicators
 • Staff hired                                • Increased leverage in grant
 • Contract with BEC written and                  application processes
      executed
DAC HHS Alliance Action Plan                129                                    9/6/2006




Action 4.2: Add oral health surveillance indicators to HCAP data collection activities

Forum Goals Addressed:
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral health, for
     uninsured and underinsured populations
 • Develop effective outlets and referral system for access to oral health services in the
     rural community/colonias
 • Identify and address service needs not met by indigent program
 • Increase links between services for effective case management
 • Develop a system for data collection and evaluation

Action Items:
 • Determine feasibility of adding oral health to HCAP MIS
 • Establish baseline for current use of oral health services
 • Coordinate with NMDOH Oral Health Surveillance system for indicators
 • Cooperation and support of dental community to collect and share data
 • Create a web-based “dental home” for consumers
 • Better overall picture of oral health status of DAC residents – needs, gaps, etc.
 • Data for grant applications public/private

 Rationale: Oral health care is an integral part of overall health care. The New Mexico
 Department of Health is in the process of developing an oral health surveillance system.
 By collecting data on oral health and participating in NMDOH oral health surveillance
 system, Doña Ana County can better assess the oral health care needs of residents and
 leverage state and federal funding for oral health.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Lack of access to basic dental services  • Prevention
                                            • Access
                                            • Research

Healthy Gente Indicator:
 • Increase percent of people using oral health care system annually to 75% (per
     100,000 inhabitants)


By when/for how long:                         Responsible Parties:
 • Oral health indicators integrated into      • Access to Care Consortium
     HCAP by September 06                      • DACHHSD staff
 • Data collection activities by June 07       • Oral healthcare providers
 • Data evaluation                             • BEC
DAC HHS Alliance Action Plan                  130                                 9/6/2006


Short-term measures of success :                Long-term measures of success :
 • Indicators identified                         • Number of oral healthcare providers
 • Indicators integrated into HCAP                   using system
      software                                   • Baseline established for dental care
 • Data collected                                    needs and utilization in DAC
 • Data evaluated                                • Number of consumers using system
 • Secure additional funding for oral            • 10% increase in number of people
      health data collection and evaluation          visiting dentist twice yearly
DAC HHS Alliance Action Plan               131                                     9/6/2006




Action 4.3: Request technical assistance and training from, and provide student
internship opportunities to, the Border Epidemiology Center and other relevant
departments at New Mexico State University

Forum Goals Addressed:
 • Develop a system for data collection and evaluation
 • Identify and coordinate existing prevention and education programs in Doña Ana
     County
 • Increase access to primary care and prevention services, including oral health, for
     uninsured and underinsured populations
 • Develop effective outlets and referral system for access to oral health services in the
     rural community/colonias
 • Develop healthcare resources, including healthcare human resources and financing

Action Items:
 • Establish contact with key individuals in pertinent departments at NMSU
 • Assist NMSU faculty in pursuing pertinent research grant opportunities
 • Create a process for students to engage internship/service learning opportunities
 • Establish intern position descriptions
 • Establish intern line item in DAC HHSD budget

Rationale: New Mexico State University offers a wealth of technical expertise to Doña
Ana County, as well as student interns who can assist in the county’s healthcare planning
and implementation efforts.

Priority Health and Service Issues:        Priority Infrastructure Issues:
 • Type 2 diabetes mellitus                 • Access
 • Teen pregnancy and parenthood            • Research
 • Violence, specifically domestic          • Resource development
      violence and sexual assault, teen
      violence, and bullying and gangs
 • Lack of access to basic dental services
 • Lack of access to specialty care
 • Lack of access to obstetrics services
 • Lack of case management and
      coordination for behavioral health
      services

Healthy Gente Indicators:
 • Research and technical assistance can help Doña Ana County to move toward all
     Healthy Gente 2010 indicators.
DAC HHS Alliance Action Plan                 132                                 9/6/2006


By when/for how long:                          Responsible Parties:
 • Internships by Sept 06                       • DAC HHSD Staff
 • Ongoing                                      • NMSU Business Department
                                                • NMSU Southwest Center for
                                                    Healthcare Disparities
                                                • NMSU BEC
                                                • HCAP staff
                                                • Providers
                                                • County contractors

Short-term measures of success:                Long-term measures of success:
 • Relationships established with key           • Improved efficiency
      individuals in pertinent departments      • Data collection and evaluation
 • Internship/service learning process in           processes standardized
      place                                     • Ongoing pool of student help
 • Faculty with pertinent research              • Private and public research grant
      interests identified                          funding awarded
DAC HHS Alliance Action Plan               133                    9/6/2006




VI. Appendices
                      Appendix A: Alliance Operating Guidelines




                         Doña Ana County
                Health and Human Services Alliance

                               Operating Guidelines

                                  Approved July 13, 2005




                                  Amended May 10, 2006
DAC HHS Alliance Action Plan                    134                                             9/6/2006




                     Doña Ana County
                  Las Cruces, New Mexico
    DOÑA COUNTY HEALTH AND HUMAN SERVICES ALLIANCE
                 OPERATING GUIDELINES


                                          ARTICLE I
                                       ESTABLISHMENT

Name                   Section 1. Doña Ana County Health and Human Services Alliance.

Purpose                Section 2. The purpose of the Alliance is to serve as the primary advisory body
                       to the Doña Ana County Health and Human Services Department consistent
                       with the guidance provided in Board of County Commissioners Resolution No.
                       05-04 dated: January 11, 2005.

Office                 Section 3. The home office of the Alliance shall be at the offices of the Doña
                       Ana County Health and Human Services Department, Las Cruces, New Mexico.

Adoption               Section 4. These guidelines shall be effective at the first meeting of the General
                       Membership after a majority vote of the members.


                                          ARTICLE II
                                         MEMBERSHIP

Eligibility            Section 1. Eligibility for membership shall be as defined and determined by the
                       members of the Executive Committee with the advice of the General
                       Membership (except for the initial appointment of the General membership) in
                       each of the following categories:

                       (a)   Public Members.                                           (3)
                       (b)   Private Members.                                          (3)
                       (c)   Not-for-Profit Members.                                   (3)
                       (d)   Private Voluntary Members.                                (2)
                       (e)   General Community/consumer Members.                       (2)
                       (f)   Professional Association Members.                         (2)
                       (g)   Academic Members.                                         (2)
                       (h)   Geographic Appointee Members.                             (3)
                       (i)   Other Special Designation Members.                        (5)

Duration               Section 2. In the event there are more than two qualified applicants for a vacant
                       position on the Alliance a primary run off shall be held. The two candidates
                       with the highest vote count from the primary run off shall then be elected by a
                       majority vote of the Alliance.

                       Section 3. Membership of a person eligible under Section 1 shall commence
                       with the acceptance of an application for membership and confirmed by the
                       General Membership of the Alliance (except for the initial members of the
                       Executive Committee and General Membership as appointed by the County
                       Manager with the endorsement of the BOCC). Membership is for a period of
DAC HHS Alliance Action Plan                    135                                            9/6/2006


                       three years and unlimited election possible with confirmation of the General
                       Membership.

Alternates             Section 4. Each member shall designate, in writing and within 30 days of
                       appointment, an alternate member who shall be permitted to attend and vote in
                       the designated member’s absence.

Termination            Section 5. Members who fail to attend three (3) consecutive General
                       Membership or two (2) consecutive Executive Committee meetings without
                       alternate representation or written explanation received by the office of record
                       prior to the meeting shall be terminated. The General Membership may remove
                       members for due cause upon two-thirds vote of the members.

Conduct                Section 6. Members must agree to abide by the Doña Ana County Code of
                       Conduct adopted by the Board of County Commissioners in May 2001.

Ex-Officio             Section 7. Employees of the Doña Ana County Department of Health and
                       Human Services shall serve only as ex-officio members and at the discretion of
                       the Department Director.

BOCC Ex-Officio        Section 8. The Board of County Commissioners may appoint one of their
                       members to serve in this capacity.

Other Ex-Officio       Section 9. The Executive Committee may appoint, at their discretion, other ex-
                       officio representatives as may be deemed necessary to support the work of the
                       Alliance.



                                          ARTICLE III
                                          MEETINGS

General                Section 1. General meetings of the members shall be held not less than ten
                       times per annum.

Annual                 Section 2. There will be one annual meeting so designated by the members.

Special                Section 3. Special meetings of the members shall be at the call of the
                       Chairperson but must be preceded by advance notice to all members of not less
                       than three (3) working days.

Committee              Section 4. Committee meetings shall be at the call of the committee
                       Chairperson.

Public Notice          Section 5. All meetings of the Alliance will be open to the public. The
                       designated staff shall prepare minutes of actions taken. All minutes of the
                       Alliance will be made available for public access within 10 working days of the
                       meeting.

Quorum                 Section 6. A quorum shall be constituted by a majority of the enrolled members.

Voting                 Section 7. A simple majority of the members present shall govern in all matters
                       properly brought before the meeting. Only members or designated alternates
                       may vote and the alternate may vote when in representation of the absent
                       member.
DAC HHS Alliance Action Plan                    136                                            9/6/2006


Conflict of Interest   Section 8. Members must abstain from voting on issues that are actual or
                       perceived as “conflict of interest”. The Executive Committee shall consider all
                       reports received on the action of members and may determine after appropriate
                       review that the member’s vote will be nullified and may also consider making a
                       recommendation of removal to the General Membership.



                                          ARTICLE IV
                                         COMMITTEES

Executive              Section 1. The Executive Committee shall consist of the Chairperson, Vice-
                       Chairperson, Secretary and not less than four (4) other members elected by the
                       General Membership. The duties of the Executive Committee shall be to
                       conduct all reasonable tasks necessary for the proper conduct of the Alliance but
                       must not assume responsibilities properly within the purview of the General
                       Membership.

Tenure                 Section 2. The members of the Executive Committee shall serve for two (2)
                       years and may be elected to serve a total of two terms. The election of the
                       Executive Committee will have a two year rotation, not less than Three
                       Members At-large and the Chair Person the first year, not less than one Member
                       At-large, the Vice Chair and the Secretary the second year.

Standing or Ad Hoc     Section 3. The Executive Committee may establish Standing and Ad Hoc
                       Committees by a vote of the committee. The Chairperson shall appoint a
                       Committee Chairperson and provide written guidance outlining the purpose and
                       tasks for each established committee.


                                           ARTICLE V
                                           OFFICERS

Officers               Section 1. Officers shall be comprised of a Chairperson, Vice-Chairperson and
                       Secretary.

Tenure                 Section 2. Officers shall be nominated by the General Membership and elected
                       at the annual meeting of the General Membership. Officers shall serve for two
                       years and may be re-elected to serve a total of two terms in any one position.

Duties                 Section 3. The Chairperson shall preside at all meetings of the General
                       Membership and Executive Committee. The Vice-Chairperson shall preside at
                       all meetings in the absence of the Chairperson and perform other additional
                       duties as determined by the Chairperson. The Secretary shall be responsible for
                       the proper maintenance of the official records in conjunction with the designated
                       support staff. The officers shall perform other such duties as are customarily
                       performed by such officers and similar associations, and such others as may be
                       imposed upon them by the general membership.

Vacancies              Section 4. Any vacancy on the Executive Committee shall be acted upon by the
                       General Membership at the next regular meeting with nominations will be taken
                       by the chair from the floor. In the event more than two candidates are
                       nominated a run off election will be held and the two candidates with largest
                       vote will then be elected by a majority vote of the Alliance.
DAC HHS Alliance Action Plan                     137                                            9/6/2006


                         a. Officer vacancies shall be filled by a majority vote of the Executive
                         Committee. The Chairperson shall appoint interim officers until such time the
                         Executive Committee elects new officers.



                                           ARTICLE VI
                                          AMENDMENTS

Change Process           Section 1. These guidelines may be altered, amended, changed, or new
                         guidelines adopted, by a two-thirds vote of the members at any meeting of the
                         members, provided that notice of the specific alteration, amendment, change, or
                         if new guidelines be contemplated, a complete set thereof be sent to each
                         member in the call of the meeting at which the proposed action is to be
                         submitted.


ADOPTED by the Doña Ana Health and Human Services Alliance at the meeting of July13, 2005.

ATTEST:


______________________
Frank Crespin, Chairperson
Date:__________________


_______________________
Peter Garcia, Vice-Chairperson
Date:___________________


_______________________
John Myers, Secretary
Date:___________________

Witness:


________________________
Silvia Sierra, Director
Health & Human Services Department
Doña Ana County
Date:____________________
DAC HHS Alliance Action Plan           138                               9/6/2006


Appendix B: DAC HHS Alliance Membership


               Doña Ana County Health and Human Services Alliance
                             Executive Committee



Frank Crespin, M.D. - Chairperson        Glenna Telles - Member
Chief Medical Officer                    Area Manager, Business Development
La Clinica de Familia, Inc.              HME Specialists, LLC
1100 S. Main Street, Suite A             2301A South Main
Las Cruces, NM 88005                     Las Cruces, NM 88005

Donna Brown, CPA – Vice Chairperson      Angela Townsend - Member
Executive Director                       Operations Manager
Mesilla Valley Hospice                   Ben Archer Health Center
299 E. Montana Ave.                      P.O Box 370
Las Cruces, NM 88005                     Hatch, NM 87937

John Myers – Secretary                   Louise Tracey – Member
Jail Diversion Program for the           Executive Director
Mentally Ill                             La Piñon
1812 Ash Street                          418 W. Griggs
Las Cruces, NM 88001                     Las Cruces, NM 88005

John Taylor- Member
Head Strength and Conditioning Coach
New Mexico State University
1900 Myrtle Avenue
Las Cruces, NM 88001
DAC HHS Alliance Action Plan                 139                                 9/6/2006


               Doña Ana County Health and Human Services Alliance
                             General Membership


Virginia Acosta                                Tony Martinez
Program Director                               Community Outreach Coordinator
Third Judicial District Court – Adult Drug     Molina Healthcare of New Mexico
Court Program                                  701C Parker
201 W. Picacho, Suite A                        Las Cruces, NM 88005
Las Cruces, NM 88005

Aurelia (Ella) Alvarez Nelson                  Delfi Mondragon
Physical Therapist                             Professor
2950 W. Union Avenue                           New Mexico State University, Department
Las Cruces, NM 88005                           of Health Science
                                               2308 La Senda Drive
                                               Las Cruces, NM 88003

Ron Gurley                                     Lorena Saenz
NAMI-DAC                                       Executive Director
NMSU                                           Centro Fuerza Y Unidad
604 W. Organ Avenue                            P.O. Box 1116
Las Cruces, NM 88005                           Mesquite, NM 88048


Harry Hansen                                   Silvia Sapien
Mesilla Valley Community of Hope               Promotora Director
4168 Sotol Ct.                                 La Clinica de Familia, Inc.
Las Cruces, NM 88011                           P.O. Box 3420
                                               Anthony, NM 88021

Beverly Hine                                   Sandra Tatum
Health Services Coordinator                    Trustee-Community Activist
Las Cruces Public Schools                      Robledo Community Association
505 South Main Street, Suite 249               P.O. Box 111
Las Cruces, NM 88001                           Radium Springs, NM 88054

Pam Lillibridge
CEO
Tresco, Inc.
P.O. Drawer 2469
Las Cruces, NM 88004
DAC HHS Alliance Action Plan         140                     9/6/2006


Appendix C: Healthy Gente 2010 Indicators, Doña Ana County
DAC HHS Alliance Action Plan              141                                   9/6/2006



VII. References
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      Mexico Department of Health, Bureau of Vital Records and Health Statistics in
      Partnership with the New Mexico Commission on the Status of Women, Santa Fe,
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2003 New Mexico Youth Risk and Resiliency Survey. County Results: Doña Ana County.
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      and University of New Mexico Center for Health Promotion and Disease
      Prevention.

2004 Preliminary Data. Bureau of Vital Records and Health Statistics. New Mexico
      Department of Health, Epidemiology and Response Division. Santa Fe, NM.
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“Adult Asthma Prevalence Using the Behavioral Risk Factor Surveillance System.” New
       Mexico Department of Health Office of Epidemiology. 2001 Data.

American Academy of Pediatrics. “Oral Health Risk Assessment and the Dental Home.”
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American Cancer Society. Cancer Facts and Figures 2006. Atlanta, GA: American
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Asplin, Brent R et al. “Insurance Status and Access to Urgent Ambulatory Care Follow-
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At the Cross Roads: US/Mexico Border Counties in Transition. US/Mexico Border
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Behavioral Health Needs and Gaps in New Mexico. The Technical Assistance
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Bernstein, Jared, Elizabeth McNichol, and Karen Lyons. Pulling Apart: A State-by-State
       Analysis of Income Trends. Center on Budget and Policy Priorities and the
       Economic Policy Institute, Washington, DC. January, 2006.

Bhandari, Shailesh. Health Status, Health Insurance, and Health Services Utilization:
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Bodenheimer, Thomas S. and Kevin Grumbach. Understanding Health Policy. Fourth
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DAC HHS Alliance Action Plan              142                                    9/6/2006




Challenge 2005: Doña Ana County. New Mexico Family Planning Program.
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“Covering the Uninsured: Growing Need, Strained Resources.” Kaiser Commission on
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Cunningham, Peter J. and Jessica May. A Growing Hole in the Safety Net: Physician
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DeNavas-Walt, Carmen, Bernadette D. Proctor, and Cheryl Hill Lee, U.S. Census
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Diemer, J.A. and C. Willingham. Community-Based Planning for Effective, Cost-
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Grading the States: A Report on America’s Health Care System for Serious Mental
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Guzman, Betsy. The Hispanic Population. Census 2000 Brief. United States Census
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Health Indicators: Building Blocks for Health Situation Analysis. Epidemiological
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Health Status Disparities in New Mexico: Identifying and Prioritizing Disparities. New
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Healthy Border 2010: An Agenda for Improving Health on the United States-Mexico
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Healthy Gente 2010: Summary of Baseline Data for Doña Ana County. Border
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Healthy People 2010: Understanding and Improving Health. US Department of Health
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DAC HHS Alliance Action Plan              143                                   9/6/2006


“Heart Disease and Stroke Statistics – 2006 Update. A Report from the American Heart
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“Heart Facts 2006: Latino/Hispanic Americans.” American Heart Association, 2006.
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Hoffman, Christine and Susan Starr Sered. Threadbare: Holes in America’s Healthcare
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Holohan, John and Allison Cook. “Are Immigrants Responsible for Most of the Growth
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Holohan, John and Allison Cook. “Changes in Economic Conditions and Health
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Injury Hurts New Mexico. New Mexico Department of Health, Office of Injury
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“Just the Facts” American Association for Homecare homecaremag.com

Medical Emergency: Costs of Uncompensated Care in Southwest Border Counties.
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Mueller, Mark. “Prescription Drug Overdose Death New Mexico, 1994-2003.”
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Lawrence, Jean et al. “Prevalence and Correlates of Depressed Mood Among Youth with
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“National Diabetes Fact Sheet.” Centers for Disease Control, Washington DC. 2005.
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DAC HHS Alliance Action Plan             144                                   9/6/2006


New Mexico Comprehensive Strategic Plan. New Mexico Department of Health. July
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New Mexico Kids Count Data Book 2005. New Mexico Voices for Children 2005.

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DAC HHS Alliance Action Plan            145                                 9/6/2006


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