In New Mexico, Pathways Care Coordination Supports People With Opioid Use Disorder

State and local leaders can better invest in evidence-based programs to combat opioid use disorder (OUD) when they understand how to most effectively prevent overdose deaths, provide treatment, and ensure that communities have the resources they need. Amid an ongoing national opioid overdose crisis made worse by the COVID-19 pandemic, many community initiatives are working to limit overdoses and save lives.

The substance use prevention and treatment initiative of The Pew Charitable Trusts is supporting six such initiatives over the next two years in a partnership focused on helping them evaluate their programs and encouraging broader adoption of successful, innovative models.

This profile is part of a series.

Rio Arriba Health and Human Services

Rio Arriba is a mountainous, mostly rural frontier county in north-central New Mexico dotted with isolated villages that have supported an agrarian lifestyle for generations. Its culture can be attributed to its largely Indigenous, Hispanic, and Mestizo population. Many residents face economic challenges and health disparities at rates similar to those in impoverished urban areas; the county has experienced epidemic levels of substance use disorder (SUD).

In contrast with counties in most states, New Mexico counties do not run the local public health offices. They are administered and staffed by the state Department of Health, while counties provide office space as required by statute. In 1997, upon discovering a growing and seemingly localized opioid epidemic, Rio Arriba County established the Rio Arriba Health and Human Services Department (RAHHS), the first county-run health and human services department in the state. It serves all county residents. Staff members reach out to constituencies experiencing SUD, including people who have survived overdose at the local hospital; those who are identified at the jail, by law enforcement, or before a court; and those who are referred by providers or who self-refer. 

Many of these individuals face significant obstacles to treatment. According to a 2020 evaluation report, 75% of those receiving RAHHS services over the previous three years had a history of incarceration, 54% lacked reliable transportation, and 47% reported housing concerns. The lack of essential resources such as transportation and housing in the country has undermined the recovery process for decades. To address these issues, RAHHS in 2006 adopted the Pathways model of intensive case management to treat OUD. Two pediatricians—Mark and Sarah Redding—developed the model to address low birth weights among underserved communities in Alaska and Ohio.

Pathways model

For more than a decade, Rio Arriba County has used Pathways Care Coordination, an outcomes-based chronic disease case management service delivery model that works to mitigate social factors that influence patients’ ability to manage their disease. It treats each individual as a whole person with a chronic condition—not unlike diabetes or heart disease—and has been shown to lead to better overall outcomes. Rio Arriba is the first county in the nation to use this specific model of intensive case management to treat OUD.

The complexity of OUD requires attention to the many factors that complicate treatment and recovery. The Pathways model works to connect clients to education, employment opportunities, and secure housing, which can increase an individual’s social supports. Without this assistance, people with OUD often experience cycles of hopelessness and continued opioid misuse, even with access to treatment. By lessening the stigma associated with OUD and providing access to a broader array of services, RAHHS is working to increase client success and sustain recovery.

Evaluating care coordination

RAHHS and the local evaluation partner, i2i Institute—an organization that supports effective, sustainable social change—have collected and analyzed Pathways outcomes data for more than a decade. Together, they are looking for expected outcomes, such as increases in access to needed services, motivation for sustained recovery, and ownership of and engagement with the recovery process. They also want to see decreases in unmet needs, use of emergency services, relapse, involvement in the criminal justice system, and drug overdose rates.

The review will focus on three domains: participants, systems, and data. A first step will be to survey participants to evaluate how and to what extent the Pathways model of care meets their diverse needs and leads to sustained recovery. Evaluators also will examine the various systems to identify what it takes to build a functioning community of care for people experiencing OUD, and what processes support a system of care that aligns with the Pathways approach. Finally, the analysts will determine how best to work with the community to collect data to support a community-based, community-owned, sustainable and continuous assessment of participant outcomes. That also should support a system for data-driven storytelling.

Overall, the goal of the work is to reduce overdose deaths and morbidity linked to opioid misuse by helping people engage in appropriate treatment and supplying supportive disease management through a coordinated continuum of care. This coordination occurs when health providers and others involved in the treatment system offer appropriate, aligned care to people experiencing OUD with a primary focus on people who have been involved with the criminal justice system.

RAHHS’ work has continued through the pandemic, but COVID-19 has presented challenges to implementation of the services being evaluated. The state and county have experienced multiple shelter-in-place periods. Low staffing has been an issue across the organization, and services such as transportation have been restricted. These variables, combined with a surge in overdoses apparently related to the pandemic, make the department’s efforts more difficult and more vital.

RAHHS leaders are continuing the planned evaluation. The project is slated to end in 2022, with dissemination of results to follow.

For more on this initiative, please contact Leslie Paulson, [email protected]

Beth Connolly is the project director and Leslie Paulson is an officer with The Pew Charitable Trusts’ substance use prevention and treatment initiative.