Santa Fe County Connect

Story Telling Project - (YouTube)

Santa Fe County Connect is a network of navigators at clinics, city and county programs and community organizations that link people to services and resources in our community.  Based on an Accountable Health Community model, Santa Fe County Connect addresses the unmet, non-medical social needs of County residents by forging a stronger link between clinical care and community services. We aim to improve community health, increase quality of care for individuals, and reduce health care costs to the system overall.

Health is more than just health care. Good health depends not only on access to quality healthcare providers, but also on the “social determinants of health.” According to the World Health Organization, the social determinants of health are “the conditions in which people are born, grow, live, and age and the wider set of forces and systems shaping the conditions of daily life.”

Non-medical social needs, such as secure housing, utilities, reliable transportation, nutritious food, and safe physical and social environments, are key to health and well-being. Santa Fe County Connect works with partners by breaking down communication and funding silos, and addressing these needs by supporting the relationships between health and social service providers, as well as those between individuals and the navigators who help them through the system. These relationships are at the heart of Santa Fe County Connect.

Our Vision

By 2020, all Santa Fe County residents regardless of income have access to high quality health care and are linked to the resources they need for health and well-being.

Our Goals

• Residents and providers collectively identify problems and co-create solutions. 
• Navigators link residents to resources within a cohesive provider network. 
• Social, economic, and physical environmental resources are available to all residents. 
• Information systems are coordinated, and data are evaluated to improve services and population health, while reducing health care costs.

Our Network

In January, 2018, the network included three Federally Qualified Health Clinics and eight nonprofit community service organizations and programs. In the following year and a half, the network grew and added an additional 14 community service organizations and had 60 navigators in all. As of July 2019, the City of Santa Fe joined as a partner bringing twenty navigators from thirteen community organizations.  The network now has over 80 navigators in 37 programs funded by the City and County.

Stakeholders meet regularly to define best practices and benchmarks for success in meeting social needs. All network navigators are linked by a common software platform to make referrals for services and goods in and out of network.  The Unite Us software platform allows for on-line and in real time data sharing, communication and reporting.

Quarterly newsletters provide information about the network and three short videos document how Santa Fe County Connect has impacted the lives of three individuals in our community.

We, or someone we know, are one circumstance away from benefiting from Santa Fe County Connect.   

For more information, contact:

Jennifer Romero
Health Care Assistance Administrative Program Manager
[bot protected email address]  
(505) 995-9525