Accountable Health Community

Santa Fe County’s Accountable Health Community (AHC) project 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 wellbeing. The AHC project builds up the health and human services system to address these needs. The AHC does this by supporting the relationships between health and social service providers, as well as those between individual clients and the “navigators” who help them through the system. These relationships are at the heart of the Santa Fe County Accountable Health Community.

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

As of January, 2018, our network includes four Federally Qualified Health Centers—Presbyterian Medical Services, La Familia Medical Center, Pecos Valley Medical Center, and First Choice Clinic in Edgewood—and eight nonprofit community service organizations and programs—Las Cumbres Community Services, United Way’s First Born program, Santa Fe Public Schools Teen Parent and Adelante programs, The Lifelink, Interfaith Shelter, St. Elizabeth’s Shelters and the City of Santa Fe’s Mobile Integrated Health Office (MIHO). Populations served include at-risk pregnant women and residents with behavioral health needs. In addition, we target enrollment into health insurance and access to primary care for hard-to-reach populations via contracts with the NM Immigrant Law Center and Health Action New Mexico, as well as through the Community Service Department’s Health Care Advocate. 

Partners meet regularly to define best practices and benchmarks for success in meeting social needs. All AHC partners update and use the SHARE New Mexico online resource guide to serve their clients. 

We produce monthly newsletters that provide stories of how people are benefiting from this new approach.  In December, we celebrated the first year of the Accountable Health Community Project and the numbers of people connected to necessary services through our community partner navigators.  

• AHC 2017 Annual Report
• AHC One Year Follow Up Presentation

Santa Fe County Staff Contact

Jennifer Romero
Community Services Department
[bot protected email address]  
(505) 995-9525