Population Health Collaborative
Constellation Consulting, LLC works in collaboration with the New Mexico Department of Health, Heart Disease & Stroke Prevention Program to convene the Population Health Collaborative (PHC). The PHC will meets throughout the year, and together addresses the six strategies developed by the CDC to reduce the burden of cardiovascular disease:
STRATEGY 1: Utilizing Electronic Health Records (EHR) to identify patients with undiagnosed or uncontrolled high blood pressure.
STRATEGY 2: Utilizing team-based care (non-physicians, such as pharmacists, nutritionists, nurse practitioners) to help patients manage high blood pressure and high cholesterol.
STRATEGY 3: Utilizing Community Health Workers (CHWs) to help control high blood pressure and high cholesterol.
STRATEGY 4: Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support.
STRATEGY 5: Systematic referral of patients with hypertension and high cholesterol to community programs/resources.
STRATEGY 6: Promote the adoption of Medication Therapy Management (MTM) between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification.
A video and slides and resources from the Population Health Collaborative 2023 Conference are now available. Please select PHC 2023 Conference below.
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Population Health Collaborative 2023 Conference
The Population Health Collaborative 2023 Conference was held in-person and online on May 10. The New Mexico Department of Health Heart Disease & Stroke Prevention Program reviewed the progress made to reduce the burden of cardiovascular disease in New Mexico, as well as looked towards the impact of the social determinants of health on heart disease and stroke in New Mexico.
CLICK HERE for a video of the 2023 Conference. Slides and resources provided by our presenters have been posted.
This year's Conference is designed for those working in health systems and clinical settings, as well as those with Community Based Organizations providing health services and addressing the social determinants of health.
Welcome Remarks from Dr. Laura Parajon
Deputy Cabinet Secretary, New Mexico Department of Health
Housing & Homeless Advisor, New Mexico Office of the Governor
How solving the housing crisis can support the overall health of New Mexico
Dr. Roberto Martinez
Interim Health Equity Director, New Mexico Department of Health, Public Health Division
Community engagement efforts to advance health equity across New Mexico
Director, New Mexico Department of Health Office of Community Health Workers
Understanding the process to include the CHWs in Medicaid billing
MCO Panel featuring Western Skies Community Care and Blue Cross Blue Shield of New Mexico
A discussion about how New Mexico’s MCOs are addressing the social determinants of health
Resources from Western Sky Community Care:
- WSCC Website - https://www.westernskycommunitycare.com/
- Free Trainings - https://www.westernskycommunitycare.com/providers/resources/provider-training.html
- WSCC email for providers that have credentialing questions for WSCC – Contracting@WesternSkyCommunityCare.com
- WSCC 2023 Value Added Services Flyer
Program Manager, New Mexico Department of Health Heart & Stroke Prevention Program
The impact of social determinants of health on heart disease and stroke
The Population Health Collaborative is funded by the New Mexico Department of Health Heart Disease & Stroke Prevention Program.
The Spring-23 Population Health Collaborative meeting was held online Wednesday, March 29 at 1 p.m. This meeting featured Dr. Nadia Fazel, a dentist and Chief Clinical Officer for Albuquerque Health Care for the Homeless discussing how social and structural determinants of health affect the most vulnerable of our population in dramatic ways.
At Albuquerque Health Care for the Homeless, we operate under a Housing First model to address the needs of our patients and clients that are most heavily impacted by external forces. Poor health is both a major cause and consequence of homelessness – it creates new health problems and exacerbates existing ones. Individuals experiencing homelessness have high rates of acute and chronic illness and recovery is far more difficult without housing. Of all the determinants of health, housing is one of the most basic and powerful. This presentation will address how our understanding of social and structural determinants of health can advance a patient’s healthcare needs and how working on interdisciplinary teams embraces person-centered healthcare.
- Understanding social and structural determinants of health
- Learning what a Housing First Model encompasses
- Who makes up an interdisciplinary team?
- How person-centered healthcare is defined by addressing determinants of health
You can view a recording of this meeting here: https://youtu.be/TnKwXblugxg
The Winter 2023 Population Health Collaborative meeting was held online on Wednesday, February 15 with a focus on addressing the Social Determinants of Health. Dr. Art Kaufman, Vice President for Community Health for the University of New Mexico Health Sciences Center, presented Social Determinants: Population Health’s Necessary Ingredient, and discussed the role of Social Determinants of Health (SDoH) and the greater role they play in peoples' and communities' health over health care systems. The session presented research data on the impact of screening for and addressing SDoH, and the rise of two new health worker categories (community health workers and health extension agents). Finally, there was a summary of the cross-campus involvement of all UNM colleges and community-engaged programs all of which address the SDoH.
The session learning objectives are:
- Participants will be able to identify five common social determinants of health.
- Participants will be able to identify reasons social determinants play a far larger role in health than does the healthcare system.
- Participants will be able to distinguish the roles in addressing social determinants of health of community health workers (CHWs) and Health Extension Regional Officers (HEROs).
- Participants will be able to identify the facilitating roles State Medicaid and the national Center for Medicare and Medicaid play in addressing social determinants of health.
- Participants will be able to identify two research questions needing answers to further understand how addressing social determinants affect the outcomes for the healthcare system.
You can view a recording of this meeting here: https://youtu.be/yMnEUNfJjTA
The Fall 2022 Population Health Collaborative meeting was held online on Wednesday, November 16 from 1 - 2 p.m. MT, and focused on Strategy 6: Promoting the adoption of Medication Therapy Management (MTM) between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification. Our presenters were Tesia Buszkiewicz, Pharmacist with Duran Central Pharmacy, and Amy Bachyrycz, Assistant Professor, University of New Mexico, and Clinical Pharmacist, Walgreens.
During this PHC session, our presenters will discuss the adoption of MTM in both the community pharmacy and chain pharmacy environments. Our session learning objectives are:
- Identify the need for community pharmacy staff participation in Medication Therapy Management.
- Provide an understanding of MTM in community pharmacy and larger pharmacy chains.
- Identify barriers and benefits of pharmacies who implement MTM.
You can view a recording of this meeting here: https://youtu.be/27XAzfUYvCE
The Spring 2022 Population Health Collaborative meeting was held online in March, 2022. The topic was Team-Based Care, and featured Best Practices in Team-Based Care and Team-Based Care Models, presented by Lindsey Haakenson, Program Manager, New Mexico Department of Health, Heart Disease & Stroke Prevention Program; Implementation of Team-Based Care in Chronic Care Management, presented by Bianca Kertson, MPH, Population Health Manager, La Clinica de Familia; and Community Health Workers in the Team-Based Care Model, presented by Jamie Slama, Training Coordinator/Certification Coordinator, New Mexico Office of Community Health Workers.
You can view a recording of this meeting here: https://youtu.be/dCE2lEQF0Bs
The Winter 2022 Population Health Collaborative meeting was held online in January, 2022. The topic was Utilizing Electronic Health Records (EHR) to Identify Patients with Undiagnosed or Uncontrolled High Blood Pressure, and presented by Dr. David Larsen, Christus Health in Tyler, Texas. Dr. Larsen's presentation was followed by a panel discussion featuring Comagine Health, West Virginia University, and Syncronys discussing:
- Connecting attendees with DOH and supporting contractors who can provide technical assistance with EHR support;
- Health systems that currently use EHRs, and how to use EHRs to their full capacity;
- What are the benefits of utilizing EHR in New Mexico (if your clinic is part of a larger system or not).
You can view a recording of this meeting here: https://youtu.be/oN2cWliGfmw
The Spring 2021 Population Health Collaborative Meeting was held online in March, and focused on the role of Community Health Workers to help control high blood pressure and high cholesterol. This session also included information about training opportunities for CHWs, Community Health Representatives, and Promotoras. Our presenters included Jamie Slama, New Mexico Department of Health Office of Community Health Workers; Robin Hetzler, MCD; and Sandra Adondakis, New Mexico Community Health Workers Association.
You can view a recording of this meeting here: https://youtu.be/9k_slnbgTv8
The Fall 2020 Population Health Collaborative Meeting was held online in November, and focused on facilitating the use of self-measured blood pressure monitoring with clinical support. Our presenters included Kim Sabo, Community Health Program Manager for Presbyterian Healthcare Services, and Sara Ukeiley, Self-Monitoring Blood Pressure Program Director for the YMCA of Central New Mexico.
You can view a recording of this meeting here: https://youtu.be/2CPPolVgJ8o
The New Mexico Population Health Collaborative 2022 Conference featured opportunities for those working in health systems and clinical settings to learn more about population health and strategies to reduce the burden of cardiovascular disease in New Mexico.
Session with Leigh Caswell, Vice President for Community Health, Presbyterian Healthcare Services
Session with Sheryl Wilkeson, Community Impact Director, New Mexico & Southern Colorado, American Heart Association
Session with Sara Ukeiley, Self-Monitoring Blood Pressure Program Director, YMCA of Central New Mexico
Session with Dr. Rizwan Sardar, Interventional Cardiologist, Memorial Medical Center
The New Mexico Population Health Collaborative 2021 Conference was on June 10 and featured opportunities for those working in health systems and clinical settings to learn more about population health and strategies to reduce the burden of cardiovascular disease in New Mexico.
Prior to her appointment as New Mexico Secretary of Health, Dr. Tracie C. Collins served as dean of the College of Population Health at the University of New Mexico, bolstering the state’s public health and pandemic-response leadership.
Collins has served in a variety of academic leadership roles, in addition to providing clinical care and conducting and overseeing clinical research. Prior to her tenure at the University of New Mexico, she served as chair of Preventive Medicine and Public Health at the University of Kansas, where she also served as the Kansas Health Foundation distinguished professor of public health and as a professor of internal medicine. At the University of Minnesota, she was co-leader of the Primary Care Research Consortium, co-director of the school’s Center for Health Equity Research Core, and an associate professor of medicine. In Texas, Collins served as an assistant professor of medicine at the Baylor College of Medicine and the director of the General Internal Medicine Consult Service of the Michael E. DeBakey V.A. Medical Center in Houston.
In addition to her clinical education and research in the United States, Collins has also lectured in Nepal and Kenya. She has produced nearly 80 scholarly publications over the course of her career, and she maintains a clinical practice as a vascular specialist. Collins earned a master of public health degree from the Harvard School of Public Health in Boston, Mass., where she also served as a clinical instructor, and a master of health care delivery science degree from Dartmouth College. She earned her doctor of medicine degree from the University of Oklahoma and her bachelor’s degree, in chemistry, from the University of Central Oklahoma.
Dr. Jennifer Gomez-Chavez has 30 years of experience working on issues of diversity and equity through her positions with the LULAC National Educational Service Center and the University of New Mexico (UNM) in Albuquerque. She holds a B.A. in Criminal Justice, a Master’s in Counseling, and a Doctorate in Educational Leadership. Currently, she serves as the Special Assistant to the Associate Vice Chancellor in the Office of Diversity, Equity, and Inclusion at UNM’s Health Sciences Center. In her role, Jennifer is the Executive Director of the Unidos Project, Central Region Director for ENLACE NM, and directs Collective Impact Initiatives. Jennifer is active in the community and has been recognized as a grassroots leader. She has received countless awards and recognitions for her service including the following: Inducted into the National LULAC Women’s Hall of Fame, Albuquerque Business First Women of Influence, Ohtli Mexican Government Award, UNM Presidential Luminaria Award for Inclusion, Access & Student Success, National Verizon Award – Latina Business Professional, New Mexico Hispano Round Table Legislative Walking the Talk Award, and the National MS Society induction into the Volunteer Advocacy Hall of Fame. Jennifer is a national speaker empowering individuals to use their voice for self-advocacy on educational and health issues.
Stephanie is an ALMOST native New Mexican. She moved to New Mexico at the age of 5, and grew up in several different small towns in New Mexico, thus giving her a front-row view of health care, or lack thereof, in rural areas of our state.
She attended the University of New Mexico College of Pharmacy, and obtained her BS in pharmacy in 1992. While in pharmacy school, she answered a 2-inch ad for a pharmacy intern posted on the bulletin board at the pharmacy school, and this begin her journey at Duran Central Pharmacy. After 2 years as an intern, she graduated and took a position as a staff pharmacist at Duran’s. As of May, she has worked for Duran’s for 31 years. During these years, she has seen pharmacy go from dispensing prescriptions, to dispensing the knowledge that was taught in pharmacy school. The changes have been drastic, but exciting, and she is grateful to work at a pharmacy where forward thinking is encouraged. The programs that have been developed at Duran’s over the years have kept them at the forefront of pharmacy practice and given them the ability to do so much for their patients’ healthcare beyond dispensing. Wellness and nutrition are a passion for her, and she also spends time learning and educating her patients about the herbals, supplements, and homeopathics that have become a vital part of the pharmacy.
Dana Bloomquist is Senior Account Executive at CWA Strategic Planning, Paths to Health New Mexico marketing lead, and a Contractor to the New Mexico Department of Health. Dana joined CWA Strategic Communications in August 2001. Her responsibilities have included working with the Early Childhood Education and Care Department’s Family Infant Toddler (FIT) Program; the New Mexico Department of Health’s Breast and Cervical Cancer Early Detection, Comprehensive Cancer and Diabetes Prevention and Control Programs; and the Children, Youth and Families Department.
Lynnzy McIntosh has worked with integrating community-based programming and health care since 2008 when she joined the staff of the Consortium for Older Adult Wellness (COAW) in Colorado; eventually serving as Executive Director. Workshop Wizard was created in 2009 to meet the needs of developing referral systems with an entire spectrum of community based programs, including falls prevention, chronic disease self-management and diabetes prevention. Her friendship with the New Mexico Department of Health Diabetes Prevention and Control Program began in 2010 and expanded to include Workshop Wizard in 2015. Now, as Vice President of PAC Software, Inc. she continues as a contractor to the New Mexico Department of Health Diabetes Prevention and Control Program and brings her experience in health care referrals, implementation, and data management to programs across the country including the 16 states now using Workshop Wizard.
From our partners at Comagine Health:
As part of Comagine Health’s partnership with the New Mexico Department of Health’s Heart Disease and Stroke Prevention Program (HDSPP), you have the opportunity to receive FREE technical assistance to support current work to begin, continue, or to expand a Self-Measured Blood Pressure (SMBP) program as a tool to help more patients achieve blood pressure control. We are here to help you regardless of which stage you are at and look forward to working with you!
As the CDC States, “The evidence base for implementing SMBP in health care systems and practices is very strong. Several studies show the positive effect of SMBP in improving blood pressure control. Comprehensive implementation guidance is available to facilitate the adoption of this strategy by health care systems and practices.” (Self-Measured Blood Pressure Monitoring With Clinical Support | CDC | DHDSP)
To submit your request for no-cost technical assistance, please complete the following questionnaire via SurveyMonkey. This questionnaire should take less than 10 minutes to complete.
Comagine Health can provide targeted technical assistance to support your SMBP program in several key areas, including:
- Working with culturally specific communities including Tribal governments and Tribal Health Clinics (638, Urban Indian Centers and Indian Health Service).
- Support for culturally specific communities can include identifying opportunities to adapt and expand programming to be culturally responsive and inclusive.
- Patient identification, evaluate readiness.
- Creating team workflows within an SMBP program.
- Participant engagement and retention in SMBP services (virtual and/or in-person).
- Quality Improvement and implementation methodologies.
New Mexico Department of Health will support targeted technical assistance for up to four sites from Comagine Health.
If you have questions or want to learn more about getting involved with the New Mexico Self-Measured Blood Pressure Programs, please contact: Edy Taylor, Improvement Advisor, or Alberta Davis Associate Improvement Advisor. If there are any questions about this partnership, please contact: Lindsey Goodhue, Program Manager, Heart Disease & Stroke Prevention Program, Population and Community Health Bureau, Lindsey.email@example.com, 505-403-7820.
Check out these resources!
General Information & Reports
- Self-Measured Blood Pressure Monitoring (SMBP) Resources
- What is Self-Measured Blood Pressure Monitoring
- NM PHC: Health Systems Assessment Report, June 2020; prepared by Comagine Health
Community Health Workers, Community Health Represetatives, and Promotoras
The New Mexico Department of Health Office of Community Health Workers offers a variety of resources for CHWs, CHRs, and Promotoras. Please visit them online for more information: https://www.nmhealth.org/about/phd/pchb/ochw/
- National Association of Community Health Centers (NACHC): How to Use Your Home BP Monitor is a brief video explaining the value of SMBP to patients and the key steps they should follow to take an accurate blood pressure measurement outside of the clinical office.
Resources to Find a Home Blood Pressure Monitor
- AMA SMBP cuff selection
- US Blood Pressure Validated Device Listing (VDLTM)
Select Case Studies
- National Association of Community Health Centers (NACHC): Self-measurement: How patients and care teams are bringing blood pressure to control; A video describing the experience of three community health centers in providing SMBP and the stories of their patients who used SMBP to improve their health.
https://www.youtube.com/watch?v=XGO-I59UMDg (full video)
https://youtu.be/VNQQ8ranUZo (D’Angelo’s Story)
https://youtu.be/malq4KnCESY (Natalia’s Story)
- Hypertension Control Champions Success Stories - A webpage with SMBP success stories from the Million Hearts® Hypertension Control Champions, those clinicians, practices, and/or health systems recognized by CDC for achieving exemplar hypertension control rates.
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