Addressing Healthcare’s Blindside in Albuquerque’s South Side is:

  • Implementing a membership rewards program to incentivize healthy behaviors.
  • Developing a referral tracking system to promote health behaviors among patients beyond the clinical setting.

Key Partners

  • Adelante Development Center
  • Presbyterian Healthcare Services
  • Bernalillo County Office of Health and Social Services

In partnership with:

  • First Choice Community Healthcare and Agri-Cultura Network

Obstacles to Health and Identified Health Challenges

Extreme poverty, illiteracy, and high rate of high school dropouts; obesity and behaviorally unhealthy community


Addressing Healthcare’s Blindside in Albuquerque’s South Side (AHBASS) targets the low-income Southeast Heights and South Valley neighborhoods in Albuquerque, New Mexico. Bernalillo County, which encompasses metro Albuquerque, is characterized by both extreme poverty and wealth, with disadvantaged neighborhoods displaying markedly worse health outcomes than wealthier ones.

AHBASS’s vision is to reshape the community to promote healthy eating, active living, and education that can lead to job opportunities. They have created a membership rewards program that incentivizes healthy behaviors and keeps participants engaged through events, email, texts, and an app. AHBASS hopes to use this program to connect people with the services they need, track their movement between programs, and provide wellness rewards for participation.

The mobile market goals include:

  1. Reduce obesity rates by 3% by increasing access to healthy food options and safe places for physical activity.
  2. Reduce rates of diabetes and heart disease by 5% by increasing access to chronic disease prevention and self-management resources.
  3. Expand access to healthy food by delivering fresh produce & 5-lb. food boxes from the pantry to the South Valley Community Commons (a service hub), two Presbyterian Healthcare Services clinics, and other target sites.
  4. Offer cooking demos, nutrition education, and benefits enrollment.

How the wellness rewards program works:

  1. When patients enter the health system, they are enrolled in the wellness rewards program, entered into a Referral Tracking System, and screened for social determinants
  2. A positive screening triggers a benefits checkup and a prescription.
  3. A Community Health Worker assists patients with referrals, accessing resources and addressing barriers as needed.
  4. When patients fill their prescriptions, they present their wellness rewards membership card, so their profile in Salesforce can be accessed.
  5. The resource provider records the activity in the database, and the database generates email offers to keep the member engaged.
  6. Members are surveyed on their experience, and a report will be provided monthly to the health system for entry into the patient’s EHR.
  7. Every 6 months, the patients’ utilization of recorded non-medical resources will be evaluated against health status indicators.