Resources » Pathways

Pathways

What is Pathways? 

Pathways is a program that connects people in our community with the health care and support they need — and helps them every step of the way. We focus on underserved and at-risk residents in our county, making sure no one has to navigate the system alone.

Our Role:

• Meet you where you are and assess your needs.
• Guide you through your Pathway and track your progress.
• Share and address barriers in the system so we can improve services for everyone.
 
What We Do:
• Connect you to health care, social services, and other resources.
• Walk with you through each step of the process, from start to finish.
• Coordinate services so you get better health and improved well-being.
• Work together with community partners to make our health care system better for everyone.
 
Ingrid Montoya who is an alumni and GBCS graduate, Certified Peer Support Worker, Navigator, and Ed fellows, and Atiliana Montoya Bernco Navigator. They can help navigate:
 
Behavioral Health
Pharmacy / Medication
Dental Care Public Benefits
Driver's License / ID Substance Abuse
Employment Victim Advocacy 
Food Security Vision / Hearing 
Heat / Utilities  
Health Care / Home  
Housing  
Legal assistance  
Medical Debt  
 
Email or call to schedule an appointment:
Ingrid Montoya HS/AE [email protected] or call 505-452-7527
Atiliana Montoya AE [email protected] or call 505-916-8618

How it Works? 

We start with an identified problem — something that’s getting in the way of your health, wellness, or independence. Together, we make an action plan (your “Pathway”) with clear steps to address that problem. As you complete each step, you move closer to your goals. The Pathway ends when you reach a meaningful outcome — like better health, stability, or self-sufficiency.

Step 1: First Meeting We meet you through a referral (teacher, MDC, Leilani, Jake) or you walk in. If you need them, we can give hygiene items or other basic supplies. Step 2: Getting Started You sign a Release of Information form (lets us share info to help you). You take a short Risk Score Assessment. We write down your phone number, email, and other contact info. You choose 3 Pathways you want to work on. Step 3: Checking Eligibility We look at your answers to see if you can start. If you can start, we set up your next appointment. We put your info in the Pathway system and write notes. We begin looking for resources that match your needs. Step 4: Staying Connected We will call, text, or email you to stay in touch. We help you: Get documents Fill out forms or applicatio

Understanding Local Resources & Challenges

Housing Support

  • Homeless Prevention – Includes wellness centers and transitional living. These often have requirements that can be hard to meet, plus waitlists up to 4 months.

  • Housing Assistance – Based on referrals and applications. We don’t issue housing vouchers, and there are few options without requirements in Albuquerque. Bernalillo County and Albuquerque Housing have long waitlists, and applications are lottery-based.

Utilities Help

  • Assistance is available but requires specific documents and qualifications.

Employment Connections

  • Only a few employers hire people recently released with felony charges. We have some connections, but spots fill quickly.

Social Security Benefits (SSDI, SSI)

  • We refer clients to SOARS, who are experts at handling these applications.