Harnessing the Power of New Mexico’s Communities: The Case for State-wide Coordinated Care

Testimony Prepared for: The New Mexico State Joint Committee on Veterans Affairs
Prepared by: Anthony Cosby, the Institute for Veterans and Military Families (IVMF) at Syracuse University


Anthony cosby

Anthony Cosby

For the last decade, the IVMF has dedicated its mission to supporting those who have served in our nation’s defense. Through innovative programs and actionable research, we’ve learned much about the asset this population represents to our communities, and the challenges they face upon transitioning home.
In doing this work we’ve come to understand the ‘sea of goodwill’, the large number of nonprofits in communities across the country that impact and serve veterans every day. But even with all these services available to this population, over and over again we see veterans and their families fall through the cracks, not get the services they need.

We believe one reason this happens, is because for all the goodwill that exists, navigating the sea of resources available can be challenging, draining and discouraging, particularly for those needing assistance in more than one way. That’s why, 6 years ago the IVMF launched its AmericaServes initiative. To bring communities together in a coordinated way, leveraging technology, local leadership and shared goals to empower communities to serve veterans and their families better and more effectively.

It’s also why we are here today, to share insights from our research and experiences that we believe indicate a state-wide network of coordinated care could greatly improve the lives of veterans and their families here in New Mexico.

The Challenges New Mexico faces

Many of the states we operate in face significant challenges. Housing affordability, poverty, access to VA benefits, the struggles of rural living, are all things we’ve encountered before in our AmericaServes networks. New Mexico is not immune to these challenges either. According to a recent ABQ journal report, New Mexico experiences an unemployment rate of just over 8%, and it has the second highest poverty rate in the country at 18%. These socioeconomic data paired with the pervasive and disturbing trend of veteran suicide happening across the country are reflected in many of the communities we work with in the AmericaServes program.

These challenges speak to the need of a coordinated system of social and health services across New Mexico for veterans. Veteran well-being is about more than quality clinical care delivered by the VA, it’s also about providing veterans with a wide array of coordinated social supports to meet all their needs. To address the social determinants of their health.

AmericaServes networks do this by bringing social and health nonprofits and government agencies together in a coordinated system, backed by technology to provide a single point of entry for every veteran seeking any type of service. This single point of entry exists as a connector to health services, employment, housing, legal, nutrition etc. Since 2015 AmericaServes fielded more than 100,000 service requests across 21 different service categories for over 40,000 clients. Today, the top three types of services requested in our AmericaServes networks nationwide are 1) Housing 2) Employment and 3) Benefits Navigation. In some of our more rural networks, issues like food assistance, utilities and income support also rise to the top of the list in the demand for services requested.

Addressing co-occurring needs is critical because of the aggregate impact they have on overall wellness. Consider a recent study that found stressors associated with the social determinants of health (unemployment, financial troubles, food insecurity etc) increased the likelihood of suicidality by 64% for every new stressor.

Our experience through AmericaServes showed us veterans and their families often experience more than one of these stressors at once. Especially during COVID:

  • 51% of AmericaServes clients in 2020 reported more than one need. Of those, 76% displayed needs that spanned multiple social determinants of health. No single agency or organization possesses all the resources necessary to combat these issues alone.

The value to nonprofits in the state of New Mexico

Nonprofits in communities across the state are on the frontlines of serving veterans and their families, meeting their needs where they live. They do this work often on small budgets and with limited staff. In our networks across the country, we’ve consistently seen coordinated services alleviate administrative burdens and costs for providers participating in the network.

Coordinated care means a single point of entry. It means someone’s story only needs to be told once, and after that information is collected, it is stored in a standardized, accessible way that makes it easy for nonprofits to focus on delivering their service and meeting that need, as opposed to paperwork and other administrative tasks. By getting communities on a shared technological platform and collaborating to provide services (rather than one provider trying to provide everything) resources are assigned to their first best use, and providers, as well as the entire community, realize efficiency gains and reductions in administrative burdens and costs.

The technology itself brings significant economic value to the nonprofit, a value that many small community providers may not otherwise afford unless communities, or states, come together to use and provide that technology collectively. With the shared technology also comes with it the added benefit of data analytics support that would often be difficult for small nonprofits to achieve. The IVMF provides its communities with robust data analytics support, analyze real-time data and identifying trends and insights that can immediately inform the actions of the network.

Take our Pittsburgh network for example. Before the pandemic, nutritional assistance requests never even broke the top 3 services requested. During the early months of the pandemic, it jumped to the number one requested service in Pittsburgh. Armed with this data, the network was able to enter the community, and add more providers to their network prepared to meet this rising demand.

Serving rural communities

Rural communities are one of the special parts of New Mexico that make it a great state. But rural communities also experience very real barriers to accessing care and services associated with

geographic isolation. A state-wide New Mexico Serves network would mean a single point of entry for rural veterans to many of the services they may need across the state. No matter what is available in their specific community, there is a number they can call, or a website they can visit, that can get them on the right path connecting them to the nearby services they need. Having no initial point of entry is not the only barrier for rural veterans, but it is a major barrier, and a state-wide network would alleviate those concerns.

Another major benefit of AmericaServes networks is the way they leverage the power of non-veteran- specific community providers. Many veterans access services or could be accessing services from providers who don’t exclusively serve veterans as a component of their core mission, but who deliver services to veterans as a part of a broader population they support.

By bringing these nonveteran service providers into our veteran provider networks, we’re ensuring access to a wide variety of culturally competent veteran services even by those who don’t exclusively serve veterans. For rural communities, this means veterans can be directed to whatever local resource can best meet their needs regardless of if it’s exclusively veteran serving or not.

The inclusion of non-veteran specific providers also has relevance for specific populations such as Native veterans. Local providers in those communities can be included in the state-wide network, helping government reach and furnish services to populations they might otherwise struggle to connect to. It is one example of an efficiency gain, the state can ensure veterans are receiving the specific services they require, delivered in a culturally competent way, by local community providers well connected in a specific area or population.


New Mexico’s veterans and their families deserve the best service this state has to offer. Providers in communities are already doing the hard work of delivering services, and the state agency already has the connections and ability to bring all those services together in a coordinated way.

With the experience of the better half of the last decade, the IVMF can help facilitate the state’s progression from siloes to collective impact, getting the state all rowing in the same direction towards the shared goal of connecting veterans to the best services as easily and efficiently as possible.

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