Specifications include, but are not limited to: The aim of Pathways is to work with the most difficult-to-reach populations in Bernalillo County. Examples of difficult-to-reach populations include, but are not limited to, low income, uninsured adults who may be experiencing one or several of the following: • Have multiple or complex unmet needs and reports feeling unhealthy • Have had a minimum of one Emergency Room visit within the last year • Presently homeless or at high risk of becoming homeless and not currently receiving services • Urban off-reservation Native American not connected to or trusting of the currently existing resources in Bernalillo County • Undocumented and/or limited-English proficient (LEP) immigrant/refugees who do not understand how to access existing resources and/or has run into barriers trying to navigate the system • Recently arrived refugee populations that are struggling to adapt to their new community and country