This year the UW School of Medicine and Public Health and the Center partnered with Aurora Health Care and the other health system members of the Milwaukee Health Care Partnership to conduct a collaborative Community Health Needs Assessment (CHNA) in six counties in southeast Wisconsin. The CHNA for Milwaukee County is done in collaboration with the twelve municipal health departments in the county. The CHNA relies on three sources of information:
The Center analyzed the key informants and focus groups, compiles the secondary data report and creates a summary of all reports.
This assessment is conducted every three years; the 2015 CHNA findings show some changes since the previous assessment in 2012. Although access to affordable health care services continues to rank as a pressing need, chronic disease management and prevention rose as a high priority among survey respondents and key informants. So too, is the issue of violence, which factored prominently in key informant feedback.
In addition to the need for primary care, the CHNA showed that Milwaukee residents also lack access to oral health and behavioral health care services. Along with difficulty in navigating complex systems of care, these concerns were consistently noted among respondents across Milwaukee County, which ranks second to last in state health outcomes, according to the County Health Rankings.
In recognizing the impact of socio-economic factors such as poverty, education, and employment on individual and population health, the findings reinforce the Partnership’s cross-sector collaborations to improve community health.
Based on the health assessment’s key findings, each hospital and local health department in Milwaukee will select priorities and develop individualized plans to improve the health of the community it serves. The findings will also inform the Partnership’s 2016 – 2017 operating plan.
The Milwaukee Health Care Partnership members: Aurora Health Care, Children’s Hospital of WI, Columbia St. Mary’s Health System, Froedtert Health, Wheaton Franciscan Healthcare
In Collaboration with the City of Milwaukee Health Department and the surrounding municipal health departments
The Emergency Department (ED) Care Coordination is a priority initiative of the Milwaukee Health Care Partnership. The goals of this initiative include:
· Decreasing avoidable ED visits and related hospitalizations
· Reducing duplicative ED tests and procedures
· Connecting high-risk individuals with primary care health homes and other health resources
This community-wide health improvement initiative uses standard transition care management processes, aided by health information technology, to connect patients with primary care services. Ten adult hospital EDs and more than 10 community clinics in Milwaukee County participate, including four federally qualified health centers (FQHCs). Although this remarkable initiative requires complex systems and use of cloud-based technology, it is very simple for the patient.
If a patient presents in one of Milwaukee County EDs with one of five priority conditions, a social worker provides the patient with education about the initiative and their eligibility. The social worker then is able to identify a time and location that is convenient to the patient and schedules the appointment with their new medical home. This is possible through the use of MyHealthDIRECT appointment scheduling technology. Local community health centers post open appointments, and the EDs can schedule appointments electronically while the patient is at the hospital. Once the appointment is scheduled, the intake coordinators at community health centers reach out to patients prior to the first appointment and attempt to reschedule if the appointment is not kept.
The project is successful; year-to-date appointments are up 43% compared to the previous year and patients are filling 93% of the available appointments at the federally qualified health centers, their new medical home.
Center researchers from UW-Milwaukee evaluate the project through the use of appointment data to evaluate scheduled and kept clinic appointments according to the hospital system, clinic site, and payer type.
Partners: Aurora Health Care, Aurora Family Services, Center for Urban Population Health, Milwaukee Health Care Partnership, and the local Federally Qualified Health Centers, My Health Direct, and UW-Milwaukee
WISCONSIN'S COLLABORATIVE APPROACH TO INCREASING COLORECTAL SCREENING
Colorectal cancer (CRC) is the second most common cancer diagnosed in Wisconsin and the second leading cause of cancer death among both men and women in the state. Early detection and screening can detect colorectal cancer in its earliest stages increasing the success of treatment and reducing mortality (death) from the disease. In 2012, 72% of Wisconsin adults were considered ‘up-to-date’ on their colorectal cancer screening yet local Federally Qualified Health Centers (FQHCs) and community health centers who serve a high population of African American, Hispanic, Native American and Hmong men and women living below the poverty line in the Milwaukee area, their CRC screening rate was around 34%.
This year The UW School of Medicine and Public Health and the Center, with funding from the Centers for Disease Control and Prevention, are partnering with all Milwaukee-Area Federally Qualified Health Centers and Aurora Health Care’s Walkers Point Clinic to increase colorectal cancer screening rates to coincide with the National Colorectal Cancer Roundtable (NCCRT) initiative of reaching 80% screening rate by 2018. Strategies include:
· Establish clinic teams and champions and assess baseline CRC screening rate.
· Improve organizational policies and impact systems change that will increase screening rates and decrease disparities in screening and colorectal mortality by the adoption of evidence-based interventions (EBIs) such as provider reminders, patient reminders, and reduction of structural barriers.
· Assess process and outcome measures and evaluate the quality improvement initiative.
This five-year project targets patients aged 50-75 years old who seek their medical care from one of the Milwaukee area clinic partners.