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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

St. Mary's Hospital (Madison)

Implementation Approaches

Chronic Conditions Goals:

  • Reduce number of ED visits for uncontrolled diabetes.
  • Improve access, education, and ease for Primary Care engagement with a focus on those populations disproportionately affected

Action Plan:

  • Further explore Healthy Dane Funders /AHA—food deserts
  • Continue supporting Double Dollars Program—access to local / fresh produce for underserved populations
  • On going partnership with REAP—kids education and nutrition support in the schools

Maternal Child Health Goals:

  • Reduce the number of babies born with very low birth weight (
  • Work with Moms/families on continuing support through 4th Trimester - increase post-partum visits and measure post partum depression

Action Plan:

  • Enhance collaboration with the Wisconsin Women’s Health Foundation to increase awareness and educational opportunities around prenatal and preconception care, focusing on smoking cessation

Chronic Conditions Goals:

  • Reduce number of ED visits for uncontrolled diabetes.
  • Improve access, education, and ease for Primary Care engagement with a focus on those populations disproportionately affected

Action Plan:

  • Increase support of Rebalanced Life Wellness Association—Men’s Health Center and Wellness Center
  • Engage with the Foundation for Black Women’s Wellness —working specifically on Black Women’s Heart Health
  • Support Edgewood students at Triangle (Diabetic Clinic) and support at RLW (above)
  • Pulse Point partner—educate the community on importance of early intervention of CPR
  • Further explore Healthy Dane Funders /AHA—food deserts
  • Explore expansion of Community Paramedic Program
  • Continue supporting Double Dollars Program—access to local / fresh produce for underserved populations
  • On going partnership with REAP—kids education and nutrition support in the schools
  • Explore Primary Care Provider education options (vs. coming to ED)

Mental Health Goals:

  • Decrease the suicide rate
  • Decrease the mental health inpatient readmission rate within 30 days of discharge

Action Plan:

  • Increase Telehealth opportunities with our medical group partners to allow for more timely access to care
  • Partner with Safe Communities Coalition on the Recovery Coach program at St. Mary’s ED as well as the Pregnancy to Recovery program within OB
  • Work with Healthy Dane partners on opportunities to collaborate to create, enhance, or sustain evidence-based community programs/efforts to reduce the incidence of suicide in Dane County
  • Collaborate with Zero-Suicide Initiative partners to sustain community efforts across Dane County
  • Explore expansion of the Community Paramedic program to include Mental Health
  • System change in approach to measuring Mental Health needs using Columbia Tool (2018)
  • Continued efforts in county-wide initiative on patient safety plans following discharge
  • Explore options for more follow-up and controlling day-to-day needs as well as transportation concerns for patients

Maternal Child Health Goals:

  • Reduce the number of babies born with very low birth weight (
  • Work with Moms/families on continuing support through 4th Trimester - increase post-partum visits and measure post partum depression

Action Plan:

  • Continue partnership with the Health Council on disparities in low birth weight—focusing specifically on racial inequities
  • Enhance collaboration with the Wisconsin Women’s Health Foundation to increase awareness and educational opportunities around prenatal and preconception care, focusing on smoking cessation
  • Work with the Healthy Dane Collaborative partners on opportunities to collaborate on evidence-based community programs/efforts to increase access to culturally competent preconception, prenatal and post-partum care with local community partners
  • Elevate efforts with Safe Communities—Pregnancy to Recovery program
  • Pursuit of Baby-Friendly Designation at St. Mary’s Madison
  • Support prenatal care services at Access Community Health Centers
  • Expand Group Prenatal Care within Dean Medical Group locations — focus on cohorts with increased diversity
  • Continued growth of post-partum support and education in the hospital and medical group