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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Aurora Medical Center in Oshkosh

Implementation Approaches

Impact goal: Increased linkages to appropriate screening and care for behavioral health

Strategies:

For our patients:

  • Provide ABHS social worker in our ED to assess and appropriately expedite patient referrals for behavioral health services
  • Provide behavioral health referrals through telepsychiatric program

For our community:

  • In collaboration with the Winnebago County Health Department, evaluate options for activities focused on primary prevention of alcohol abuse, with a focus on the middle school age population and patients filling new prescriptions
  • In collaboration with AHCMG and community partners, develop new services to address mental health issues, especially addiction prevention and treatment strategies

Impact goal: Increased opportunities to maintain a healthy weight

Strategies:

For our community:

  • Continue to participate in initiative to geomap tri-county obesity hot spots in collaboration with ThedaCare and Ascension Health
  • Work with local employers in Winnebago County to adopt some level of worksite wellness programming as an active member of the Worksite Action Team; advance awareness and distribution of FV Worksite Wellness Toolkit
  • Support the Active Communities Team mission to promote use of trails and bike routes and leverage regional planning work to assure coordination across jurisdictions
  • Create and maintain more low-cost opportunities for families to be active on a year-round basis, including developing Safe Routes to School, etc.
  • Provide professionals, such as pediatric nurse practitioner, dietitian and exercise scientists, to staff community-based initiatives such as re:TH!NK

Impact goal: Increased linkages to appropriate screening and care for behavioral health

Strategies:

For our patients:

  • Provide ABHS social worker in our ED to assess and appropriately expedite patient referrals for behavioral health services
  • Provide behavioral health referrals through telepsychiatric program

For our community:

  • In collaboration with the Winnebago County Health Department, evaluate options for activities focused on primary prevention of alcohol abuse, with a focus on the middle school age population and patients filling new prescriptions
  • In collaboration with AHCMG and community partners, develop new services to address mental health issues, especially addiction prevention and treatment strategies

Impact goal: Increased access to care

Strategies:

For our patients:

  • Provide appropriate follow-up with non-emergent patients using our ED for primary care
  • Actively screen patients for coverage through the Marketplace or financial assistance programs and assist with application processes
  • Establish new agreements for primary care options: Our hospital had a longstanding collaborative and reciprocal partnership with the UW-Oshkosh Living Healthy Community Clinic to care for patients with disproportionate unmet health needs (DUHN). The clinic’s closure as of December 28, 2017 left us with both a challenge and opportunity to identify, explore and evaluate new FQHC/free clinic partners during 2018. In 2019 our plan is to formalize reciprocal partnerships to assure ongoing community-based primary care access points to help underserved populations establish a health home:
    – Research prospective new partnership with a community free clinic or FQHC to assure appropriate linkages for un- and under-insured patients seeking primary care services in our hospital ED
    – Develop and establish a collaborative relationship
    – Refer uninsured and self-pay patients using our ED for primary care to FQHC/free clinic

For our community:

  • Develop agreement with new free clinic/FQHC partner to provide specialty care to patients

Impact goal: Increased opportunity for cancer screening and support

Strategies:

For our patients:

  • Provide nurse navigator to work with all cancer patients to develop a survivorship plan
  • Hold ongoing annual survivorship activities for our cancer patients and their caregivers to provide information about cancer support resources and to address quality of life issues during and after cancer treatment
  • As part of a system-wide population health strategy, identify and screen clinic patients at risk for hepatitis C; treat those who test positive

For our community:

  • Provide cancer screenings and educational sessions at a variety of community venues and events

Impact goal: Increased linkages to appropriate screening and care for behavioral health

Strategies:

For our patients:

  • Provide ABHS social worker in our ED to assess and appropriately expedite patient referrals for behavioral health services
  • Provide behavioral health referrals through telepsychiatric program

For our community:

  • In collaboration with the Winnebago County Health Department, evaluate options for activities focused on primary prevention of alcohol abuse, with a focus on the middle school age population and patients filling new prescriptions
  • In collaboration with AHCMG and community partners, develop new services to address mental health issues, especially addiction prevention and treatment strategies

Impact goal: Increased access to care for survivors of sexual assault

Strategies:

For our patients:

Consistent with Aurora’s system-wide Sexual Assuault Nurse Examinier (SANE) program and AHAS, provide:

  • Provide 24/7 trauma-informed and victim-sensitive services, including forensic evidence collection and SDFI®-TeleMedicine forensic photodocumentation system based on the Federal Rules of Evidence
  • Refer as appropriate to medical, clinical, counseling and advocacy services

For our community:

  • Provide community education/prevention/outreach trainings