-Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

• Actively participate in Waukesha and Washington County steering committees and project teams: Heroin Task Force, Drug Free Communities Drug Collection and Awareness Events, Washington County Community Health Coalition
• In-kind support of Froedtert Health leaders, staff and physicians with knowledge and expertise in behavioral health
• Identify service gaps within Froedtert Health
• Screen patients for underlying AODA/Mental Health Conditions

-Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

• Actively participate in Waukesha and Washington County steering committees and project teams: Heroin Task Force, Drug Free Communities Drug Collection and Awareness Events, Washington County Community Health Coalition
• In-kind support of Froedtert Health leaders, staff and physicians with knowledge and expertise in behavioral health
• Identify service gaps within Froedtert Health
• Screen patients for underlying AODA/Mental Health Conditions

-Continue the support of Community Outreach Health Clinic and community stakeholders to increase access to preventative and primary care, improve quality and reduce costs

• Continue referral process for uninsured/underinsured populations from CMH to Community Outreach Health Clinic
• Provide ancillary/specialty care services for COHC patients
• Screen uninsured patients for financial assistance programs (Marketplace, BadgerCare etc) including Froedtert Health’s Financial Assistance Program
• Provide financial support for clinic operations and functions
• Screen patients for underlying AODA/Mental Health Conditions
• Provide behavioral health coaching and referral to community services

-Provide wellness checks within 48 – 72 hours of discharge for high risk populations for 65% of patients that qualify for program

• Develop Community Paramedicine Pilot Program – December 2015
• Determine technological needs, templates, care plans, agreements, education and related resources for pilot program
• Identify patients at risk for readmission and develop referral and tracking process with Menomonee Falls and Lisbon Fire Departments

-Increase self-management of high risk populations by addressing social determinants of health in CMH’s service area

• Audit existing partnerships with non-profit health and human service agencies in Froedtert Health’s service area
• Create new partnerships based upon demographics and health needs
• Recruit and train individuals on Community Health Worker model
• Conduct routine evidence based health prevention and management programs (Living Well with Chronic Conditions, Community Education Programs etc.)

-Increase self-management for individuals living with chronic conditions and reinforce healthy lifestyles to encourage behavior change

• Facilitate a minimum of three Living Well with Chronic Conditions/Diabetes programs each year
• Explore new community partners/agencies in service area to hold Living Well with Chronic Conditions/Diabetes and Service Line programs
• Explore opportunities for enhancing and expanding clinical support groups and community health education programs in community based settings

-Implement programs to increase cancer awareness, screening and early detection at CMH and organizations across the hospital’s service area

• Dedicated nurse navigators working with patients receiving care in the CMH Cancer Center and provide assessment and referrals for health system and community resources
• Screen all uninsured patients for financial assistance programs through the Marketplace or government sponsored programs
• Execute a minimum of two community cancer screening programs per year
• Execute quarterly cancer awareness and education events (classes, health fairs, events etc.)

-Provide wellness checks within 48 – 72 hours of discharge for high risk populations for 65% of patients that qualify for program

• Develop Community Paramedicine Pilot Program – December 2015

• Determine technological needs, templates, care plans, agreements, education and related resources for pilot program

• Identify patients at risk for readmission and develop referral and tracking process with Menomonee Falls and Lisbon Fire Departments

-Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

• Actively participate in Waukesha and Washington County steering committees and project teams: Heroin Task Force, Drug Free Communities Drug Collection and Awareness Events, Washington County Community Health Coalition
• In-kind support of Froedtert Health leaders, staff and physicians with knowledge and expertise in behavioral health
• Identify service gaps within Froedtert Health
• Screen patients for underlying AODA/Mental Health Conditions
• Provide behavioral health coaching and referral to community services