Assessing and Improving Community Health in Wisconsin
Community Memorial Hospital-Menomonee Falls
Implementation Approaches
-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