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University of Wisconsin–Madison

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