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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Gundersen Lutheran Medical Center

Implementation Approaches

Identified Need/Issue: Reduce obesity & rate of diabetes

Goal: Leverage community partnerships to address obesity and improve outcomes among patients with diabetes

Actions:

  • Develop dashboard that will identify and monitor impact of services
  • Continue to develop weight loss initiatives (Winning Weighs, LEAP)
  • Deliver or partner with the HLC to implement disease management programs (HLWD, Dig Deep, Diabetes Support Group)
  • Address policies related to offering free or reduced cost services (i.e. anti-kickback, Stark)
  • Provide education and resources that engage the community (Minutes in Motion, 5210, other wellness challenges, Farm to School, Complete Streets)

Identified Need/Issue: Livable wage

Goal: Reduce the impact of poverty on poor health by 5% by 2021, by partnering with communities to address SDOH

Actions:

  • Address food insecurity in our service area by increasing screening of patients and partnering with related community organizations

Identified Need/Issue: Mental health & substance abuse

Actions:

  • Develop dashboard that will identify and monitor impact of services
  • Alliance to HEAL (IHI initiative)
  • Continue participation in community collaboratives (i.e.: Change Direction, LCPN, Better Together)
  • Support community recovery coaches
  • Reduce the number of patients exposed to opioids in the management of pain
  • Reduce harmful effects of drug addiction in pregnancy (Gunderkids)

Identified Need/Issue: Livable wage

Goal: Reduce the impact of poverty on poor health by 5% by 2021, by partnering with communities to address SDOH

Actions:

  • Continue to support and develop the current HUB model
  • Support the implementation of Social Determinants of Health screening and referral for Gundersen Health System patients and families

Identified Need/Issue: Reduce obesity & rate of diabetes

Goal: Leverage community partnerships to address obesity and improve outcomes among patients with diabetes

Actions:

  • Develop dashboard that will identify and monitor impact of services
  • Continue to develop weight loss initiatives (Winning Weighs, LEAP)
  • Deliver or partner with the HLC to implement disease management programs (HLWD, Dig Deep, Diabetes Support Group)
  • Address policies related to offering free or reduced cost services (i.e. anti-kickback, Stark)
  • Provide education and resources that engage the community (Minutes in Motion, 5210, other wellness challenges, Farm to School, Complete Streets)

Identified Need/Issue: Mental health & substance abuse

Goal: Reduce number of deaths due to poor mental health and substance abuse and reduce the number of poor mental health days by 5%

Actions:

  • Develop dashboard that will identify and monitor impact of services
  • Alliance to HEAL (IHI initiative)
  • Continue participation in community collaboratives (i.e.: Change Direction, LCPN, Better Together)
  • Support community recovery coaches

Identified Need/Issue: Livable wage

Goal: Reduce the impact of poverty on poor health by 5% by 2021, by partnering with communities to address SDOH

Actions:

  • Develop dashboard that will identify and monitor impact of services
  • Continue to support housing needs in La Crosse & Region
  • Continue to support affordable transportation options available throughout the region
  • Support Neighborhood Plan (PPH) & JDC

Identified Need/Issue: Mental health & substance abuse

Actions:

  • Reduce harmful effects of drug addiction in pregnancy (Gunderkids)

Identified Need/Issue: Wraparound support throughout the lifespan to improve quality of life

Goal: Augment and disseminate wrap around services for children and adults that will improve selected outcomes by 5% (determined by dashboard)

Actions:

  • Develop dashboard that will identify and monitor impact of services
  • Create a trauma-informed community
  • Provide education and resources that enhance ability for older adults to stay active and independent for as long as possible (falls prevention, caregiver support, dementia care, healthy aging)
  • Continue rollout of coping/resilience program at schools (based on Heartmath methodology) and other locations
  • Offer programming to meet the needs of disadvantaged students
  • Support social diversity through education and involvement in community organizations/coalitions