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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Aurora Lakeland Medical Center

Implementation Approaches

  • Partner with WCDHHS to provide referrals to women: – Women’s alcohol and other drug abuse (AODA) Wrap-Around program – My Baby & Me program to reduce alcohol use during pregnancy – First Breath program to reduce smoking during pregnancy
  • Screen primary care patients for problematic alcohol use
  • Partner with WCDHHS to provide referrals to women: – Women’s alcohol and other drug abuse (AODA) Wrap-Around program – My Baby & Me program to reduce alcohol use during pregnancy – First Breath program to reduce smoking during pregnancy
  • Educate and train local EMS providers about current heroin use to facilitate appropriate early response
  • Provide medical oversight and training to law enforcement in Narcan administration, including Walworth County Sheriff and Lake Geneva Police Department
  • Partner with WCDHHS to provide referrals to women: – Women’s alcohol and other drug abuse (AODA) Wrap-Around program – My Baby & Me program to reduce alcohol use during pregnancy – First Breath program to reduce smoking during pregnancy
  • Provide appropriate follow-up with non-emergent patients using our emergency department (ED) for primary care
  • Refer uninsured and self-pay patients using our ED for primary and dental care to OAFC
  • Actively screen patients for coverage through the Marketplace or financial assistance programs and assist with application processes
  • Provide follow-up calls to ED patients to assure they understand their discharge instructions, address any questions related to the visit and identify any barriers or obstacles
  • Provide free radiology and specialty services to patients referred by OAFC
  • Conduct (with our AHCMG partner) a cardiology clinic one evening per month at OAFC
  • Continue to support increased care-coordination and continued expansion of behavioral health services at OAFC
  • Provide free outreach blood pressure screenings and education at various community locations/events
  • Continue to support increased care-coordination and continued expansion of behavioral health services at OAFC
  • Provide ABHS referrals through tele-intake services in our ED and through inpatient tele-psychiatry consultations
  • Provide suicide risk screening to ED patients
  • Screen primary care patients for problematic alcohol use
  • Partner with WCDHHS to provide referrals to women: – Women’s alcohol and other drug abuse (AODA) Wrap-Around program – My Baby & Me program to reduce alcohol use during pregnancy – First Breath program to reduce smoking during pregnancy
  • Assure that frail elderly patients and persons referred to our SRNs are assessed for: – Behavioral health needs – Cognitive impairment (using MoCA Montreal Cognitive Assessment) – Family and social support – Home visits when possible – Nutrition needs – Pharmaceutical assistance program – Safe-At-Home or appropriate supportive placements – Transportation needs for follow-up care
  • Provide patient education and support for: - Advance Directives (Power of Attorney) - Family guidance and support services - Medication management/safety

Consistent within Aurora’s system-wide Sexual Assault Nurse Examiner (SANE) program and AHAS, 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
  • Referrals as appropriate to medical, clinical, counseling and advocacy services
  • Continue Care Management strategies to address high blood pressure (BP) within our clinic population by scheduling the patient’s 6-month hypertension follow-up visit before they leave the clinic; rechecking any BP 140/90 or higher; scheduling for a 1-2 week nurse visit if BP remains elevated; scheduling with provider if BP remains elevated at nurse visit
  • Provide two evidence-based Healthy Living with Diabetes programs annually, open and promoted to the community covering understanding diabetes, getting the right health care, monitoring blood glucose, learning about food and diabetes, adding activity to your life, understanding medications and living with diabetes
  • As part of a system-wide population health strategy, identify and screen patients at risk for hepatitis C; treat those who test positive
  • Provide free outreach blood pressure screenings and education at various community locations/events
  • Include the Expectation Management and Medical Information (EMMI) program, as used within our patient population, in conjunction with chronic disease outreach and screenings
  • Provide education on a variety of chronic disease-related topics including hypertension, stroke, heart disease, chest pain, sexual assault, injury prevention, and women’s health at the Walworth County Fair. A dry event with over 135,000 attendees in 2016, the Walworth County Fair provides an excellent opportunity to interface with community residents who might not otherwise be reached or attend our events.
  • Assure that frail elderly patients and persons referred to our SRNs are assessed for: – Behavioral health needs – Cognitive impairment (using MoCA Montreal Cognitive Assessment) – Family and social support – Home visits when possible – Nutrition needs – Pharmaceutical assistance program – Safe-At-Home or appropriate supportive placements – Transportation needs for follow-up care
  • Provide patient education and support for: - Advance Directives (Power of Attorney) - Family guidance and support services - Medication management/safety
  • Provide Hospital Elder Life Program© (HELP and HELP at Home) elder care nursing program. HELP is an evidence-based program comprised of six protocols targeting key risk factors of delirium that are deployed by trained and supervised volunteers under the direction of an Elder Life Specialist. HELP decreases the onset and/or length of delirium episode and functional decline in hospitalized older adults, and is a cost-effective method for improving outcomes.
  • Provide four Stepping On sessions annually. Stepping On is a high-level, evidence-based program proven to reduce falls and build confidence in older people.
  • Additionally, SRNs conduct outreach activities led by SRNs throughout the year, including: - Grief support groups - Blood pressure screenings - Clergy trainings - Presentations to law enforcement on identifying “at-risk” elderly in the community in relation to dementia and delirium, common triggers for agitation and challenging behaviors related to dementia, and tips to deescalate crisis situations
  • Continue to support increased care-coordination and continued expansion of behavioral health services at OAFC
  • Provide ABHS referrals through tele-intake services in our ED and through inpatient tele-psychiatry consultations
  • Provide suicide risk screening to ED patients
  • Screen primary care patients for problematic alcohol use
  • Partner with WCDHHS to provide referrals to women: – Women’s alcohol and other drug abuse (AODA) Wrap-Around program – My Baby & Me program to reduce alcohol use during pregnancy – First Breath program to reduce smoking during pregnancy
  • Provide educational classes to community residents: – Infant CPR classes – Two babysitting classes per year to area teens, with education including babysitting as a business, baby development, baby safety with CPR and choking, baby care, and include a video by the American Safety & Health Institute
  • Provide education to new mothers prior to discharge on: – Car seat safety – Infant safe sleep
  • Provide 12 community education/prevention/outreach trainings
  • In collaboration with Aurora Medical Center in Kenosha, participate in Country Thunder music festival sexual assault education by providing SANE nurse coverage from 2:00 p.m. to 10:00 p.m. each day at two different locations within the festival grounds, along with providing a public service announcement about sexual assault to be played between each musical act throughout the four-day event, which reaches approximately 20,000 attendees
  • Support expansion of sexual assault treatment capacity and advocacy services for teens and elders at the Association for the Prevention of Family Violence – Walworth County
  • Participate in training to expand sexual assault treatment capacity and advocacy services, including a new child abuse and neglect therapy program, through the Walworth County Alliance for Children

Consistent within Aurora’s system-wide Sexual Assault Nurse Examiner (SANE) program and AHAS, 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
  • Referrals as appropriate to medical, clinical, counseling and advocacy services

Infant Mortality

  • Staff our Lactation Center with International Board-Certified Lactation Consultants accessible seven days a week to: – Provide telephone consults, advice, support and schedule outpatient consults – Inform mothers about – and promote – available resources, such as Lactation Consultants, Peer Counseling and Lactation Rooms, within their county of residence
  • Provide education to new mothers prior to discharge on: – Car seat safety – Infant safe sleep
  • Provide referrals for portable cribs distributed by WCDH
  • Provide four Spanish-language childbirth classes per year
  • Provide educational classes to community residents: – Infant CPR classes – Two babysitting classes per year to area teens, with education including babysitting as a business, baby development, baby safety with CPR and choking, baby care, and include a video by the American Safety & Health Institute