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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Aurora Lakeland Medical Center

Implementation Approaches

Impact Goal: Increase linkages to appropriate care for behavioral health

Strategies:

  • Screen for behavioral health issues in the ED including mental health, depression, alcohol abuse and drug use, and provide follow-up care and referral as appropriate
  • 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

Impact Goal: Increase linkages to appropriate care for behavioral health

Strategies:

For our patients:

  • Screen for behavioral health issues in the ED including mental health, depression, alcohol abuse and drug use, and provide follow-up care and referral as appropriate
  • 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

For our community:

  • 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

Impact Goal: Increase linkages to appropriate care for behavioral health

Strategies:

  • 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

Impact Goal: Increase access to care

Strategies:

For our patients:

  • 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

For our community:

  • 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

Impact Goal:

  • Increased awareness and control of chronic disease
  • Decreased burden of hepatitis C across Aurora's population

Strategies:

For our patients:

  • 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

For our community:

  • Provide free outreach blood pressure screenings and education at various community locations/events
  • Provide free drop-in blood pressure screenings at Lake Geneva Clinic
  • 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.

Senior Care

Impact Goal: Reduced readmissions and admissions for falls

Strategies:

For our patients:

  • 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.

For our community:

  • Provide two 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 blood pressure screenings throughout the year.

Impact Goal: Increase linkages to appropriate care for behavioral health

Strategies:

For our patients:

  • Provide ABHS referrals through tele-intake services in our ED and through inpatient tele-psychiatry consultations
  • Screen for behavioral health issues in the ED including mental health, depression, alcohol abuse and drug use, and provide follow-up care and referral as appropriate

Impact Goal: Increased access to care for sexual assault

Strategies:

For our patients:

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

For our community:

  • Provide 12 community education/prevention/outreach trainings
  • Provide SANE monitoring at events held at Alpine Valley amphitheater, ensuring proactive support for individuals at-risk
  • Provide the award-winning Healthy Kids Club program, an interactive health education program for kindergarten students that teaches kindergartners about healthy habits, personal safety around strangers, safe touches, and appreciating the differences in individuals
  • 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

Behavioral Health

Impact Goal: Increase linkages to appropriate care for behavioral health

Strategies:

  • 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

Infant Mortality

Impact Goal: Decreased risks to infant health and safety

Strategies:

For our patients:

  • 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 baby boxes and referrals for portable cribs distributed by WCDHHS as needed

For our community:

  • Provide childbirth classes in English and Spanish
  • Provide educational classes to community residents:
    - Infant CPR classes
    - Two reduced-cost 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