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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Aurora Medical Center in Burlington

Implementation Approaches

Impact goal: Increased linkages to appropriate screening and care for behavioral health

Strategies:
For our patients:

  • Provide ABHS nurse in our ED to assess and appropriately expedite referrals for behavioral health services
  • Provide behavioral health referrals through ABHS tele-psychiatric program
  • 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 linkages to appropriate screening and care for behavioral health

Strategies:

For our patients:

  • Provide ABHS nurse in our ED to assess and appropriately expedite referrals for behavioral health services
  • Provide behavioral health referrals through ABHS tele-psychiatric program
  • 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

For our community:

  • Provide training to EMS agencies and quarterly continuing education based upon needs identified by EMS agencies, run report trends and state requirements, including care for opioid overdoses
  • Provide medical oversight and training to law enforcement for Narcan administration
  • Support and actively engage in local drug Take-Back programs and promote availability of prescription drug collection boxes throughout the county

Impact goal: Increased access to care

Strategies:

For our patients:

  • Provide appropriate follow-up with non-emergent patients using the ED for primary care
  • Actively screen patients for coverage through the Marketplace or financial assistance programs and assist with application processes
  • Refer uninsured and self-pay patients using our ED for primary care to HCN

For our community:

  • Accept vouchers from Health Care Network for eligible diagnostic lab and radiology services

Impact goal: Increased opportunity for identification and management of chronic disease

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 Health Management Resources (HMR), an intensive, medically supervised weight-loss and lifestyle-change program designed to help participants lose weight and build healthy routines
  • As part of a system-wide population health strategy, identify and screen clinic patients at risk for hepatitis C; treat those who test positive

For our community:

  • Offer free blood pressure screenings in a variety of community settings and at community events
  • Provide educational information on blood pressure, cholesterol, stroke, chest pain, DASH diet and overweight/obesity
  • Provide free drop-in blood pressure screenings at AHCMG clinics
  • Facilitate Walk with a Doc program, providing primary care physicians one Saturday per month to walk with attendees and provide health education, encouraging physical activity and allowing participants to ask health-related questions in a non-clinical setting

Senior Health

Impact goal: Increase awareness and management of health issues among seniors

Strategies:

For our patients:

  • Assure that frail elderly patients and persons referred to our Senior Resource Nurses 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

For our community:

  • Provide Stepping On, a high-level, evidence-based program proven to reduce falls and build confidence in older people
  • Provide Strong Bodies, a 12-week exercise program including progressive weight training, flexibility, and balance activities designed to improve bone density, reduce falls, improve arthritis symptoms, improve flexibility and strength, and improve sleep quality and energy level
  • Provide Chronic Pain Self-Management and Powerful Tools for Caregivers programs on demand, as requested by community organizations

Impact goal: Increased linkages to appropriate screening and care for behavioral health

Strategies:

For our patients:

  • Provide ABHS nurse in our ED to assess and appropriately expedite referrals for behavioral health services
  • Provide behavioral health referrals through ABHS tele-psychiatric program
  • 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 with Aurora’s system-wide Sexual Assuault Nurse Examinier (SANE) program and AHAS, provide:

  • 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
  • Refer as appropriate to medical, clinical, counseling and advocacy services
  • Provide training for ED nurses on the signs of strangulation and human trafficking, increasing their ability to identify victims

For our community:

  • Provide 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

Impact goal: Increased knowledge about birth and childcare

Strategies:

For our community:

  • Provide childbirth classes in both English and Spanish
  • Provide two reduced-cost babysitting classes annually to area teens, with education on babysitting as a business, baby development, baby safety with CPR and choking, baby care, and including a video by the American Safety & Health Institute