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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Aurora Medical Center in Kenosha

Implementation Approaches

Impact Goal: Increased access to care

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 care to KCHC
  • Actively screen patients for coverage through the Marketplace or financial assistance programs and assist with application processes
  • Provide follow-up call to ED patients to assure they understand their discharge instructions, address any questions related to the visit and identify any barriers or obstacles
  • Provide Coverage to Care (C2C) program

For our community:

  • Support KCHC in providing medical, dental and behavioral health care to underserved populations in Kenosha and the surrounding area:
    - AHCMG obstetricians accept 10 patients per month
  • Aurora’s Better Together Fund grant (awarded in 2015) supports KCHC’s Mobile Medical Unit to provide care for medically underserved persons in neighboring Racine County, which does not have an FQHC

Impact Goal: Increased opportunity for stable employment, education

Strategies:

For our patients:

  • Through the Coverage to Care (C2C) program, provide intensive and systematic case-management for hospital ED high utilizers incorporating health care literacy, health care advocacy, health care coordination and health care homes. The service delivery of the C2C program: 
    - Focuses on the patient’s health beliefs and attempts to reshape those beliefs in a way that promotes effective health care utilization and management; 
    - Provides patients with necessary knowledge, skills and tools to successfully navigate the health care system and to advocate on their own individual health care needs and preferences; 
    - Considers the influence of patients’ cultural factors and pays particular attention to the impact of social determinants such as poverty, trauma, racism and mental health.

Impact Goal:
- Increased awareness and control of chronic disease
- Decreased burden of hepatitis C across Aurora's population

Strategies:

For our patients:

  • Provide two evidence-based Healthy Living with Diabetes programs annually, covering understanding diabetes, getting the right healthcare, monitoring blood glucose, learning about food and diabetes, adding activity to your life, understanding medications and living with diabetes (open and promoted to the public)
  • Implement Care Management strategies to address high blood pressure (BP) within our clinic population by: scheduling the patients’ 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
  • 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 community diabetes support group meetings facilitated by our diabetes educator with Aurora caregivers presenting relevant topics, such as pharmacy, physical fitness and rehab, nutrition and wellbeing
  • Provide community diabetes education classes, free of charge to all community residents
  • Provide monthly free outreach blood pressure screenings at various community locations/events

Impact goal: Decreased burden for persons diagnosed with cancer in Kenosha County

For our patients:

  • Provide cancer nurse navigators for all patients, regardless of payer status, to support them in their cancer treatment journey
  • Administer our distress tool and, as appropriate, refer patients to our principal and community partners for needed support services
  • Provide art therapy, aroma therapy and therapeutic massage free of charge, open to anyone with a cancer diagnosis
  • Provide Aurora Wig program to all patients free of charge

For our community:

  • Provide cancer screening and education at community events
  • Host annual Community Breast Cancer Fair at AMCK

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 and followed-up 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
  • Launch a Geriatric ED program for senior-friendly care
  • Collaborate with Kenosha Area Family and Aging Services, Inc. to provide therapist support for two Stepping On programs annually. Stepping On is a high-level, evidence-based program proven to reduce falls and build confidence in older people

For our community:

  • Conduct outreach activities led by SRNs throughout the year, including: 
    - Grief support groups 
    - Blood pressure screenings 
    - 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
  • Provide group exercise classes three times per week at the Kenosha Senior Center, led by an AHCMG/AMCK licensed athletic trainer
  • Provide annual senior health fair, with community access to Aurora senior resources including pharmacy, dietetics, benefits specialists, elder safety, Advance Directives, and bone density, blood pressure, and fall screenings, in addition to other local agency resources

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
  • Provide behavioral health coordinator in our ED to expedite behavioral health services referrals

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 based on the Federal Rules of Evidence
  • Referrals as appropriate to medical, clinical, counseling and advocacy services

For our community:

  • Provide community education/prevention/outreach trainings
  • In collaboration with Aurora Lakeland Medical Center, 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
  • Participate in the annual forum on human trafficking each spring
  • Participate in development and provision of a consistent, cohesive approach to sexual violence awareness and victim services at the University of Wisconsin – Parkside, Gateway Technical College and Carthage College
  • Promote two programs addressing the needs of victims of sexual assault and/or domestic violence at Women and Children’s Horizons

Impact Goal: Increased opportunity for stable employment, education

Strategies:

For our community:

  • Fund and provide clinical preceptorship site for three individuals in CNA training for future employment with AMCK
  • Host healthcare careers fair for community residents
  • Serve on community boards addressing social determinants:
    - Chief nursing officer on Boys & Girls Club board
    - Vice President of Operations on United Way board

Impact Goal: Decreased risks to infant health and safety

Strategies:

For our patients:

  • Provide bedside classes on baby care and breastfeeding to new mothers
  • Prior to discharge, provide: 
    – Free “infant nest” starter kits to new mothers 
    – Safe sleep and Halo sleep-sack education 
    – Car-seat safety education to new mothers prior to discharge; perform safety tests 
    – Education on effects of second-hand smoke; smoking cessation support 
    – Follow-up appointment scheduling with pediatrician
  • Conduct post-discharge follow-up calls for mothers and infants delivered at our hospital
  • Provide contact information to Kenosha County Division of Health to receive coupons for Pack ’N Plays

For our community:

  • Provide AHCMG obstetric care for 10 KCHC patients per month
  • Provide free classes on lactation, well-baby care, and prenatal education to community members
  • Collaborate with Kenosha County Division of Health on well-baby fair held at AMCK to cover topics noted above
  • Sponsor Racine Kenosha Community Action Agency Baby Expo, providing educational resources to approximately 200 attendees each year
  • Integrate infant mortality community outreach efforts via Fetal and Infant Mortality Review with our Parish Nursing outreach efforts