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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

St. Joseph's Hospital, West Bend

Implementation Approaches

Goal: To provide knowledge our community needs and the access necessary for early intervention and continued treatment of mental illness and/or substance abuse

Objective: Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

Actions:

  • Actively participate in the coalition
  • Provide clinical support/education through internal behavioral health resources
  • Collaboration with Albrecht Free Clinic, Casa Guadalupe Education Center Community Health Navigators and AODA screening and referral networks.

Goal: To provide knowledge our community needs and the access necessary for early intervention and continued treatment of mental illness and/or substance abuse

Objective: Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

Actions:

  • Actively participate in the coalition
  • Provide clinical support/education through internal behavioral health resources
  • Collaboration with Albrecht Free Clinic, Casa Guadalupe Education Center Community Health Navigators and AODA screening and referral networks.

Goal: Expand assistance and support of the Albrecht Free Clinic to improve access to healthcare for uninsured and underinsured populations.

Objective: Strengthen our collaborative partnership with Albrecht Free Clinic and community stakeholders to increase access to preventative and primary care, improve quality and reduce costs

Actions:

  • Continue referral process for uninsured/underinsured populations from St. Joseph’s Hospital to Albrecht Free Clinic
  • Serve on Board of Directors
  • Provide vouchers for ancillary/specialty care services for AFC patients
  • Screen uninsured patients for financial assistance programs (Marketplace, BadgerCare etc) including Froedtert Health’s Financial Assistance Program

Goal: Expand assistance and support for the Community Health Worker network to improve access to healthcare services for vulnerable populations.

Objective: Increase the number of health education programs and activities conducted at various community-based settings and referrals to primary care and medical homes

Actions:

  • Provide financial support through a community grant that covers the expenses for two Community Health Navigators at Albrecht and Casa Guadalupe
  • Integrate Community Health Navigators with SJH/CP Clinical Leaders and Staff
  • Conduct routine evidence based health prevention and management programs (Living Well with Chronic Conditions, Community Education Programs etc.)

Goal: Impact 211 call center and website will be the premier information and referral service provider in Washington County

Objective: Increase utilization and awareness of Impact 211 service for the health and wellbeing of individuals, organizations, and workplaces in Washington County

Actions:

  • Assess the current state of Washington County organizations, programs and services available in in Impact 211 database
  • Participate in Impact 211 database education and training session to further understand the functionality and capabilities of the system
  • Working with Impact 211 staff, facilitate multiple Impact 211 database training sessions for Washington County area businesses and non-profit organizations

Goal: Reduce readmission rates and increase timely access to care for individuals living with Chronic Conditions (Pneumonia, Congestive Heart Failure, Diabetes and Stroke)

Objective: Provide wellness checks within 72 hours of discharge for high risk populations

Actions:

  • Develop Community Paramedicine Pilot Program
  • Seek funding from St. Joseph’s Community Foundation for funding and support pilot program
  • Identify patients at risk for readmission and develop referral and tracking process with West Bend Fire and Rescue
  • Provide clinical oversight and education for patients and community partners involved

Goal: Expand assistance and support for the Community Health Worker network to improve access to healthcare services for vulnerable populations.

Objective: Increase the number of health education programs and activities conducted at various community-based settings and referrals to primary care and medical homes

Actions:

  • Provide financial support through a community grant that covers the expenses for two Community Health Navigators at Albrecht and Casa Guadalupe

  • Integrate Community Health Navigators with SJH/CP Clinical Leaders and Staff

Goal: Support non-profit organizations and resources that will promote healthy lifestyle choices as well as provide support for programs and services committed to the promotion of health and wellness in Washington County

Objectives:

-Increase self-management in high risk populations by addressing social determinants in health
-Expand health resources to assist, support, and navigate through community based clinical services and insurance coverage

Actions:

  • Facilitation and management of Healthy Community Fund operations and committee functions
  • Restricted grant funding to non-profit organizations that address community health needs
  • Monitoring outcomes and impact for organizations receiving HCF funding
  • Promotion and awareness of impact of funding with Washington County residents and partners

Goal: Reduce readmission rates and increase timely access to care for individuals living with Chronic Conditions (Pneumonia, Congestive Heart Failure, Diabetes and Stroke)

Objective: Provide wellness checks within 72 hours of discharge for high risk populations

Actions:

  • Develop Community Paramedicine Pilot Program
  • Seek funding from St. Joseph’s Community Foundation for funding and support pilot program
  • Identify patients at risk for readmission and develop referral and tracking process with West Bend Fire and Rescue
  • Provide clinical oversight and education for patients and community partners involved

Goal: Decrease the cancer mortality rate in Washington County

Objective: Implement programs to increase cancer awareness, screening and early detection

Actions:

  • Dedicated nurse navigators working with patients receiving care in the Kraemer Cancer Center and provide assessment and referrals for health system and community resources
  • Screen all uninsured patients for financial assistance programs through the Marketplace or government sponsored programs
  • Execute a minimum of two community cancer screening programs per year
  • Execute quarterly cancer awareness and education events (classes, health fairs, events etc.)

Goal: Reduce morbidity and mortality from chronic conditions

Objective: Increase self-management for individuals living with chronic conditions and reinforce healthy lifestyles to encourage behavior change

Actions:

  • Facilitate a minimum of three Living Well with Chronic Conditions/Diabetes programs each year
  • Explore new community partners/agencies in Washington County to hold Living Well programs
  • Identify bilingual resources for teaching Living Well series for Spanish speaking populations and connect to a medical home

Goal: Improve the behavioral health of Washington County

Objective: Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

Actions:

  • Actively participate in the Washington County Community Health Coalition
  • Identify service gaps within Froedtert Health

Goal: To provide knowledge our community needs and the access necessary for early intervention and continued treatment of mental illness and/or substance abuse

Objective: Increase community awareness of mental health and alcohol and other drug abuse problems and collaborate for better case management and navigation of treatment

Actions:

  • Actively participate in the coalition
  • Provide clinical support/education through internal behavioral health resources
  • Collaboration with Albrecht Free Clinic, Casa Guadalupe Education Center Community Health Navigators and AODA screening and referral networks.