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University of Wisconsin–Madison

Assessing and Improving Community Health in Wisconsin

Aurora Sinai Medical Center

Implementation Approaches

Based upon the evidence-based Wholesome Wave FVRx fruit and vegetable prescription program, provide:

  • Nutrition counseling and educational materials
  • Fruit and vegetable prescriptions, written by a medical provider and redeemable at a local food market
  • A guide on shopping at the market including the fruits and vegetables that are available and how to store and use them
  • Provide care to pregnant women addicted to opioids


  • Participate in the MHCP Emergency Care Coordination Initiative to link Medicaid-eligible and uninsured patients with medical homes in the Milwaukee area by scheduling appointments in the ED
  • Triage Medicaid-eligible and uninsured patients in our ED to the 12th Street Urgent Care clinic adjacent to our ED and promote referrals to Kilbourn Avenue Health Center in our physician office building
  • Provide prescriptions upon discharge free of cost to uninsured patients who lack resources through the Aurora Essential Medication Fund
  • Provide the coordination of refugee health screenings and primary medical care


  • 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


  • Screen and diagnose patients for hepatitis C in primary care and specialty clinics
  • Manage, treat and track all patients diagnosed with hepatitis C


  • Provide immediate, acute care and forensic nursing to individuals who have been sexually assaulted
  • Provide community education/prevention/outreach presentations
  • Innovate new ways to assess, prevent and respond to sexual assault in our community by convening the Milwaukee Sexual Assault Review
  • Expand sexual assault forensic nursing and crisis counseling to reach victims in community based programs / settings through Aurora SANE and crisis counselor placed at Sojourner Family Peace Center
  • Provide individual and family counseling for survivors of sexual assault and their families
  • Provide support groups including: Survivors Toward Recovery, Men’s Group, Sexual Wholeness, Adult Rape/Sexual Assault, Adults Molested as Children
  • Survey counseling and support group participants for improvements in mental health and coping techniques
  • Conduct community education and sexual assault advocacy training to teach professionals, mental health service providers and community members about sexual violence and how to advocate for survivors
  • Provide training to physicians, nurses, social workers, medical residents and other health care providers on domestic violence and trauma-informed care at ASMC and Aurora’s other Milwaukee County hospitals
  • Serve as a resource for all Aurora staff with questions about referring or treating patients reporting domestic violence
  • Conduct clinical visits with ED patients to provide advocacy and counseling regarding shelters, restraining orders, transportation, additional counseling or other community resources
  • Provide support to abused pregnant women through case management, education and advocacy, including intensive case management when needed

Infant Mortality


  • Provide home visiting services for expectant and new parents and their families, including ongoing family centered case management services, in-home parent education, assistance with navigating the health system, support and advocacy, managing stress and anger, completing school and learning skills
  • Provide CenteringPregnancy groups
  • Provide care to pregnant women addicted to opioids
  • Provide Baby Boxes to all mother delivering at ASMC
  • Refer mothers who did not deliver at ASMC to Stork and Company