Happy New Year!
Evolving Patient Navigation - In and Out of Health Care

Social determinants of health are factors like where we live, learn, work and play that shape our health. Our Center was founded 22 years ago on the population health model. A model that sets out to understand all the factors that contribute to a community’s health. Our colleagues at the UW Population Health Institute have estimated that the social and economic factors out weigh any other factor, including behavior and health care. There continues to be growing research linking the importance of addressing these social factors to improving the quality of life and life expectancy across communities. There is also a growing number of initiatives that seek to understand the best models for doing this, inside and outside of health care.

We have been fortunate to have partnered with a variety of organizations in Milwaukee to explore different models and have benefited from low turnover (average tenor is 9 years) in our team to bring organizational learnings along the way. One of the things we have learned over the years is that meeting people where they are and addressing their needs when they are ready is health equity, and everyone benefits.

Take a look, below, at a brief history of our journey of partnerships to help navigate and connect patients to resources to meet their social and economic needs.

If you have any questions or just want to set up a time to connect, please don't hesitate to email me directly at dfrazer@wisc.edu.

Thank you and have a good start to the new year.

David Frazer

Emergency Department to Medical Home Program 2009-2015

The Center partnered with the area health care systems and the Milwaukee Health Care Partnership to evaluate a then pilot to build a social work-based program within the area emergency departments and screen those who might not be requiring emergency room service and directly schedule them at their primary care provider or with an area federally qualified health center. An early study found cost avoidance estimate, based on 30% reduction in ED visits for those with scheduled appointments, was $2.3 million over six months in 2012. A later study found a 44% reduction in subsequent ED visits. More intensive ED transition care coordination models are being piloted for frequent users with complex health and social needs.

Outcomes: Healthier patients, unnecessary health care cost avoidance and improved use of health care.

Health Resource Center Embedded in a Free Clinic 2016-2018

The Center partnered with the Bread of Healing Clinic, a free clinic at the Cross Lutheran Church, and the Milwaukee Health Care Partnership to develop and evaluate a Health Resource Center. The model employed social workers, community health workers and team of students in medical and health related fields. Its goals were to support and guide uninsured patients for their social services and medical care coordination needs. The model quickly adapted to move participants through a well-defined path from screening, navigation and follow up. The program successfully assisted in getting participants enrolled in appropriate insurance and linked back to their primary or specialty health care systems where they could be supported by the area health systems.

Outcomes: Screened over 2,250 people who reported almost 600 social needs and more than 3,500 health care related needs. Over 60% had their social and medical needs were met through the initial pilot. 

Integrating Social Needs Screening in an FQHC 2019- present

Funded by the Wisconsin Partnership Program, this project, initiated in 2019, aims to gain a deeper understanding of the socio-economic factors, such as housing insecurity, that influence health on the south side of Milwaukee.

The process of implementing universal screening for social needs among primary care patients at Sixteenth Street Community Health Centers has been used to develop a collaborative model for health care and social service delivery to close these health gaps and improve health outcomes for patients.

As of mid-2022 the screening and referral model has been implemented in primary care settings with over 5,300 patients to date, 70 % in Spanish. The team has begun to understand what it takes to staff up and follow through with patients. Early evaluation has shown that housing insecurity and social isolation were most reported needs in 2021. Those who reported housing needs also report having significantly more other social needs than those who were housing secure.

Center Researcher, Michelle Corbett, MPH, CHES co-presented with SSCHC partners on the project as part of our anniversary series last year. Video Archive

Early Learnings: It takes a tremendous amount of capacity to integrate social needs screening and follow up in primary care settings. Providers report that it helps their patients. So far 77% of social needs were referred or a resource was provided and 66% of housing related needs were referred or a resource was provided. More work is needed to meet the housing needs in Milwaukee. 

Gees Clippers Wellness Clinic 2020 - present

In late 2019 the Center worked with Gee’s Clippers, Anthem Blue Cross Blue Shield, UW Center for Community Engagement and Health Partnerships, the City of Milwaukee Health Department, Froedtert and the Medical College, Aurora Health Care and Hayat Pharmacy to launch a wellness clinic in Gee’s Clippers barbershop. The aim is not only to provide basic medical care but also to connect residents to services to help overcome challenges with education, employment, housing, health and food insecurity that are critical to overall wellness. “Wellness Gee’niuses” work with the barbers and their clients to identify their needs and work with them to meet each need on site or help them navigate the broader system in Milwaukee.

Early Learnings: Like everyone, this program was paused for much of COVID and vaccine clinics were set up in its place to meet the need. Overall, the leading services and referrals include additional health education, access to follow up health care services and healthy lifestyle programming. Strong partnerships make this unique program possible. 

Out and About

The Voices of Gun Violence Project, a collaboration between UW-Milwaukee (CUPH staff), Carroll University, and Mother’s Against Gun Violence participated in the Latino Arts, Inc. Day of the Dead Ofrendas event and the Wisconsin Network for Peace and Justice Fall Assembly.

The posters shared information about the Milwaukee Bus Stop Murals around the city of Milwaukee that showcase stories of those impacted by gun violence.

Learn more about Voices of Gun Violence Project.