1. health and fitness

Community Health Needs Assessment
Implementation Strategy
Milwaukee 2013
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Our community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Addressing our community’s needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Children’s Hospital action steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Priority #1: access to mental, oral and primary health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Mental health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Adoption therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Child and family counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Psychiatry and Behavioral Medicine Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Oral health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Children’s Hospital of Wisconsin Dental Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Coordinating for Better Oral Health workgroup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dental exams and services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Wisconsin Seal-A-Smile Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Milwaukee Oral Health Task Force – Emergency Room Diversion Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Earlier Is Better . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Community Health Navigators Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Medical Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
School nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Priority #2: obesity and weight management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Coordinated school health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Healthy shopping education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Milwaukee Childhood Obesity Prevention Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Mission: Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Priority #3: infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Healthy Mom Healthy Baby . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Medical Home Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Priority #4: sexual health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Healthy Kids, Healthy Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Pregnancy Counseling and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Priority #5: community and home safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Access and Visitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Act Now! Bullying Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Child Protection Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Project Ujima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Safe Kids: injury prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Treatment Foster Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
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Introduction
In 2013, Children’s Hospital of Wisconsin and four other Milwaukee-area health systems commissioned a
comprehensive community health needs assessment to:
• Provide baseline information about the health status of our community;
• Assess the health needs of our community;
• Identify areas for improvement that Children’s Hospital could meaningfully impact;
• Prioritize community benefit programming at Children’s Hospital.
Through a process of primary research, data analysis, validation and prioritization, the assessment process
identified the following priorities for Children’s Hospital:
• Access to mental, oral and primary healthcare
• Obesity and weight management
• Infant mortality
• Sexual health
• Community and home safety
These priorities from the community health needs assessment were shared with community partners, staff and
stakeholders and action plans were developed for each health issue. The following pages outline the strategies
Children’s Hospital has deployed to meet the community’s health needs.
The full community health needs assessment can be found at chw.org.
About Children’s Hospital
Children’s Hospital is the region’s only independent health care system dedicated solely to the health and
well-being of children. The hospital, with locations in Milwaukee and Neenah, Wis., is recognized as one of the
leading pediatric health care centers in the United States. Children’s Hospital provides primary care, specialty
care, urgent care, emergency care, community health services, foster and adoption services, child and family
counseling, child advocacy services and family resource centers. In 2011, Children’s Hospital invested more
than $100 million in the community to improve the health status of children through medical care, advocacy,
education and pediatric medical research. Children’s Hospital achieves its mission in part through donations
from individuals, corporations and foundations and is proud to be a Children’s Miracle Network Hospital.
Children’s Vision
The Children’s Hospital vision is simple – to
have the healthiest kids in the country live in
Wisconsin. As the map to the right shows, the
foundation is internal integration – building
a culture without silos where resources are
aligned to achieving the vision. The strategy
includes external collaboration as a large
part of the process, acknowledging that no
organization can achieve such an enormous
goal alone. Above all, this strategy map puts
healthy kids at the center of every decision
made at Children’s Hospital.
For more information about Children’s
Hospital, visit the website at chw.org.
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Our community
Children’s Hospital’s main campus is located in Milwaukee County, Wisconsin. Although Children’s Hospital
serves children and youth in communities across the entire state of Wisconsin and Midwest, we defined our
community as the children and youth in southeastern Wisconsin, including Milwaukee, Waukesha, Racine,
Kenosha, Ozaukee and Washington counties, for the purposes of the CHNA. The CHNA results showed that
the highest levels of needs are in the city of Milwaukee and, therefore, in alignment with our core values and
mission, Children’s Hospital has focused on and invested in significant resources to address health disparities in the
city of Milwaukee’s lowest income neighborhoods.
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Lake Michigan
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Children’s Hospital
of Wisconsin
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43
94
Milwaukee
894
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94
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Addressing our community’s needs
During the community health needs assessment process, eight broad health needs were identified by
community residents, public health officials and other health stakeholders:
• Health care access and coverage
• Behavioral health
• Obesity, nutrition and physical activity
• Chronic disease
• Infant mortality
• Sexual health
• Health literacy
• Disparate impact: race, ethnicity, education and income
After these needs were identified, Children’s Hospital created a set of high priorities meant to address the
community’s most pressing health needs. Because Children’s Hospital is a pediatric specialty hospital, it is
important to focus our attention and resources on areas where we can make the biggest impact on the health
of children. Considerations for prioritization included clear alignment with Children’s Hospital’s mission and
vision, the scope of the problem, the availability of the necessary resources to adequately address the issue
and the projected capacity of Children’s Hospital to create a positive impact on the issue.
The following issues were identified as the highest health needs of the pediatric community and the highest
priorities for Children’s Hospital:
Priority #1: Access to mental, oral and primary health care
Priority #2: Obesity and weight management
Priority #3: Infant mortality
Priority #4: Sexual health
Priority #5: Community and home safety
We believe that we have aligned our priorities to best meet each of the health needs identified by the community.
Children’s guiding priority: Priority #1
Community need identified: Health care access and coverage
Health care access and health insurance coverage were identified as a concern, issue or need in every
assessment conducted in connection with the Community Health Needs Assessment. This includes responses
from community members, public health officials, staff members and clinical providers.
Community need identified: Behavioral health
Community members who participated in the survey identified alcohol and drug use as the top priority for the
community, whereas mental health emerged as the top priority issue for Key Informants.
Community need identified: Chronic disease
The Milwaukee County Community Health Survey revealed increasing rates of high blood pressure, diabetes
and asthma in the overall population. More concerning, rates for heart failure, diabetes and chronic
obstructive pulmonary disease were significantly higher in the lowest income ZIP codes compared to the
highest income ZIP codes in Milwaukee County.
Community need identified: Health literacy
Stakeholders identified issues relating to how health information is disseminated, accessed and understood.
Challenges to navigating complex health systems also were noted.
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Children’s guiding priority: Priority #2
Community need identified: Obesity, nutrition and physical activity
The combined reports suggest that consumption of fruits and vegetables is on the decline and access to fresh
produce has not increased. Key Informants identified obesity as a top concern.
Community need identified: Health literacy
Stakeholders identified issues relating to how health information is disseminated, accessed and understood.
Challenges to navigating complex health systems also were noted.
Children’s guiding priority: Priority #3
Community need identified: Infant mortality
Infant mortality is a top issue for Key Informants and community residents alike. Low birth weight, prematurity
and receiving late or no prenatal care are risk factors for infant mortality seen at high rates in Milwaukee’s
lowest income ZIP codes.
Community need identified: Health literacy
Stakeholders identified issues relating to how health information is disseminated, accessed and understood.
Challenges to navigating complex health systems also were noted.
Children’s guiding priority: Priority #4
Community need identified: Sexual health
The Henry J. Kaiser Family Foundation estimates there are more than 200,000 new cases of sexually transmitted
infections in Wisconsin each year. Rates for teenage pregnancy and sexually transmitted infection in Milwaukee
continue to be some of the highest in the U.S. Teenage birth rates, chlamydia and HIV infection have high risk
ratios in Milwaukee’s lowest income ZIP codes compared to the highest income ZIP codes.
Community need identified: Health literacy
Stakeholders identified issues relating to how health information is disseminated, accessed and understood.
Challenges to navigating complex health systems also were noted.
Children’s guiding priorities: Priorities #1, #2, #3, #4, #5
Community need identified: Disparate impact: race, ethnicity, education and income
The Community Health Needs Assessment confirmed the persistence of racial, ethnic and socioeconomic
disparities and recognized these issues continue to impact the community’s health.
Community need identified: Health literacy
Stakeholders identified issues relating to how health information is disseminated, accessed and understood.
Challenges to navigating complex health systems also were noted.
Children’s Hospital action steps
Children’s Hospital recognizes these issues are large in magnitude and complicated. Solving these issues will
require the effort of many people in the community. No single organization has the resources necessary to
address every issue identified in this assessment. However, Children’s Hospital is committed to working with
community partners to leverage all available resources to ensure the best care possible for the children in our
community. Children’s Hospital will address the priority health issues identified through the community health
needs assessment process through programming, collaboration and education.
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The following sections will provide more information on the work Children’s Hospital is undertaking in the areas
of access to mental, oral and primary healthcare, obesity and weight management, infant mortality, sexual
health, and community and home safety.
Priority #1: access to mental, oral and primary health care
Mental health care
Adoption therapy
This is an outpatient counseling program designed to meet the unique needs of pre- and post-adoptive
children and their families. The adoption therapist also may conduct bonding/attachment assessments to
facilitate decision making in the adoption process. No one is turned away for inability to pay.
Child and family counseling
Children’s Hospital’s counseling programs are based on the idea that a child lives within a family, and a
family lives within the community. Our therapists deal with the big picture while working with children, parents
and other family members to address problems and improve social and emotional difficulties. Traumainformed counseling services can reduce stress and conflict, improve parenting skills and strengthen family
ties. Our therapists work primarily with kids who have been victims of child maltreatment or community-based
interpersonal violence. We’ve also provided services to victims of mass casualty. No one is turned away for
inability to pay.
Psychiatry and Behavioral Medicine Center
The Child and Adolescent Psychiatry and Behavioral Medicine Center provides mental health diagnostic
and treatment services to children and families. Staff includes experts in the fields of child and adolescent
psychiatry, pediatric psychology, neuropsychology and psychotherapy.
We offer diagnosis and treatment for:
• Adjustment to an illness or life circumstance
• Anxiety disorders
• Attachment disorders
• Attention deficit hyperactivity disorder (ADHD).
• Behavioral disorders of childhood
• Bipolar disorder
• Child abuse and neglect
• Depression.
• Psychotic disorders.
Oral health care
Children’s Hospital of Wisconsin Dental Centers
Children’s Hospital operates four dental centers in Milwaukee dedicated to providing comprehensive oral
health services for infants, children, adolescents and young adults, regardless of their ability to pay. In 2012,
Children’s Hospital Dental Centers had more than 27,000 visits.
Strategic partners include the Child Protection Center, Next Door Foundation, Clark Street School, Lloyd Street
School and the Downtown Health Center.
Locations: Downtown Health Center, Metcalf Park, North Avenue and Children’s Hospital in Milwaukee.
Coordinating for Better Oral Health workgroup
Children’s Hospital Community Health leads Coordinating for Better Oral Health, an active workgroup that
brings together both Children’s Hospital resources and community resources – from clinical to community
– all focused on the goal of improving student’s overall oral health. Participants include community-based
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organizations in addition to Children’s Hospital school nurses, community health educators, as well as Children’s
Hospital clinical managers and hygienists. These participants work together to better understand patient
families’ needs, barriers and identify ways in which more families can access oral health services.
Dental exams and services
Children’s Hospital provides case management services for children in the child welfare system in Milwaukee
County. One target that is closely monitored is compliance with getting children in for medical and dental
exams in a timely manner, which is defined as receiving medical and dental care in accordance with the
schedule of the Wisconsin Medicaid Health Check program. The figure below illustrates rates for dental exams:
Children’s Hospital Performance, Calendar Year 2013
Month
Children needing
a dental exam
Children up-to-date
on dental exam
Percent up to-date
on dental exam
January 2013
798
740
93%
February 2013
781
731
94%
March 2013
786
712
91%
April 2013
795
745
94%
May 2013
793
722
91%
June 2013
804
675
85%
YTD
4757
4325
91%
In 2012, 50.3 percent of children enrolled in Children’s Community Health Plan in Southeast Wisconsin (Milwaukee,
Waukesha, Racine, Kenosha, Washington and Ozaukee counties) had a dental service provided by a dentist or
primary care physician. For children residing in Milwaukee County, the rate was similar – 50.5 percent.
In 2011, 46.1 percent of children enrolled in CCHP in Southeast Wisconsin (Milwaukee, Waukesha, Racine,
Kenosha, Washington and Ozaukee Counties) had a dental service provided by a dentist or primary care
physician. Rates from other HMOs were 41.7 percent, United Healthcare, 36.9 percent, Community Connect,
and 33.9 percent, Molina.
Wisconsin Seal-A-Smile Program
The Wisconsin Seal-A-Smile program targets children in elementary schools with more than 35 percent of
students who receive free or reduced school lunches in the City of Milwaukee. During the 2011-12 school year,
preventive dental services were provided to more than 11,400 children at 82 Milwaukee area schools.
Milwaukee Oral Health Task Force – Emergency Room Diversion Program
The Milwaukee Oral Health Task Force is a group of organizations with resources to improve access to oral
health providers in Milwaukee. Emergency Room Diversion is a pilot program created to divert adult patients
presenting in emergency rooms at two area hospitals to dental providers for necessary care. Initial data from
this pilot shows that there are one to two patients daily that are referred to an oral health provider. In 2014, the
program will be evaluated using MyHealthDirect, a custom health software that will collect data on referrals
and appointments.
Earlier Is Better
Earlier is Better is an early oral health education program that targets Early Head Start children at two locations
in Milwaukee: Bruce Guadalupe and Next Door Foundation.
Primary care
The need for accessible and affordable health care has never been greater. By increasing access to primary
care services, chronic diseases like asthma, juvenile arthritis or Crohn’s disease will be better managed and
decrease utilization for specialty care. Children’s Hospital works to provide every child access to the best
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care possible and strives to make care accessible closer to home. Our primary care clinics are dedicated to
providing quality pediatric primary care for children and adolescents in Milwaukee, regardless of their ability
to pay. Children’s Hospital operates 18 primary care clinics throughout southeast Wisconsin, with 5 clinics in
Milwaukee. Three of these clinics, the Downtown Health Center, Next Door Pediatrics and Dental Center, and
Good Hope Pediatrics have a long history of operation in Milwaukee. In 2012, these three clinics served more
than 18,000 children. The two other clinics, Children’s Hospital primary care clinic at COA Goldin Center and
Children’s Hospital primary care clinic at the Northside YMCA, opened in partnership with Marquette University
College of Nursing in 2013 to address health care disparities in high need neighborhoods.
Community Health Navigators Program
The community health navigators serve families living in three neighborhoods in Milwaukee’s inner city: Amani,
Metcalfe Park and Lindsay Heights. Community health navigators build relationships with families and link
them to established resources within their communities that work to improve overall health and well-being. The
navigators also serve as neighborhood capacity builders bringing a combination of awareness and education
about more resources available for residents in underserved neighborhoods.
The navigators serve about 30 families each month in each neighborhood. This means more than 1,000 families
have received help that is tailored to their needs in navigating through health care systems.
Medical Exams
Children’s Hospital provides case management services for children in the child welfare system in Milwaukee
County. One target that is closely monitored is compliance with getting children in for medical and dental exams
in a timely manner, which is defined as receiving medical and dental care in accordance with the schedule of
the Wisconsin Medicaid Health Check program. The figure below illustrates rates for medical exams:
Children’s Hospital Performance, Calendar Year 2013
Children needing
a medical exam
Children up-to-date
on medical exam
January 2013
988
936
95%
February 2013
979
920
94%
March 2013
984
930
95%
Month
% up to-date on
medical exam
April 2013
1,021
981
96%
May 2013
1,053
1,017
97%
June 2013
1,073
1,040
97%
YTD
6,098
5,824
96%
School nurses
Children’s Hospital supports full-time school nurses in nine schools within the Milwaukee Public Schools.
The school nurses role includes “traditional” school nursing support from student daily care, medication
administration, vision screening, chronic disease management and education, support and implementation of
health policies. The school nurses access and document in the hospital’s electronic health record allowing for
them to be an active part of a child’s care delivery team. Essentially, the nurses serve as a conduit between
primary and specialty care and the child and family.
In addition, the school nurse also serves as the coordinator of the Center for Disease Control’s coordinated school
health model in each of our schools. As the coordinator, they bring together educational, community and clinical
resources that work in concert to support the academic achievement of students. For example, school nurses are
the on-site coordinator for parental/guardian consent forms for participation in the community-based oral health
program that provides students with dental cleaning, sealants and fluoride treatments at school. With the support
of the Children’s Hospital school nurses, consents at those schools are significantly higher than other sites.
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Priority #2: obesity and weight management
Coordinated school health
Children’s Hospital school nurses and community health educators work with eight schools within Milwaukee
Public Schools to actively implement the Centers for Disease Control’s coordinated school health model.
To date, implementation has included a school assessment and development of school wellness teams.
Assessments identified opportunity for improvement in many areas including physical activity and nutritional
services offered through the school. School wellness teams, lead by Children’s Hospital school nurses, have
identified annual goals in each of these areas. Strategies have included education to students, staff and
families to healthy meal nights to classroom physical activity breaks. Children’s Hospital educators provide
education support and training as needed to support the goals of each school wellness team. In total, the
eight schools represent over 3,000 students.
Healthy shopping education
Children’s Hospital and Children’s Community Health Plan have teamed up to provide healthy shopping
classes to teach Milwaukee residents how to read food labels and create a food budget. Participants also
tour a full-service grocery store. The program currently targets two neighborhoods – Metcalfe Park and Amani/
Franklin Heights – but will expand to other neighborhoods in 2014.
Milwaukee Childhood Obesity Prevention Project
Children’s Hospital is a member of the Milwaukee Childhood Obesity Prevention Project, a coalition with
the goal of reducing childhood obesity in Milwaukee through environmental and policy improvements and
changes that promote healthy eating and active living. Members include leaders and staff from the eight United
Neighborhood Centers of Milwaukee; community residents; youth-serving organizations; and specialists in the
fields of nutrition, exercise science, physical education, public health, medicine, urban planning and others.
Key areas of focus:
• Healthy foods and beverages
• Land use
• Active living
• Curriculum and professional development
Mission: Health
Mission: Health is an e-learning program that was developed by Children’s Hospital to change knowledge,
attitudes and behaviors of kindergarten through eighth-grade students around healthy eating and activity.
Annually this program reaches nearly 16,000 students statewide including more than 4,000 students in Milwaukee
County. The program can be used as a stand-alone health and wellness curriculum or as a supplement to a
school’s current curriculum. Mission: Health also features a comprehensive teacher’s guide that prepares teachers
and counselors to deliver the curriculum to their students. The number of lessons varies per grade level, but is up to
nine hours of education when participating in both the online and classroom lessons.
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Priority #3: infant mortality
Healthy Mom Healthy Baby
The Healthy Mom Healthy Baby program provides care coordination
services to pregnant members of Children’s Community Health Plan. An
outreach attempt is made to every pregnant woman and prenatal care
coordination is offered in Milwaukee County. In the remainder of CCHP’s
service area other opportunities are offered for case management. Once
contact has been established with a pregnant woman, the Healthy Mom
Healthy Baby program is offered to the member. As a part of the program,
incentives are used to keep members engaged in their medical care.
Healthy Mom Healthy Baby
Program Snapshot
Deliveries to Date = 330
Full Term Births = 83%
Enrolled in WIC = 94%
Started Immunizations = 96%
Birth Control Method = 86%
Breastfeeding = 40%
Scheduled Postpartum Visit = 80%
Members are followed in the program through the postpartum period. Faceto-face visits are conducted at a location that is comfortable for the member. Depression screening is conducted
prenatally and postpartum with each member. Contraception and sexual health is discussed throughout the
pregnancy. Condoms are given to each member in a welcome kit to decrease sexually transmitted disease
and promote safe sex during the pregnancy and beyond. As part of the visit after the baby is born, educational
information published by the March of Dimes, “Your mommy years: living healthy, living smart” is given to each
member regarding self-care. The new mother also is given a book to read to baby to promote reading and the
publication “What to do when your child gets sick” to provide guidance and encourage seeking care at the
appropriate level.
Other areas of focus include breastfeeding, smoking cessation, safe home environment and safe sleep
practices for baby, counseling for alcohol and drug use and creating access for dental care.
The Healthy Mom Healthy Baby program has an increased focus on the period of time between pregnancies
for women to provide education to women on the importance of pregnancy spacing, keeping current with
medical and dental checkups, healthy eating and getting regular exercise.
Medical Home Pilot
The Medical Home Pilot is a collaborative effort with the Wisconsin Department of Health Services to determine
if pregnant women enrolled in the pilot will have improved birth outcomes. Children’s Community Health Plan
recruited several health care providers to participate in the Medical Home Pilot:
• Columbia/St. Mary’s Family Practice Clinic
• Life Time OB/GYN
• St. Joseph’s Family Practice Clinic
• Waukesha Family Practice Clinic
• Sixteenth Street Community Health Center
• St. Joseph’s Outpatient Center
• Froedtert East OB Residency Clinic
• Aurora Midwifery Clinic
• Progressive
• Milwaukee Health Services
• Marquette Neighborhood Health Center
Referrals to the Medical Home Pilot program are made by the “medical home” site or from the health plan.
Care coordinators from CCHP have been assigned as liaisons to each medical home site. Liaisons are social
workers or nurses that assist the staff at the medical home sites to meet the needs of the members and
the medical home site. The care coordinators can also provide prenatal care coordination services to the
members if the services are not available at the medical home site.
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The table below shows the preliminary outcomes of the women enrolled in the Medical Home Pilot through
April 2013:
CCHP Medical Home Pilot Data
January 2011 through April 2013
Milwaukee Birth Data
2006-2008 (all ZIP codes,
all socioeconomic statuses)
# Women enrolled
547
N/A
% of deliveries ≥ 37 weeks
93%
89.1%
Birth weight (kg) < 2.5
6%
N/A
Birth weight (kg) 2.5 – 4.5
94%
N/A
Birth weight (kg) > 4.5
0%
N/A
# of deliveries
347
11,166
Priority #4: sexual health
Healthy Kids, Healthy Choices
Children’s Hospital operates the Healthy Kids, Healthy Choices program to educate youth in out-of-home
care and foster and child welfare staff about teen pregnancy prevention. This program helps to increase the
choices available to teens and helps them recognize the benefits of making choices that are more likely to
lead to positive outcomes. To achieve this, youth, ages 11 to 18, are provided comprehensive reproductive
health education including information on sexually transmitted infections, contraception and HIV prevention.
Additionally, caregivers, caseworkers, child welfare staff and foster parents are equipped with evidence-based
curriculum that assist them with addressing sexual and reproductive health with youth in their care.
Pregnancy Counseling and Resources
Children’s Hospital’s Pregnancy Counseling and Resources specialize in providing free quality pregnancy
counseling for adolescents and young adults up to 24 years of age. The program extends to partners, parents,
other family members and social supports. The program also provides accurate and age-appropriate education
on teenage pregnancy and promotes honest communication between adults and adolescents.
Priority #5: community and home safety
Access and Visitation
The Visitation Center is a program designed to ensure safe contact between parents and their children and to
meet the needs of children and their separated or divorced parents. The center is designed for parents who
need a neutral, comfortable place to visit or transfer their children, with the goal of eliminating or reducing
trauma and harm to the children. This program is new in 2013.
Act Now! Bullying Prevention
The overall goal for the Act Now! program is to reduce bullying in schools through prevention education
focused on the bystander, including students, teachers, staff and school administrators. The anticipated
impact of this program includes long-term reduction in bullying and violence; more time spent on learning,
resulting in increased achievement; improved student attendance; and an increase in the number of schools
participating in bullying prevention. After participating in Act Now!, one Milwaukee Public School had a 57.2
percent reduction in students who reported bullying another student and a 31.4 percent reduction in students
who reported being bullied.
During the 2013-14 school, Act Now! anticipates reaching 10,000 students in Milwaukee public and private schools.
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Child Protection Center
Children’s Hospital of Wisconsin’s Child Protection Center provides assessments to children who may have been
harmed. The goal of the center is to protect children from abuse and provide resources to help them heal.
In addition to providing case reviews, expert court testimony and professional consultations, the Child
Protection Center provides the following services:
Child abuse assessment
The assessment process includes a complete medical examination and an interview with a social worker
specially trained to work with traumatized kids. All work is carefully documented on videotape or DVD to meet
judicial standards.
Referral
Following assessment, center staff members refer suspected victims of abuse to counselors, medical doctors
and psychiatric and developmental rehabilitation specialists who can help them recover.
Foster care health checks
A complete physical is provided for all children entering a foster-care environment. Foster care health
screening aims to:
• Document recent signs of abuse/neglect.
• Ensure children receive quality, consistent and timely health evaluations.
• Encourage and support children receiving ongoing quality health care.
• Improve the health of children in foster care.
Professional and community education
The center provides ongoing training to law enforcement officers, social workers, physicians, nurses and other
professionals in the Milwaukee area, and facilitates the sharing of research in investigative techniques.
Project Ujima
The mission of Project Ujima, a community project, is to stop the cycle of violent crimes by reducing the number
of repeat victims of violence through individual, family and community interventions and prevention strategies.
Goals:
• Reduce the physical and psychosocial consequences of the injury
• Reduce the chances of re-injury
• Prevent the victim from becoming a violent offender
Key Elements:
Hospital-based services that are culturally and developmentally appropriate, including medical care, peer
support, crisis intervention and social and emotional assessment.
Home-based services, including medical follow-up of injuries, evaluation of primary health care needs, psychological
screening for patient and family mental health needs and ongoing individual, group or family counseling.
Community-based services, including mentoring, youth development, family and youth support groups, gang
interventions, job preparedness and advocacy to address legal, education and housing issues.
Community and professional education about youth violence, including seminars on youth violence and youth
development, and support of community-based activities, forums and debriefing.
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Safe Kids: injury prevention
Safe Kids Wisconsin is one of more than 300 grass-roots coalitions in the U.S., including the District of Columbia
and Puerto Rico, that bring together health and safety experts, educators, corporations, foundations,
governments and volunteers to educate and protect families.
Safe Kids Wisconsin, led by Children’s Hospital of Wisconsin, is a member of Safe Kids Worldwide, a global
network of organizations dedicated to preventing accidental injury.
Safe Kids Wisconsin and its coalitions participate in the following:
• Car Seat Recycle Day.
• Child passenger safety and safety in and around cars (Safe Kids Buckle Up).
• Fire and carbon monoxide safety (Delivering Fire Prevention).
• Furniture tip over.
• Pedestrian safety (Safe Kids Walk This Way).
• Safe Kids Day.
• Safe infant sleep (Cribs for Kids).
• Water safety.
• Wheeled sports safety.
Treatment Foster Care
The Treatment Foster Care program is operated statewide, including a fully staffed program in Milwaukee
County. The goal of this program is to recruit, screen, license and train foster parents to provide home-based
care for children and adolescents with more significant emotional, behavioral, physical or medical needs.
Children of all ages are referred to TFC, although most are 10 or older. Many of the children have had numerous
placements, are leaving their current placement or are at risk of entering a more restrictive setting such as a
group home or institution.
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