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TRIUMPH GRADUATION 2020 Third-Year Studentsâ€™ Posters

Creating an Evidence-Based Approach to Obesity Management at Sixteenth Street Community Health Centers

Creating an Evidence-Based Approach to Obesity Management at Sixteenth Street Community Health Centers Connor Enright; Tammy Hoang; Michelle Buelow MD MPH; Jorge Ramallo, MD MPH

Introduction • SSCHC is a federally qualified health center (FQHC) in the near southside of Milwaukee that serves a predominantly Latinx population. • In an analysis of 897 patients, representing a small cross-section of the SSCHC patient population, 78% of adult patients and 40% of pediatric patients were overweight or obese. • The clinical approach to obesity lacks the rigor and evidence-based approach of similar chronic diseases like diabetes and hypertension. • Despite evidence for efficacy, obesity pharmacotherapy is underutilized. Contributing factors include clinician hesitancy due to lack of education around pharmacotherapy for obesity.(1) • Project goal: develop a multidisciplinary obesity management program that will combine pharmacotherapy, counseling, behavioral interventions, and education to reduce obesity rates.

Model 3 stages that correspond to the transtheoretical model of behavior change: 1. Red zone (Precontemplation/Contemplation): Patients who are clinically obese who are not interested or have reservations about weight loss. 2. Yellow zone (Preparation/Action): Patients who are are committed and require specific guidance on how to lose weight. 3. Green zone (Action/Maintenance): Patients who have begun physiciansupervised weight loss program and desire ongoing guidance and treatment.

Intervention Group 6 Clinicians Control Group 3 Clinicians

• Program introduced to every patient with overweight or obesity • Interested patients are scheduled for initial “yellow zone” appointment and subsequently progress through the 3-stage model

• Patients receive current standard of care based on individual clinician's practices and utilization of services at SSCHC

Assess and modify program at 3-month intervals based on feedback from clinicians and participants, as well as EHR data on anthropometric measurements and related labs (HA1C, lipid panel, etc.)

• We aim to have overweight or obese adult patients reduce their initial body weight by ≥ 5%. • In overweight or obese pediatric patients, we aim to reduce BMI z score by 0.15 standard deviations. • These BMI reductions have been demonstrated to significantly improve health outcomes, including reduce blood pressure, cholesterol, and insulin levels.(2)

Methods • Conducted literature reviews and interviews with stakeholders from SSCHC and community organizations working on obesity management. • Developed model based on evidence from literature review and from interviews with SSCHC departments and community organizations. • Program will be evaluated and modified every 3 months using the Plan-Do-Study-Act (PDSA) cycle.

Pilot Design & Goals

Results/Discussion Resources at SSCHC

PDSA Cycle

Conduct Literature Reviews

• Next steps include analyzing data from baseline chart review and beginning pilot program. • Pilot start date has been delayed due to COVID-19 situation and is tentatively rescheduled for May 2020. • If our program demonstrates a significant decrease in patient BMI, we hope to share this model with other FQHCs and through publication in medical and public health journals.

Assessment of Available Resources in SSCHC and Community

References

Creation of Obesity Management Protocol

1. 2.

Pilot Program

Granara B, Laurent J. Provider attitudes and practice patterns of obesity management with pharmacotherapy. J Am Assoc Nurse Pract. 2017;29:543-550. Jensen MD, Ryan DH, Apovian CM, et al.. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014; 129(suppl 2):S102–38.

Adapted from: https://www.garyrjones.com/blog/2019/1/26/the-school-research-lead-and-pdsa-cycles-whats-the-evidence-

What is TRIUMPH? TRaining In Urban Medicine and Public Health (TRIUMPH) is an educational program for University of Wisconsin School of Medicine and Public Health medical students which integrates clinical, community, personal and leadership skill development in Milwaukee, WI. TRIUMPH prepares students to become community-engaged physician leaders who will promote health equity for people living in urban health professional shortage areas. Website: http://www.med.wisc.edu/education/md/triumph/main/681

Creating a Youth Wellness Series at the Urban Ecology Center

Creating a Youth Wellness Series at the Urban Ecology Center David Glaubke MS3; Angélica Sánchez ; and Melissa Lemke MA ◊¤

¤†

◊

†

University of Wisconsin School of Medicine and Public Health; TRIUMPH Program; Urban Ecology Center; Center for Urban Population Health

Introduction The Organization

• The Urban Ecology Center (UEC) is a local nonproﬁt organization founded in 1991 with a mission to connect Milwaukee residents with nature and each other • The UEC conducts year-round programming for youth, adults, and families with the goal of restoring urban parks, educating the public about the environment, and building community outdoors • Today, the UEC has three locations in urban parks: - Riverside Park, on the city’s upper east side - Menomonee Valley, on the city’s south side - Washington Park, on the city’s northwest side • The UEC has a thriving Young Scientist Club (YSC), a program aimed at 5- to 12-year olds that encourages scientiﬁc inquiry and interest in nature and takes place at the Menomonee Valley and Washington Park locations during after-school hours The Communities • The neighborhoods around Washington Park and the Menomonee Valley have ties to Milwaukee’s manufacturing sector, which has been in steady decline since the recession of the early 1980s¹ • High levels of unemployment have led to decades of socioeconomic challenges for residents, which are compounded by legacies of housing segregation as industry has moved to suburban communities • Based on the Milwaukee Health Report 2013², the regions containing Washington Park and the Menomonee Valley both fall in the lower third of socioeconomic status (SES) by zip code in Milwaukee • SES involves income and educational attainment; it is a social determinant of health, meaning it has a concrete and measurable impact on people’s health status and health outcomes (see data in green inset)

Riverside Park Washington Park

Menomonee Valley

UEC Locations Milwaukee Health Report Data, 2013²

LOWER SES GROUP HIGHER SES GROUP

LOWEST 1/3 OF MILWAUKEE ZIP CODES BY SOCIOECONOMIC STATUS - INCLUDES WASHINGTON PARK AND MENOMONEE VALLEY ZIP CODES HIGHEST 1/3 OF MILWAUKEE ZIP CODES BY SOCIOECONOMIC STATUS

PERCENTAGE OF POPULATION THAT... 26%

44%

IS OBESE

HAS NO ACCESS TO HEALTHY FOOD

DAYS WITH POOR MENTAL HEALTH: IN THE LAST 30 DAYS

41%

47%

IS NOT PHYSICALLY ACTIVE

LIFE EXPECTANCY:

64%

Methods

Discussion

• The Urban Ecology Center has an engaged group of students at the Washington Park and Menomonee Valley locations who have aged out of the Young Scientist Club but remain eager to participate

• A 6-part topic outline has been developed based on federal guidelines for youth health and physical activity as well as best practices for adolescent wellness education (see list of topics below)

• The UEC hopes to develop educational programming for these students, with two primary goals: - To engage a core audience of 12-16 year-olds - To promote nature-based education & community

• Curricula are being ﬂeshed out with additional research and developed in collaboration with UEC education staff who know the YSC student population well & have a background in nature-based education

• Given TRIUMPH’s focus on public health, it was important to consider the legacy of socioeconomic challenges in these communities as well as the resultant impact on residents’ health status & nutrition

• Data collection is being conducted via surveys:

Project Scope

Results Evidence Base • Adolescence is an optimal time to intervene with health and wellness promotion, as this is the age when lifelong adult habits begin to take root³ • The UEC is optimally situated to provide this education, as nature-based programming can be a gateway to healthy habits; further, exposure to nature is broadly associated with better health outcomes4 • The Milwaukee Community Health Improvement Plan (2017-2022) seeks to improve health outcomes through the promotion of healthier habits and the inclusion of mental health topics5 Addressing the Community Organization’s Needs

VS.

YEARS

DAYS

80 YEARS

DAYS

• Based on the literature review and in consultation with federal guidelines for youth wellness6, the decision was made to create a Youth Wellness Series • The 6-part series will address and promote key health and wellness topics in conjunction with the UEC’s established focus on nature and the outdoors

Next Steps

- Pre-existing knowledge survey: evaluating students’ current information levels, establishing demographic baselines before Series begins - Pre- and post-series behavior surveys: gathering data during the ﬁrst and last sessions to evaluate effectiveness of programming and elicit feedback • The initial run of the Youth Wellness Series will take place over six subsequent weeks from mid-August through mid-September 2020 • Based on facilitator feedback and data collected from participant surveys, curricula will be adjusted and updated to be more effective in future iterations

The 6 topics covered in the Youth Wellness Series

Staying Active Eating Healthy Reducing Stress Preventing Illness Engaging Community Tying it all Together

References

1. Wilkerson, Isabel. “How Milwaukee Has Thrived While Leaving Blacks Behind.” The New York Times, 19 Mar. 1991, nytimes.com. 2. Greer, D.M., Baumgardner, D.J., Bridgewater, F.D., Frazer, D.A., Kessler, C.L., LeCounte, E.S., Swain, G.R., & Cisler, R.A. (2013). Milwaukee Health Report 2013: Health Disparities in Milwaukee by Socioeconomic Status. Center for Urban Population Health: Milwaukee, WI. 3. Viner, Russell M., et al. "Adolescence and the social determinants of health." The lancet 379.9826 (2012): 1641-1652. 4. Lewis Jr, Terence Grant. "Youth and nature: assessing the impact of an integrated wellness curriculum on nature based play and nature appreciation for youth in out-of-school time recreation programming." (2009). 5. Triguero-Mas, Margarita, et al. "Natural outdoor environments and mental and physical health: relationships and mechanisms." Environment international 77 (2015): 35-41. 6. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health and Human Services; 2018.

What is TRIUMPH? Training In Urban Medicine and Public Health (TRIUMPH) is an educational program for University of Wisconsin School of Medicine and Public Health medical students which integrates clinical, community, personal and leadership skill development in Milwaukee, WI. TRIUMPH prepares students to become community-engaged physician leaders who will promote health equity for people living in urban health professional shortage areas.

Blood Lead Screening Rates in Children Aged 12-35 Months within a Milwaukee Family Medicine Residency Clinic

Blood Lead Screening Rates in Children Aged 12-35 Months within a Milwaukee Family Medicine Residency Clinic Priti Rana DO, Morgan Lively DO, Marianne Klumph MA, Do Dang BS, Bonnie Bobot MD, Kjersti Knox MD, Jalan Alonzo MD

INTRODUCTION • There is no safe level of lead in the body. • Elevated blood lead levels (>5 mcg/dL) primarily affect the development of the CNS in infants and young children1,2 resulting in: • Behavioral issues • Mental health issues • Learning disabilities • Hearing loss • Lead levels are highest between the ages of 18-36 months due to an increase in mobility and hand-to-mouth behavior. • Despite the national downtrend of childhood lead poisoning, Milwaukee continues to have a higher than national average incidence of children testing positive for lead exposure due to high density of housing with leadbased paint and lead lateral water pipes. • In Milwaukee, children with Medicaid are recommended to be screened for lead levels at 12, 18, and 24 months, followed by annual screening through the age of 54. • Only 32% of Medicaid enrolled children received screening at 1 and 2 years of age in 2016 according to the report on Childhood Lead Poisoning in Wisconsin3.

PURPOSE To review the rate of appropriate lead screening in children aged 12 to 36 months at Advocate Aurora Sinai’s Family Care Center (FCC) and to identify risk factors for elevated blood lead levels.

METHODS

• Retrospective chart review study (N=383) using Aurora Health Care’s electronic health records and the Wisconsin Lead Registry on children 12 through 35 months who attended FCC for well child exams during 10/01/2018 to 9/30/2019. • Screening results were sorted into the age groups of 12-17, 18-23, and 24-35 months, per screening recommendations. The decision to include 24-35 months was intended to capture all 2-year-old patients.

RESULTS

DISCUSSION

• Lead screening rates at FCC (62%) were comparable to statewide screening for the general pediatric population (67.6%) in 2016. • Higher screening rates seen with Medicaid patients may be attributed to the benefits of being a Women, Infants, and Children (WIC) member. Additionally, Black patients were more likely to be enrolled in Medicaid, which can serve as a proxy for low socioeconomic status, demonstrating a disproportionate impact on Black communities. • FCC will implement point of care (POC) lead testing which should bypass need for lab processing and increasing screening accessibility. This will provide an excellent opportunity to continue data collection to compare screening rates before and after the implementation. We expect to see a significant increase in screening rates.

Figure 1: Racial disparities in childhood lead testing

• Appropriate lead level screening rates of children were as follows: 45% for 12-17 months, 26% for 18-23 months, and 35% for 24-35 months. 62% of children at FCC ages 1 and 2 years had at least one blood lead test. • Certain zip codes in Milwaukee had higher amounts of children tested for elevated blood lead levels, correlating with more impoverished areas (Table 1). • There was no statistically significant difference in screening based on ethnicity as defined by Black vs non-Black (P=0.56), although Black was the majority tested for lead exposure (Fig. 1). There was also no statistically significant difference in testing for male vs female patients (P=0.948). • However, there was a statistically significant difference (P=0.016) between insurance carriers, with Medicaid patients (n=342, 89.3%) being screened more than those with other insurance types (n=41, 10.7%)

• Other future step community outreach and advocacy to understand and confront increased blood lead levels among Black communities and gather data from clinics with POC testing to determine its efficacy. Figure 2: FCC patient with two granddaughters who tested positive for elevated blood lead levels and subsequently treated. "Lead is not a new problem for me. When I was raising my son and daughter in Milwaukee, I used to bring to them in weekly to have their lead levels monitored. Back then, I was given information about diet and how to help get the levels down. Here I am again with my grandchild dealing with the same problem.”

Table 1: Zip code stratification for childhood lead testing of all tested children.

ZIP CODE 53209 53208 53204 53218 53206 53205 53212 53216 53225 53233 53210 53215 53224

COUNT 35 33 29 29 28 27 22 22 21 21 19 16 15

ZIP CODE 53223 53202 53222 53227 53214 53207 53213 53219 53221 53110 53132 27707 33884

COUNT 11 6 6 5 5 4 4 4 4 2 2 1 1

• Basic descriptive statistics were computed, and Fisher Exact Test was used for categorical analysis. What is TRIUMPH? Training In Urban Medicine and Public Health (TRIUMPH) is an educational program for University of Wisconsin School of Medicine and Public Health medical students which integrates clinical, community, personal and leadership skill development in Milwaukee, WI. TRIUMPH prepares students to become community-engaged physician leaders who will promote health equity for people living in urban health professional shortage areas.

ZIP CODE 46360 53022 53076 53130 53143 53154 53185 53220 53226 53405 53406 Total

COUNT 1 1 1 1 1 1 1 1 1 1 1 383

REFERENCES 1. Report to the General Assembly by the Task Force on Point of Care Testing for Lead Poisoning Chapter 365. Maryland Department of Health and Mental Hygiene Web Site. https://phpa.health.maryland.gov/Documents/Final%20Report_Lead%20Poisoning%20Point% 20of%20Care%20Testing.pdf Updated January 2014. Accessed March 17, 2019. 2. Protect Children from Lead Exposure and Preserve their Potential. https://www.wismhi.org/wismhi-files/PDF/Resources-tab/Resources-for-Public-Health/2018-LCC/Nov-2018/B-T-3-201811-14.pdf Updated November 14, 2018. Accessed March 17, 2019. 3. 2016 Report on Childhood Lead Poisoning in Wisconsin. Wisconsin Department of Health Services Web Site. https://www.dhs.wisconsin.gov/publications/p01202-16.pdf Updated October 2017. Accessed March 17, 2019. 4. Wisconsin Blood Lead Screening Recommendations. Wisconsin Department of Health Services Web Site. http://www.dhs.wisconsin.gov/lead/links/wibloodleadscreeningrecommendations.pdf Updated December 21, 2015. Accessed March 17, 2019.

_______________________________________________________________________________

ACKNOWLEDGEMENTS Special thanks to Dennis Baumgardner, MD for performing the statistical analyses, to Glenda Sundberg, NP for providing the patient story and to Julie Walters for providing the photograph.

Social Determinants of Health Screening at Sixteenth Street Community Health Centers

Gerardo Rodriguez, MPH1; Hayley Severson, BS2; José Salazar3; Rosamaria Martinez, MBA, RD, CBC 4; Michelle Buelow, MD-MPH5

1UW

School of Medicine and Public Health (UWSMPH), MD Candidate; 2UW SMPH, MD-MPH Candidate; 3Sixteenth Street Community Health Centers (SSCHC), Director of Health Education and Community Programs; 4SSCHC, Vice President of Community Health Initiatives; 5UW SMPH, TRIUMPH Associate Director

Introduction

• Social determinants of health (SDOH) are a set of factors that influence the wellbeing of individuals (Figure 1) • SDOH must be addressed in the clinic to improve health outcomes and equity

TRIUMPH Student Activities

• We need partnerships with community resources and organizations • Workflow must be flexible • We need a better technology to track referrals and resources utilized by patients • Many of the training concepts introduced were new to Navigators • By integrating SDOH screenings and offering services, health outcomes can improve

Results of Student Activities

TRIUMPH Next Steps

• • • • • •

• Sixteenth Street Community Health Centers (SSCHC) is a federally qualified health center in Milwaukee with an overwhelmingly Latinx patient population • SSCHC recently implemented a SDOH screening and patient navigation program to connect patients to community resources

What We Have Learned

• Assessed clinic workflows • Developed training materials for Volunteers and Care Navigators • Facilitated training sessions with Navigators • Analyzed social services encounters • Gauged SSCHC staff awareness/readiness to engage in social needs program

Navigator Training Topics

Figure 1: 50% of our health is determined by the SDOH!

Responses to questions about social needs

Motivational Interviewing Relationship/rapport building Implicit bias Cultural Humility Health literacy Patient advocacy

Figure 3: Set of visuals demonstrating responses to the most recent screener questions about SDOH (~400 between September-November 2019) outlining the extent of social needs in SSCHC’s patient population

Responses to questions about housing insecurity—a priority issue

• Analyzing 2019 social needs encounters • Process evaluation of training materials • Spread awareness of screening/navigation program with SSCHC providers • Survey SSCHC providers • Facilitate additional training sessions with care navigators

Data Analysis: Patient Encounters

Figure 2: A graph demonstrating the number of SDOH needs addressed with each patient in one social services encounter among a random sample of patient encounters in 2018

Figure 4: Set of visuals demonstrating responses to the most recent screener questions about housing (~400 between September-November 2019) as addressing housing insecurity is a major priority of the program

1. Adler, N.E., et al. 2016. Addressing Social Determinants of Health and Health Disparities: A Vital Direction for Health and Health Care. National Academy of Medicine’s Vital Directions for Health and Health Care Initiative: Perspectives. Retrieved 5/21/17 from: https://nam.edu/wp-content/uploads/2016/09/Addressing-Social-Determinants-of-Health-and-Health-Disparities.pdf.; 2. Braveman, P., S. Egerter, & D. Williams. 2011. The Social Determinants of Health: Coming of Age. Annu. Rev. Public Health 32:381-98. doi: 10.1146/annurev-publhealth-031210-101218. Retrieved 5/21/17 from: http://annualreviews.org/doi/abs/10.1146/annurev-publhealth-031210-101218.; 3. Braveman, P. & L. Gottlieb. 2014. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Rep 129(Suppl 2):19-31. doi: https://dx.doi.org/10.1177%2F00333549141291S206.; 4. Gottlieb LM, Hessler D, Long D, Laves E, Burns AR, Amaya A, Sweeney P, Schudel C, and NE Adler. 2016. Effects of Social Needs Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial. JAMA Pediatr. 170(11). doi:10.1001/jamapediatrics.2016.2521; 5. Heiman, HJ, and S. Artiga. 2015. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation. KFF.org. Retrieved 5/17/17 from: http://kff.org/disparitiespolicy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/; 6. World Health Organization [WHO]. 2017. Health Impact Assessment (HIA): The determinants of health. WHO. Retrieved 5/17/17 from: http://www.who.int/hia/evidence/doh/en/.

Surveying Anxiety and Depression in the Milwaukee Oneida Community

Introduction Native Americans have the highest rates of both depression and completed suicide of any racial or ethnic demographic.1,2 It is believed that these numbers are even greater among Urban Indian populations.3 A 2015 survey among the Oneida living in Milwaukee found a significant burden of anxiety and depression, with prevalence rates above 20% in both categories. As a result, Southeastern Oneida Tribal Services (SEOTS) launched an additional survey to further evaluate the state of mental health in the Milwaukee Oneida community.

Joe Archer, BA and Mark Powless, MBA

Results Prevalence of Mental Illness • 32% of respondents reported experiencing a depressive episode in the last year • 21% of respondents reported being diagnosed or treated for depression in the past 3 years • 30% of respondents reported experiencing anxiety (based on the standard Generalized Anxiety Disorder definition) in the last year. • 23% of respondents reported being diagnosed or treated for anxiety in the past 3 years.

Stigma Toward Mental Illness DEPRESSION AND ANXIETY ARE EMBARRASSING PROBLEMS

Press release in the Oneida Tribal Newspaper, August 2019 Unsure, Agree, or Strongly Agree 45%

Comfort Discussing Mental Health In the past year, have you had a conversation with a friend or family member about… 160

Disagree or Strongly Disagree 55%

140

120

Methods Our survey sought to evaluate the following: • Prevalence of anxiety and depression • Knowledge of mental health services and resources • Utilization of mental health services and resources • Comfort discussing mental health • Stigma toward mental illness • Knowledge of cultural concepts related to mental health To evaluate these items, we took the following steps: 1. Developed an 18-question survey that was mailed to all Oneida Tribal members served by SEOTS. 2. Respondents were enticed by entry into a raffle for the chance to win one of 25 possible gift card prizes. 3. 1088 surveys were sent out with 239 responses (22% response rate).

100

Knowledge of Oneida Cultural Concepts

HAVE YOU HEARD OF THE ONEIDA CULTURAL CONCEPT OF "THE GOOD MIND?"

0 YOUR psychological and/or emotional well being?

THEIR psychological and/or emotional wellbeing?

Yes

Yes 18%

Discussion The results of our survey revealed several areas of prioritization for our anxiety and depression awareness initiative. Survey results revealed that most respondents (55%) are not discussing their own mental and emotional health openly with friends and family and a large number (39%) are not discussing their friends’ and family’s mental health either. Despite this, the vast majority (74%) agree or strongly agree that they are comfortable discussing their own mental health and similar numbers (73%) agree or strongly agree that they are comfortable discussing the mental health of friends and family. This means that there is an openness to increasing conversations surrounding mental health in the community that we can tap into and encourage. One of our primary goals for the initiative will be to increase the number of people that have had conversations about mental health in the past year.

I am comfortable talking to friends and/or family about…. 200 180 160 140 120 100 80

No 82%

60 40 20

Furthermore, in evaluating stigma, a large number (45%) of respondents were unsure or agreed that depression and anxiety are embarrassing problems, indicating that stigma reduction will be an important piece of our initiative. Finally, an alarming number of Oneida Tribal members (82%) have never heard of ”The Good Mind,” an important cultural concept surrounding mental health among the Haudenosaunee. Because of this outstanding statistic, Oneida cultural concepts surrounding mental health will be the focal-point for our initiative

References

0 MY psychological and/or emotional well being

Agree or Strongly Agree

THEIR psychological and/or emotional wellbeing

Unsure, Disagree, or Strongly Disagree

The results displayed here are not comprehensive of the survey. For complete results please contact the authors of this poster.

1. National Institute of Mental Health. Major Depression. February 2019. https://www.nimh.nih.gov/health/statistics/major-depression.shtml 2. National Institute of Mental Health. Suicide. February 2019. https://www.nimh.nih.gov/health/statistics/suicide.shtml 3. Urban Indian Health Commission. Invisible Tribes: Urban Indians and Their Health in a Changing World. October 13, 2015. https://www2.census.gov/cac/nac/meetings/2015-10-13/invisibletribes.pdf

Implementation of an Early Childhood Developmental Monitoring Program

Implementation of an Early Childhood Developmental Monitoring Program Kathryn Henschel, BA, Lisa Pollnow, CSW, Theresa Umhoefer Wittry, MD

Introduction

Methods

Results

Importance of Developmental Monitoring

Selecting a Developmental Monitoring Program

Data from First Round of Screening

• One in six children in the United States have a diagnosable behavioral or developmental disability • Even more children have developmental delays • Most delays are not recognized until elementary school, when early intervention is important

• •

Literature review of common programs Discussions with staff to choose best program and potential barriers to implementation • ASQ for collection of data • Teaching Strategies GOLD to assess data, provide individualized classroom/student interventions, and handouts for guardians

Discussion

Table 1. Accessing Children for Developmental Screening Total screened

22/41

• Developmental monitoring can provide teachers with specific developmental information to guide individualized interventions for children • Screening and subsequent intervention has been shown to lead to children’s improved kindergarten readiness and third grade reading level

Next Steps

Of those not screened: Screened through Birth to 3

11/19

Not Screened

8/19

Due to not being in attendance

• Discuss with teachers and guardians the results of the first round of screening and potential improvements • Make adaptations based on input from teachers and guardians • Repeat data collection, monitoring, and evaluation every six months

Table 2. Specific Developmental Screening Results from One Classroom

Figure 1. Heckman’s Curve demonstrating importance of early intervention in terms of brain development and return on investment.

Penfield Children’s Center

• Fully-inclusive early education and childcare center • Serves children aged 6-weeks to 5-years old • Four early education classrooms, two special care nursery rooms • 41 children, 12 teachers

Initiation of Screening • •

Every child who is not enrolled in the Birth to 3 program will be screened every six months Based on results, teachers will implement individualized classroom interventions or refer to Birth to Three for children who are significantly developmentally delayed

Objectives 1. Implement a systematic developmental monitoring program in the early education classrooms at Penfield 2. Collect data from the developmental monitoring tool to appropriately adapt classroom curriculums 3. Share the results with guardians to increase their knowledge and involvement in their child’s development

Continued Evaluation and Follow-up • •

After each round of screening discuss results with guardians Ask guardians and teachers about potential changes to improve developmental monitoring process

Child 1

ASQ 42

Communication As Expected

Gross Motor As Expected

Fine Motor As Expected

Problem Solving As Expected

Personal-Social As Expected

As Expected

Delayed

As Expected

Delayed

As Expected

Delayed

As Expected

Assessing Success 1. Number of students who are being screened every six months 2. Number of students who are receiving appropriate services after positive screen 3. Number of guardians who are informed of their child’s development

References: 1. Boyle CA, Boulet S, Schieve L, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD. Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics 2011;127:1034–1042. 2. Doyle, O., Harmon, C. P., Heckman, J. J., & Tremblay, R. E. (2009). Investing in early human development: timing and economic efficiency. Economics & Human Biology, 7(1), 1-6. 3. Unicef. "Building better brains. New frontiers in early childhood development." (2014).

New Strategies for Combating the Opioid Epidemic:â€¨ Medication Assisted Treatment in Primary Care

New Strategies for Combating the Opioid Epidemic: Medication Assisted Treatment in Primary Care Lucia Covert, MS3, Bret Valentine, MD, Jody Epstein, MD, Michelle Buelow, MD

Introduction

Setting & Methods

➢ Milwaukee County had approximately twice the state average in number of deaths due to opioids in 2018 at a rate of 30.6 per 100,000. 1

Sixteenth Street Community Health Center- Waukesha is a Federally Qualified Health Center (FQHC) with a growing MAT program supported by its Family Medicine Physicians, Psychiatrists, and Alcohol and Other Drug Abuse (AODA) trained Therapists Phase 1: Patient Interviews • Interviews were conducted over twelve weeks as part of routine visits with Family Practice physicians Dr. Valentine and Dr. Epstein. Office treatment protocol below.

➢ We know that substance use disorders (SUDs) are multifaceted with physiologic, psychologic, and social components and require a similar treatment approach. 2 ➢ Medication Assisted Treatment (MAT) is an effective tool in the treatment of SUDs with significant improvement in treatment retention, reduction in illicit opioid use, burden of opioid craving and relief of withdrawal symptoms. 3 ➢ However, in 2016, Wisconsin lagged behind the national average in the use of MAT in opioid addiction treatment. And safety-net, publicly supported substance use services continued to decline by 3% each year. 4

Establish Care:

Induction:

Initial evaluation with AODA counselor & initial history & physical with Primary Care Provider

First administration of MAT supervised by medical staff to monitor for signs of precipitated withdrawal

Follow up:

Weekly for 1 month, Biweekly for 2 months, Monthly thereafter (Adjustments made if needed for relapse, risky behaviors, dose adjustments, and clinical instability.)

Access - Enrollment: lack of providers, infeasible program rules, unaffordable, burned bridges - Transportation: travel up to 3 hours for care, need for drivers

Themes from Patient Interviews

Medication Cost - Uninsured: $600 for refill - Sliding Fee Scale at SSCHC: $8 - Street Cost: more affordable than prescribed suboxone

Feeling that MAT is a “crutch”

Cost of a Punitive Legal System

- Conflicting Messages: NA and AA groups, and some treatment programs reinforcing the “total sobriety” method

- Legal Fees

Numerous Barriers to Care -

Phase 2: Provider Interviews • Interviews of MAT providers serving the Milwaukee & Waukesha Communities Phase 3: Retrospective Chart Review • Chart analysis of the 100 most recent patients actively enrolled in the MAT program looking at: • Patient Demographics • Treatment success (Negative UDS, maintenance of treatment) • Patient SUD History • Patient Comorbidities

Conclusion Study Aim: To assess the power of Medication Assisted Treatment as part of a comprehensive addiction medicine service in the primary care setting.

Results

Lack of insurance Undocumented status Lack of transportation Frequent healthcare visits Financial instability Housing instability Job insecurity

Long- Term Treatment

- Mandatory Drug Testing - Feelings of guilt and shame constantly reinforced by a system with a “once an addict, always an addict” mentality

- Patient on 8mg suboxone twice daily for 5 years with monthly therapy appointments - Patient receiving monthly Vivitrol injection

Stigma - Face the stigma of being an addict from Health care providers, law enforcement, judges, employers, landlords, some friends and family

Rewarding Practice - Patients are largely very grateful for their care - Truly a life changing and life saving treatment

Themes from Provider Interviews

• MAT is an important part of our changing approach to addiction medicine. An approach that recognizes addiction, not as a failure of character, but as a chronic, relapsing disease with complex physiologic, psychologic, and social components.

• SSCHC is unique in that it can offer both medical care and AODA counseling through its MAT program. As a FQHC, SSCHC has systems in place to reach underserved populations. We hope this model can be adapted in other Community Health Centers across the state to increase access to care.

• Next Steps include ongoing data collection and analysis, program growth, improved AODA and medical team integration across SSCHC clinics, and community partner outreach. Ultimately, we would like to develop a sustainable, generalizable MAT model for other primary care clinics across Wisconsin.

References: 1. Wisconsin Department of Health Services. Data Direct, Opioid Summary Module [web query]. Data last updated 9/30/2019 11:00:59 PM. 2. Phd, H. M. S. M., Phd, A. S. M., Mph, I. M. M., Mph, J. K. M., & Drph, M. H. A. M. (2019). Biopsychosocial determinants of opioid use disorder (OUD) and implications for maternal and child health research: A scoping review. Journal of Opioid Management, 15(1), 77–91. doi: 10.5055/jom.2019.0488 3. Connery, Hilary, Smith MD, PhD. Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. Harv Rev Psychiatry. 2015;23(2):63-75. doi:10.1097/HRP.0000000000000075. 4. Wisconsin mental health and substance abuse needs assessment update, Wisconsin mental health and substance abuse needs assessment update (n.d.).

RaĂces: A Parental Support Group Aimed at Improving Mental Health Outcomes Among Latina Adolescents

Raíces: A Parental Support Group Aimed at Improving Mental Health Outcomes Among Latina Adolescents Mariana Nino de Guzman Ramirez, BS; Mireya Taboada, BS; Paloma Reinoso, MD; Melissa Waldo, LCSW; Michelle Buelow, MD, MPH

• Latina adolescents experience the highest rates of suicidal ideation and attempts among adolescents in the US1. • The Self-Esteem, Empathy, Empowerment, Discovery of Self (SEEDS) program was designed to provide group mental health therapy for Latina teenage girls at the Sixteenth Street Community Health Center in Milwaukee, WI. • Benefits of the SEEDS program were impacted by familial stress and parental perception of mental health. • Raíces was developed to further support the mental health outcomes of SEEDS participants.

Objective

• The objective of Raíces is to engage parents in a parallel program to SEEDS to normalize mental health disorders using peer support and psychoeducation

Results

• Evaluation is currently underway. • We anticipate that parents participating in Raíces will better understand their daughters’ mental health concerns and feel empowered to take a more active role in their wellbeing. • We hope Raíces will decrease stigma associated with mental health disorders and help normalize the need for treatment. Raices Retention Rate for Cohort 1-5 0.8 0.7

Methods

• Parents of SEEDS participants meet weekly for 16 weeks covering mental health topics concurrent with SEEDS. • The group is co-facilitated by bilingual medical students. • Pre- and post-Likert scale surveys exploring cultural stigma and attitudes towards mental health are administered to participating parents.

0.6 RETENTION RATE

Introduction

0.5 0.4 0.3

Current Challenges

• Retention of participants • We currently do not provide childcare services for participants • Sustainability of the program • We currently depend on recruitment of bilingual medical students to co-facilitate

Future Direction

0.2 0.1 0 1

3 COHORT NUMBER

Figure 1: Retention rate for Raices cohorts 1-5. Overall participant retention has improved since the program was piloted. However retention of participants continues to be an ongoing challenge as exhibited by decreasing retention rate in groups 4 and 5 after steady improvement.

Figure 2: Raices Survey Data Results. Pre and post test results were compounded for Cohorts 1-5. Survey questions were grouped into general themes of cultural stigma towards mental health, attitudes towards mental health and feelings of guilt. Likert scale responses were added for each category to demonstrate overall changes. Figure shows overall cultural stigma and feelings of guilt decreased after participation on Raices. Positive attitudes towards mental health increased slightly.

• Continued improvement of the curriculum and information handouts • Create testimonial videos to improve parental recruitment • Continued program evaluation • Pilot peer mentor program with SEEDS alumni (Árboles) References 1. U.S. Department of Health and Human Services Office of Minority Health. Mental Health and Hispanics. (2016). Available at:https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=69)

Addressing Lack of Diversity amongst Health Professionals through Exposure of Underrepresented High School Students to Careers in Health

Addressing Lack of Diversity amongst Health Professionals through Exposure of Underrepresented High School Students to Careers in Health Mishaal Ali MS3, Leo Dreyfuss MS4, Lena Law MS2, Suzanne Letellier, Bess Prichard

◊ University

• For this project, we worked the Youth Health Service Corps (YHSC), an organization under the Milwaukee Area Health Education Center (AHEC). • AHEC’s mission and role is to enhance access of care to underserved populations through health professions centered education and promotion of health equity through community partnerships. • YHSC is a program designed for high school students interested in health careers. YHSC ultimately aims to expose underrepresented high school students to careers in health and connects them to resources to pursue these careers. • Our goal is to follow the mission of AHEC and YHSC by addressing the lack of representation in the health care field. • We currently have a population of health care professionals who do not match the patient population, and ultimately are not well enough equipped to provide care for an increasingly diverse patient population. • With YHSC, we hope to work individually with a group of students at Messmer High School to not only increase interest in health careers, but also to address barriers to achieving higher education.

Methods

To address barriers to higher education, we did a crash course on financial aid resources, including scholarships, FAFSA, and grants. The students also met weekly to plan and implement their public health project on a schoolwide basis. Next steps include surveys on the effectiveness of the resources that we provided them with, as well as surveys to longitudinally track career outcomes of students once they graduate.

Students named factors that they felt were barriers to gaining college/university admission. The most common barrier they named for themselves was financing an education.

One major goal was to identify and address barriers to higher education for these students. We attempted to do this by the creation of two surveys. The first one assessed what the students saw as personal barriers to attending a college or university. The second survey focused on standardized test preparedness. It assessed whether the students have taken test prep courses, how familiar they were with these exams, and how ready they felt to take them. Another goal of ours was to increase interest in public health career fields. We worked with the students to help them implement a student- led and coordinated public health project at their high school. We asked them to identify public health issues at Messmer High as well as potential solutions to these issues. They ranked these issues in order of importance and feasibility.

Discussion

Results The public health project that the students decided to pursue was one focusing on stress management.

WHAT DO YOU SEE AS A BARRIER TO COLLEGE/UNIVERSITY? 12

Number of Students

Introduction

of Wisconsin School of Medicine and Public Health, ∆ Milwaukee AHEC, ∆ Messer High School

The students plan on conducting an assessment of needs through a schoolwide survey. The project will then be carried onto the next school year. On our end, we plan on doing regular check ins with the students to assess their interest in health careers, and how to better serve their needs in terms of resources and mentorship. We also hope to assess their interest in community health involvement once graduated from the YHSC program.

4 3

Participants

• The students we are working with consist of 25 students from Messmer High school, grades 10-12. • Messmer is in the 53206 area code • 90% of its students qualify for free or reduced price lunch • The majority of students at Messmer are from non-traditional or single parent households.

0 GPA

FINANCES SAT/ACT Barrier to Higher Education

OTHER

Life Skills Programming for Housing Insecure Families: Supportive Programming Development at the Salvation Army Emergency Lodge

Life Skills Programming for Housing Insecure Families: Supportive Programming Development at the Salvation Army Emergency Lodge Nivedita Nair◊, MS3, Steve Ohly ∆, RN, ANP, Melissa Lemke ■, MA  ◊ University of Wisconsin School of Medicine and Public Health, ∆ Advocate Aurora Health Care Milwaukee, ■ University of Wisconsin School of Medicine and Public Health Training in Urban Medicine and Public Health (TRIUMPH) Program

Identifying the Health Concern • •

Prior parenting programs at the SAEL well attended and highly reviewed Programs ended due to funding and longitudinal attendance issues: most clients transition out of SAEL in 90 days ! program funding requirement of completing at least 12 of 16 weeks not met

•

Conducting a Health Needs Assessment

Improve mental health, coping skills, and stability of Salvation Army Emergency Lodge (SAEL) parents through brief, self-contained, sustainable, peer group programming focused on life skills, parenting, and mental health.

Clients of the SAEL face myriad challenges, which are exacerbated by a culturally, generationally, and socio-economically propagated lack of parenting, mental health, and life skills, as identified by both SAEL staff and clients.

Community driven Program subject matter requested by SAEL based on needs identified by staff Much of programming development based on evidence base from other community organizations doing similar work

Capacity investigation

• •

• • • •

Staff at SAEL identified needs Review of prior and current programming provided at SAEL led capacity assessment Loni Fitzgerald (Children’s Development Program Director, SAEL) Stephanie Kallas (Family Social Worker, SAEL) Mandi Degner (Psychotherapist, AWPCC) Steve Ohly (TRIUMPH mentor, AWPCC)

Theoretical framework

•

• • •

Logic Model

•

OBJECTIVES

Relevant: programming focuses on developing parenting skills but also emphasizes mental health and positive coping skills of parents Sustainable: flexible programming that can be delivered with minimal cost and facilitator training Useful: time spent in sessions not only provides skills, but tangible certification that can be provided to interested parties (courts, CPS, etc.)

Curriculum selection

•

Develop programming focused on life skills and parenting, with mental health integrated • Weekly, 1.5 hour-long parenting sessions at SAEL as part of cycling 8 session curriculum Improve mental health, coping skills, and stability of SAEL families • Pre-post-course testing, participant satisfaction reports, frequency of in-shelter issues within and between curriculum cycles to evaluate skill development

Nivi Nair, MS3; Melissa Lemke, TRIUMPH Program Manager Identified parenting curriculum from the Institute of Behavioral Research at Texas Christian University (TCU) Free, 8-module curriculum; full program manual available online; each session largely free-standing in content Curriculum included in NREPP (SAMHSA’s National Registry of Evidence-based Programs and Practices) Curriculum already in use at Meta House, an AODA treatment program in Milwaukee

Future Steps: Implementation and Evaluation Implementation

Resources

Situation

• •

Serves housing insecure individuals and families Clients of SAEL face many challenges in regaining stability, which are exacerbated by incomplete life skills • Intergenerationally propagated difficulties secondary to insufficient parenting skills

•

Top Priorities For Curriculum

Project Aim

1 in 4 Milwaukeeans live in poverty; approximately 1,000 people sleep on the streets each night 1/3 of Milwaukee’s children live below the poverty line

Salvation Army Emergency Lodge (SAEL)

• •

Program Design

Outputs

INPUTS

ACTIVITIES

• • • •

UW SMPH Aurora WPCC Salvation Army Programming: TCU • Funding • Resources: MPS, Parenting Network

• Community outreach • Developing programming • Conducting programming • Advocacy

PARTICIPANTS • Clients • Program leaders • Community organizations • Legislature/ legal system

Assumptions • 20+ year existing partnership between Salvation Army and AWPCC (established trust) • Many clients served at SAEL are parents with school aged children • Programming on life skills and mental health appropriate solution to needs present in these families • Involving community members with lived experience adds value • Curriculum can be developed to be delivered with minimal volunteer leader training • Offering life skills training will improve post-shelter stability

Outcomes-Impact SHORT TERM • Understand community desires and needs • Understand baseline parenting and life skills, and mental health issues MEDIUM TERM • Select/develop curriculum focused on life skills with mental health integrated • Develop sustainable programming, offered consistently • Develop partnerships with other organizations for resources/incentives • Volunteer leader recruitment and trauma informed training LONG TERM/IMPACT

• Weekly programming expected to start May 2020 • Sessions will progress through 8 modules, then repeat • No mandate on coursework; participants can enter and exit the program at any point and will receive documentation of completion of modules attended

Evaluation

• Curriculum: pre- and post-course testing; satisfaction surveys • Programming success: sustainability; participation rates; satisfaction reports; •

decreased frequency of in-shelter issues among participating families Monitoring trends over time

Lessons Learned From a Work in Progress Aspects of engaging community members

• Improve participant self-sufficiency upon leaving SAEL • Improve mental health, life skills, and parenting strategies of SAEL families • Change attitudes around parenting, coping with trauma in housing insecure families • Realize community leaders through program graduate engagement

• Communication • Soliciting feedback • Community driven

Goals vs. outcomes

• Be comfortable with • •

evolution of expectations Changing priorities Differential paces

Acknowledgements Assets

Barriers

• Community interest, particularly at SAEL • Established models for life skills training • Clients already required to attend programming as part of stay

• • • • • •

Conflict between duration of curriculum vs length of stay at SAEL for average family Other competing demands that must meet during stay Stigma against perception of being “bad parent” may disincline participation Family dynamics in shelter may not reflect family dynamics while housed outside shelter Availability of volunteer leaders and likely lack of representation of served community Bureaucratic hurdles and political factors, including demands on parents made by legal system/CPS that cannot be met through our program • Institutionalized racism and cycles of poverty

• • • •

Steve Ohly, Mandi Degner, and Heather Hankins; Aurora Walker’s Point Community Clinic Loni Fitzgerald and Stephanie Kallas; Salvation Army Emergency Lodge Melissa Lemke; UWSMPH TRIUMPH Program Will Singleton, Alma Center

References • • • •

Health Belief Model: US Department of Health and Human Services. (2005). Theory at a glance: A guide for health promotion practice, 2nd Ed. National Institutes of Health. Curriculum: Institute of Behavioral Research. (2019). Partners in Parenting (the Parenting Manual). Texas Christian University. Accessed from http:// ibr.tcu.edu/wp-content/uploads/2013/09/ppmanual.pdf ITR: Help For Trauma (2019). Trauma Effective Professional (TEP) For Educators. Accessed from: https://helpfortrauma.com/courses/trauma-effectiveprofessional-tep-for-educators/ Parenting Network: The Parenting Network. (2019). Resources. Accessed from: https://www.theparentingnetwork.org/resources

Supporting Female Cancer Survivors in Urban Milwaukee

Supporting Female Cancer Survivors in Urban Milwaukee Payden White, BS & Ilka Hoffins, BA ~ Project Partner: Advocate Aurora Team Phoenix

What is Team Phoenix? Team Phoenix is an innovative 14-week fitness program in which a leadership team of multidisciplinary clinicians, triathlon coaches and volunteers encourage and assist cancer survivors to regain endurance, strength, flexibility, and overall health and wellness after cancer treatment by training for a sprint-distance triathlon. This program is rigorously researched and evaluated to ensure that it best meets the needs of survivors. As a program of Advocate Aurora Research Institute, Team Phoenix also collaborates with higher education institutions on research seeking to better understand the effects of group-led, goal-oriented exercise and psychological well-being after cancer treatment (1).

Results

Context

At this stage of the project, we have been preparing our research materials and plans. Upon initial data review from past Team Phoenix season, less than 15% of participants resided in a zip code within Milwaukee County. These observations have prompted further investigation into the factors that may be limiting participation from women in Milwaukee zip codes.

• Team Phoenix has historically recruited participants for the training program through word of mouth and advertising in clinics. According to the data from 2019 participants, only about 13% resided in a zip code within Milwaukee County (2). • Exercise has many well-known benefits for both physical and mental health. One study also suggests that exercise is an effective intervention to improve quality of life, cardiorespiratory fitness, physical functioning, and fatigue in patients who are fighting or recovering from breast cancer. Long-term benefits still need to be explored further in this population (3).

Though we do not have specific results from our own study yet, we anticipate that our surveyed athletes will report barriers such as: • Transportation • Tiime restraints • Equipment • Need for childcare • Other resources that may be less available based on certain demographics.

• According to August & Sorken, racial/ethnic minorities generally engaged in less healthy exercise and dietary behaviors than whites. The disparities were the greatest among English-proficient minorities. They disparities may result from unequal access to affordable healthy foods and recreational facilities. • Previous studies have indicated that people with lower socioeconomic status tend to be less likely to meet physical activity recommendations (3).

Project Objectives

1. To understand the current exercise habits among women in Milwaukee’s zip codes 2. To explore the barriers that prevent women from exercising according to the American Heart Association recommendations 3. To implement strategies to increase participation in Team Phoenix and/or related programs among urban underserved women

Methods - Tracked and analyzed exercise data from research participants who are using watches to assess continued activity after the Team Phoenix training season - Administered and analyzed activity level and barrier surveys to women in Milwaukee’s zip codes - Conducted key-informant interviews with community members in urban Milwaukee to discuss barriers to exercise and ways to better engage women - Presented findings to Team Phoenix leadership to inform future recruitment efforts

We anticipate that the results of our study will inform future recruitment efforts, allowing us to better accommodate the needs of women in Milwaukee County.

Recommendations for Action • • •

Discussion of ways Team Phoenix specifically can use the information collected in this project to influence recruitment techniques Discussion of ways barriers to exercise can be addressed (both by Team Phoenix and other organizations) Discussion of potential future research to further understand barriers to our underserved communities in regard to exercise

Sources 1. Advocate Aurora Health Care. “Team Phoenix: Survivorship Redefined.” https://www.aurorahealthcare.org/aurora-research-institute/research-specialties/cancer-research/team-phoenix#More-Information. March 2020. 2. City Data. “Milwaukee, Wisconsin.” http://www.city-data.com/income/income-Milwaukee-Wisconsin.html. March 2020. 3. McNealy et al. “Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis.” Canadian Medical Association Journal. 2006 Jul 4;175(1):34-41. https://www.ncbi.nlm.nih.gov/pubmed/16818906. Web March 2020. 4. August & Sorken. “Racial/Ethnic Disparities in Exercise and Dietary Behaviors of Middle-Aged and Older Adults.” Journal of General Internal Medicine. 2011 Mar; 26(3): 245–250. Published online 2010 Sep 24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043172/. Web March 2020.

Youth Health Ambassadors: â€¨ Connecting Communities & Healthcare Through Social Services

Youth Health Ambassadors: Connecting Communities & Healthcare Through Social Services Rachel Her BS, Mayhoua Moua, Melissa Lemke MA

Introduction

The Issues

Resources

Expected Results

>> WHO ARE WE?

>> THERE ARE MANY DISPARITIES BETWEEN THE

>> STAKEHOLDERS:

>> WE ARE CURRENTLY IN THE PROCESS OF

The Youth Health Ambassadors (YHA) is a program

HMONG AND THE GENERAL POPULATION.

run by the Milwaukee Consortium for Hmong Health (MCHH) that focuses on educating and empowering

▪ ▪

Increased poverty: poverty rate at 20% 2 Low rates of education: 29% of Hmong over 25

youth to provide basic health and social services to

have no formal schooling and only 13% have a

others in order to deliver culturally competent care to

Bachelor’s or higher 2

the Southeast Asian (Hmong, Lao, Karen) community

▪

▪ ▪

largest Asian ethnic subgroup in Wisconsin, making up about 38% of Asians in the

state.2 Milwaukee

Increased rates of diabetes 3 Lower rates of cancer screening and increased cancer mortality rates 4

identifies as Asian.1 The Hmong population is the

▪

CONDUCTING THE CURRICULUM.

MHCC staff and volunteers Program participants, parents

>> EXPECTED RESULTS INCLUDE:

Community health and

▪ ▪

health professionals

Limited English fluency/literacy: 68% of the

English well or at all 2

3% of the state and 4% of the city of Milwaukee

Southeast Asian community

Hmong women are less likely to receive prenatal care in the first trimester2

county has the largest total Hmong population in the

Quantification of program use in the community Qualitative data on program efficacy at teaching participants, via participant and parents survey

▪

Hmong population older than 65 do not speak

and bridge health disparities in Milwaukee.

>> WHY DOES THIS MATTER?

▪ ▪ ▪ ▪

>> METHODS:

▪ ▪ ▪ ▪ ▪ ▪

Quantitative data on changes in health outcomes of community

Identify similar programs Develop YHA curriculum

▪

Stakeholder perspectives on program strengths and weaknesses

Recruit participants Conduct curriculum Obtain feedback Assess impact

Next Steps

state.2 1. Obtain feedback from participants, parents, and other shareholders

>> CURRICULUM:

2. Review quality improvement process of program Part One:

Foundations of Community Work

Part Two:

Care Coordination in Milwaukee

Part Three:

Chronic Disease Prevention

Part Four:

The Future for Ambassadors

3. Escalate program via recruiting additional participants, expanding curriculum to incorporate individualized community health projects 4. Create sustainability by training additional staff to run the program, applying for grants.

Figure 1. Wisconsin Asian population by

Figure 2. Wisconsin Hmong population by county.

ethnicity/nationality, U.S. Census Bureau 2000

Milwaukee and Marathon counties have the highest

census.

number of Hmong.

References 1. US Census Bureau (https://www.census.gov/quickfacts/fact/table/WI,milwaukeecountywisconsin,milwaukeecitywisconsin/PST045218) 2. Hmong in Wisconsin: a Statistical Overview (https://counties.extension.wisc.edu/washington/files/2010/07/hmong_chartbook_2010.pdf) 3. Thao, KK et. al (2015). The Prevalence of Type 2 Diabetes Mellitus in a Wisconsin Hmong Patient Population. WMJ, 14(5), 190-195. 4. Lee, H. Y., & Vang, S. (2010). Barriers to cancer screening in hmong americans: The influence of health care accessibility, culture, and cancer literacy. Journal of Community Health, 35(3), 302-314. https://doi.org/10.1007/s10900-010-9228-7

Prevalence and Correlates of Vaccine Hesitancy in a Sample of Low-Income Mothers

Prevalence and Correlates of Vaccine Hesitancy in a Sample of Low-Income Mothers Introduction

• Routine childhood vaccination is a cost-effective preventive health measure that will avert approximately 42,000 early deaths and 20 million cases of infectious disease while saving nearly $70 billion in societal costs among the US birth cohort1 • Despite an excellent safety record, confidence in vaccine safety and efficacy is falling in the US, coinciding with rising rates of vaccine delay and refusal2,3 • Delay in acceptance or refusal of vaccines, termed “vaccine hesitancy,” represents a threat to public health that coincides with rising rates of underimmunization2,3 and outbreaks of preventive disease such as measles, mumps, rubella, and pertussis4 • Research on the general population shows that vaccine decision-making is complex and that many parent, child, and household characteristics influence hesitancy5 • Parental distrust in health care providers6 and poor maternal mental health7 have both been linked to vaccine hesitancy in the general population • Compared to non-Hispanic white families, US Hispanic and non-Hispanic black families have lower vaccination rates,8 and other demographic factors like socioeconomic status,8 level of maternal education9 have been evaluated and show mixed results Knowledge Gaps • Previous research disproportionately represents samples that are whiter, more educated, and more affluent than the general population10 • Home visiting programs provide prenatal and postpartum support to families in low-resource settings and have logical potential to promote vaccine adherence, however it is uncertain whether trust in community-based service providers, such as home visitors, is associated with vaccine hesitancy or delay • Vaccine literature largely excludes American Indians despite health disparities they experience Our Study • Focuses on a racially and ethnically diverse sample of lowincome families who received home visiting services in Wisconsin • Aims to quantify the prevalence of vaccine hesitancy and potential correlates (household demographics and alterable factors such as maternal mental health, trust in healthcare providers and trust in home visitors)

Ross M. Gilbert, B.S., Joshua P. Mersky, Ph.D., Chien-Ti P. Lee, Ph.D.

Methods

• Data was collected from a sample of women with children who enrolled in the Families and Children Thriving (FACT) Study, a longitudinal investigation of low-income families in Wisconsin, United States. All participants received evidence-based home visiting services. Over 98% of households were within 200% of the federal poverty line or were eligible for means-tested benefits. • Three items assessed the degree to which respondents perceived childhood vaccines to be (1) important for my child’s health; (2) effective; and (3) safe. Participants rated their level of agreement with each statement on a scale from (1) strongly agree to (5) strongly disagree. A total score was computed by summing the items (range 315). Participants also reported if they had ever delayed or avoided vaccinating their child out of safety concerns (yes = 1). They were also asked if the child received all vaccines recommended for children up to his/her age (yes = 1). • Mothers also reported their level of home visitor trust, ratings of their child’s overall health, number of child health care visits, health care provider trust , global mental, mother’s age, child’s age, mother’s race/ethnicity and mother’s education • A descriptive analysis was conducted for all study measures. Multivariate regressions were conducted to test associations between study outcomes and their correlates. Tests of association were conducted using Ordinary Least Squares (OLS) regression for vaccine hesitancy measures including the perceptions of vaccine importance, efficacy, and safety. Logistic regression was used to analyze vaccine delay and adherence

Results

• Table 1 (left) shows that 5.0% of respondents disagreed that vaccines are important for their child’s health, while 5.4% disagreed that vaccines are effective, and 6.2% disagreed that vaccines are safe. Results indicated that 14.3% of parents had delayed vaccinating their child, and that 94.0% of sample children had received all their recommended vaccines • Table 2 (top left) shows that participants who reported less trust in their health care provider rated vaccines as less important for their child’s health, less effective, and less safe. Respondents who disclosed lower levels of home visitor trust also rated vaccines as less effective and less safe, and they reported greater total vaccine hesitancy. • Compared to non-Hispanic whites, American Indians rated vaccines as less important for their child’s health, less effective, and less safe, and they reported greater total hesitancy. Compared to whites, vaccines were rated as less important by non-Hispanic blacks and more important by participants classified as other race/ethnicity. The other race/ethnicity group also reported that vaccines were safer than did whites. • Table 3 (top right) results indicated that greater trust in health care providers was associated with a reduced likelihood of vaccine delay and an increased likelihood of being up to date on vaccines. Children were more likely to be up to date on vaccines if they were older and if their mothers reported more positive mental health scores. Compared to non-Hispanic whites, American Indians were less likely to report that their vaccines were up to date, and black families were more likely to report that they delayed vaccination

Discussion ● Results show a high percentage of children who were up to date on vaccines (94%). However, many caregivers reported that they had delayed vaccination at some point (14%), and many endorsed various markers of vaccine hesitancy. ● A substantial minority outright disagreed that vaccines are important (5.0%), effective (5.4%), and safe (6.2%); even higher percentages of respondents reported that they somewhat agreed and somewhat disagreed that vaccines are important (10.9%), effective (14.5%), and safe (21.9%). ● Findings support prior research that shows trust in health care providers and better maternal mental health scores are important correlates of vaccine acceptance ● Interestingly, the respondents with less home visitor trust also revealed greater vaccine hesitancy. This is an important finding as these programs reach many underserved families and have great potential to influence vaccine ● While much of our demographic data failed to reach significance, American Indians reported more vaccine hesitancy and were less likely to be up to date, while African Americans were more likely to delay vaccination

Harm Reduction and Syringe Exchange Programs

Harm Reduction and Syringe Exchange Programs Sara Adelina Cuadra Aruguete BA, Gina Allende, Theresa Umhoefer Wittry MD

Discussion Table 1: All free responses for the first survey question are listed below

1. What do you do with your used needles if you don’t bring them here? Throw them in the garbage Bring them back to another syringe exchange program (ARCW or 16th Street) Leave them outside

Introduction A major risk of injection drug use (IDU) is the transmission of bloodborne infectious diseases such as HIV, Hepatitis C, and Hepatitis B1. Since 2017, for the first time in the past ten years there has not been a decline in HIV among IDU in Wisconsin2. Injection drug use, the main risk factor for infection with hepatitis C, has been associated with 63% of acute hepatitis C infections in Wisconsin during 20173,4. Syringe exchange programs (SEP) are an important harm reduction initiative to decrease transmission of these diseases and are supported by the Wisconsin Department of Health Services (DHS)5. In 2018 UMOS, a non-profit advocacy organization, implemented a SEP in Milwaukee that provides sterile needles, safe syringe disposal, syringe home pick-up services, as well as other harm reduction initiatives.

Purpose: To reduce the transmission of sexually transmitted infections such as Hepatitis C and HIV via injection drug use in Milwaukee county by implementing a syringe exchange program.

Methods A verbal survey was conducted to 25 UMOS SEP participants to assess barriers to syringe return and other health risk behaviors. Surveys were available in English and Spanish. 25 Total Surveys

5 Pilot Surveys

20 Surveys with Updated Questions*

* $20 Family Dollar Gift Cards were used as an incentive for participation

Give them to a friend Cops take them Figure 1: Final survey with updated edits that was administered to 20 participants

In addition, the number of syringes UMOS distributed, disposed of, and picked up was measured and compared monthly. The syringe return rate was used as a measure of efficacy. This value did not include syringes from home pick-ups.

Save them in the home

Table 2: The free responses for the second survey question are listed below. The number of people that provided answer choice is listed in the adjacent column. There were 25 total responses.

Since UMOS’ SEP began in 2018, there has been an increase in the syringe return rate. This is most likely attributed to increasing awareness of the program and trust built between SEP clients and employees. The survey responses provided tangible recommendations to improve the program (i.e. business hours were expanded in 2019 due to client's request). In addition, these results support the need for the SEP, as unsafe syringe disposal puts the community at risk. For the future, the same survey will continue to be administered as clients may have new needs due to a change in the UMOS SEP location. Continued survey administration will strengthen relationships between UMOS and its clients within its community. Figure 3: Images of the zip codes 53204 and 53207 are depicted to show the potential change in population utilizing the SEP 53204

2. What would make it easier to bring used needles back to UMOS?

Results Syringe Return Rate (SRR) Figure 2: The syringe return rate has increased from the beginning of the program in August of 2018 to December of 2019. *Values above 100% indicate that more syringes have been returned than distributed.

2018

August

September

October

November

December

Year Average

2019 January February March April May June July August September October November December Year Average

% 57 40 39 122 130 58 26 207 140 39 58 78 83

No police arrests/ tickets

Ride/ transportation 2 to SEP

Expanded business hours

Being asked for them 2

Pick up services

Public drop box

Incentives for participation

Law changes

Portable van to drop off needles

Unsure

Table 3: The following table only includes responses where greater than three participants shared the same answer. Participants were allowed to provide multiple free responses.

3. How would your life change if this needle exchange did not exist? Transmit or acquire HIV or Hepatitis C

Share equipment

53207 Acknowledgements Much appreciation to UMOS Health Promotion Manager Gina Allende for her mentorship and service to public health. Special thanks to TRIUMPH faculty Melissa Lemke and UW SMPH for coordinating the utilization of TRIUMPH grant funds and to Hector F Cuadra Baez for assistance in graphic design.

References 1. Centers for Disease Control and Prevention (2019). Injection Drug Use and HIV Risk. Retrieved from https://www.cdc.gov/hiv/risk/idu.html. 2. Wisconsin Department of Health Services (2018). Wisconsin HIV Annual Surveillance Report 2017. Retrieved from https://www.dhs.wisconsin.gov/publications/p00484.pdf 3. Centers for Disease Control and Prevention. Surveillance for acute viral hepatitis—United States, (2007). MMWR 2009;58(No. SS-3). 4. Centers for Disease Control and Prevention MMWR (2014). Rapid Hepatitis C Testing Among Persons At Increased Risk For Infection - Wisconsin, 2012–2013. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6314a3.htm?s_cid=mm6 314a3_e 5. Wisconsin Department of Health Services (2016). Envisioning the End of the HIV Epidemic – Wisconsin Integrative HIV Prevention & Care Plan 2017-2021 ata-glance. Retrieved from https://www.dhs.wisconsin.gov/publications/p01631.pdf

Hotspotting for Medically and Socially Complex Patients In a Primary Care Setting: Aurora Health Center Midtown

Yanzi Jiang, BS; Laura Miller, BA; Rachel Castillo, MSW; Sharon Krukowski, NP; Glenda Sundberg, FNP-CS, Kjersti Knox, MD

Methods

Introduction PROBLEM: The current United States healthcare system is not designed for medically and socially complex patients. Five percent of patients incur fifty percent of the healthcare cost (1). SOLUTION: Hotspotting - a multi-disciplinary, coordinated care system that treats the whole patient, including social needs that affect health: housing, mental health, substance abuse, emotional support. CONTEXT:: Hotspotting at St. Luke’s Family Practice Center and Sinai Family Care Center in Milwaukee, Wisconsin identifies patients in a primary care setting through a comprehensive review. Data from 2017 and 2018 show that these hotspotting programs addressed the quadruple aim: improving patient experiences, improving population health, decreasing costs, and potentially reducing burnout among providers and staff (2,3,4).

Figure 3: The 2019 Aurora Health Care Midtown hotspotting team.

Discussion

Results Midtown hotspot patients

Midtown patients overall

Race

100% African American

83.3% African American

Insurance

60% Medicaid 27% Medicare 0% Commercial 13% Both

40.7% Medicaid 28.7% Medicare 22.2% Commercial

Table 1. Demographics of Aurora Health Center Midtown hotspot patients compared to the clinic as a whole. .

96 visits 56 visits

Hotspotting Process in 2019 18 visits

OBJECTIVE: In 2019, our goal was to enroll 15 patients in a hotspotting program adapted to Aurora Health Center Midtown – a primary care clinic serving areas of Milwaukee County that face the steepest disparities in socioeconomic status and health outcomes.

16 visits

Figure 6 and 7. Percentage of hotspot patients who identified various social needs: 100% of hotspot patients screened positive for a social need. 80% of patients screened positive for care coordination problems which include difficulty making appointments, refilling medications. Total number of hospital visits increased while ED visits decreased in 2019 compared to 2018. Figure 4: The process of hotspotting at the Aurora Health Center Midtown in 2019.

Aurora Health Center Midtown ● Serves a total of 2530 community members ● 83.3% Black/African American, 13.6% White, 2.6% Asian ● Top 5 Zip Codes Represented: 53216, 53218, 53209, 53210, 53206 ● Insurance Status ○ Medicaid: 40.7% ○ Medicare: 28.7% ○ Commercial: 22.2%

Aurora Health Center Midtown

Figures 1 and 2. The community served by Aurora Health Center Midtown (3,5).

Area of improvement Patient identification and enrollment

1. Start rolling admission for patients and triage by patient need. 2. Identify patients by perceived complexity by staff. 3. Collaborate with other care coordination programs.

Measuring success

1. Set and track specific goals at the interactive meetings. 2. Conduct case studies to identify successes and failures.

Sustainability

1. Liaison with billing.

Teamwork and Roles

1. Check-in via Epic messenger after every home visit for tasks. 2. Increase RN involvement. 3. Liaison with behavioral health.

Care Team Well-being

1. Identify how to better support home visitors. 2. Accommodate initial investment for later pay-off.

Figure 5: The various components of hotspotting a patient.

DATA COLLECTION AND ANALYSIS CARE TEAM WELL-BEING AND THE HOTSPOTTING PROCESS: TRIUMPH students and hotspotting team gathered in person qualitative feedback from interactive meetings and a clinic-wide meeting. PATIENT EXPERIENCE: hotspotting team collected in person feedback from patients at the end of their home visit. QUANTITATIVE DATA: Glenda Sundberg analyzed hospital admissions and ED utilization. Rachel Castillo assessed Social Determinants of Health for each patient.

Future changes

Table 2: Feedback from clinic staff about the hotspotting process and the subsequent adjustments that will be made in 2020.The feedback on the 2019 hotspotting process fell into these categories: patient identification and enrollment, measuring success, sustainability, teamwork/roles and care team well-being.

OUR PATIENTS: Hotspotting at Aurora Health Center Midtown is reaching more African American and Medicaid patients compared to the rest of the clinic population (Table 1). Given the well-known impact of poverty and racism on health, it appears some of the clinic’s most vulnerable patients were identified for hotspotting via comprehensive patient review. SOCIAL NEEDS: Many of the hotspots had social needs (Figure 6).The large percentage of patients who screened positive for multiple social needs highlights the importance of collaboration between social work and the medical team. THE STORIES BEHIND THE NUMBERS: Tracking ED visits and hospitalizations may be an incomplete way to measure success (Figure 7). For example, while the decrease in ED visits appears to be a success, it was in fact due to one patient being incarcerated. Another patient was considered a success because hotspotting helped increase her healthcare engagement and strengthen her social support symptoms, but her ED utilization and hospitalizations were unchanged (picture below). Our point is that the quantitative data does not give us the full picture of whether a hotspot was a success. “I always tell people that my name is Angel for a reason. I had a stroke in 2014 and it was God’s way of giving me another chance at life because before then I was not really living up to my name. I was impatient, sometimes mean, and was taking my life for granted. After my stroke, I had to...rely on other people to help me because I couldn’t do many things on my own anymore. I’m now more patient, humble, and kind. I’m grateful for my team, including Dr. Getzin, Dr. Boujelbane, the clinic social worker, my Family Care nurse and case manager, [my nurses], and my family. They help to keep me going by focusing on the positives and ways I can keep doing better. I’m still battling with certain deficiencies, but I try to stay strong and keep going even when it’s hard, because I know my story isn’t over yet.” --Angel LIMITATIONS INCLUDE: Obtaining both meaningful and anonymous formal feedback from patients and staff. Hotspotting one patient was different from hospotting another because of diverse range of patient needs. Small sample size. NEXT STEPS: Adjusting the hotspotting process at Midtown. Conducting case studies to identify what is a successful hotspot.

References 1. Stanton MW, Rutherford MK; Agency for Healthcare Research and Quality. The high concentration of US health care expenditures. http://meps.ahrq.gov/mepsweb/data_files/publications/ra19/ra19.pdf. Published Jun 2006. 2. Goodson, B. D., et al. “Enhancing Home Visiting With Mental Health Consultation.” Pediatrics, vol. 132, no. Supplement, 2013, doi:10.1542/peds.2013-1021s. 3. Taylor-Coleman K, Sundberg G, Kram J. Hotspotting medically complex socially at-risk patients accomplishes the quadruple aim. 2019 4. Advocate Aurora Population Health 5. Boulton, Guy. “In Milwaukee and U.S., Hospitals Follow Money to Suburbs.” Poor Health | Special Report - In Milwaukee and U.S., Hospitals Follow Money to Suburbs, 14 June 2014, archive.jsonline.com/news/health/in-milwaukee-and-us-hospitals-follow-money-to-suburbsb99282952z1-262901951.html/. 6. Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim. American Journal of Medical Quality 2019; 34(4):339-347

What is TRIUMPH? TRaining In Urban Medicine and Public Health (TRIUMPH) is an educational program for Acknowledgements. Thank you Glenda Sundberg for mentoring the Midtown hotspot team during the Aurora Health Center Midtown pilot; Dr. Kjersti Knox for serving as our TRIUMPH mentor; Advocate Aurora Population Health for providing 2017-2019 data; Sharon Krukowski and Rachel Castillo for leading the hotspotting process and serving as the community mentors; Dr. Anne Getzin and the entire Midtown clinic staff for providing support and thoughtful feedback on the hotspotting process; Angel Madison for allowing us to honor her story; Julia Walters for sharing her photo of Angel.

University of Wisconsin School of Medicine and Public Health medical students which integrates clinical, community, personal and leadership skill development in Milwaukee, WI. TRIUMPH prepares students to become communityengaged physician leaders who will promote health equity for people living in urban health professional shortage areas. Website: http://www.med.wisc.edu/education/md/triumph/main/681

“Alone, we can do so little; together, we can do so much.” –Helen Keller