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TRIUMPH Graduation 2021

THIRD-YEAR STUDENTS’ POSTERS

Mental Health of Teenagers at North Division High School

Mental Health of Teenagers at North Division High School Alexis Ray BS, Elizabeth Eiland BA, Elsa Banks BA

Introduction

Discussion

High school is a difficult time for any teenager. Current high school students now also face the unique challenge of navigating high school during a pandemic. • According to the CDC, mental health concerns including depression and/or anxiety were diagnosed in more than 10% of American children (2017). • This figure is widely considered an underestimate. • This puts children at increased risk of self-harm behaviors and suicide, which is the 2nd leading cause of death in people aged 10-24 (CDC, 2017). When surveyed about a variety of issues including physical/sexual health, home/school safety, and mental health, students at North Division High School self-identified symptoms of depression and/or anxiety as a major issue for them. A systemic review (Florescu, 2019) on interventions to reduce stress and improve mental health in teenagers found that various coping skills (sports, music, etc) can be beneficial when tailored to the individual and community context of the teen.

A major goal of this project is continued sustainability regardless of placement of a TRIUMPH student at the site. We plan to give teachers and students encouragement and guidance for adding their own ideas to create new coping sessions in the future. We hope to ultimately create a coping sessions reservoir to be used by all teachers moving forward, which is added to and updated by those using it.

Methods

Results

Based on the data, the project team developed coping skill sessions to be delivered during the school day. These sessions were developed by the TRIUMPH student in consultation with teachers and school counselors. Considerations when developing coping skills sessions: • Designed to be easy to implement and require little guidance from teachers to avoid burdening already overextended teachers. • Sessions are optional at the discretion of each teacher. • Each session’s materials will be made permanently available to teachers and staff to maintain project sustainability with or without TRIUMPH student. • Student and teacher feedback will be heavily incorporated into continued development of new sessions.

Quantitative results will be based on a mental health survey given before and after each semester of coping skills sessions. The survey includes questions from the PHQ9 depression screening and GAD7 anxiety screening, as well as a general assessment of overall mood. Qualitative results will be based on virtual interviews with students and teachers about the impact of the coping sessions. This will include quotes about personal and overall impact of the sessions.

There is significant literature (Florescu, 2019) discussing the importance of parental involvement in shaping adolescent mental health. While directly involving parents in the mental health coping sessions was not part of this project, it is a possible avenue of next steps to further promote mental health of students at NDHS.

• •

Sources “FastStats - Adolescent Health.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2017, www.cdc.gov/nchs/fastats/adolescent-health.htm. Florescu, S; Mihaescu Pintia, C; Ciutan, M; Sasu, C; Sfetcu, R; Scintee, S G; Vladescu, C. “Interventions to reduce stress, anxiety, and depression in teenagers – a systematic review.” European Journal of Public Health, Volume 29, Issue Supplement 4, November 2019.

Spring 2020

Fall and early spring 2021

Summer and fall 2021

Early spring 2022

“Needs Assessment” survey filled out by NDHS students

Summer mental health guide developed

“Coping Skills Sessions” developed and implemented

Repeat mental health survey

• Identified depression and anxiety symptoms as highpriority issues for students • Developed by previous TRIUMPH student on project, Madeline Kenzie.

• Used both evidence-based research and qualitative research (student/teacher suggestions) • Listed suggested activities aimed at improving student mental health over the summer

• Series of 10-15 min, bimonthly sessions • Implemented feedback from students about the summer activities and incorporates new sessions • Surveyed students prior to first session with mental health survey

• Check for short-term impact of coping skills on student mental health • Use student feedback to make changes to existing sessions and add new ones

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: https://www.med.wisc.edu/education/md-program/triumph/

Complex Discharge Planning

Complex Discharge Planning Andrew Carlson Project Mentor: Sarah Becker, Social Services Director with Advocate-Aurora Health Care (MKE South)

Introduction When a social worker is planning the discharge for a patient, they need to take a few key matters into consideration: • Where is the patient going after discharge? Do they have housing? • Who will be providing care for the patient after they leave the hospital? • Does the patient have ongoing care needs that require professional support? For these reasons, discharge planning for complex patients is very challenging. Previous work in this area has demonstrated that:

• post-discharge facility placement is a major structural barrier leading to delayed discharge. • Other barriers to timely discharge include socioeconomic status, patient behavior issues, lack of patient readiness to discharge, medical complexity, and communication problems in the discharge process.1

Objective: Develop resources, processes, and training to improve the effectiveness and timeliness of complex patient discharge at Advocate-Aurora hospitals in the Milwaukee area.

Dimension 4: Improve ongoing professional development for social workers, by designing a mentorship program and introducing new onboarding materials

Methods

Results

Expected Dimensions to this Project:

Themes, derived from focus groups: • Placement is multifactorial; includes facility willingness, medical complexity, patient insurance status, patient housing history, and patient behavior history. • It is difficult to initiate the discharge process when the team’s medical decision-making has not been finalized. • Relationships with community organizations are difficult to leverage in discharge planning, due to differences in priorities and timescale expectations.

Dimension 1: Conduct a series of semistructured discussions with social workers to identify the unique challenges of discharge planning in Advocate Aurora hospitals and outline competencies for social work discharge planners

Dimension 2: Create a series of in-service trainings for social workers with community-based patient advocacy organizations Dimension 3: Develop long-term partnerships with community organizations which have expertise relevant to discharge planning, which will include the production of a comprehensive patient advocacy guide

Competencies for social work discharge planners, derived from focus groups: • Multidisciplinary communication and medical literacy • Task shifting and priority-setting • Recognizing limitations and eliciting peer support • Creativity and flexibility

Community Organizations Identified for Partnership Development

Discussion So far, this project has been effective at identifying and characterizing the dynamics influencing complex discharge planning. Major breakthrough: Engaging social workers from different experience levels, to illicit their insights and identify potential partners in the community. Next steps 1. Engaging with new community partners to create a package of ongoing professional development materials for social workers. 2. Design a supplement to social worker onboarding, through community partner engagement. Works Cited 1. Ragavan MV, Svec D, Shieh L. Barriers to timely discharge from the general medicine service at an academic teaching hospital Postgraduate Medical Journal 2017;93:528-533.

A Virtual Frontier: The Intersection of Care Coordination and Telehealth during the COVID-19 Pandemic

A Virtual Frontier: The Intersection of Care Coordination and Telehealth during the COVID-19 Pandemic Ben Kannenberg, MS3; Greg Stadter, MPH

Introduction

Methods

Results & Discussion

The MHCP

The Project

Patient Perceptions | Best Practices

Established in 2007, the Milwaukee Health Care Partnership (MHCP) is a public/private consortium dedicated to improving health care for low income, underserved populations in Milwaukee County, with the aim of improving health outcomes, promoting health equity and lowering the total cost of care. Enhancing care coordination and navigation across social and health care delivery systems is one of the MHCP’s primary goals.

When the COVID-19 pandemic began affecting Milwaukee in

Data collection will involve both internal EDCC/partner clinic records and surveys conducted by two local FQHCs.

Members of the MHCP include: • 4 major health systems in Milwaukee • Medical College of Wisconsin • 5 Milwaukee-based FQHCs • City, county and state governmental health agencies

March 2020, several processes occurred simultaneously: • Many of the EDCC receiving clinics switched to a majoritytelehealth model of providing care. • EDCC referrals dropped, likely due to lower ED volumes, ED social work going virtual, and other demands on time. • The show rate for EDCC follow-up visits increased. This number had historically hovered around 45%; since March 2020, the average show rate has been around 60%.

Surveys, which consist of 5 questions, are designed to assess patient perceptions of telehealth on multiple axes and invite follow-up statements:

General Perceptions: “How did the visit go? Did you feel prepared for the visit?”

Accessibility: “Was it easier to attend the visit via telehealth?”

Desirability: “Which type of visit did you prefer, or were they about the same?”

Sustainability: “Would you consider making another telehealth visit?”

Project Aim: To understand the root cause of the increase in show rate, especially the intersection of this increase and the increase in telehealth usage during the pandemic.

To Date: 20 surveys collected | Goal: 40 from each clinic

Predisposing Demographics Left: EDCC show rate vs. number of referrals. Above: Map of EDCC receiving clinics.

The EDCC The MHCP’s Emergency Department Care Coordination (EDCC) Initiative aims to decrease avoidable ED visits, services, and hospitalization for low-income and underserved populations, as well as connecting these patients to primary care health homes and other health resources. This forms a partnership between local EDs and community FQHCs and free clinics. In Milwaukee, 80% of frequent ED users (10+ visits/year; roughly 4000 patients in 2017) use multiple EDs across the city. Having a community-wide approach to connect these patients to a medical home provides better health outcomes while reducing healthcare costs across multiple EDs.

Project Goals 1) Understand barriers to in-person primary care attendance among at-risk populations outside of the COVID-19 pandemic. 2) Assess telehealth usage during the COVID-19 pandemic and gain insight into patient perceptions of telehealth care. 3) Develop best practices for telehealth usage both during and after the COVID-19 pandemic, seeking to address barriers.

• Young age (17-40) • Male gender • Non-married • Low SES • High healthcare usage • Diagnosed mental health condition • Non-white ethnicity • 1st generation immigrant

Social work staff at 16th Street Community Health Centers and Outreach Community Health Centers have incorporated these surveys as part of the regular followup for patients who have attended a telehealth visit. Once a critical mass of surveys has been reached, results will be analyzed, including contrast and comparison between the two sites. Once completed, analysis will be passed back to participating clinics and best practices will be developed, focusing on the future of telehealth as a treatment modality for EDCC receiving clinics after the pandemic has run its course.

Barriers to Care After completing a literature review regarding barriers to attending primary care, at-risk populations were identified alongside salient barriers both inside and outside the healthcare system.

Systemic Barriers • >1 year between appointments, or multiple appointments within 2 weeks

Social Barriers • Transportation • “Forgetting”

• Language barrier

• Negative past experiences with healthcare system

• Long distance to clinic, especially if visit scheduled in winter

• Time off work

• Cost

• Childcare

Community Leaders Engaged in Aquatic Research (CLEAR); Utilizing Citizen Science to Better Understand Milwaukee’s Rivers

Community Leaders Engaged in Aquatic Research (CLEAR); Daniel

Utilizing Citizen Science to Better Understand Milwaukee’s Rivers

1 Arndorfer ,

Maggie

2 Steinhauer ,

Ethan

2 Bott ,

Joseph J.

3 Piatt ,

Todd R.

4 Miller ,

Cheryl

5 Nenn ,

Katie

5 Rademacher ,

J. Val

6 Klump ,

Tim

2 Vargo

1University

of Wisconsin School of Medicine and Public Health, Madison, WI ; 2Urban Ecology Center, Milwaukee, WI; 3Carroll University, Department of Chemistry, Waukesha, WI; 4University of Wisconsin- Milwaukee, Joseph J. Zilber School of Public Health, Milwaukee, WI; 5Milwaukee Riverkeeper, Milwaukee, WI; 6University of Wisconsin- Milwaukee, School of Freshwater Sciences, Milwaukee, WI

Introduction

Results

The city of Milwaukee, Wisconsin contains three major rivers: the Milwaukee, Menomonee and Kinnickinnic. These urban rivers receive significant pollutant input from city runoff and frequently demonstrate poorer quality than Environmental Protection Agency standards for water body health.1-2 However, more research is needed on the temporal and spatial distribution of emerging contaminants, such as antibiotics. Recently, there has been an increased awareness in the impact and utility of citizen science; involving community members in the scientific process. Participation in citizen science has been associated with improved understanding of study results, increased community buy-in, and behavioral change.3-

Water quality • Over 50 volunteers, including students, participated in data collection from all three rivers • Analysis detected caffeine in over 80% of samples and the antiseizure medication carbamazepine in over 60% of samples • Atrazine and triclosan were detected at harmful concentrations at several sites • Concentration of over 50 contaminants examined Educational material • High school students participated in informational sessions about water quality and performed additional analysis over four classroom sessions as part of community dissemination efforts

The purpose of this project was to utilize citizen science to aid in the collection of water quality data from Milwaukee’s Rivers and redistribute this data back to community members. Overarching goals included gathering water quality data for Milwaukee’s Rivers, increasing awareness of water pollution, and educating communities on ways to reduce pollution.

Methods

Image 1: Grading of Milwaukee’s Rivers in 2017 https://www.jsonline.com/story/news/local/milwaukee/2017/11/17/ch ronic-pollutants-continue-plague-milwaukee-river-outdoor-enthusiastsflock/871748001/

Data collection • Community organizations recruited volunteers in-person and online. • Online signup was offered, and premade water sampling kits with instructions were provided. Data analysis • Mass spectrophotometry performed via partnership with University Wisconsin Milwaukee • Community members and students across the training spectrum assisted in analysis Distribution of results • Social media posts were created for advocacy group pages • Pilot curriculum designed for Escuela Verde students to analyze data and learn about results

Image 2: Example of social media post created to raise awareness

Discussion & Future Directions

Figure 1: Detection rate of various contaminants in our samples

Image 3: Education slide use in school curriculum program

The partnership between multiple organizations and research groups allowed community involvement at every level of study. While most substances were detected below toxic concentrations, recent studies have called into question safe exposures given bioaccumulation. Carbamazepine, for example, has been found to cross the placenta and accumulate in fetuses.6 Students were actively involved in sessions and were given the opportunity to learn about the scientific method while analyzing the sample data. Social media posts will continue to be rolled out on Milwaukee River Keepers social media pages with thousands of followers. We hope to safely restart sampling events once contact precautions from COVID-19 have lessened. In addition, we hope to extend the pilot curriculum to additional schools and continue our community outreach.

Image 4: Community members tour the laboratory

Sources 1) WDNR. 1995. Milwaukee Estuary Remedial Action Plan: Progress through January 1994. A Plan to Clean Up Milwaukee’s Rivers and Harbors 2) Wisconsin. Department Of Natural Resources. The state of the Milwaukee River Basin. [Dept. of Natural Resources, 2001] Web.. Retrieved from the Library of Congress, <lccn.loc.gov/2002418368>. 3) Ballard, Heidi L. and Belsky, Jill M.(2010) 'Participatory action research and environmental learning: implications for resilient forests and communities', Environmental Education Research, 16: 5, 611 — 627 4) Jordan RC, Gray SA, Howe DV, Brooks WR, Ehrenfeld JG. Knowledge gain and behavioral change in citizen-science programs. Conserv Biol. 2011 Dec;25(6):1148-54. doi: 10.1111/j.1523-1739.2011.01745.x. Epub 2011 Oct 3. PMID: 21967292. 5) Toomey, A., & Domroese, M. (2013). Can citizen science lead to positive conservation attitudes and behaviors? Human Ecology Review, 20(1), 50-62. Retrieved March 2, 2021, from http://www.jstor.org/stable/24707571 6) . Kaushik, G., Huber, D. P., Aho, K., Finney, B., Bearden, S., Zarbalis, K. S., & Thomas, M. A. (2016). Maternal exposure to carbamazepine at environmental concentrations can cross intestinal and placental barriers. Biochemical and Biophysical Research Communications, 474(2), 291-295. doi:10.1016/j.bbrc.2016.04.088

Returning Citizens Transitions Clinic Implementation: A Partnership Between Advocate Aurora Health and the Progressive Community Health Center

Returning Citizens Transitions Clinic Implementation: A Partnership Between Advocate Aurora Health and the Progressive Community Health Center JB Hernandez BS, Sarah Reimer MD, Jacob Bidwell MD, Jennifer Sevenich CEO, Pamela Graf, MBA, Nicole Wooters LCSW

Background 167,000 Justice-involved persons in Milwaukee County or DOC facilities during the last 10 years • 109,000 are AAH patients; 80,000 have lived in Milwaukee County

Methods Inclusion Criteria: Release within 1 year AND one of the following: • Age greater than 50 y/o • Chronic Medical Condition • Chronic Mental Health Condition • Substance Use Disorder

Discussion

Workflow

Returning Citizens are often Medically Complex and Underserved: • High rates of chronic medical conditions, HIV, and substance dependence1 • Increased risk of 3,4 Hospitalization • 13x mortality compared with peers in first two weeks after release5,6 • Barriers to appropriate care • Under-insured (primarily Medicaid) • Criminal record discrimination • Patient distrust

TCN Outcome Parameters

CHW’s with lived experience integrated into primary care team

Meet individuals prior to release to smooth transition

Receive referrals from DOC, caregivers, or community

Proven Results: • 50% fewer ED visits over 12 months when compared with expedited care in a safety net primary care clinic, saving Medicaid $912/client 1 • 50% fewer preventable hospitalizations 2 • Reduced average hospital stay • 25 days fewer in jail per year on average • Fewer technical violations for probation/parole

Engage in primary care Screen for SDOH needs and make referrals Coach in disease mgmt

• • • • •

Future Directions Stakeholder Analysis Funding Sustainability Women’s Health Initiatives Family Interventions Education and Retraining

Celebrations! Team resiliency, adaptability, and willingness to learn from our CHW’s!

Addressing Cultural Barriers to Early Diagnosis and Intervention of Autism Spectrum Disorder

Addressing Cultural Barriers to Early Diagnosis and Intervention of Autism Spectrum Disorder J.A.M. 1University

1,2 Villaruz ,

3 Sparrow , A.

Van

4 Hecke ,

1,2 Umhoefer-Wittry

of Wisconsin School of Medicine and Public Health, Madison, WI; 2TRIUMPH, Milwaukee, WI; 3Next Door Foundation, Milwaukee, WI; 4Next Step Clinic, Milwaukee, WI

Methods

Background • Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder defined by restrictive, repetitive behaviors/interests and impairments in social interaction and communication.1 • Current estimates reveal that ASD affects 1 in 54 children in the US2. • Early diagnosis and behavioral interventions have consistently shown to significantly improve ASD outcomes, such as IQ and adaptive functioning.3 • While rates of early evaluation of all children are improving nationally, Black and Hispanic ASD children have historically gone underdiagnosed compared to White peers.4 • While this delay in diagnosis is surely multifactorial, cultural stigma towards ASD and a lack of sufficient outreach to vulnerable populations likely play large roles in perpetuating this disparity5,6. • This project is a collaborative effort with Next Door Foundation and Next Step Clinic, local organizations that promote early childhood education and developmental health.

Discussion

Community Readiness Assessment (CRA) • Open-ended questionnaire developed to collect data on ASD literacy and trends in cultural beliefs about ASD. • Disseminated to Next Door Foundation and Next Step Clinic clients via email/Zoom.

Community Outreach • CRA data will inform educational materials geared towards dismantling stigmatized aspects of ASD. • Virtual workshops will be held for parents of ASD and nonASD children within Next Door or its community sites. • Pre- and post-intervention surveys will be administered to assess ASD literacy before and after workshops.

Next Step Clinic Referrals • Robust referral methods will be established at Next Door community sites. • Number of referrals pre- and post-intervention will be compared from each site.

• Objective: Identify and address knowledge gaps or cultural stigma about ASD within Milwaukee community members in the hopes of facilitating early diagnosis and treatment of ASD.

Anticipated Results

References

Provide families with accessible information regarding ASD. Empower individuals to advocate for affected children in their community.

Increase amount of evaluation referrals to Next Step Clinic. Develop methods for ASD screening within community sites. Support and facilitate families’ access of available ASD resources within Milwaukee.

Long Term Outcomes

Stimulate important conversations about child development within communities of color.

Medium Term Outcomes

• Through our outreach and advocacy efforts, we hope to:

Short Term Outcomes

• Through the CRA, we expect to find similar themes in cultural perspectives on ASD as previously reported in literature5,6, such as: • Participant-cited lack of ASD knowledge within their own communities. • Stigmatization of mental health and disabilities within communities of color may lead to hesitancy to seek care. • Pervasive belief that ASD “does not occur in our community” or that ASD is exclusively an issue of the dominant culture. • Evidence of distrust of the systems that would provide opportunities to receive ASD care.

• The current work plans to examine the extent to which cultural factors and misconceptions of ASD additionally impact the rates of early ASD diagnosis and intervention within the city of Milwaukee. • We hope that emphasizing the importance of seeking evaluations will allow families to receive care earlier, which is proven to improve outcomes for ASD children. • Deconstructing harmful attitudes towards ASD and mental health may allow affected families to feel better supported by their social environment and thus better equipped to cope with a challenging disorder. • COVID Challenges • Lack of in-person workshops or screening sessions. • Difficulty in recruiting participants. • Potential exclusion of families with limited access to electronics. • Difficulty in ability to form personal relationships within community sites. • Future Directions • Disseminating educational material beyond Next Door Foundation community partners. • Implementing ASD screening questionnaires at various community sites. • Expanding workshop topics to include other developmental disorders or topics (ex. adverse childhood events).

1American

Increase rates of early ASD screening and diagnosis throughout Milwaukee.

Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). 2013. Washington, DC: Author. 2Maenner MJ, et al. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2016. MMWR Surveill Summ 2020;69 (No. SS-4):1–12. doi: http://dx.doi.org/10.15585/mmwr.ss6904a1. 3Dawson G, et al. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010 Jan;125(1):e17-23. doi: 10.1542/peds.2009-0958. 4Nevison C, et al. Race/Ethnicity-Resolved Time Trends in United States ASD Prevalence Estimates from IDEA and ADDM. J Autism Dev Disord. 2019 Dec;49(12):4721-4730. doi: 10.1007/s10803-019-04188-6. 5Zuckerman KE, et al. Latino parents' perspectives on barriers to autism diagnosis. Acad Pediatr. 2014 May-Jun;14(3):301-8. doi: 10.1016/j.acap.2013.12.004. 6Burkett K, et al. African American families on autism diagnosis and treatment: the influence of culture. J Autism Dev Disord. 2015 Oct;45(10):3244-54. doi: 10.1007/s10803-015-2482-x.

Improve families’ satisfaction with ASD healthcare, financial, and social programs. Dismantle the stigma surrounding ASD and promote acceptance of affected individuals.

Safer at Home: Expanding STI Services to Reach People at Home

Saferat Home: Expanding STIServicesto ReachPeople at Home Julia DeSantis MS3, Melissa Ugland MPH, Julie Katrichis MSN, RN, CNL, Theresa Umhoefer Wittry MD

Introduction The Milwaukee Health Department (MHD) provides sexual health services at Keenan Health Center on Milwaukee’s near north side. Keenan implements a range of medical and educational programs focused on sexually transmitted infection (STI) prevention, testing and treatment. However, COVID-19 has caused massive disruptions to STI prevention and STI clinical services worldwide.

Discussion

Methods One local health department, Cudahy Health Department (CHD), does screening via phone and then people can come pick up a self-collect kit (image 1) to do at home or at the CHD. Labs are done at the State Lab of Hygiene. Planned Parenthood of Wisconsin offers mail-in testing in some cases. The Cudahy Health Department and Planned Parenthood show that there is both an established need for and ability to provide such services in the area.

Time-frame

Activities

2020

Data review of STI numbers in Milwaukee County to assess needs and assets

Summer 2020 Create shared google doc with ideas for social media/communications regarding COVID with focus on sexual health and STI prevention and treatment

Spring 2021

Ongoing

Possible suggestions for adaptations to be made at the local level for STI education, testing, treatment practices as well as individual sexual practices and precautions Set of initial recommendations & plan for pilot

Effective June 1, 2019: The Milwaukee Health Department Laboratory (MHDL) began offering patientcollected vaginal swabs in clinical setting as an alternate specimen source for nucleic acid amplification testing (NAAT). These tests are not currently offered by MHD, despite a growing acceptance of and desire for athome/drop-off (image 2). There is a need to consider whether this is something MHD is capable of offering and if it would benefit the population MHD serves. The CDC has encouraged the development of innovative testing protocols for self-collected clinical laboratory specimens.1 The STI Strategic Planning Committees are now discussing how to offer selfcollection lab testing for STIs. As part of this effort, it will be necessary to assess feasibility and barriers.

According to the Milwaukee Health Department's Monthly Clinical Laboratory Updates (Figure 1), Milwaukee started off 2020 with increased STI testing rates compared to the previous year. Due to the pandemic, testing quickly fell below the previous year’s levels. Therefore, there is a need to further assess COVID's impact on MHD’s STI services and the STI rates in Milwaukee. We must also consider adaptations at the local level to get testing back to pre-pandemic levels and decrease STI rates overall.

Anticipated outcomes of this project this year include a written summary of recommendations and framework for expanding STI services to include self-collection kits, including a feasibility assessment and implementation guide.

Ideally, a pilot implementation will be planned, carried out, and evaluated as part of this process. 2020

2021

Figure 1: Monthly comparison of syphilis data with year over year comparisons Jan 2020-February 2021. Number of specimens screened at MHDL, darker bars represent confirmed tests.

In Summary… COVID-19 is disrupting STI prevention and clinical services around the world. There is a need to assess COVIDs impact on sexual health in Milwaukee and improve public health education and services accordingly. Offering self-collect/test-at-home kits for STIs could help combat the drop in testing seen as a result of COVID. Image 1: Self-collection kit example

Image 2: Drop-off box

References: Figure 1: Milwaukee Health Department. 2020-2021. Milwaukee Health Department's Monthly Clinical Laboratory Updates. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention

What is TRIUMPH? TRaining In Urban Medicine and Public Health (TRIUMPH) is an educational program for UW School of Medicine and Public Health medical students which integrates clinical, community, personal and leadership skill development in Milwaukee, WI. Website: https://www.med.wisc.edu/education/md-program/triumph/

Fondy Food Center’s Fruit & Vegetable Prescription Program: Increasing Access to Fresh Produce through Farmer’s Market and Clinic Partnerships

Fondy Food Center’s Fruit & Vegetable Prescription Program: Increasing Access to Fresh Produce through Farmer’s Market and Clinic Partnerships KaHoua 1University

1 Yang ;

Minaliza Shahlapour,

1 MD ;

Jennifer

2 Casey ;

Kjersti Knox,

1,3 MD

of Wisconsin School of Medicine and Public Health; 2Fondy Food Center, Milwaukee, WI; 3Department of Family Medicine, Advocate/Aurora Medical Group

Introduction

Methods

Future Directions

Milwaukee has a food insecurity problem.

Program Goals

QI Challenge: How can we increase FnVRx prescription redemption rates?

Even before the hardships brought on by the COVID-19 pandemic, widespread food insecurity plagued Milwaukee’s communities, especially among its children. Data collected by Feeding America in 2016 estimated that more than 47,000 children live in food insecure households.1 Numerous studies have also suggested that inadequate nutrition can have long lasting impact not only on children’s physical health but also on their behavioral and emotional well being.2 In the wake of the pandemic, the number of households struggling with food insecurity is projected to grow.1

Patient interviews conducted in 2017 identified several recurring reasons for why they did not fill their FnVRx prescriptions.4 • Lost paper prescriptions • “Forgot about it” • Transportation

Post-Market Season Analysis • Analyze data from PPs regarding number of prescriptions written. • Analyze data from FFM regarding number of prescriptions redeemed.

QI Initiative: Implement follow-up reminders to patients to encourage utilization of FnVRx prescriptions.

Program Partner Interviews Figure 1. Estimated food insecurity in Milwaukee County in 2018 and projected increase in 20201.

Fruit & Vegetable Prescription (FnVRx) programs can be effective means to increase access to fresh produce. Studies have demonstrated the positive impact that clinically-based FnVRx programs can have on improving diets in children from low-income households.3 The Fondy Food Center’s FnVRx program seeks to increase access to fresh and affordable produce by partnering with local clinics to screen for food insecurity. However, the program struggles with low prescription redemption rates. Improving these rates would be beneficial for future efforts to evaluate the impact of the program on participants.

• Identify barriers to program participation • Identify successful strategies employed by PP to encourage participation

Results In 2019, 4 clinics participated in the program with 27% of total prescriptions redeemed at FFM by end of season.

Anticipated Results • Similar programs have reported that reminder phone calls from their program staff to participants assisted in boosting redemption rates.5 • Increasing redemptions rates will assist us in future evaluation of the program’s impact.

How the Fondy FnVRx Program Works:

Next Steps Figure 2. Fondy FnVRx prescriptions written and redeemed during 2019 market season.

FFC = Fondy Food Center FFM = Fondy Farmer’s Market

Food Insecurity Screening Questions 1. ”Within the past 12 months, we worried whether our food would run out before we got money to buy more.” 2. “Within the past 12 months, the food we bought just didn’t last, and we didn’t have money to get more.”

Reaching out to patients may be helpful in reminding patients to utilize their prescriptions. Bread of Healing (BoH) had 56% redemption rate, higher than other sites. • Patients regularly seen at BoH clinic each month. • Volunteers reached out to each participant to remind them of FnVRx. • Social workers at BoH are in regular contact with patients to address medical and non-medical needs.

• We are in the process of searching for and securing sustainable funding. • We are also working on recruiting clinics that would be most appropriate for implementation of our QI initiative.

References 1. 2. 3. 4. 5.

“Map the Meal Gap.” Feeding America. 2020. http://map.feedingamerica.org/county/2018/overall/wisconsin/county/milwaukee Shankar et al. J Dev Behav Pediatr 2017. Association of Food Insecurity with Children’s Behavioral, Emotional, and Academic Outcomes: A Systematic Review. Ridberg et al. Prev Chronic Dis 2019. Effect of a Fruit and Vegetable Prescription Program on Children’s Fruit and Vegetable Consumption. McAsey et al. 2017. Fruit and Vegetable Vouchers: One Ingredient for Increasing Produce Consumption, but not the Whole Recipe. [Poster Presentation]. UW-SMPH TRIUMPH. https://institutionalrepository.aah.org/cgi/viewcontent.cgi?article=1027&context=residents Aiyer et al. TBM 2019. A pilot food prescription program promotes produce intake and decreases food insecurity.

Advocate Aurora & The COA Goldin Center: Centering Amani Families

Advocate Aurora & The COA Goldin Center: Centering Amani Families Karina Barretto, Rachel Castillo MSW, Anne Getzin MD, Kjersti Knox MD COA Partners: Nicole Thompson, Lorenzya Polnitz

Results

Introduction The Amani Neighborhood of Milwaukee faces deep disparities in maternal and child health outcomes • Women are 2x more likely to receive late or no prenatal care vs. WI avg1 • Infant mortality and childhood poverty are 3x more prevalent vs. US avg1

Door hanger distributed by COA outreach program.

COVID-19 Vaccine FAQ & MHD Clinic information distributed in COA Food Pantry.

COVID-19 information featured in Amani United Community Newsletter created with Alice Wei, MD.

Initially, the team provided a group-based model of pediatric care that fosters empowerment and community building; project goals focused on increasing enrollment. Given COVID-19, objectives refocused to explore a virtual model of care and to provide COVID-19 & vaccine health education.

Barriers to implementing a successful virtual program include access to internet and a capable device. Possible solutions included offering laptop access in dedicated spaces in both the Goldin Center and Midtown Clinic. Ultimately, we decided not to pursue a virtual model given these barriers and the emergence of new opportunities to serve Amani families with the emergence of COVID-19 vaccines.

AAH Midtown

Next Steps

SES REGIONS2 HIGH MEDIUM-HIGH MEDIUM MEDIUM-LOW LOW

Methods 1. Increase CenteringParenting enrollment • Create recruitment door hangers to be distributed through COA programming • Implement RN Referral program to incentivize recruitment on Aurora Newborn Service 2. Provide public health education • COVID-19 FAQ and information in Amani Newsletter • COVID-19 Vaccine & Milwaukee Health Dept. community clinic information flyers distributed through COA Food Pantry 3. Explore a virtual model for CenteringParenting • Create virtual CenteringParenting landing page for recruitment and survey introduction • Create virtual interest & accessibility survey • Survey participants of COA Food Pantry for 6 weeks

Unfortunately, the efficacy of door hangers in increasing community recruitment was unable to be assessed due to suspension of CenteringParenting during COVID-19. COVID-19 public health information was created to improve education, promote safety measures, and help parents navigate the pandemic’s affect on children. Vaccine information was created to aid in vaccine preparedness and increase awareness of zip code-specific guidelines and MHD community clinics. Flyers are being distributed at the COA Food Pantry and Midtown Clinic and will be used in Medical Student outreach.

The CenteringParenting team is a partnership between AdvocateAurora (Midtown) and the COA Goldin Center, which provides social support to Amani families through educational and social programs.

COA Goldin Center

Discussion

Virtual CenteringParenting Survey Results from 17 participants. Results show favorable interest in virtual programming, with 0% answering “No interest”. 35% of participants did not have internet access and 12% did not have access to a device. 59% participants reside within the zip code of COA Goldin Center (88% reside within or in adjacent zip codes).

VIRTUAL INTEREST MAYBE 24%

INTERNET ACCESS

NO 35% YES 76%

DEVICE USE

53226 53205

NONE YES 65%

CPU

ZIPCODE

SMART PHONE

TABLET

53212 53209

Vaccine preparedness of the Amani and Goldin Center communities Through coordination of medical student volunteer outreach at COA Food Pantry Anticipated methods: • Recruit TRIUMPH and MCW students • Coordination with COA Family Resource Center • Maintain knowledge of current vaccination eligibility and requirements through • Milwaukee Health Department • AdvocateAurora Healthcare

53206

CenteringPregnancy Given the difference of face-to-face requirements of wellchild visits vs. prenatal visits, we hope to eventually relaunch this partnership as a CenteringPregnancy program.

Inspiring Students to Careers: Pursuit of Health Careers Among High School Students

Inspiring Students to Careers: Pursuit of Health Careers Among High School Students Lena Law, MS3; Mishaal Ali, MS4; Elizabeth Prichard, MEd; Suzanne Letellier, MEd, MCHES; Michelle Buelow, MD, MPH

BACKGROUND • Racial disparities in healthcare, such as discrimination in care, can result in poor health outcomes1 • Studies show that more diverse healthcare workforces reduce disparities in outcomes through provision of more culturally and linguistically appropriate care2 • Pipeline programs that target pre-college students are one effective method to increase workforce diversity3

OBJECTIVE Through the Youth Health Service Corps (YHSC) program, we aim to increase the diversity of the healthcare workforce by targeting high school students from underrepresented minorities and providing tools and resources to help them successfully pursue a career in healthcare

METHODS YHSC Programming • Annual new member training • Monthly meetings with topics based on both student and staff input • Health advocacy project • End-of-Year Awards Celebration

COVID-19 Adaptations • No in-person new member training • Virtual meetings • Virtual graduation celebration

ANTICIPATED RESULTS Short-Term Outcomes Students gain knowledge about the healthcare field and possible healthcare career opportunities Students gain hands-on experience with health-related skills, such as anatomy lab or CPR, and health advocacy work Students gain face-to-face interaction with community mentors and healthcare workers

Medium-Term Outcomes Students express interest in pursuing healthcare careers after graduation Students prepare for healthcare careers after graduation by exploring programs and preparing for college applications Students develop relationships with mentors in the healthcare field

Long-Term Outcomes More students from Messmer High School have careers in the health field Former YHSC students return to support current YHSC members in their educational and career journey Healthcare field is populated by more workers from diverse backgrounds, reducing health disparities

Measuring outcomes Pre- and post-participation surveys comparing: • 1) Knowledge of healthcare field and career opportunities • 2) Desire to pursue a health career and confidence in successfully pursuing a health career • 3) Perceived connection to a mentor in the health field

NEXT STEPS • • • •

Focus on increased member recruitment and retention Establishment of an annual YHSC Scholarship Fund Creation of an alumni network for continued connection building More robust data collection, with more opportunities for student feedback

References: 1. Jackson, C. S., & Gracia, J. N. (2014). Addressing health and health-care disparities: The role of a diverse workforce and the social determinants of health. Public Health Reports, 129(1_suppl2), 57-61. doi:10.1177/00333549141291s211 2. Bouye, K. E., McCleary, K. J., & Williams, K. B. (2016). Increasing Diversity in the Health Professions: Reflections on Student Pipeline Programs. Journal of Healthcare, Science, and the Humanities, 6(1), 67-79. doi:29644118 3. U.S. Dept. of Health and Human Services, Office of the Secretary, & Office of the Assistant Secretary for Planning and Evaluation and Office of Minority Health. (2015). HHS Action Plan to Reduce Racial and Ethnic Health Disparities: Implementation Progress Report 2011-2014 (Rep.). Washington, D.C.

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: https://www.med.wisc.edu/education/md-program/triumph/

Improving Service Engagement & Mental Health Outcomes at the Sojourner Family Peace Center

Improving Service Engagement & Mental Health Outcomes at the Sojourner Family Peace Center Peter Ngo BS, Erin Schubert PhD

Intro

Methods & Expected Results

Discussion

What is the Sojourner Family Peace Center (FPC)?

Goal:

The Sojourner Family Peace Center is largest nonprofit provider of domestic violence prevention and intervention services in Wisconsin, serving over 11,800 clients each year.

Rationale: There is minimal data to assess the effectiveness of the FPC model in Milwaukee, which has its own unique demographic and social challenges.

Preliminary data reveals that the mental health outcome related to Hope, Empowerment and Distress scores improve at the 12-month mark compared to baseline. Scores worsened slightly from the 6 month to 12-month mark but were all still higher compared to baseline.

What is an FPC? Family Peace Centers are an innovative model that co-locates multi-sector agencies to serve families impacted by violence in a single facility.

150

This project focuses on assessing the mental health outcomes of clients at the Sojourner FPC and how services can improve to maximize these outcomes.

client interviews

Baseline

What we are measuring:

HOPE

Shelter + Hotline

Legal Services

Health Care Agencies

The issue

6 mo.

12 mo.

Preliminary data suggests:

From now until Spring 2022, analysis is underway to answer more granular questions such as: ❑ Are there certain demographics that are more risk of being lost to engagement?

using the Disposition Hope Scale

This measures client’s motivation and belief in their ability to achieve future goals, which are related to a variety of positive outcomes including education, physical and mental health, and career outcomes.

Schools & Other Nonprofits

3 mo.

Insights into this dip correlates with formal programming at Sojourner decreasing at the 6-month mark. Clients have also expressed difficulties with engaging with Sojourner on a long-term basis.

HOPE scores increased from intake to the 3 month follow up. Scores at the 6 and 12 months mark were higher than baseline. The greatest drop in HOPE scores was seen between 6 months and 1 year

❑ Are some service clusters better at retaining clients for long term engagement?

Next Steps EMPOWERMENT

using the MOVERS Scale

This measures client’s feeling of empowerment in terms of their safety. In other words, do they feel that they have the tools and support to achieve their safety goals?

❑ Implement strategies to continually engage clients after the 6-month mark.

EMPOWERMENT scores increase from baseline to one year. Similar to HOPE, there is a dip in score between 6 months to 1 year.

❑ Improve cross agency referral and streamlining services offered at the Sojourner FPC.

➢ Over half of female homicides in the US are intimate partner violence (IPV) related 1 ➢ African American and American Indian women are killed at nearly three times the rate of nonHispanic white women 1 ➢ Women who are victims of IPV are at an increased risk for developing mental health problems, such as PTSD, depression and substance use disorders 2

❑ Implement a workgroup to address client barriers in accessing the complete breadth of services.

DISTRESS

using the K6 Distress Scale

This is a non-specific and non-diagnostic measure of the client’s mental health challenges.

DISTRESS scores decrease from baseline to 6 months. Scores at 12 months are lower than baseline, but slightly higher than compared to 6 months.

Citations 1

Petrosky E, Blair JM, Betz CJ, Fowler KA, Jack SP, Lyons BH. Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence — United States, 2003– 2014. MMWR Morb Mortal Wkly Rep 2017;66:741–746.

Nathanson AM, Shorey RC, Tirone V, Rhatigan DL. The Prevalence of Mental Health Disorders in a Community Sample of Female Victims of Intimate Partner Violence. Partner Abuse. 2012;3(1):59-75. doi:10.1891/1946-6560.3.1.59

Screening for Traumatic Brain Injury among Survivors of Intimate Partner Violence

Screening for Traumatic Brain Injury among Survivors of Intimate Partner Violence Samantha Prince BS, Erin Schubert PhD, Hector Hernandez, Liz Marquardt

Introduction

Methods

Traumatic brain injury (TBI) is common in the intimate partner violence (IPV) setting. TBI can result in long-term adverse behavioral, cognitive, and physical outcomes. Most IPV survivors who experience TBI do not seek medical attention at the time of the head injury. The goal of the current project is to build on a previous TRIUMPH students’ work by implementing and measuring outcomes data from a TBI screener tool (HELPS screener tool) at Sojourner Family Peace Center. We will collect and analyze the data from the screener tool to determine if clients are at risk of TBI and whether they get referred to medical care services they need. We are working to establish community referral sites for those at risk for TBI.

Interview 150 current or past clients at Sojourner using closed and open-ended questions to gain baseline data including: • client utilization and satisfaction with Sojourner services • demographic characteristics • identifiers of clients at risk for TBI

Short-Term Outcomes

Clients are recruited from Sojourner’s temporary housing services, and clients currently receiving other services. Each client receives a $25 Walmart gift card for their participation. After baseline interviews, clients are contacted via phone for follow-up interviews at 3-month, 6-month, and 1-year intervals. Data analysis will then be conducted for each results of HELPS screener (itemized list of 5 items) and related client outcomes Medium-Term Outcomes

Long-Term Outcomes

Increased knowledge among Sojourner advocates regarding the health impacts of TBI

Improved screening of new clients for history of TBI during intake process

Strengthened support systems for IPV survivors who have history of TBI

Increased motivation among Sojourner advocates to ask clients about TBI during intake process

Clients with a history of TBI are identified and referred to a medical provider

Reduced burden of TBI symptoms on clients

Increased motivation among partner physicians to assess and treat survivors of IPV with history of TBI

Clients with a history of TBI receive medically appropriate and traumainformed care

Improved quality of life for clients

Anticipated Results • We anticipate proper screening and identification of clients with TBI will improve client quality of life • HELPS screener tool incorporated into client intake forms • Have 4-7 established community referral sites

Implications and Next Steps • Clients presenting to Sojourner will be screened for possible TBI and connected directly to selected community clinics for care • Greater awareness of TBI in IPV situations, both among community physicians and Sojourner advocates • HELPS screener tool continues to be utilized beyond this project’s tenure

References AP;, Gagnon KL; DePrince. “Head Injury Screening and Intimate Partner Violence: A Brief Report.” Journal of Trauma & Dissociation : the Official Journal of the International Society for the Study of Dissociation (ISSD), U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/27775489/ Cimino AN;Yi G;Patch M;Alter Y;Campbell JC;Gundersen KK;Tang JT;Tsuyuki K;Stockman JK; “The Effect of Intimate Partner Violence and Probable Traumatic Brain Injury on Mental Health Outcomes for Black Women.” Journal of Aggression, Maltreatment & Trauma, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/31929719/. M;, Wu V;Huff H;Bhandari. “Pattern of Physical Injury Associated with Intimate Partner Violence in Women Presenting to the Emergency Department: a Systematic Review and Meta-Analysis.” Trauma, Violence & Abuse, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/20430799/

Viviendo Integrando, Dieta, Actividades física y Salud mental (V.I.D.A.S.): a culturally appropriate multidisciplinary obesity program at Sixteenth Street Community Health Centers

Viviendo Integrando, Dieta, Actividades física y Salud mental (V.I.D.A.S.): a culturally appropriate multidisciplinary obesity program at Sixteenth Street Community Health Centers Tammy Hoang, Connor Enright, Jorge Ramallo MD, MPH, Michelle Buelow MD, MPH

Introduction

Methods

Discussion

•

Obesity is a growing epidemic affecting 18.5% of children1. Childhood obesity is likely to persist into adulthood and increases the risk of developing cardiovascular disease and mental health disorders. Sixteenth Street Community Health Centers (SSCHC) is a federally qualified health center that provides comprehensive healthcare primarily to low-income and Latinx families in Milwaukee, WI. Focus on pediatric patients: The pediatric portion of the Viviendo Integrando, Dieta, Actividades física y Salud mental (V.I.D.A.S.) program provides a culturally appropriate, sustainable model that integrates lifestyle modifications, behavioral therapy, and pharmacotherapy to reduce obesity rates and improve the cardiometabolic health2 among pediatric patients at SSCHC.

•

A four-stage model for obesity management among younger pediatric populations was developed to address their specific needs. Patients progress through stages of increasing time- and resource-intensiveness as appropriate based on treatment response. The original program will continue to serve as a model for obesity management among adults and adolescents.

Stage 1: PREVENTION

•

Basic Metabolic Needs

Promote healthy eating behaviors and physical activity. Acknowledge how culture may influence lifestyle behaviors.

Prevention of Obesity

PEDIATRIC PATIENTS Stage 2:

Lifestyle Modifications

Screen for other health conditions. Structured diet plans and encourage monitoring

Original Program Pilot After extensive literature review, exploration of existing ancillary programs at SSCHC, and input from stakeholders at SSCHC, a three-stage model was created for management of obesity. Due to COVID-19 pandemic, the program transitioned to a virtual format.

•

Pediatric-Specific Model

WEIGHT MANAGEMENT

•

Pediatric patients have basic metabolic needs required for adequate growth and development. The pediatric specific model stresses familial involvement in the prevention and management of obesity. More frequent visits and enrolling qualified family members may facilitate weight management goals and promote accountability.

Family Involvement

Next Steps Stage 3: MULTIDISCIPLINARY TEAM

Stage 4: PHARMACOTHERAPY

Structured lifestyle behavioral changes utilizing multidisciplinary teams, if not already done, with formal monitoring and frequent office visits.

• • • • •

Further develop obesity management clinical guides and workflow among pediatric populations. Create pediatric-specific resources. Encourage enrollment, enrollment, enrollment! Create support groups for enrolled patients. Revisit Plan-Do-Study-Act cycle regularly for improvement opportunities.

Consider pharmacotherapy depending on patient age.

References 1

“Childhood Obesity Facts.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 11 Feb. 2021, www.cdc.gov/obesity/data/childhood.html. 2 Hunt LP, Ford A, Sabin MA, Crowne EC, Shield JP. Clinical measures of adiposity and percentage fat loss: which measure most accurately reflects fat loss and what should we aim for? Arch Dis Child. 2007 May;92(5):399-403. doi: 10.1136/adc.2006.103986. Epub 2007 Jan 29. PMID: 17261578; PMCID: PMC2083742.

Sixteenth Street Community Health Centers Diabetes Prevention Program: Developing a Community-Based Lifestyle Modification Program for Patients with Prediabetes

Sixteenth Street Community Health Centers Diabetes Prevention Program: Developing a Community-Based Lifestyle Modification Program for Patients with Prediabetes Tom Enright1, Alba Peterson2, Carmen Cosme2, Michelle Buelow, MD, MPH1,2 (1) University of Wisconsin School of Medicine and Public Health (UWSMPH), (2) Sixteenth Street Community Health Centers

Introduction

Discussion

Methods

• Type 2 diabetes mellitus (DM2) is a chronic and progressive disease with significant morbidity, mortality, and healthcare cost burdens. • Prediabetes precedes DM2 and is characterized by asymptomatic insulin resistance. • Lifestyle intervention is a highly effective means of preventing the progression of prediabetes to DM2. • Sixteenth Street Community Health Centers (SSCHC) serves a primarily Latinx population (86%)1 in which the prevalence of DM2 is higher than the national average.2 • SSCHC serves > 1,000 patients/year with diagnosed prediabetes. A diabetes prevention program (DPP) could substantially reduce the individual and community burden of DM2.

Figure 2: Example diagram from program curriculum illustrating the basic pathogenesis of type 2 diabetes.

Results

• SSCHC currently has robust programming for patients with poorly controlled DM2 but no dedicated program for DM2 prevention. • The CDC National Diabetes Prevention Program offers a framework for DM2 prevention but is not well-suited to the abilities and cultural preferences of the SSCHC population.

• Create a diabetes prevention program tailored to the abilities and goals of SSCHC patients with the education, resources, community support, and structure to facilitate sustainable lifestyle change.

Secondary Outcomes

Outcome

Metric

Hemoglobin A1c

Hgb A1c < 5.7%

Body weight

Reduction in body weight by 5%

Perceived stress, anxiety, and depression

Perceived Stress Scale, Beck Depression Inventory, GAD-7

Health literacy and health- Short Test of Functional Health related quality of life Literacy in Adults (TOFHLA), Health-related quality of life (HRQ) Physical activity and dietary habits

Figure 4: Incidence of diabetes by study group among prediabetics from seminal 2002 trial published in NEJM.3

Act

Study

Next Steps

Program Outcomes Primary Outcomes

Project Goal

Plan

Figure 3: Example diagram from program curriculum illustrating caloric restriction (i.e., portion control) as a dietary modification option available to participants.

Figure 1: Schematic of overall program structure and workflow.

The Issue

• The efficacy of the CDC National Diabetes Prevention Program has encouraged organizations to create community-based DPPs designed for specific populations. • At SSCHC, a literature review identified core components of other community-based DPPs. Key informant interviews identified program components and goals best-suited to SSCHC. • Using the Plan-Do-Study-Act (PDSA) model, the SSCHC DPP will evaluate the pilot program based on objective outcomes and subjective feedback with the goal of creating participant-centered and participantdirected program.

International Physical Activity Questionnaire (IPAQ), FatRelated Diet Habits Questionnaire (DHQ)

Table 1: Primary and secondary outcomes of SSCHC DPP with associated metrics for evaluating outcomes.

1. Conduct pilot program with cohort of 6-10 patients. 2. Utilizing primary outcome data, participant survey responses, and SSCHC staff feedback from the pilot program, future programs will be modified. 3. Expand program structure to incorporate a control cohort, a longer program follow-up duration (1 year), and established routes for referral to community resources.

References 1. 2.

Sixteenth Street Community Health Center Annual Report 2019-2020; 2. Aguayo-Mazzucato C, Diaque P, Hernandez S, Rosas S, Kostic A, Caballero AE. Understanding the growing epidemic of type 2 diabetes in the Hispanic population living in the United States. Diabetes Metab Res Rev. 2019;35(2):e3097. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403.

Hotspotting in Primary Care: An Interdisciplinary Model for Medically Complex, Socially At-Risk Patients

Hotspotting in Primary Care: An Interdisciplinary Model for Medically Complex, Socially At-Risk Patients Veronica Daniel, BS; Glenda Sundberg, FNP-CS; Kjersti Knox, MD

Introduction Medically complex, socially at-risk patients face numerous additional challenges when navigating the healthcare system. Hotspotting is a coordinated care model that promotes health equity through multidisciplinary teams that address the medical, social, and economic barriers faced by such patients. Several healthcare delivery models have been implemented nationally to address the multifaceted needs of the highest-cost patients, known as “superutilizers.” With 5% of the country’s population responsible for 50% of annual healthcare costs1, traditional hotspotting programs aim to reduce healthcare spending by targeting superutilizers of the emergency department2. At three clinic sites of Advocate Aurora Health in Milwaukee, hotspotting teams identify vulnerable patients in a different manner – by direct referral from patients' primary care providers. The goal of this project is to improve patient care by educating patients, providers, healthcare administrators, and communities about the hotspotting model that is unique to Advocate Aurora Health in Milwaukee. By disseminating this information through written publications, we hope that this hotspotting model will be implemented at other clinic sites.

Results

Hotspotting Model 1. Patient identification

2. Care planning

3. Direct patient care

4. Refinement of care plan

5. Program evaluation

• Medically complex, socially at-risk patients are identified by primary care providers • Each primary care provider refers two patients into hotspotting program (managed for one calendar year)

•

• Monthly multidisciplinary meetings involving hotspotting team (primary care physicians, nurse practitioners, social workers, pharmacists, students) • Patients’ medication review and coordinated care plan are recorded in electronic health record • Comprehensive home visit with hotspotting team addresses medical, social, and economic barriers faced by patients • Follow up care via phone calls

• Ongoing monthly multidisciplinary meetings to discuss patient updates and progress • Care plans are updated in electronic health record

•

• Feedback is gathered from patients and hotspotting team members → further program improvement • Publish written reports to educate community about our hotspotting model and enhance understanding of coordinated, multidisciplinary care of complex patients in primary care settings

Improved patient experiences • 97% of surveyed patients are interested in having another home visit due to reasons including stronger patient-provider relationships and increased provider awareness of patient’s environment • 100% of surveyed patients had greater trust in their provider following the home visit • 100% of surveyed patients stated that participation in hotspotting was a valuable experience Improved population health • Social determinants of health are evaluated and addressed at each home visit (see graph) Decreased costs • Emergency department visits among hotspotting patients decreased by 13.5% Enhanced care team wellbeing • “Home visits are a refreshing experience… They help remind you of why you became a doctor.”

Discussion

Patient Demographics • • • • • •

The inability of fractured healthcare and social service systems to adequately support complex patients highlights the importance of system-wide changes that bridge gaps between these two entities.

Total number of patients = 64 Average distance from home to hospital (see map) = 3.7 miles Age range = 2-98 years old 78% non-white 69% female 100% insured with Medicaid/Medicare

Our hotspotting model works to bridge these gaps by partnering with primary care physicians. Primary care physicians foster longitudinal, deeply rooted relationships with their patients, which helps identify medically complex, socially at-risk patients who would benefit from hotspotting’s coordinated care system. While the success of hotspotting can be measured quantitatively by decreased costs, its true measure of success is reflected by the testimonials of patients themselves.

Social Determinants of Health Among Hotspotting Patients in Milwaukee 50

% of Affected Patients

40 35

39 36

Patient testimonials: • ”I was able to show my environment affects my life.” • “I can’t leave my home, so I love that they are able to come to me.”

20 15

As we work towards our goal of writing a journal article detailing our hotspotting model, we recently published an editorial entitled “The Best Solutions to Address Frequent Hospital Attendance”3.

10 5 0 Lack of Reliable Transportation

Food Insecurity

Unsafe Relationships

Financial Instability

Unstable Housing

Acknowledgements Many thanks to Glenda Sundberg for being a dedicated community mentor and the driving force behind hotspotting in Milwaukee; Dr. Knox for serving as my TRIUMPH mentor; Kayla Heslin for creation of the map through ARCGIS.

What is TRIUMPH? TRaining In Urban Medicine and Public Health (TRIUMPH) is an educational program for University of Wisconsin School References 1. Cohen SB. The concentration of health care expenditures and related expenses for costly medical conditions, 2012. Rockville, MD: Agency for Healthcare Research and Quality, October 2014. 2. Healthcare Hotspotting, hotspotting.camdenhealth.org/. 3. Sundberg G. Solutions to Address Frequent Hospital Attendance. J Patient Cent Res Rev. 2020;7(3):222-226. Published 2020 Jul 27. doi:10.17294/2330-0698.1786

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: https://www.med.wisc.edu/education/md-program/triumph/

SATURDAY STI CLINIC DEVELOPMENT WITH THE KEENAN HEALTH CENTER

SATURDAY STI CLINIC DEVELOPMENT WITH THE KEENAN HEALTH CENTER Viktoriya Ovsepyan BA, Julie Katrichis MSN, RN, Helen Hermus RN, Melissa Ugland MPH

INTRODUCTION ➢ Milwaukee needs expanded STI services

METHODS

RESULTS

➢ Goal 1: Gather evidence on the significant STI burden

➢ Goal 2: Employees of the Milwaukee Health

➢ Goal 3: The chart below represents additional survey

in the Milwaukee area through a literature review of CDC and WI Health Department data

▪ Rates of chlamydia, gonorrhea, and syphilis have been increasing in the city in recent years, especially among youth between the ages of 15-24

➢ Goal 2: Elicit feedback and gain support for a Saturday

▪ Untreated sexually transmitted infections (STI’s) can cause: • pelvic inflammatory disease • epididymitis • reproductive and fetal complications • neurologic disease

➢ Goal 3: Assess the value of the Keenan STI clinic to

Department were supportive of opening a Saturday STI clinic and agreed that expanded hours would benefit Milwaukee residents

Key takeaways

STI clinic from Milwaukee Health Department staff via a focus group session

Publicizing Saturday hours to the Milwaukee community may be a challenge

RESULTS ➢ Goal 1: There is overwhelming evidence of high STI rates in the Milwaukee area. According to national 2016 CDC data, the Milwaukee MSA ranked 1st for gonorrhea rates in 2015 and 2016, as well as 4th for chlamydia rates from 2013-2016

➢ Keenan Sexual Health Clinic is part of the solution • • •

•

Keenan Center provides STI & HIV prevention and treatment services in the Milwaukee area Despite its wide use, Keenan clinic still operates under a limited capacity From 2015-2019, there were 2,912 turnaways due to lack of scheduling space, and 1,885 deferred patients who were initially turned away but were able to return to clinic at a later date In an effort to increase access to comprehensive STI services, in particular for young adults, the Milwaukee Health Department has launched an initiative to open a Saturday STI clinic at the Keenan Health Center

• • • •

Option of walk-in appointment Nearby location Lower cost Expert Care

What makes it difficult for you to access STI services?

• • • •

Inconvenient business hours Transportation issues High cost Stigma

Other than Keenan Clinic, where else do you go for sexual health services?

• • • • •

Planned Parenthood No where else, only come to Keenan Aurora Holton Street Clinic Diverse and Resilient

Why did you choose Keenan Sexual Health Clinic?

Consider partnering with Diverse & Resilient to offer weekend hours geared towards LGBTQ+ community

Milwaukee residents and identify potential barriers to accessing sexual health services by surveying community members who utilize Keenan services

responses. Overall, the top two reasons patients chose to come to Keenan clinic were its acceptance of walk-in appointments and nearby location. Of those who acknowledged having difficulties accessing sexual health services, inconvenient business hours was the most commonly cited barrier

Think about holding other “specialty clinic” hours

➢ Goal 3: Most of the 74 patients who were surveyed came to Keenan for STI testing. Patients reported having easy access to birth control, but experienced barriers accessing sexual health services WOULD SATURDAY HOURS MAKE IT EASIER TO ACCESS KEENAN SERVICES?

How easy is it to access birth control or condoms? Not sure

No difference No 3% 9%

Very Difficult

Somewhat Difficult

Somewhat Easy

Discussion This needs assessment demonstrates that a Saturday Clinic at the Keenan Health Center would help to meet the high demand for comprehensive STI services in the Milwaukee area. A Saturday clinic would be especially beneficial for young adults, who are disproportionately impacted by STI’s in the Milwaukee area, and have difficulty accessing medical care during the week due to work and academic commitments. Since a focus of the Saturday clinic would be to treat adolescents, it will be important to ensure providers at the Saturday clinic are trained to work with this specific age group.

Very Easy

Yes 88%

Is there anything that makes it difficult for you to access sexual health services? “Inconvenient business hours that don’t align with school and work”

Next steps include:

How easy is it to access birth control or condoms when you need them? “Condoms are easily accessible, birth control is very difficult to find with no insurance” “Very easy. Many clinics offer free contraception”

➢ ➢ ➢

Stakeholder mapping Creating an executable action plan Implementation/Piloting a Saturday Clinic

*Reference list available upon request*

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