community health center stories

Access Community Health Centers implemented a behavioral health program that integrates substance use disorder (SUD) treatment seamlessly into primary care. The program utilized an interdisciplinary approach where Behavioral Health Consultants (BHC) are an integral part of the primary care team, working alongside primary care providers (PCPs) to manage patients’ mental health and substance use needs.

This project aimed to reduce stigma associated with SUD treatment, address disparities in overdose fatalities among different racial groups, and provide access to life-saving medications. This initiative demonstrated a commitment to understanding and address the racial inequities in drug overdose deaths that show stark disparities in death rates among Black individuals. The project’s emphasis on integrated care, universal screening, and improved access to treatment aimed to provide equitable care for a diverse patient population.

Lakeshore Community Health Care Clinic (LCHC), in collaboration with Concordia University Wisconsin (CUW), embarked on a pilot project aiming to address uncontrolled diabetes within their population. LCHC identified that a significant portion of their diabetic patients had consistently high HgbA1C levels, indicating poor glucose control. In response, they partnered with CUW’s Driving Wellness Home Project (DWHP), which involves interprofessional teams assessing health and wellness of FMOW (Fresh Meals on Wheels) clients. This collaboration brought together an interdisciplinary team from all parts of the community, including CUW students studying Athletic Training, Pharmacy, Dietetics, and Nursing, LCHC primary care providers, a clinical ethnographer, LCHC pharmacy resident and local Area Health Education Center representative.

NorthLakes’ Eastern Region medical clinics located in Lakewood and White Lake, undertook a project aimed at implementing daily huddles to enhance team-based patient care. The team engaged in open discussions and gradually embraced the idea of daily huddles. The huddles, involving various members such as PSRs, medical assistants, lab staff, community health workers, and medical providers, proved pivotal in improving care coordination and addressing care gaps. Through this initiative, the team developed consistent processes and workflows that enabled them to channel their passion and skill for excellent care into a proactive, efficient, and consistent approach to care delivery.

Progressive Community Health Center developed a self-monitored blood pressure (SMBP) program to improve hypertension control among its patient population. The initiative, funded by a federal grant, aimed to distribute home blood pressure devices and educate patients on their proper use, combining lifestyle changes to effectively manage hypertension. The program reached out to 1,465 patients through in-office visits, telephone, and text outreach, ultimately distributing over 450 devices. Impressively, more than 300 patients engaged by submitting self-monitored blood pressure readings, leading to a significant control rate of 72.3%. This initiative resulted in Progressive elevating its hypertension control rate from 60% to 68% over the period from April 2021 to March 2023.

As is true in many primary care settings, diabetes and hypertension continue to be the greatest mortality/morbidity diagnoses seen at Progressive Community Health Centers (“Progressive”), making these
diagnoses a continued area of focus for quality improvement efforts. Over the past year (October 2021-October 2022), Progressive has consistently maintained performance of 17%-21% in the uncontrolled diabetes measure (source: WPHCA Core Metrics Quarterly Reports). This means that usually no more than a fifth of the patients with diabetes have HbA1c levels greater than 9, which is a common marker of uncontrolled diabetes.

With this high level performance, they are consistently performing at or above the 90th Percentile in the UDS Uncontrolled Diabetes measure at both a state and national level. This story highlights the initiatives and practices in place at Progressive that support sustained positive health outcomes for patients with diabetes. Progressive Community Health Centers is located in Milwaukee, Wisconsin and served over 14,500 patients in 2021.