Reaching Out to the Underserved - Ascension Wisconsin

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Reaching Out to the Underserved

As part of our Mission of providing exceptional and compassionate care, Ascension Wheaton Franciscan Healthcare has always had a special concern for those living in poverty. To see how we reach out to the underserved, select an initiative below.

Transitions of Care

Ascension Wheaton Franciscan Connects Emergency Department Patients to Primary Care

The community needs assessment for Ascension Wheaton Franciscan – St. Joseph Campus identified an opportunity to improve access to health care for those who are uninsured and underinsured. Many underserved patients use Emergency Departments for their primary care, which can lead to delays in getting appropriate care, hospitalizations that could be avoided, and lack of knowledge about preventive care.

To address access barriers, hospital leaders set a goal to ensure appropriate follow up care for underserved Emergency Department patients. As one step to reaching this goal, St. Joseph started the Transitions of Care program to connect patients with primary care physicians.

The Transitions of Care team is stationed in the St. Joseph Emergency Department, coordinating with physician offices and community resources. Two Health Care Coordinators assist with less complex cases and link patients to community resources and a primary care physician if they do not have a doctor. Registered nurses or a social worker help patients understand and navigate their complex, chronic conditions.

The team assesses total patient wellness for dental, OB/GYN or other needs, and provides ongoing case management for high risk patients. Patients are scheduled with a primary care physician to establish a medical home, and uninsured individuals receive guidance in enrolling in government insurance. The team also makes follow-up calls to check in with the patient and offer assistance with transportation, translation, or other potential barriers to keeping that first scheduled clinic appointment.

Program goals include helping individuals to develop a relationship with a primary care provider, prevent non-urgent Emergency Department visits by providing patients with education and resources, and to improve an individual's health literacy to promote better disease management.

A year and a half into the program, the team sees an average of more than 300 patients a month and makes about 200 appointments with physicians from Ascension Wheaton Franciscan Medical Group, Ascension Wheaton's Family Care Center, federally qualified health centers, or other community doctors.

Results show the program is working:

  • Increased show rates to first primary care appointments
  • Decreased 30-day hospital admissions
  • Ongoing disease-specific case management
  • Overall improved health

Connecting patients with a primary care physician helps promote better health and quality of life for our patients. It's also the right thing to do to reach our goal of managing population health.

Patient Centered Health Team

Ascension Wheaton Franciscan Healthcare - All Saints is taking a new approach to caring for patients who are uninsured or underinsured in an effort to keep them healthy and out of the Emergency Department and hospital. The new model uses a Patient Centered Health Team for the Family Medicine Practice on Wisconsin Avenue and provides care for those who don't have access to a primary care physician. A multidisciplinary team helps patients manage their chronic conditions in a primary care setting. The Mother Clara Healthy Connections component of the program provides strong patient support through ongoing education.

Angel of Hope Clinic

Ascension Wheaton Franciscan Healthcare - St. Francis provides support for the Angel of Hope Clinic, a free health clinic housed in a homeless shelter on Milwaukee’s south side. Nurse practitioners handle more than 3,000 visits each year including management of chronic conditions such as asthma and diabetes.

Watch this video to learn more about the Angel of Hope Clinic.

Here is one example of how the Angel of Hope Clinic provided compassionate care for a cancer patient:

Isaac Mercado-Aguilar had been experiencing gastrointestinal discomfort for a while when he walked into the Angel of Hope Clinic. After he notified the provider that his sister was suffering from colon cancer, he was referred to Dr. Garland Yarborough, who performed a colonoscopy. Unfortunately, the doctor found a malignant mass.

Isaac said the staff at Angel of Hope helped him with all of his appointments and got him in to see the doctor right away. He added, “I could not have received better care. I think of the staff here as more than medical professionals; they are like my family.”
Isaac had a resection with Dr. Mahoney and was under the care of his oncologist, Dr. Francis Cuevas.

“At Angel of Hope we provide health care to patients in the community who need it most. Often times they have not seen a health care professional in years, if ever. We provide access to health care services regardless of financial or insurance status. By overcoming language, educational, transportation, and financial barriers, we strive to live the Mission, Vision and Values of our health care ministry,” said Marni Hebert, nurse practitioner.

“I’ve recommended Angel of Hope to others. The excellent and compassionate care I received there means a lot to me and I am very grateful,” added Isaac.

Family Care Center

In partnership with the Medical College of Wisconsin and Ascension Wheaton Franciscan Healthcare - All Saints, the Family Care Center serves more than 8,000 patients annually.

The Family Care Center is recognized as a Level 3 (top) Patient-Centered Medical Home by the National Committee for Quality Assurance and consistently receives national awards for innovative programs in health maintenance and immunizations.

The Center also is active in the community with its health and wellness programs. Seeds of Hope is an on site education garden used to promote healthy eating with the goal of reducing obesity. Students from area schools visit in spring to help plant the garden and return in fall to pick the vegetables, make a recipe with the produce and sample their fine work. Some students tell us this is the first time they have eaten fresh produce. Cooking classes and education on the benefits of healthy eating are also offered.

Su Salud Breast Health Program

Su Salud is a bilingual prevention program educating Spanish-speaking Latinas in a culturally appropriate manner on breast health and prevention of breast cancer. The program pairs an RN breast care coordinator with a Hispanic lay health educator or cultural companion to give Latinas brief presentations on breast health. The Foundation also provides mammograms to women who cannot afford them.

Stork’s Nest Program

In cooperation with the March of Dimes®, the Stork’s Nest program at Ascension Wheaton Franciscan – St. Joseph and the Family Care Center provides incentives, education and encouragement for low-income, high-risk women to keep prenatal care appointments, a critical factor for helping babies get a healthy start in life.

Parish Nursing

Registered nurses with specialized education reach out to low-income neighborhoods in Racine County lacking basic health resources and information. Parish nurses provide educational outreach on health-related topics of interest as well as primary care services such as blood pressure checks and weight management.

Hope Fund

The Hope Fund at Ascension Wheaton Franciscan Healthcare - All Saints and Ascension Wheaton Franciscan - Elmbrook Memorial Campus helps alleviate the financial burden of cancer for newly diagnosed patients who may be forced to decide between taking time off work to receive medical treatments and continuing to work to put food on the table and pay rent and utilities. The Hope Fund was established to help with basic living expenses so no cancer patient has to make this type of decision.

Fresh Start Program

A unique partnership with the Racine Unified School District, the Fresh Start program helps grade school children with adjustment difficulties to develop positive behaviors, receive proper medications and find family-centered support. The goal is a return to the traditional classroom and continue appropriate behaviors and academic success in a mainstream setting.

Mother Angela Fund

The Mother Angela Fund at Ascension Wheaton Franciscan Healthcare - Franklin and St. Francis provides emergency financial assistance for the medical needs of patients in crisis. Uninsured or low-income patients are identified by social workers for pharmaceutical, food, medical expenses or transportation assistance. The fund also provides a safety net for patients with no other resources, particularly when being discharged from the hospital.

Safe Place for Newborns™ Program

Ascension Wheaton Franciscan – St. Joseph Campus provides the state headquarters for the Safe Place for Newborns™ program, which supports the Safe Haven Law. Under the state law, any parent is allowed to relinquish a newborn infant up to 72 hours old to any firefighter, police officer, EMT or hospital staff member.

Dream A Little Dream

The Dream a Little Dream program gives our residents with unique and sometimes life-limiting challenges an opportunity to fulfill a special wish or life-long dream. Whether it’s a fishing trip or dinner and a concert with family, donations help to make the lives of our patients and residents a little brighter.

Adopt-A-Room Program

Our Adopt-A-Room program allows donors to provide new decorating for a more home-like environment for our long-term care and transitional care residents, promoting comfort and encouraging healing.

Learn how you can donate.

Community Care

Ascension Wheaton Franciscan Healthcare offers a charity care program known as Community Care that assists qualified individuals in financial need. In 2010, we provided $16.8 million in charity care to patients in Southeast Wisconsin, which is based on the actual cost of providing that care.

To learn more about Community Care, view our policy or read about those impacted by it.

Women’s Outpatient Center

The Women's Outpatient Center at Ascension Wheaton Franciscan - St. Joseph Campus offers care for low-income women and their babies throughout pregnancy, delivery and early parenting months. Mothers-to-be with no other resources receive top-notch care, resulting in improved birth weights and reduced premature and infant mortality.

The Center also offers life-saving gynecological screenings for breast, cervical and other reproductive system cancers.

Mother Clara Healthy Connections Clinic

The Ascension Wheaton Franciscan Healthcare - All Saints Mother Clara Healthy Connections Clinic has served the poor in the Racine community since 2006. The clinic is run by a registered nurse who sees patients who have been referred for further education and support based on their health care needs such as prenatal care, hypertension, diabetes and smoking cessation.

Phenomenal Women

Funded in part by the Southeast Wisconsin Affiliate of Susan G. Komen for the Cure, Phenomenal Women is a breast health program to help educate low-income African American women about breast cancer and the importance of consistent breast health care. The program also helps remove barriers to mammograms and clinical breast exams and provides navigation services to African American women to get mammograms.

Watch this video to learn more about the Phenomenal Women program.