Community-based Chronic Disease Management (CCDM)

Project Overview

6th Funding Cycle Impact Award
     Project Start Date: 2/1/2011
     Project End Date: 1/31/2016
     Award Amount:     $750,000

Project Goal Statement: CCDM will effect prevention of complications by screening for/managing hypertension, diabetes, and obesity at churches and food pantries that serve Milwaukee's poor and by promoting low-cost medicine, nutrition, and education in a tiered community model.

 Community Partner:

Primary Community Partner: Bill Solberg, MSW, LCSW, Columbia-St. Mary's

 Academic Partner:

Primary Academic Partner: Jim Sanders, MD, MPH, Department of Family and Community Medicine

 Project Progress Summary Reports:

   Project Progress Report Summary 2/1/2011 - 9/30/2011
    Project Progress Report Summary 10/1/2011 - 9/30/2012  
    Project Progress Report Summary 10/1/2012 - 9/30/2013
    Project Progress Report Summary 10/1/2013 - 9/30/2014

 Affiliated Web Pages:

Columbia-St. Mary's
Columbia-St. Mary's Community-based Chronic Disease Management (CCDM) Clinic

 Project Dissemination Efforts (as reported by project partners)
  • Articles
    • Article in the Associated Press – Neergaard L. Medical Clinics Expanding Care to Needy. The Associated Press.
    • Article in the Journal Sentinel about the grand opening of Word of Hope Clinic
    • Article in the Journal Sentinel Online – Clinics team up with churches to fight hypertension. The Journal Sentinel Online. May 31, 2011. Available at: Accessed on October 22, 2012.
    • Article in the Journal Sentinel titled "Columbia St. Mary's, churches team up for health" (April 2013)
    • Article in the Catholic Health Association's Health Progress publication titled "Health Liaisons Expand the Power of Parish Nursing"
    • Project mentioned in opinion article in the Milwaukee Journal Sentinel (June 2014)
    • Featured in article in the Milwaukee Journal Sentinel about Columbia St. Mary’s use of community health workers in its CCDM clinics and community outreach efforts (September 2014)
  • Outreach Materials/Events
    • Presentations about health improvement during Church health Liaison training
  • Papers
    • Publication in the Journal of Primary Care & Community Health – Sanders J, Guse C, Onuoha BC. Pilot study of a new model for managing hypertension in an uninsured population. Journal of Primary Care & Community Health. June 2012.
    • Publication in the Journal of the American Board of Family Medicine – Sanders J, Solberg B, Gauger M. Breaking barriers to care: A community of solution for chronic disease management. Journal of the American Board of Family Medicine. May 2013.

  • Presentations
    • Presentation to Ascension Health Community Access Leadership (Feb – Sept 2011)
Contact Us

Advancing a Healthier Wisconsin Endowment Research and Education Program (REP)
P: 414.955.8075 | E:

Advancing a Healthier Wisconsin Endowment Healthier Wisconsin Partnership Program (HWPP)
P: 414.955.4350 | E:

Medical College of Wisconsin
8701 Watertown Plank Road
Milwaukee, WI 53226
(414) 955-8296
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Page Updated 01/16/2015