Emergency Department (ED) to Primary Care Medical Home Referral and Retention Project

Project Overview

4th Funding Cycle Impact Award
     Project Start Date: 7/1/2008
     Project End Date: 12/31/2011

Project Goal Statement: Milwaukee Health Care Partnership (MHCP) plans to implement and evaluate the ED to Medical Home Referral and Retention Project for the dual purposes of ED diversion and linking low-income patients to primary care medical homes in Federally-Qualified Health Centers.

Original Award Amount: $450,000
Adjusted Award Amount: $372,285*

Community Partners:
Primary Community Partner: Milwaukee Health Care Partnership (MHCP)
Additional community partner organization names:

• Health Care for the Homeless of Milwaukee, Inc.
• Milwaukee Health Services, Inc.
• Westside Healthcare Association, Inc.

Academic Partners:
Primary Academic Partner: Eric Gass, PhD, Department of Family and Community Medicine
Additional Academic Partners: Marie Wolff, PhD, Department of Family and Community Medicine

Project Progress Summary Reports:
     Project Progress Report Summary 7/1/2008 - 4/30/2009
     Project Progress Report Summary 5/1/2009 - 6/30/2009
     Project Progress Report Summary 7/1/2009 - 12/31/2009
     Project Progress Report Summary 1/1/2010 - 6/30/2010
     Project Final Report Summary    

Affiliated Web Pages:
    Health Care for the Homeless of Milwaukee, Inc.
    Milwaukee Health Care Partnership
    Milwaukee Health Services, Inc.
    Westside Healthcare Association, Inc.

Project Dissemination Efforts (as reported by project partners)

• Articles
  • Featured in article in Healthcare Financial Management Association Journal – Lewins G. Physician integration: The community health center collaboration option. Healthcare Financial Management Association Journal. January 2011.
• Outreach Materials / Events
  • Developed a guide for patients to determine when to use the Emergency Department and when to use their Primary Care Clinic
  • Shared project information and lessons learned with other IHI Avoidable ED Visits prototyping communities and at a conference in Chicago in October 2009
  • Shared a status report with the Milwaukee Health Care Partnership Board, January 2010.
  • Consulted with the Maine Office of the National Coordinator. August 2011.
  • Developed an Emergency Department Care Coordination Fact Sheet
• Posters
  • Poster presentation at the HWPP Community Engagement for Health Conference – Emergency Department to Primary Care Medical Home Referral and Retention Project. HWPP Community Engagement for Health Conference. Milwaukee, WI. October 2010.
• Presentations
  • Presentation at the AHA Association of Community Health Initiatives. Jacksonville, FL.
  • Presentation at the Communities Joined in Action (CJA) Annual National Conference. Denver, CO. October 2010.
  • Presentation at HWPP Community Engagement for Health – A Community-wide Approach to Care Coordination: Connecting ED Patients with Primary Care. HWPP Community Engagement for Health. Milwaukee, WI. October 26, 2010.
  • Presentation to the Wisconsin Primary Health Care Association: Webinar for Board. May 14, 2012.
  • Presentation at the Leading the Way: A Joint Conference of Advancing a Healthier Wisconsin and Wisconsin Partnership Program. Milwaukee, WI. September 27, 2012.
  • Presentation at the Communities Joined in Action. Denver, CO. October 2012.
  • Presentation to the American Case Management Association. October 9, 2012.
  • Presentation to the New York State ED Triage Demonstration Project, Webinar. October 15, 2012.
• Publications
  • Publication for the Robert Wood Johnson Foundation: National Meeting. San Francisco, CA. November 2012. Aligning Forces for Quality.
  • Publication in AHRQ Health Care Innovations Exchange - Agency for Healthcare Quality and Research Innovations Exchange: Innovation Profile. Emergency Department-Based Case Managers Throughout County Electronically Schedule Clinic Appointments for Underserved Patients, Allowing Many to Establish a Medical Home. August 29, 2012.
  • Publication in Healthcare Financial Management - Lewins, G. Physician Integration: The Community Health Center Collaboration Option. Healthcare Financial Management. January 2011. Pages 72-76.

  • Publication in the Robert Wood Johnson Foundation’s Aligning Forces for Quality – Small Tests of Change Grow to Big Results in Reduction of ED Overuse. Aligning Forces for Quality (AF4Q) in FOCUS. March 2013. Pages 59-62.