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

Project Overview (PDF)

4th Funding Cycle Impact Award

Project Start Date: July 1, 2008
Project End Date: December 31, 2011
Original Award Amount: $450,000
Adjusted Award Amount: $372,285*

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.

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  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:
  Affiliated Web Pages:
  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.

*In 2009 award amounts, based on the remaining budget, were adjusted to reflect the decline in endowment asset value due to the downturn in the economy.

Contact Us

Advancing a Healthier Wisconsin Endowment Healthier Wisconsin Partnership Program (HWPP)
(414) 955-4350 | healthierwisconsin@mcw.edu