Community-based Chronic Disease Management (CCDM)

Project Overview (PDF)

6th Funding Cycle Impact Award
    Project Start Date:    February 1, 2011
    Project End Date:      January 31, 2016 – No Cost Extension Through: July 29, 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.

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  Community Partner:

Primary Community Partner:  Columbia-St. Mary's

  Academic Partner:

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

  Project Progress Summary Reports:
  Affiliated Web Pages:
  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. 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)
    • Scholarly article titled "Reaching urban poor hypertensive patients: a novel model of chronic disease care versus a traditional fee-for-service approach"  published in the Journal of Primary Care and Community Health, 2016
  • Outreach Materials/Events
    • Presentations about health improvement during Church health Liaison training
    • Developed a storybook highlighting the stories of people served through the project
  • 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 (February – September 2011)
    • Presentation at the WONCA Africa Regional Conference
    • Two platform presentations at MCW
    • Poster presentation at the MCW Faculty Research Day
Contact Us

Advancing a Healthier Wisconsin Endowment Healthier Wisconsin Partnership Program (HWPP)
(414) 955-4350 |