Ascension Wisconsin’s Mission is to deliver compassionate, personalized care to all, with special attention to those most vulnerable. It was with this in mind when, in early March of 2024, Ascension Wisconsin leaders met with a common goal: to develop a collaborative plan addressing social determinants of health (SDoH) in an effort to achieve health equity and optimize the health of those most in need.
People in vulnerable populations — as defined by socioeconomic characteristics — historically make more preventable visits to emergency rooms than others, according to a U.S. Census Bureau working paper which defines visits to emergency departments as preventable when they are for health conditions that could have been handled in a non-emergency setting or avoided if the patient had adequate prior preventive care. E
nsuring access to both primary care services and community-based resources can help close gaps in identified SDoH, reduce avoidable emergency department utilization, and better support patients with complex needs not often addressed by the traditional medical model.
“Understanding a patient's living circumstances is vital to being able to effectively treat that patient's illnesses and promote that patient's health. Clinicians, in particular those of us in primary care, strive to get to know our patients and to understand their work, eating, transportation, where they live and their social situations,” said Dr. Patricia Golden, DO Chief Medical Officer, Ascension Medical Group Wisconsin.
Increasing access to preventative care for conditions such as diabetes, maternal health, mental health and addressing those areas that impact health beyond healthcare such as housing, food insecurity, and violence, among others, have been shown to improve health outcomes and life expectancy.
“Designing and implementing a more integrated care model will help our patients find care in the appropriate setting,” said Chintan Desai, MD, MSHI, MHA, CPE, Chief Medical Officer, Ascension Wisconsin. “By forming trusting relationships with them, their families, and community partners, we’ll be better able to address patients’ medical, behavioral health and social needs, and coordinate services that support their well-being and help keep them out of the hospital.”
Representatives from Ascension Columbia St. Mary’s Hospital - Milwaukee Campus, Ascension All Saints Hospital, Ascension SE Wisconsin Hospital - St. Joseph Campus, and Ascension St. Francis Hospital have come together with a shared commitment to prioritize this important work and develop innovative ways to work across disciplines, settings, and sectors to test and implement change.
“Hospitals play a vital role in the community,“ said Dr. Desai. “Within the health system, the clinical team has a unique opportunity to be that bridge to services and resources for our patients so we can better meet their needs. By identifying high users of our emergency departments we can then work with them on an individual basis to discover why that is and get them connected to the resources they need to live a healthy life.”
While each patient is unique with their own set of challenges, redesigning the delivery system with a common set of concepts and actions will provide a better understanding of those needs. Physician leaders, emergency department and hospital leadership teams, as well as community program advocates, will continue to work on identifying additional opportunities to partner and collaborate. Finding tangible solutions to the barriers individuals must overcome to achieve a better quality of life is an important way Ascension Wisconsin is working to reduce preventable disparities in health outcomes.
