UWM Institute for Urban Health Partnerships

Member Service Description

The University of Wisconsin-Milwaukee (UWM) Institute for Urban Health Partnership (IUHP) operates two nurse managed Community Nursing Centers (CNCs). The UWM Silver Spring (SS) CNC is located on the northwest side of Milwaukee in the largest subsidized public housing development in Wisconsin. The UWM House of Peace (HOP) CNC is in central Milwaukee. The HealthCorps Member serving at UWM IUHP will provide services at both CNCs. TITLE: AmeriCorps Member 1. Essential Responsibilities and Functions The UWM Institute for Urban Health Partnerships (IUHP) HealthCorps Member responsibilities and functions include:

Outreach and Advocacy: Conduct outreach in the communities served by UWM SS CNC and the UWM HOP CNC, which includes providing education about health insurance eligibility, available health and related programs, and health care options. Similar client education will take place during scheduled on-site health information and referral sessions.

Enrollment: Assist individuals with the enrollment process for CNC health promotion sessions, Medicaid health insurance plans, and /or pharmaceutical assistance programs.

Improve Use of Health Services and Programs: Provide linguistically and culturally appropriate assistance; provide health education in one-on-one and group settings; assist individuals with navigating health services and other needed community resources and services, including prescription assistance programs; provide positive reinforcement of treatment plans and prevention (behavioral) goals; follow-up as needed (e.g., reminder calls, home visits) for surveillance of progress, facilitate further support and education, and remind patients of CNC appointments.

Provide Health Education: Lifestyle modification and health promotion programs for targeted groups identified in community assessments (i.e. those at risk of Cardiovascular Disease, Hypertension, or Diabetes, pregnant women, adolescents).

Capacity building: Conduct outreach and secure resources in support of health promotion programs.

2. Training The training plan for the UWM IUHP HealthCorps Member will include: Introduction to UWM IUHP site

History and model of IUHP and Community Nursing Centers (CNC)

Tour of UWM offices and introduction to staff

UWM campus policies and procedures

UWM HIPAA training online

Introduction to UWM resources (Library, Refworks, email, Nursing Learning Resource Center)

Meeting with Site Supervisor and CNC Directors to discuss Member interest, skills, strengths

Orientation to documentation system / electronic health record

2

Orientation to each CNC site (SS CNC & HOP CNC)

Tour of CNC sites, CBO services, and target communities

Introduction to all CNC staff and community partners; participate in CNC staff meetings

Orientation to CNC services and collaborative programs Training specific to skills to achieve the Goals/Objectives for the 2011-2012 HealthCorps Member, including but not limited to:

Culturally sensitive care for African American and Hmong individuals and families

CNC Health Information & Referral session procedures and referral resources

Immunization schedules and state immunization registry

Outreach strategies

Health careers promotion in community

Required documentation and tracking of outcomes 3. Community Need The UWM IUHP’s mission is to increase access to health care and decrease health disparities for low-income, vulnerable populations. The CNCs provide individual, family and group primary health care services to achieve this mission. The HealthCorps Member will contribute to our efforts to address the following four specific needs in the CNC communities:

Problem/Need Statement: The CNCs are partnered with two Local Federally Qualified Health Center (FQHC) sites that do not have the capacity to meet current demand for un/under-insured individuals in need of primary care services due to a recently closed community hospital, a decrease in community providers taking Medicaid, and worsening economic conditions in the target communities.

o Our Plan: Expand clinic services at Silver Spring CNC and House of Peace CNC as access/triage points of entry for primary care services in their respective medically underserved communities.

Problem/Need Statement: The Hmong population is increasing in both targeted service areas. This population is among many ethnically diverse groups, who tend to mainly use primary care for urgent care purposes and have a limited knowledge of Western preventive and/or health promotion services. Improvements in the health status of these ethnic groups will depend upon developing successful community-based strategies that include building trust, partnering with the community and having a diverse and culturally competent workforce. These strategies are key to the delivery of accessible and acceptable primary care and health promotion services.

o Our Plan: Expand CNC strategies used successfully with African American populations to engage Hmong families (in these service areas) through outreach activities that promote and encourage use of the CNCs for health education and walk-in health care services.

Problem/ Need Statement: Although addressing the social determinants of health is increasingly acknowledged as key to improving the overall health status of communities, medical services are typically separated from and not coordinated with the human service organizations/providers frequently sought out by low income community residents at greatest risk for poor health outcomes.

o Our Plan: Expand and coordinate population based assessment and programming between two UWM community nursing centers and two trusted human service agencies – Silver Spring Neighborhood Center and House of Peace Community Center – to improve the ability to address a full range of health and human services issues where people live, work, learn and play.

3

Problem/Need Statement: There are growing shortages of primary health care providers available to provide health promotion and safety net services in the neediest urban communities. Diversity in health care providers, to date, has fallen far short of the identified needs to serve culturally and ethnically diverse populations. The opportunities to promote and develop a diverse population of health care providers for the future is also of critical importance and is key components of the nursing centers’ academic activities.

o Our Plan: Promote and support educational success by strategically and intentionally reaching out to members of the target communities to promote nursing and other health professions as career options.

4. Plan for Volunteer Recruitment The IUHP volunteer program is in the final development phase after achieving institutional risk management approvals. The IUHP HealthCorps Member will assist in developing volunteer management systems for the CNCs that include volunteer applications, screening and matching procedures, coordination of volunteer supervision, and recruitment of volunteers. In addition, each CNC partners with a community-based organization (CBO) where the WI HealthCorps. These CBO partnerships are for SS CNC with the Silver Spring Neighborhood Center and for the HOP CNC with the House of Peace. Both CBOs have active volunteer programs. Member may collaborate with CBO staff in recruiting volunteers and supporting volunteers to ensure they have a quality experience. 5. Measurable Goals, Objectives, and Outcomes We have planned specific programmatic goals/ objectives along with related key action steps and expected outcomes to address the four community needs identified above for both Community Nursing Centers (CNCs). Table 1 (below) describes those that the HealthCorps Member would achieve during the year. Table 1. UWM IUHP Goals/Objectives, Key Action Steps and Expected Outcomes to be met by the HealthCorps Member Goals/ Objectives Key Action Steps Expected Outcomes for the Year 1. AmeriCorps member will provide walk-in/phone-in information and referral sessions at each CNC site.

1a. Provide health information and referral sessions at least 2 sessions per week at each of the CNCs. 1b. Coordinate care for clients to link them with CNC, FQHC and/or other community resources.

1a. Provide 400 walk-in client visits with appropriate referrals and surveillance for follow-up of referrals made. 1b.1. Report number of referrals/mo. 1b.2. Report # of clients, visits, problems & interventions/month.

2. Increase rates of immunization compliance.

2a. Screen children and adults who access walk- in sessions and/or other services for immunization compliance. 2b. Assist parents in accessing child’s immunization history through communication with their provider or WI immunization

2a. Assess immunization status in at least 200 walk-in visits. 2b. Assist at least 50 parents to determine the immunization status of their children

4

registry.

3. Increase participation in CNC wellness programs focused on exercise & nutrition for parents and children

3a. Identify/engage those at risk of chronic disease at FQHCs and partner agencies and engage them in CNC self management health promotion (HP) programs. 3b. Conduct periodic community needs assessments to keep wellness programs focused on community needs/interests.

3a. Report increasing numbers of participants of at least 10% in CNC HP programs . 3b. Conduct one needs survey for HP program needs/interests. 3b. 90% of all CNC clients participating in HP programs report high satisfaction in evaluations.

4. Increase family participation in CBO family focused health promotion programs

4a. Increase outreach activities at CNC and partner FQHC sites regarding CBO and community wide health promotion events and programs.

4a. Perform at >6 outreach activities for CBOs or collaborative sponsored events.

5. Increase access to primary care health services for Hmong families especially Hmong women and children

5a. Schedule and staff walk-in information &referral sessions with Hmong nursing staff targeting Hmong women & children.

5a. 1. >50 Hmong women receive specific health education during walk-in sessions. 5a.2. Follow-up telephone surveys to assess health knowledge, behaviors and status (KBS) will be made to >50% of these women receiving walk-in health education services. Of these, 60% will have increased KBS scores.

6. Expand lifestyle modification and health promotion programming at both CNCs.

6a. Implement health promotion programs for targeted groups identified in assessments (i.e. young parents, those at risk of CVD or DM, pregnant women, adolescents.)

6a. At least 4 group encounters provided for high risk community residents in areas of greatest need

7. Increase outreach strategies regarding the promotion of and participation in life style modification programming.

7a. Utilize current and develop new strategies to promote programs utilizing multimedia approaches to the community 7b. Expand/enhance social marking strategies in CNCs, partner FQHCs and CBOs for life style modification /health programs.

7a. Increased participation in lifestyle modification programs evidenced in the PHASE II annual progress report 3/13. 7b. Add >2 community based venues and linkages to promote programs.

8. Identify and encourage clients in elementary, secondary and college programs who have the potential to enter the health

8a. Integrate age appropriate vocational anticipatory guidance and positive life options counseling into client encounters.

8a-d. Provide vocational counseling for at least 100 clients.

5

professions and support their educational pursuits to join the nursing workforce in community/public health practice and other health professions.

8b. Support academic success for all students. 8c. Refer interested students to existing UWM programs with goals of recruiting and retaining diverse pre-college and college students, like College for Kids, TRIO, Pre College Program… 8d. Offer mentorship to students expressing an interest in health professions.

8c. Refer >4 students to a UWM pre-college program. 8d. Identify 1+ student as a mentee.

9. Represent health professions, including nursing and community/ public health nursing as an attractive and viable career option in the CBOs.

9a. Role model health care and nursing as a satisfying career choice; is available for informal discussions of health professions career options/provide information packets and counseling to those expressing interest. 9b. Display positive images of health careers in each CBO (Campaign for Nursing’s Future). 9c. Give health career options talks.

9a & 9b. 8+ students from the CBOs seek further information about nursing and other health professions as evidenced by number of information packets distributed. Track students’ decisions over the year. 9c. 1+ talks/year reported.

10. Increase volunteer programs in CNCs and their partnering CBOs.

10a. Assist in development of volunteer management systems for the CNCs that include position descriptions, screening and matching techniques, and volunteer policy and procedure manuals inclusive of UWM volunteer policies. 10b. Collaborate with staff in each CBO to recruit volunteers and then support the volunteers to ensure they have a quality experience.

10a. A complete volunteer management system will be in place for the CNCs by the end of the year. 10b.1. Recruit at least 4 volunteers for each CBO, who serve ≥ 6 hours per month. 10b.2. All CBO volunteers report a positive volunteer experience after 3 months of service.