Diabetes Wellness in Waukesha

Developing an integrated model between community hunger relief resources and health care systems in Waukesha County

Full Project Name:Diabetes: Working wellness in Waukesha—togetherPrimary Community Organization:ProHealth CarePrimary Academic Partner:David Nelson, PhD, Family and Community MedicineAward Amount:192985
Award Date
January2013
Project Duration:30 months

Project Description Narrative:


According to the U.S. Centers for Disease Control and Prevention, diabetes is a serious and growing public health problem, affecting 8.3% of the U.S. population, or approximately 25.8 million people, in 2011. That number is only expected to grow. By 2050, the number of people diagnosed with diabetes is projected to increase from 18.8 to 29 million.

Locally, in Waukesha County, 19,430 adults live with a diagnosis of diabetes and another 99,230 are estimated to have pre-diabetes according to the State of Wisconsin's 2011 Burden of Diabetes. Diabetes is not only a serious health threat, but also a financial burden. In 2009, Waukesha County residents with diabetes paid $228 million in direct costs and an additional $114 million in indirect costs for medical care, with a significant impact on those living below the federal poverty level. In the city of Waukesha alone, 2010 U.S. Census data indicate that approximately 7,000 people live on a household income below the federal poverty level. It is estimated by government and health care leaders that there are 800 city residents with diabetes who have health care access issue due to their low socio-economic status and/or lack of health insurance.

The goal of this project is to develop an integrated model between community hunger relief resources and health care systems to ensure consistent quality care for uninsured or underinsured people with diabetes in Waukesha County.

Community partners:
Food Pantry of Waukesha County, Lake Area Free Clinic, Medical Eye Associates, S.C., Mount Mary University, National Kidney Foundation of Wisconsin, NuGenesis Farms, Oconomowoc Lions Club, St. Joseph's Medical Clinic, Inc., The Salvation Army of Waukesha, UW Extension Waukesha County, Waukesha Community Health Center, Waukesha County Community Dental Clinic, Waukesha Family Practice Clinic

Additional MCW academic partners:
Marie Wolff, PhD, Family and Community Medicine; Melissa DeNomie, MS, Family and Community Medicine

Outcomes & Lessons Learned:


• Developed an implemented coordinated strategies among hunger relief partners to improve access to healthy foods through education, training and policy, improving collaborative efforts among local food pantries, health educators, and health care organizations

• Conducted nutritional analysis of current menus, resulting in changes to food bags provided by the Food Pantry of Waukesha County and the meal program at the Salvation Army, and led to the development of strategies to re-integrate EBT into local farmers' markets

• Hosted numerous community education activities including cooking classes, diabetes cooking classes, point-of-service nutrition education, and mini-nutrition sessions and recipe sampling

• Identified and implemented consistent best practices for the care and education of un/underinsured clients with diabetes, developing and enrolling clients in a pilot program that provided assistance navigating preventive services and establishing a medical home

• Presented and distributed project information at various community, public health, and health care meetings, including the State of Wisconsin Department of Health Services Combined Chronic Disease Partner Meeting

• Leveraged approximately $207,000 in in-kind funding from other sources for project work and program assistance

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