GRACE Hub

Bridging the gap between health care delivery and the social service sectors in La Crosse

Full Project Name:Gathering Resources & Aligning Community Engagement (GRACE) HubPrimary Community Organization:La Crosse Health DepartmentPrimary Academic Partner:David Nelson, PhD, Family and Community MedicineAward Amount:$294,901
Award Date
July2017
Project Duration:54 months

Project Description Narrative:


Sprawling development has created concentrations of poverty in La Crosse, evidenced by an increased need for free/reduced price meals reaching 62% in some neighborhoods. Poverty has increased rates of decline in these neighborhoods and exacerbated other challenges such as deteriorating housing, increasing crime and emergency resource use. The Gathering Resources & Aligning Community Engagement (GRACE) Hub in La Crosse aims to create, implement and adapt a system to bridge the gap between health care delivery and the social service sector for cost savings, improved population health outcomes, and increased client experience and engagement.

Community partners:
Great Rivers United Way, La Crosse Area Family Collaborative, St. Clare Health Mission, Gundersen Health System, Mayo Clinic Health System including the Foundation

Project Updates:


• Launched Hub with four community care coordinators in three agencies in August 2017, expanding to train three additional care coordinators in three new community care coordination agencies in November 2017

• Conducted 58 outreach and engagement efforts with various sectors including health care, nonprofit community-based organizations, business, health plans, community coalitions, policymakers, schools, fire and law enforcement

• Established contracts with Great Rivers Hub and La Crosse County Health Department, La Crosse County Human Services, St. Clare Health Mission, Family & Children's Center, and Independent Living Resources. Developed MOUs with payers including Gundersen Health System and Mayo Clinic Health System

• Supported six agencies in changing policies to increase capacity for community health workers and community care coordinators, aiming to improve continuty of care across both health and social services for clients

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