Community-based Chronic Disease Management

Engaging Milwaukee churches and food pantries in efforts to improve chronic disease management

Full Project Name:Community-based Chronic Disease ManagementPrimary Community Organization:Columbia St. Mary'sPrimary Academic Partner:James Sanders, MD, MPH, Family and Community MedicineAward Amount:$750,000
Award Date
February2011
Project Duration:66 months

Project Description Narrative:


In Wisconsin, significant racial disparities exist in chronic diseases such as diabetes, stroke, and heart disease, with each claiming the lives of significantly more African-Americans compared to their white counterparts: Diabetes alone claims the lives of twice as many African-Americans in Wisconsin, while stroke kills 50% more African-Americans and heart disease kills 20% more African-Americans than whites. In Milwaukee County, heart disease, diabetes, and stroke account for more deaths than cancer, lung disease, and infection combined. In Milwaukee, signficant economic disparities exacerbate need for basic necessities such as food and shelter. For poor people facing such hardships, chronic disease management is not likely a priority or accessible.

For this reason, project partners aim to expand the capacity of Community-based Chronic Disease Management (CCDM), increasing access to primary and preventive health services for vulnerable people through a capacity-building strategy involving local churches and food pantries.

Outcomes & Lessons Learned:


• Established wellness sites in specific areas of Milwaukee with severe poverty and health disparities, creating a model of service delivery that utilized a "window-of-opportunity" approach to provide as much care as possible when a person came to a project site. Partners identified that the CCDM approach was as effective in achieving patient results as a more-resourced primary care clinic approach, working to screen, diagnose, and prescribe medications for chronic disease while also connecting people to insurance, other health care providers, and food through this approach

• Collaborated with a large network of African-American churches to establish a health education, screening, and referral network, with over 80 churches identifying and training church health liaisons and establishing support within participating churches to continue these roles beyond the project

• Engaged community health workers (CHWs) at wellness sites to screen, refer, and provide education to participants and produced materials to promote wellness clinics

• Engaged larger community in wellness activities, including numerous community organizations as well as medical and nursing students

• Disseminated project results and lessons learned to academic and community audiences, including completing three peer-reviewed publications

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