One Hundred Healthy, At-Risk Families

Preparing a network of pastors, nurses, at-risk seniors and their care support workers across 10 urban Milwaukee church communities

Full Project Name:One Hundred Healthy, At-Risk FamiliesPrimary Community Organization:Columbia College of NursingPrimary Academic Partner:Jeff Morzinski, PhD, MSW, Family and Community MedicineAward Amount:$192,793
Award Date
January2013
Project Duration:30 months

Project Description Narrative:


Older adults have higher rates of hospital use. For seniors, hospitalization is often a "tipping point" for physical and cognitive health decline. As many seniors in our communities face more than one chronic disease, they are at a high risk for hospitalization, emergency room use, and remain at high-risk for return hospitalization.

Among racial and ethnic groups, African-American adults face a greater burden of chronic disease than other ethnic groups, while health care utilization among this population presents a complex picture: Fewer urban, African-American families have access to continuous, coordinated, high-quality primary care providers — but hospitalizations and emergency room visits are significantly higher than for other groups and preventable hospitalizations for African-American are more than double that of whites.

Project partners aim to build on a network of 10 Mliwaukee church communities and seven organizational partners to establish better coordination of care and support for at-risk seniors within these 10 urban church communities, helping seniors establish "activated" support teams that will monitor for and identify hospitalization risk factors while hleping the individual work toward health goals.

Community partners:
Alzheimer's Association-Southeastern Wisconsin, Arthritis Foundation, Milwaukee Inner-City Congregations Allied for Hope (MICAH), St. Martin de Porres Catholic Church, UW School of Medicine and Public Health Additional MCW academic partners:
Karen Krause-Framm, Family and Community Medicine; Kevin Izard, MD, Family and Community Medicine; Melissa DeNomie, MS, Family and Community Medicine

Outcomes & Lessons Learned:


• Developed effective individualized community health support teams for at-risk seniors in 10 Milwaukee church communities, developing "Check-status Evidence-based Education and Support Sessions" and additional resources for participating seniors to manage and monitor their risk factors

• Shared effective health safety and risk prevention strategies and resources with church pastors and health ministry teams, creating and distributing a project newsletter and conducting a 100 Healthy Families Summit on senior health and safe homes

• Developed a curriculum team to plan and deliver an advocacy curriculum, working with 10 pastors in a seven-part series to create an intiative aiming to provide minor home improvements to allow seniors to remain living at home and well longer. Initaitive has successfully launched as an independent, church-based initiative with more than 20 new and continuing partners

• Monitored the status of at-risk seniors to determine project impact with end-of-project evaluation indicating that among the 63 at-risk seniors who completed eight support sessions, the intervention was well-received and feasible, however was not intensive enough to make a statistically significant difference in fall rates or preventable hospitalization data

• Presented project at various meetings and events such as Society of Teachers of Family Medicine (STFM) Practice Improvement Conference and Presentation at STFM pre-doc conference

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