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