A Healthier Wisconsin


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
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

Outcomes & Lessons Learned:

  • Developed the Hub to bridge the gap between health care delivery and the social service sector, resulting in seven agreements with care coordination agencies and placement of community health workers (CHWs) at care coordination agencies, representing a 58% increase of CHW placements prior to the Hub
  • Conducted CHW trainings, Hub onboarding trainings, CHW supervisor trainings, Care Coordination Systems (database) trainings, professional development trainings, protocol trainings, Community of Practice (COP) meetings, CHW case conferencing meetings and referral trainings throughout the project period to onboard new agencies and partners to the Hub
  • Supported six agencies in changing policies to increase capacity for community health workers and community care coordinators to improve continuityof care across both health and social services for clients
  • Supported the implementation of a regional CHW network, the Coulee Region CHW Network
  • Leveraged project efforts to secure seven grants to support hub and CHW work

AHW Logo

8701 W Watertown Plank Road,
Milwaukee, WI 53226-0509
(414) 955-4350