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Creating a Community Clinical Network

Strengthening food security through resident-driven service coordination and cross-sector collaboration in Milwaukee

Full Project Name:Creating a Community Clinical NetworkPrimary Community Organization:Children's Health Alliance of WisconsinPrincipal Investigator:Constance Gundacker, MD, MPH, FAAP, PediatricsAward Amount:$249,961
Award Date
November2025
Project Duration:24 months

Project Summary:


Food insecurity in Wisconsin, affecting over 26% of children in Milwaukee County, is a pressing health concern linked to increased risk of chronic illness, mental health issues, and hospitalization. Inadequate nutrition undermines children’s ability to focus in school and heightens healthcare costs, with national expenses reaching nearly $52 billion annually. Addressing food insecurity is essential for the health and well-being of Wisconsin’s children and families.

To meet this need, the FoodCare Coalition—a cross-sector partnership of organizations led by Children's Health Alliance of Wisconsin includes Feeding America Eastern Wisconsin, Chorus Community Health Plan, NourishMKE, Milwaukee Health Dept, Data You Can Use and Children’s Wisconsin—has developed a collaborative model to streamline access to resources, enhance data sharing, and prioritize community-driven solutions. Since 2021, this coalition has implemented successful pilots that connect families to FoodShare benefits and local food resources, providing thousands of additional meals and engaging community members in ongoing needs assessment.

In 2023, AHW-supported data chats with residents revealed four barriers to food security: educational gaps, financial constraints, access disparities, and health impacts. This project aims to strengthen Milwaukee’s community-clinical network by improving service integration and deepening resident engagement. Approaches include refining referral processes, developing a universal intake form for easier information sharing, and working with residents and local organizations to address education and access gaps identified in the data chats.

By creating efficient pathways to resources, fostering resident-centered collaboration, and utilizing both quantitative and qualitative evaluation metrics, this project strives to reduce food insecurity, improve health outcomes, and create a scalable model for cross-sector cooperation in addressing social determinants of health.

Community Partners: NourishMKE, Feeding America Eastern WI, Data You Can Use, Children's WI, Chorus Community Health Plans, Milwaukee Health Department/WIC

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