New Connect to Care Program Expands Access to Primary Care, Mental Health Appointments

As the health care delivery landscape shifts and patient needs and utilization patterns change, the Milwaukee Health Care Partnership (MHCP) Emergency Department to Medical Home Program (EDMH) is expanding the number of participating referring and receiving organizations to ensure residents get timely, clinically appropriate and acceptable access to a variety of health care services. Moving forward, the EDMH Program will be renamed the Connect to Care Program to reflect this expansion in scope.

Since 2009, EDMH has worked to screen and connect (or re-connect) high-risk patients in local emergency departments (ED) with follow-up appointments at primary care health homes. Tested screening and patient engagement practices, supported by a community-wide appointment scheduling software, allow ED providers and discharge planners to directly schedule a real-time follow-up appointment before the person leaves the ED. The goal of the EDMH process is to connect high-risk people with long-term health homes to better address their continuing health needs and reduce avoidable ED visits or subsequent hospitalizations. More than 60,000 appointments have been scheduled to date resulting in a 44% reduction in subsequent ER visits for patients who kept their appointment.

“The program has demonstrated the capability and capacity to have a larger impact,” said Greg Stadter, Director of Access at MHCP. “Post-pandemic, people are engaging less in preventative and regular primary, behavioral and oral health care. Through this expansion, we intend to leverage every opportunity to screen, link and engage patients with the right care at the right time in the right place – and involve them in the choice.”

Currently, EDMH involves eight local adult EDs as referring organizations and more than 20 primary care clinics as receiving organizations. The expanded program, Connect to Care, will involve additional referral and receiving organizations, further broadening access to care. New referral organizations will include inpatient hospitals, mobile health units, community-based lead testing clinics, health department clinics, and community paramedics. New receiving organizations will include Milwaukee County Behavioral Health Access Clinics (crisis behavioral health walk-in clinics) and dental clinics through a collaboration with the Milwaukee Oral Health Task Force.

“The additional receiving organizations participating in the Connect to Care network will give community health workers, discharge planners, like social workers and nurse case managers, paramedics and public health nurses more options – and give patients more choice,” said Jenni Cadman, Director of Nursing for Care Management at Froedtert Hospital. “Linkages via WISHIN and/or Epic will also allow health care providers to understand patients’ past provider and care management relationships to “re-connect” to continuing care where appropriate.”

Both referring and receiving organizations are trained in patient engagement practices that result in higher show rates and stick rates (patients who attend their appointment and come back within a year).