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13. ICTR Neighborhood Health Partnerships Program: Timely, Local Data to Guide Action in Wisconsin



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Background: The University of Wisconsin Institute for Clinical and Translational Research (ICTR) Neighborhood Health Partnerships Program aims to advance the health of Wisconsin communities by reducing barriers to learn, act, and sustain improvements. Program goals include: 1) Learning about the health of Wisconsin neighborhoods through timely and actionable health outcomes and care data, 2) Supporting report users in moving from data to action with a trained core of navigators to help users better understand the data; use action tools to select, adapt, and implement interventions; and create partnerships to develop, implement, and evaluate interventions, and 3) Monitoring outcomes and motivating sustained improvement over time with frequent data refreshes and enhancement of existing data. Methods: Through a partnership with the Wisconsin Collaborative for Healthcare Quality (WCHQ), the data used in the reports includes electronic health record data from 24 health system members of WCHQ, representing approximately 65% of Wisconsin's primary care providers. These data include 27 measures that span the care continuum including vaccinations, screenings, risk factors for chronic disease, and chronic disease management. We are also incorporating additional data from the U.S. Census to provide more context about the ZIP population and data coverage. Data are loaded into our Qlik infrastructure for rapid creation of standardized reports by ZIP code. We are prototyping standardized ZIP code reports across all WCHQ measures and an action tool set that promotes the use of data for action. A group of early adopter navigators has been identified to disseminate reports to potential report users including community organizations, researchers, clinics, pharmacies, health systems, and government agencies. Navigators will be trained to assist users in understanding data and identifying potential partnerships and opportunities for action. Co-design sessions with navigators and potential report/tool users are being conducted in 2020. Through these sessions, we will engage and learn from the community about organizational needs and priorities, potential report/tool uses, design, and other data and resources needed to improve community health. In Fall 2020, we will begin piloting use of the neighborhood reports and action tools through trained early adopter navigators and their existing research and community partners as user groups.  Implications: This program leverages existing data, infrastructure, and partnerships to address the need for timely, actionable data at the neighborhood level in Wisconsin. Through engagement of navigators and end users, additional opportunities for health improvement and provision of resources to take action will be identified. We hope to deepen connections between academic and community partners, leading to the development or modification and implementation of sustainable interventions. Future work will incorporate user feedback to improve the reports/tools and refine to more granular geographies, such as census tract.

Korina Hendricks - 
Health Innovation Program

Lauren Bednars, Jessica Bonham-Werling
Health Innovation Program


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