person holding broken cigarette

Quit Connect Health: Improving Tobacco Quit Line Referrals

To reduce tobacco use, we improved quit line referrals for tobacco users by 20-fold through Quit Connect, a 90-second clinic staff protocol that integrates the electronic health record with the Wisconsin tobacco quit line. This protocol is being implemented in both primary care and specialty care clinics in multiple Wisconsin health systems including Gundersen and UW Health, with a pending grant to implement at Grady Memorial public hospital in Atlanta (83% African American, 40% uninsured).

women talking to young boy

Helping Youth & Families with Diabetes Self-Management

To prevent the long-term complications of diabetes among children, our program tailored diabetes self-management resources offered to children and their families at two pediatric diabetes centers, meeting the individual needs of over 2,200 Wisconsin children with type 1 diabetes (T1D) and their families.  In addition, elements of this program were incorporated into diabetes clinics at Children’s Hospital of Wisconsin in Milwaukee.  The study’s methods for engaging youth and families has inspired others like the American Diabetes Association and the Wisconsin Department of Public Health to make use of similar strategies.   

Man and woman in hospital talking to doctor and nurse

Reducing Disparities in Healthcare

To reduce disparities in healthcare quality, we are partnering with the Wisconsin Collaborative for Healthcare Quality and the Collaborative Center for Health Equity to measure and publicly report on disparities in the quality of healthcare in Wisconsin.

In 2019, we will release a statewide report documenting disparities in the quality of care for health systems across Wisconsin by race, ethnicity, and payer.

Nurse explaining medications to patient

Matching Complex Patients with Case Management Programs

To find high-risk patients who might benefit from additional health and social services, we have developed and implemented an artificial intelligence system to identify patients in need of enhanced care coordination in partnership with one of our state’s largest health systems (UW Health).  We are currently screening over 120,000 patients in Dane County each month using the system.

In the upcoming year, we will extend this system across the southern half of Wisconsin in partnership with one of the state’s largest health plans, screening an additional 166,000 patients each month.

Diverse young adults

Bringing Patients’ Voices to American Healthcare

Patient experience is an aspect of health and health care that has received increasing attention in the U.S.  For patients and caregivers facing a new diagnosis, or needing to make a health-related decision, other people’s experiences of the same diagnosis, treatments, and impact on the life course have always been valued. With the advent of web-based health information, the influence of patient experience has grown even more rapidly.

Recognizing this gap, researchers at four universities—including UW-Madison—and the Veterans Administration formed a collaboration called the Health Experiences Research Network (HERN) in order to bring an internationally-vetted method of rigorously collecting diverse health experiences to the U.S.

In 2016, they launched with an inaugural module on diverse young adults’ experiences with depression, a disease that can have significant consequences for future social, occupational, and health outcomes.

Checking blood pressure

BP Connect: Improving Blood Pressure Follow-Up

High blood pressures are the most prevalent and reversible cardiovascular disease risk factors among adults with chronic conditions, who are often vulnerable to gaps between specialty and primary care. Increasing preventive services to address hypertension could prevent more early deaths than any other preventive service. To address these issues, the BP Connect staff protocol was created to connect patients with high blood pressure in a specialty visit back to primary care for timely follow-up.


Primary Care Academics Transforming Healthcare

The mission of the UW Health PATH collaborative is to bridge primary care clinical transformation and rigorous scientific study in order to improve our health system for the benefit of patients and communities. We will disseminate learnings locally and nationally, emphasizing scholarly contributions.

We are a multidisciplinary coalition of physicians and change leaders. Primary care Academics Transforming Healthcare (PATH) members are experienced in clinical delivery and span all three primary care departments (family medicine, internal medicine, pediatrics), Quality, Safety, and Innovations, Population Health, and the Center for Patient Partnerships.

Young adult blood pressure

Helping Young Adults Manage High Blood Pressure

Approximately 1 in 15 young adults in the United States have high blood pressure, but young adults have the lowest rates of blood pressure control (achieving a blood pressure <140/90 mmHg) compared to other adult age groups, and many young adults have reported having few resources to address their needs for heart health education.

To address these problems, the MyHEART program was developed with young adults and healthcare team members to address a broad range of topics. MyHEART has multiple components, including young adult education and research programs across multiple healthcare systems. 

Eye screening

Preventing Blindness with UW Teleophthalmology

Diabetic eye disease is the leading cause of blindness among working-age adults in Wisconsin, where there are currently over 135,000 adults with diabetes. Early screening and treatment can prevent 90% of blindness, but only half of adults with diabetes get their recommended yearly eye screening.

In response, Dr. Yao Liu created the UW Teleophthalmology Program that enables patients in rural locations to get screened by their primary care providers during regular clinic visits without having to make a second trip or appointment. The images are then sent to UW-Madison, where eye specialists read the images and send reports back to primary care for local follow-up as needed. 

Family-centered rounds

The Family-Centered Rounds Checklist

Family-centered care has many benefits, including improved clinical outcomes, increased patient and family engagement and satisfaction, and more effective use of health care resources.

In the hospital setting, one way to achieve these benefits is through family-centered rounds (FCR) at the bedside. In fact, the American Academy of Pediatrics recommends FCRs as part of its policy statement on the pediatrician’s role in patient- and family-centered care.

Despite their benefits, FCRs can be challenging to operationalize at the institutional level. That’s why PROKids has developed a checklist to help implement FCRs effectively and sustainably.