Diabetic Foot Ulcers

Rural patients with diabetic foot ulcers currently face 50% higher odds of major (above-ankle) amputation and 40% higher odds of death than their urban counterparts, a health disparity identified by Dr. Meghan Brennan’s team and others. Over 70% of Wisconsin residents live in rural areas, making this a particularly important topic to address in our state.

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).

Colorectal cancer blue ribbon

Increasing Colorectal Cancer Screening

To prevent death from colorectal cancer, we increased colorectal cancer screening in UW Health clinics from 63% to 81% within four years and have maintained screening rates above 80% for the past five years.  This represents an average increase of ~11,000 additional patients screened for colorectal cancer each year at UW Health.

We are currently working to expand our screening program across rural Wisconsin in partnership with the Wisconsin Collaborative for Healthcare Quality. 

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.

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.

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.

Woman pointing to board with ideas for healthy living

Improving Diabetes Self-Management

Management of diabetes lies almost entirely in the hands of those who live with the condition. The Wisconsin Institute for Healthy Aging and the Health Innovation Program are providing individuals with diabetes the resources they need for effective self-management of their disease.

Pills flowing out of bottle

Opioid Prescribing: Balancing the Benefits of Pain Management with the Risks of Opioid Abuse

Opioid misuse and abuse has become a significant public health problem in virtually all areas of the United States, including Wisconsin, where 827 people died from opioid overdoses in 2016-- up 35 percent from the previous year. Clinical guidelines for safer use of opioids were initially proposed in 2009, and have since evolved into the CDC’s widely publicized 2016 guidelines for opioid prescribing. The uptake of these guidelines has been variable across the U.S. healthcare system.

To assist in the uptake of clinical guidelines, University of Wisconsin researchers implemented a program to coach primary care doctors to follow opioid prescribing guidelines. This work was done through the use of a novel implementation strategy, called systems consultation, which was designed to promote clinical guideline implementation for opioid prescribing in primary care.