2015-16 ANNUAL REPORT Quality care for the whole person Quality Care is... Inside this issue: Dr. Kshama Keshava Bhat, Family Physician at our Waukesha location. Message from the CEO 4 Financials 5 Midwifery 6 Chronic Conditions Health Education 7 Preventative Screening 8 Our Mission Clinical 9 Population Health 10 To improve the health and well-being of Milwaukee Social Services 11 and surrounding communities by providing quality, Community Health Corps 12 Behavioral Health 13 family-based health care, health education and social services, Waukesha 14 free from linguistic, cultural and economic barriers. Board of Directors 15 Services 16 Donors 17 DEMOGRAPHICS patient demographics › 163,419 clinical encounters › 70% of patients best served in a 39,441 51% Adults language other than English patients › 84% Hispanic/Latino served › 65% at 100% Federal Poverty Level or Under 2% Seniors › 19% uninsured • 55% Medicaid • 4 % Medicare • 22% Private Insurance 47% Children 3 dear friends, from our CEO For nearly 30 years, it has been my great pleasure and extreme pride to share the neighborhoods continues, and we are now news from Sixteenth Street Community Health Centers with you. In 2017, I will aggressively working to implement telehealth be stepping down as President and CEO and our Executive Vice President, Julie services to expand the reach of counseling and Schuller, MD, MPH will be taking over the helm. She’s been with the agency for therapy with technology. more than 20 years, as a practicing physician, then Medical Director, VP of Clinical When we saw blighted areas of our community, like Affairs and now Executive Vice President. Julie’s drive for clinical quality and her the Menomonee Valley, that used to be a center of passion for the patients and community we serve has led to Sixteenth Street’s manufacturing and jobs, we sought grant funding and certification as a Primary Care Medical Home by The Joint Commission. That, and partners to build a new Menomonee Valley with new businesses, other quality achievements provide concrete support for the statement that we like community access points and hiking and biking trails. Similarly, when we saw the to make – that the patient care at Sixteenth Street is of national model quality. We’re Kinnickinnic River running through south side neighborhoods lined with concrete proud of that, and I can leave knowing that the agency will be in good hands. so that it didn’t even look like a river, we worked with the community to create a Looking back over my years at Sixteenth Street, our story has been one of growth. new vision, sought additional partners and funding to bring that vision into reality. Growth not only in terms of practice sites and numbers of patients served, but Now, our Environmental Health Department is working with the City of Milwaukee also growth in terms of creation of innovative programs that have made, and are and the Harbor District to re-imagine Milwaukee’s Harbor, where salt and coal piles making, a real difference in our community. I have always said that I didn’t want currently live next to storage tanks. Instead, in the future, we can work with new Sixteenth Street to simply provide a revolving door for sick people. The emphasis partners and the community so that our harbor can become an amenity for people on the single words that make up in addition to a commercial hub. our name should be on community “I believe that during my time at health, not health center. When I started at Sixteenth Street, we had one clinic location, in a storefront building. We now have three full-service clinics sites (soon to be five with help from I am proud that, when we saw that Sixteenth Street we not only made Froedtert Hospital and the Medical College of Wisconsin and Aurora Healthcare). childhood lead poisoning was a difference to our patients and Altogether in 2015 we cared for 39,000 patients. severe in our young patients, we community, but we found new started a door-to-door outreach I am proud of our story of growth, I feel that my time at Sixteenth Street has been ways to make that difference.” program to identify lead poisoned well spent. But, I am also sure that the best is yet to come. Thanks to you all for children and get them into care. your support of our efforts over the years. Incorporated into that program was education and training for parents to teach them how they can prevent their child Sincerely, from becoming lead poisoned through low-cost/no-cost prevention techniques. When we saw the lack of mental health services available in our neighborhood for Spanish speaking patients, we started the first bi-lingual mental health program in the city. The need for bilingual mental health services in low-income John Bartkowski, DrPH, President & CEO 1990 1993 1995 1998 2001 The Facility expansion to – HIV/AIDS outreach and case Environmental Health – Addition of Behavioral HIV services expanded to Patient care teams Bartkowski Era 30 exam rooms management program launched Department formed Health services become a department formed – First Annual Celebrity Roast – Redevelopment of the Menomonee Valley begins 4 FINANCIALS financials 2016 Sources of Funds: Uses of Funds: 68.2% Provision of 72% Insurance and Patient Fees Primary Health Care 12% Community Outreach and Health Education 17% Government Grants 19% Management, Facilities, 10% Contributions Billing and General 1% Rental, Interest and Other Income .5% United Way .8% Fundraising “Without Sixteenth Street, nearly 40,000 people would be without basic health care services.” – John Bartkowski, DrPH President and CEO 2002 2006 2010 2011 2012 2015/16 Patient care teams 20th Street location Accredited by Satellite clinic opened at Waukesha location – Collaborations with Froedtert and the Medical formed opens its doors The Joint Commission United Community Center opens its doors College of Wisconsin, and separately with Aurora, to open two additional locations – Certified by the Joint Commission as a Primary Care Medical Home 5 MIDWIFERY Quality is... receiving early and regular prenatal care Early and regular prenatal care is essential to helping women live a healthy pregnancy and consequently a healthy birth. The Sixteenth Street Midwifery Department works tirelessly to engage prenatal patients into care early for the important implications it has on birth outcomes. There are medical, social and behavioral benefits to engaging women into care early in their pregnancy. Our midwives are able to identify and manage underlying issues or conditions our patients often face, such as diabetes or asthma. They are able to help with chronic stress, which can lead to pre-term birth, by connecting patients to other clinic services such as behavioral health or social services. When engaged in early care, the midwives can also educate patients and address certain behaviors in a trusted and safe environment. All of these efforts reduce the risk of pregnancy complications and the infant’s risk for complications as well as put our patients in the best position possible for a healthy pregnancy. Ann Krigbaum, Certified Nurse Midwife, with patient Marta. 84% of patients enter into “We get the help here we wouldn’t normally get… prenatal care in it doesn’t happen at many other places. Here we their 1st trimester actually get the help we need to be healthy.” – Marta Valdivia, Sixteenth Street patient 6 CHRONIC CONDITIONS HEALTH EDUCATION building relationships and taking the time When diabetic patients maintain an A1c level under 8 it means they are successfully managing their diabetes. This is the goal of the Chronic Conditions Health Education Department (CCHE) – self management. Yet getting this number under 8 is much more than blood sugar. It is a culmination of controlled blood pressure, correct eating habits, being physically active, managing stress and mental health and more. It’s a long and difficult list. But the CCHE Department walks hand in hand with every patient to make sure they get there. According to department manager Holly Nannis, RN, “There are a lot of seeds to plant – it’s really difficult to understand everything.” At each step of the way, the CCHE team listens. The diabetes educator, the nutritionist, the Zumba leader, the support group facilitator – they all take the time to connect. The team listens as patients talk about their lives and their stressors. It is in these moments and interactions that they build relationships and trust. With trust, the CCHE team can truly understand the patient and influence behavior through education. Nannis says, “Trusted relationships, empathy and education is what converts to true Eida Berrios, Certified Diabetes Educator, with the diabetes support group that meets monthly without fail. behavioral change. “ The CCHE team supplements the high quality “Often times when I go to the grocery store, I will medical treatment given by Sixteenth Street see a patient and they will come up to me with food providers in a full-circle collaboration in their hand – showing me the labels and telling to help patients control their home 75% of diabetic me about the carbohydrates or other things they’ve environment and make sustainable patients have change. Because CCHE staff are cross learned. That’s what our department is – a family A1c levels under 8 trained for multiple chronic conditions, within our community that is available and around such as asthma, diabetes and for our patients. We help them and live through which exceeds the hypertension, they are able to work their learning and education together.” national target across disciplines and care for the patient as a whole. – Gerardo Jimenez AE-C, Certified Asthma of 70%. Educator at Sixteenth Street 7 PREVENTATIVE SCREENING Quality is..