Sixteenth Street Community Health Center

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Linkage to Care Diabetes Reengagement Program

Location: Milwaukee, Wisconsin

The Sixteenth Street Community Health Center (SSCHC) in Milwaukee, Wisconsin is a dual-site Patient Centered Medical Home (PCMH) with a 40-year history of engaging difficult-to-reach populations with a diverse set of healthcare programs to address challenges related to language, culture, and social class. Using lessons learned in a previously-implemented HIV Linkage to Care Model, this project sought to identify diabetes patients that had fallen out of treatment and reengage them in comprehensive primary care and diabetes self-management education (DSME).


The SSCHC is the primary community health center on the south side of Milwaukee serving the Walker’s Point/Fifth Ward and Bay View neighborhoods. These communities are the most densely populated area in Wisconsin and is home to a burgeoning Hispanic population. As many as 87% of SSCHC patients are Hispanic and 78% of all patients are below the federal poverty level. As many as 26% of SSCHC’s clients are without health insurance. The SSCHC serves 2,437 patients with diabetes, of which only 78% (1,895) had met the definition of “active,” defined by having visited their primary care provider twice within 12 months.


Core intervention components of the reengagement project were the development and implementation of new or modified policies and practice changes aimed at reducing system-oriented and patient-oriented barriers to appointment scheduling, patient retention, and access to primary and specialty care.


Optimizations made to clinical practice, patient contact workflows, and policies defining patient eligibility were impactful in the reengagement of patients that had fallen out of care, and for preventing new patients to be defined as having fallen out of care.