While traditional definitions of community may reflect specific geographic boundaries or people unified around a common interest, Jennifer Edgoose, MD, MPH, is influencing primary care by redefining community in ways that are both expansive and inclusive, but keep the needs of the most vulnerable patients at the center.

On March 5, Edgoose became a part of a new community – one of five to be honored this year with the UW-Madison Outstanding Women of Color Award.

Edgoose arrived at the UW Department of Family Medicine and Community Health in 2010 with more than 10 years’ experience as a clinician in a federally qualified health center and a passion to transform systems of care.

“Just turn to the work coming out of our Population Health Institute,” she says. “Their work is widely used around the country, and they’ve found that only 20 percent of health outcomes are driven by clinical care including access to clinical care.”

Addressing food insecurity, neighborhood safety, poverty and issues of racism is the primary focus of her work.

Jennifer Edgoose speaking at a podium
Jennifer Edgoose

Edgoose reflects, “When you’re in primary care, you only have to work in the trenches for a brief period of time to see what is driving health outcomes. When it comes to health disparities, it’s all about the differences between the haves and the have-nots.

“The only way to grapple with this is to reach out into the community, learn how to develop partnerships and begin to integrate public health and primary care.”

Sarah Davis, JD, MPA, clinical professor of law at the UW Center for Patient Partnerships, who nominated her for the award, says, “Dr. Edgoose offers the strategy of a tempered radical, the wisdom of someone with lived experience and the foresight to build and contribute to interdisciplinary teams in order to maximize impact. She has the ability to hold those in power accountable through processes that welcome engagement and further commitment to inclusivity.”

As an associate professor (CHS), Edgoose has played a key role in her department’s evolution to become inclusive of community health in name, culture and in practice. In 2015 the department officially expanded the focus of its work and change its name to the Department of Family Medicine and Community Health. Within the department, Edgoose serves as director of the Office of Community Health, chair of the Diversity, Equity and Inclusion Committee and co-director of the family residency community health rotation.

She is also director of the Diversity and Inclusion Advocates Program for the School of Medicine and Public Health. Nationally, she provides leadership on Family Medicine for America’s Health – Health Equity Team.

In her letter of support for Edgoose’s nomination, Department of Family Medicine and Community Health Chair Valerie Gilchrist, MD, said, “Dr. Edgoose’s passion for teaching about health care disparities and addressing racism is reflected in a career dedicated to using a scholarly approach to advocate for the disadvantaged and to create inclusive and respectful environments in the community and workplace.”

A collaboration with a low-income housing complex, Public Health Madison Dane County and Madison Fire Department is probably the best demonstration of Edgoose’s work. When the apartment complex directly behind the UW Health Northeast Family Medical Center was identified as a building making one of the most 911 calls in town, this team came together in 2015 to understand the needs of this community that comprises a largely aged and physically and mentally disabled group.

They continue to meet monthly through a community paramedicine program called Community Action Resource and Education (CARE) that was further supplemented with programming around health education and team building developed by Edgoose and family medicine residents called “Dining with Doctors.”

“It’s even proved to be an unexpected way to provide continuity of care as sometimes I can check in on patients in their own home after seeing them in clinic,” says Edgoose. “By building trust and connection and teaching about important primary care and safety issues, we aren’t just reacting to emergencies, we are decreasing the number of 911 calls and improving community capacity.”