The health of a community depends on a strong and stable foundation. Income stability, housing quality and affordability, access to healthcare and educational opportunities help build that foundation. Through its Community Impact Grant Program, the Wisconsin Partnership Program supports initiatives designed to improve health and advance health equity by building strong foundations for health.

A grant to Sixteenth Street Community Health Center, Milwaukee’s largest federally qualified health center, supports the organization’s work to build a strong foundation of community health by addressing housing instability in its community.

Sixteenth Street serves nearly 40,000 patients in a vibrant Southside Milwaukee community. Last year, 86 percent of patients were Hispanic, 72 percent best served in a language other than English, and 79 percent of those whose income is known, reported it below 100 percent of the poverty level. System barriers, such as complex insurance and health and social service information, have created roadblocks for members of this multicultural community to access some of the basic building blocks to health.  

Wisconsin Partnership Program funding supports the development and implementation of a patient screening tool to identify foundational health concerns, such as housing. Community volunteers screen patients to identify needs and connect them to patient and resource navigators, who help patients access appropriate services and resources to meet their needs. The model includes data sharing across agencies to ensure sustainable, systemic change to how Sixteenth Street addresses housing and the other basic building blocks for health.

Systemic changes are too large to be made by one organization working alone, which is why partnerships are essential. Project Manager and Director of Health Education and Community Programs Jose Salazar says, “By working together and formalizing relationships with other community agencies, we are redefining a system to better provide support that is seamless, proactive and ultimately more effective in improving health.”

Sixteenth Street Health Center
Patient and resource navigators at Sixteenth Street Community Health Center connect patients like Ever, pictured above, to social services and resources to address issues that are impacting health but cannot effectively be addressed within the context of an exam visit.

A critical partner in this work is the Milwaukee Health Care Partnership, which includes local health systems, community health centers and government health agencies, all working together to reduce fragmentation to ensure that no one slips through the cracks—which happens all too frequently under the current, siloed system.

Housing instability, which includes homelessness and overcrowded properties, as well as structural problems with mold and lead, is one of the greatest threats to health in the Sixteenth Street community. The chronic stress caused by these housing challenges exacerbates many of Sixteenth Street patients’ most diagnosed health issues, including obesity, hypertension, diabetes, depression and anxiety.

Julie Schuller, MD, a practicing physician for 25 years before becoming Sixteenth Street’s president and chief executive officer, says, “As doctors, we recognize patients have these issues impacting their health, but there is only so much we can do within the context of an exam visit.”

As an example, she shares the story of a patient with allergies who developed asthma. Though she treated the asthma at the clinic, the patient had mold in her low-income housing apartment and an uncooperative landlord. Her housing voucher made it difficult to move. Dr. Schuller asks, “How can we address this? We want to take care of people beyond the exam room—where they live, work and play—but doctors don’t have expertise in housing and social services. Projects like this provide the expertise to augment what we’re able to do in the exam room.”

“In addition,” says Rosamaria Martinez, Vice-President of Community Health Initiatives, “trust is essential to the initiative’s success. Many staff members live in the community and want to make sure their community’s needs are recognized.” She says, “We are committed to our community and want to make sure the people—both within and beyond our clinic walls—have what they need to live healthy lives.”

Our state thrives when communities have strong foundations for health. Healthcare systems like Sixteenth Street play an important role in building these foundations by addressing issues impacting health and well-being within their communities. Says Dr. Schuller, “This project allows us to contribute to health not only in the clinic setting, but within our broader community as well.”