Since 2018, the Medical Home Initiative has had the opportunity to support the Tribal Health Centers/Clinics of Wisconsin to advance family-centered care coordination for children and youth with special health care needs (CYSHCN). Throughout 2022, our initiative supported eight teams.

In 2022, each team developed a project idea based on a community-driven priority. Many chose to focus on mental health, behavioral health, or physical activity and partnered with behavioral health departments, schools or community health staff. The powerful nature of this work is how it integrates with each community, while empowering each Tribal Health Center/Clinic to create programming that will result in the most impactful change.

One team shared, “This project was far my favorite. I loved the amount of independence that each site got, which allowed them to focus on individual areas of concern for their community. I really enjoyed working on this project.”

An example of the community-driven work comes from the Stockbridge-Munsee Health and Wellness Center. The Maternal Child Health Nurse, within the Health and Wellness Center, created a six-week video workout challenge for children and their families. This idea was generated following a community survey (deployed in fall 2021) that indicated a need for healthy eating and physical activities for children. The goal was to reduce obesity, social isolation, and the risk of Type 2 diabetes, by encouraging children to become more active – an additional benefit was the increase in family time.

20 families participated in the six-week video workout challenge. One family shared, “The kids had fun with the exercises and when challenged continued to try their best with each exercise. I was very proud of them! Thank you for the opportunity.”

Another example of the community-driven work comes from Sokaogon Chippewa Health Clinic. Two of the registered nurses from the health clinic partnered with their behavioral health department to hold a children’s mental health week coloring contest for the community – the theme was, “What makes me happy.” Goals of the project included raising awareness around the available pediatric services at the health clinic, in addition to promoting mental health. The staff provided the paper, markers, and gift cards to those who submitted an entry. Since this, they have continued partnering with the behavioral health department on additional activities for the children. The activities have helped engage kids in the community while bringing them together as a group for social connectedness.

Since 2022 was so successful and received such positive feedback from teams, the 2023 project activities will once again be based on each community’s identified priorities to build and support care for children with, or who are at risk for, special health care needs.