Community & Clinic Linkages

To learn more, contact:
Jesi Wang
Vice President of Healthcare Transformation
1-608-274-1940, ext. 8269

To better understand the current state of clinic and community linkages in Milwaukee County, MetaStar facilitated a landscape assessment, funded by the DHS Centers for Disease Control and Prevention (CDC) Chronic Disease grant. Phone and face-to-face interviews were completed with the following organizations or projects:


The goal of the interviews was to identify the current state and processes used between clinics and communities. To address this, questions were asked in the following four areas:

  1. Current activities implemented or planned to be implemented to improve clinic and community services and resources
  2. Technology being used to improve information flow between clinic and social resources
  3. Gaps or challenges faced within this focus area
  4. Successes and best practices seen to date including other organizations or stakeholders that should be interviewed

Gaps Identified

MetaStar’s assessment identified the following gaps:

  • Collective future state is not clear
  • Lack of alignment
  • No coordination of care coordinators
  • Unclear and competing priorities
  • Limited resource inventories
  • Reimbursement and sustainable models
  • Information exchange and technology
  • Lack of common measures

Full Report

For the full report, click here.