Aurora Health Care’s umbrella organization Advocate Health is committed to improving health and wellbeing for all the communities it serves. By increasing access to care and improving clinical outcomes and social drivers of health (SDOH), Advocate is leading the way in whole-person care recognizing that care extends beyond the walls of the hospital. Patients experiencing limited transportation, hunger, or unstable housing are more likely to face health problems. By screening for social drivers of health, Advocate gains insight into patient needs, applies care navigation for vulnerable individuals, and utilizes data to guide investments in community resources that support patients where they need it most. Advocate patients are screened annually in primary care, emergency department, and inpatient care settings across five core domains: food, housing, transportation, utilities, and safety. By August 2025, Advocate had screened over 1.9 million patients – quickly surpassing the 2024 year-end total. Patients identified with social health needs are connected to same-day resources provided by community partners. The Community Resource Hub is a free online resource that allows patients and care providers to find programs and services in their neighborhoods by zip code, it is comprised of our Trusted Partner Network (TPN), hyper-local community-based organizations with dedicated resources for receiving direct referrals from Advocate Health care facilities. When patients screen positive for any SDOH need, our Community Health Workers (CHWs) and care teams utilize the CRH and TPN to complete referrals, ensuring patients receive the necessary support. CHWs are an integral part of the referral process. As trained patient advocates, they partner with healthcare facilities, social services agencies, and community-based organizations to connect patients to services and help them navigate the healthcare system. The Primary Care Connection (PCC) program deploys CHWs as community resource navigators to serve people in the emergency department and inpatient population. In 2024, the PCC program saw 11,427 patients across five hospital sites with 16,836 referrals given. A key aspect of the referral process is maintaining the capacity of organizations to accept and manage patient referrals. Through the Advocate Health Invests Program, Advocate has provided funding to community organizations that share its commitment to enhancing social care and access to healthcare. This investment enables partners within the TPN and throughout Advocate's reach to better serve patients and expand their operational capacity for increased impact. By addressing the social drivers of health, Advocate Health is making a significant impact on patient care outcomes. Its comprehensive screening and referral process ensures that patients' basic needs are met, leading to improved health outcomes and overall well-being for all.

Whether people have access to world-class health care should never depend on their ZIP code or the size of their town. That’s why Aurora Health Care has committed to “rewire” health care – to build the country’s leading model for access to care. This type of transformation requires improving access for all people, including those who live in rural America, where ongoing access issues continue to impede their ability to live their healthiest lives. About 20% of Americans live in rural areas. Based on our Community Health Needs Assessments, people living in rural areas often face greater health challenges. Smoking rates tend to be higher, as do rates of obesity and high blood pressure. Those underlying factors can lead to higher risk for heart disease, cancer, stroke and more. Substance abuse is an ongoing crisis in rural communities. On top of that, lower household incomes can make access to health insurance a challenge. As population density in rural areas drops, access to basic medical care does too.

Advocate Health’s commitment to rural communities is only growing, with clinicians sharing stories of their successes with their colleagues across the country and improving the quality of the care they provide right back at home. Each year, Aurora Health Care’s umbrella organization Advocate Health is investing over $3 billion in operational and capital expenses to deliver leading-edge care to rural communities, while providing an additional $600 million in uncompensated care.

“We’re going to keep learning from our dedicated rural health leaders and clinicians and putting these lessons to good use in every rural community we serve, adapting for the local context,” said Dr. Nwando Olayiwola, the president of Advocate’s National Center for Clinical and Community Impact. “For Advocate Health, this is just the beginning.”

The health challenges faced by people living in rural communities will keep changing, as will the need for new, innovative strategies to address those identified needs. The need for health care providers to commit to their communities – with support from their communities and government leaders – will be a constant. Every Aurora Health Care location, no matter how small or where it’s located, has access to the health system’s virtual critical care team. It’s comprised of a group of critical care nurses, respiratory therapists, pharmacists and physicians who are working 24/7 to consult, assess and intervene in real-time, supporting rural community members who may otherwise face multiple barriers to accessing care. In hospitals that don’t have such clinicians on staff – or overnight, after those specialists have gone home – this team can beam into a patient’s room with a precision camera with real-time audio and video.

The health system’s work on providing excellent care in rural areas is laying a strong foundation for even more substantial commitments, in concert with strategic private partnerships and critical legislative assistance from federal and state officials. Advocate Health and its leaders believe every patient – no matter where they live – should have access to the care and resources they need to thrive. Read more: AdvocateHealth.org/RuralCare

Securing access to specialty care for low-income, uninsured individuals is a complex and intractable issue. There are many barriers to receiving specialty care in a timely and coordinated manner, even for those with an established medical home and health insurance coverage. With approximately 7% of Milwaukee County residents uninsured at any point in time, Milwaukee’s health systems have sponsored free clinics and worked closely with FQHCs and other community clinics to weave a stronger safety net of care for low-income and vulnerable individuals. While these safety net clinics can provide primary care to uninsured patients, access to specialty care remained a challenge.

Through the Milwaukee Health Care Partnership, the four Milwaukee health systems – Aurora Health Care, Ascension Wisconsin, Children’s Wisconsin, and Froedtert ThedaCare Health - established the Specialty Access for Uninsured Program (SAUP) to create a barrier-free, coordinated process to provide specialty testing and treatment for uninsured patients.

SAUP improves the efficiency and effectiveness of care between health partners and offers timely, managed, and clinically appropriate access to specialty care for uninsured patients who are established in a primary care medical home at one of Milwaukee’s eleven participating safety-net clinics. The result? In 2024 alone, the three adult health systems have guided more than 1,000 referrals for specialty services – from cancer treatment to vascular surgery!

Sarah (Name changed for patient privacy) is one of these patients. Sarah does not have insurance and has been a long-time patient at Aurora Walker’s Point Community Clinic (Walker’s Point). In recent months, she experienced ongoing abdominal pain and communicated this with her doctor at a routine visit. After obtaining various labs and ultrasounds at Walker’s Point, the provider determined specialty care was needed. A SAUP referral was placed for her to see a specialist at Aurora St. Luke’s Medical Center (Aurora).

This patient saw the gynecologist who performed an exam and biopsy. Sarah received a diagnosis of metastatic cervical adenocarcinoma, gastric type. A PET scan showed uptake of the cancer at the head of the pancreas. Sarah is now actively receiving cancer care with Aurora.

Sarah described her journey from diagnosis to treatment as smooth and is eager to share her gratitude. She particularly praised her providers, noting, “I am thankful to my PCP at Walker’s Point for connecting me to the care I need, and the team at St. Luke’s has been terrific. My oncologist is a great provider, and I’m receiving excellent care.”

In February 2022, the Milwaukee Health Care Partnership (MHCP) Youth Behavioral Health (YBH) Committee convened a workgroup to address gaps in care for youth with complex, multi-system needs who were presenting to emergency rooms (ER) in behavioral health crisis. These youth were experiencing extended ER stays, delayed discharge, and/or boarding in medical hospitals without medical need. This reflected challenges in coordinating care across multiple systems and accessing the right care at the right time.

One youth, for example, arrived in the ER for the fifth time in a month with suicidal ideation, aggressive behaviors, and unmanaged chronic health conditions. The foster parent could no longer provide care, and local facilities were unable to meet the youth’s needs. Though medically stable, the youth remained hospitalized for months while hospital staff, child protective services (CPS), Wraparound, and others searched for an appropriate care setting. This scenario highlighted systemic gaps and the urgent need for standardized, cross-sector processes.

A cross-system data review and listening sessions with Wisconsin residential care providers confirmed these challenges: youth residential beds had been declining for more than a decade, facilities struggled to serve youth with complex needs, and Psychiatric Residential Treatment Facility (PRTF) care was not available in-state. While efforts to establish PRTFs are ongoing, the workgroup identified an immediate opportunity to improve care through a standardized ER crisis protocol.

Co-designed by the Milwaukee health systems, DMCPS, Wraparound, Care4Kids, Children’s Long-Term Support (CLTS), and others, the protocol clarifies roles and order of operations, streamlines communication, and ensures accountability during a crisis. Implemented at Children’s Wisconsin in Q1 2023 and the Mental Health Emergency Center in Q3 2023, it establishes six core steps: social work/RN triage; CPS case manager notification; stakeholder and treatment team notification; discharge planning; ongoing communication until youth are stable; and coordination of transfer or discharge. It also provides guiding principles for cross-agency care, centralized contact information, escalation paths, agreed-upon timelines, and increased transparency regarding feasible discharge options.

Early indicators of success include reduced ER length of stay, lower readmission rates, avoidance of unnecessary inpatient admissions, improved access to appropriate care, and enhanced experiences for youth, families, and providers. While tracking this small population (11 youth identified in a 1.5-year lookback) is challenging, the protocol establishes a structured, collaborative approach to ER crisis management for multi-system involved youth with complex needs.

This effort demonstrates the power of cross-sector collaboration in addressing systemic gaps, improving immediate care coordination, and laying the groundwork for future innovations and continuous improvement. The ER Protocol provides a common language and shared accountability, helping ensure that youth in crisis receive timely and appropriate care, even as longer-term solutions in the continuum of services continue to be developed.

The Milwaukee Health Care Partnership is comprised of the four Milwaukee health systems – Aurora Health Care, Ascension Wisconsin, Children’s Wisconsin, and Froedtert ThedaCare Health.