April 19, 2013
Volume 57, Issue 16
WHA Board Discussion on Exchanges Reveals Troubling Questions, Few Answers
Medicaid coverage, Worker’s compensation issues also discussed
The increasing uncertainty about exchanges, which are scheduled to begin open enrollment in a little over five months, was a major topic of discussion and concern at the April 18 WHA Board meeting in Madison.
As news continues to surface about the questionable status of exchanges and their near-term functionality, concerns also grow over the timing of the proposal to transition a significant portion of the state’s Medicaid population into an exchange. At issue is whether people who are now in the Medicaid program can be transitioned "seamlessly" to the exchange without losing insurance coverage.
Under the proposed state budget bill, 100,000 people currently enrolled in Medicaid will be removed from the program January 1, 2014 and transitioned into exchanges to purchase and maintain individual insurance coverage. There are 125,000 adults earning $11,500 - $15,300 who will become ineligible for Medicaid, and instead rely on the exchange.
Last week it was announced that Wisconsin, which chose to allow the federal government to run its exchange, would receive just $830,000 in federal funding for so-called exchange navigators—an amount many, including WHA, believe falls far short of what is needed to mount the robust navigator program that will be necessary to help connect people to coverage. That news added to growing concerns about how effective exchanges will be in connecting low-income populations, particularly those formerly enrolled in Medicaid, with coverage.
"Concerns about the effectiveness of the exchange grow weekly, and perhaps nowhere are they more acute than for hospitals, our health care system’s safety net," said WHA Executive Vice President Eric Borgerding. "Everyone shares the goal of reducing the number of uninsured and connecting people with affordable coverage, but the exchanges are going to take some time to be effective."
WHA is working with other stakeholders to advocate for a delay or phase-in of the proposed changes to Medicaid eligibility until exchanges are shown to be effectively functioning—not just existing, Borgerding said.
WHA Senior Vice President Joanne Alig, who is tracking the health insurance exchange rules and regulations for the Association, told Board members that it is alarming that open enrollment in the exchanges is set to start this fall while a recent focus group showed 70-80 percent of people asked have no knowledge of what to expect. For those currently on Medicaid, this is disconcerting given that they must select a health plan and pay their premium by December 31—that is, if the exchange is functional.
Alig said some implementation delays have already been announced as deadlines are fast approaching.
Insurers that want to have an insurance product in the exchange must submit a qualified health plan application to HHS by April 30. The Affordable Care Act requires insurers to maintain a network that is sufficient in number and types of providers to ensure that all services will be accessible without unreasonable delay. In addition, insurers must include a certain percentage of the "essential community providers" in the service area.
In the past, hospitals have assisted DHS in enrolling eligible patients in Medicaid, but Alig said the hospital’s role in connecting patients with the exchange is still unclear. Federal regulations on application counselors have not yet been finalized. The bottom line, though, is that patients will be looking to their providers for help, and we need to make sure there are not barriers to hospitals and health systems in assisting their patients, Alig said.
"In the end, five months before open enrollment, there is still a lot of uncertainty about what this will look like. Much is still unknown, and details are elusive on important issues about exchange enrollment, premium costs and the overall impact the exchange will have on employers," according to
Worker’s Compensation Negotiations Continue; WHA Forms Work Group
The Worker’s Compensation Advisory Council (WCAC) began negotiating this session’s "agreed-to bill" in March when labor and management representatives exchanged their initial proposals. Both sides proposed drastic reductions in reimbursement for health care services provided to injured workers. Laura Leitch, WHA senior vice president and general counsel and WHA’s liaison to the Council, reported to the Board that the Council’s management representatives are advocating for reimbursement rates of 175 percent of the Medicare rate, significantly below the amounts paid by commercial insurance.
Leitch explained that WHA has established a member work group to evaluate the Council’s proposals and provide meaningful responses. The WHA work group has emphasized that the Council should focus on the overall costs of the program by addressing the myriad of program inefficiencies.
"We are emphasizing that the insurers should not expect the same reimbursement rates that come with efficient billing and review systems and prompt payment requirements in a system that is paper-based, delays payment and is burdensome to administer," Leitch said.
Representatives of WHA and other health care organizations responded to the proposals from labor and management. WHA will continue to report to the Board as negotiations on the biennial bill develop.
Jandre Legislation Advances; Work on HIPAA Harmonization Bill Continues
WHA is making progress on several WHA high-priority legislative issues. Borgerding said the Legislature is expected to act soon on one of WHA’s top priorities—legislation that would address the Wisconsin Supreme Court’s recent decision in Jandre v. Wisconsin Injured Patients and Families Compensation Fund. The Assembly and Senate companion bills (AB 139/SB 137), which were authored by Representative Jim Ott and Senator Glenn Grothman and have 33 co-sponsors, would require a physician to inform his or her patient about the availability of reasonable alternate medical modes of treatment and the risks and benefits of those treatments. The bill is scheduled for a vote in the Assembly Committee on Judiciary April 25.
"These bills are tremendously important if Wisconsin is to avoid the outcome recently predicted in an informed consent case of an increase in defensive medicine and increased health care costs because of a plethora of unnecessary tests and procedures." Borgerding said. "Wisconsin hospitals and health systems are dedicated to providing high-quality, high-value health care to their patients. The bills would remove an unnecessary roadblock to that goal by establishing a reasonable, clear and effective informed consent statute in Wisconsin."
WHA and other health care organizations have been working with legislators to address this important issue.
WHA has also been working to enact the Mental Health Care Coordination/HIPAA Harmonization Bill that would remove statutory barriers to the coordination of care for persons with mental illness that do not exist for persons that do not have a mental health diagnosis. Borgerding said WHA is hoping that this bill, another high priority issue for the Association, will emerge as a tangible deliverable out of the Speaker’s Task Force.
President’s Report: Brenton Outlines Board Planning Session
WHA President Steve Brenton announced that the 2013 Board Planning session will focus on identifying and evaluating the factors that will influence the evolution of Wisconsin’s health care delivery system. WHA Chair-elect Ed Harding, president/CEO, Bay Area Medical Center in Marinette, will preside over the two-day event. Jim Bentley, a former senior executive with the American Hospital Association with extensive knowledge in health care delivery and payment trends, will facilitate.
Council and Task Force Reports
Audit and Investment Committee Report: Greg Britton, chair of the WHA Audit and Investment Committee, presented the 2012 audit report to the WHA Board for approval. He stated that WHA received a clean unqualified opinion and that the auditor was complimentary of the job WHA does preparing for the audit. The WHA Board approved the 2012 WHA Audit Report.
Rural Health: Ed Harding, chair, reminded members to register for the 2013 Rural Health Conference, which features Quint Studer and Todd Linden, president and CEO, Grinnell Regional Medical Center, located in Iowa.
Public Policy: Eric Borgerding reported that DHS Deputy Secretary Kevin Moore was the guest speaker at the last PPC meeting. Moore shared his thoughts on the major issues that DHS is facing including implementation of the Affordable Care Act, expanding mental health services and properly managing the state’s FamilyCare program.
Finance & Payment: WHA’s Brian Potter reported that the Council was briefed on issues related to Medicaid coverage, exchanges and worker’s compensation. Debbie Rickelman from the WHA Information Center presented preliminary results from a recent WHA survey on ICD-10 readiness.
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Wisconsin hospitals are decreasing infections, reducing readmissions and preventing hospital-associated conditions, according to a new report (www.wha.org/pdf/2012QualityReport.pdf) released April 18 by the Wisconsin Hospital Association.
"Wisconsin hospitals are keenly focused on implementing strategies to improve quality that are leading to better care for our patients and increased efficiency, which is helping to lower health care costs for our patients and for employers in our state," according to WHA President Steve Brenton. "Health care reform started in Wisconsin long before it became a federal law. Our integrated health care systems have focused on patient-centered care which has led to the development of team-based systems of care that have transformed our entire delivery system in Wisconsin."
The report illustrates the types of improvement work and the progress that hospitals have made in reducing hospital-associated conditions. Among the biggest challenges that hospitals face in infection control are the prevention of central line (CLABSI) and urinary tract infections (CAUTI). According to a recent report by the Centers for Disease Control and Prevention (CDC), hospitals across the U.S. reduced the number of CLABSIs by 41 percent since 2008. However, Wisconsin teams working to reduce these two types of infections saw a 67 percent reduction in CLABSI and a 48 percent decrease in CAUTIs.
Wisconsin hospitals are also focused on reducing the number of recently-discharged hospital patients who may return to the hospital within 30 days of discharge. The Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program, which requires Medicare to reduce payment to larger hospitals that have excess readmissions. Under this new program, 62 percent of eligible hospitals in Wisconsin had no reduction in their payments, and zero hospitals in Wisconsin received more than a 0.50 percent penalty. Wisconsin was one of the least penalized states in the country.
The WHA report also provides an overview of other areas where hospital teams are focusing their improvement work, including preventing pressure ulcers and falls. Nationally, it is estimated that nearly 60,000 hospital patients die each year from complications due to pressure ulcers. Hospitals participating in a WHA-facilitated project to reduce pressure ulcers saw a 66 percent reduction.
Patient falls are being addressed through a number of strategies, including video monitoring and through the use of "gait" belts that allow nurses to stabilize patients as they walk.
"Our hospitals are demonstrating that by adopting best practices and working in teams, they can make measurable and sustainable progress toward improving patient care," according to WHA Chief Quality Officer Kelly Court. "We are not perfect, but we have the improvement processes in place to move us closer to our goal."
Wisconsin is viewed as one of the most collaborative states in the country, an attribute, according to Court, which contributes to the high-quality, high-value care that attracts national attention. One such expert, Don Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services, was recently in Wisconsin to address more than 400 hospital quality and safety professionals. He congratulated them for the results they have achieved and encouraged them to share best practices with one another and with hospitals in other states.
"Something right is happening in Wisconsin. Given the success you have had for a decade or more, you are obviously good at quality improvement," Berwick said.
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The Wisconsin Hospital Association and the Wisconsin Medical Society along with more than 40 health organizations signed a joint letter that urges legislators to proceed with "extreme caution" in transitioning low income residents who now are in the Medicaid program into the federal exchanges.
"Any transition of Medicaid enrollees into the exchange should occur only after a Wisconsin exchange is demonstrated to be properly functioning and able to serve this low income population," according to the letter, which was sent April 11. The groups acknowledge that these are challenging times, filled with a lot of uncertainty around health care coverage and financing, but there are opportunities.
The letter encourages legislators to "transform Wisconsin’s Medicaid program, leveraging the flexibility to preserve our health care safety net and improve access to affordable coverage while saving Wisconsin taxpayers’ money."
The organizations urge legislators to "build on and improve the Governor’s budget proposal by setting Medicaid coverage levels at 133 percent FPL or $15,300 per year for low-income childless adults, parents and caretakers. This change would still represent a reduction in the Medicaid eligibility levels compared to current law, but will help ensure that our lowest income residents, those without affordable insurance options, retain access to coverage and do not exacerbate growing uncompensated care levels or the ‘hidden tax’ of cost shifting."
Wisconsin is a national leader in health care access, coverage, quality and value. It is one of the reasons why our state is attractive to employers. The letter makes it clear that Wisconsin health care providers are invested in job growth and economic development…"High quality health care is an asset that attracts good employers. Efforts to preserve this asset must be paramount during the budget deliberations."
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On April 5, CMS finalized its letter to insurers on details for participating in federally-facilitated exchanges, the kind of exchange that is expected to be operational for Wisconsin this fall (see http://cciio.cms.gov/resources/regulations/Files/2014_Letter_to_Issuers_04052013.pdf). The letter (first reported in its draft form in The Valued Voice on March 15), finalizes the timeline for insurers to apply to CMS for participation in the exchange for benefit year 2014.
Insurers that want to participate in the exchanges are now in the process of completing applications which must be submitted to the federal Department of Health and Human Services (HHS) by April 30. However, the timeline also shows the federal government won’t provide final notification of its approval to insurers until September 4, and insurers will have just five days after that to sign agreements.
The April 5 letter also indicates that HHS will review health plans applying to offer coverage in the exchange for compliance with network adequacy standards. Federal regulations include broad language requiring that insurers maintain a network sufficient in number and types of providers to ensure that "all services will be accessible without unreasonable delay."
In addition to this broad standard, health insurers must include in their network a certain percentage of the available "essential community providers" in the plan’s service area. CMS has released a non-exhaustive list of essential community providers, and insurers can include in their application essential community providers not on the CMS list by writing them into their application. Essential community providers include DSH and DSH-eligible hospitals, children’s hospitals, rural referral centers, sole community hospitals, free-standing cancer centers, and CAHs, as well as FQHCs, Ryan White providers, family planning providers, Indian providers and other entities that serve predominantly low-income, medically underserved individuals.
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The Medicaid Advisory Group (MAG) discussed several important payment and policy issues at the April 16 meeting in Madison.
Brett Davis, the state’s Medicaid Director, and Curtis Cunningham and Krista Willing from the Wisconsin Department of Health Services (DHS), briefed the group on a wide variety of topics. Brett Davis summarized the Governor’s 2013-2015 Medicaid budget, which includes an increase of $650 million GPR to cover the cost to continue and to supplant federal dollars being reduced due to a lower federal matching percentage.
DHS staff then presented the 2014 hospital rate-setting timeline and outlined work being done by the department using feedback from WHA and hospitals around the state, to increase the stability and transparency of the hospital rate-setting process moving forward. The guiding principles include promoting predictability, value, stability, timeliness and transparency. The Department is asking hospitals to submit ideas to DHS by May 1 for consideration in the 2014 rate-setting year. WHA will continue to meet with DHS on this issue.
Next, DHS staff provided the group with an EAPG implementation update. The Medicaid FFS EAPG outpatient payment system was launched April 1. DHS has been monitoring claims on a daily basis to ensure proper processing, and they have not seen any major issues so far. Any questions regarding the EAPG implementation can be sent to firstname.lastname@example.org.
Finally, DHS staff gave an update on the status of the primary care physician payment increase for the Medicaid program. Although the Affordable Care Act (ACA) requires states to raise their Medicaid fees to Medicare levels for family physicians, internists, and pediatricians for many primary care services, the lack of CMS rules until late last year and the complex nature of system changes is causing a delay in getting those payments out the door.
The payment increase can be significant. Kaiser has estimated for Wisconsin an average increase of 78 percent in physician fees as a result of this policy—an indication of the low rates of reimbursement in our state Medicaid program. The primary care fee increase applies in 2013 and 2014, is fully federally funded up to the difference between a state’s Medicaid reimbursement amounts in effect on July 1, 2009 and Medicare reimbursement rates for 2013 and 2014 as determined under a formula. The payment was only authorized for two years, leaving many to wonder what will happen in 2015 when the higher reimbursements rates revert back to previous levels.
In the meantime, DHS is working on policy implementation. To qualify for the higher reimbursement, physicians will have to demonstrate that they are board certified, or must attest that 60 percent of the Medicaid services they provide are within the applicable code set for evaluation and management services (codes 99201 through 99499). Providers may begin to submit information about their qualifications to DHS on April 12, 2013. The ForwardHealth Update document included in the meeting materials describes the process in more detail (see link below).
DHS estimates it will take longer to complete the complex system changes that are required for the payment rate change, and the higher payments may not be available until later this calendar year. The higher payment will apply to both fee-for-service and HMO services.
Materials from the April 16 meeting, along with other information about the Medicaid Advisory Group can be found on the WHA website at: www.wha.org/MAG.aspx.
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The Speaker’s Mental Health Task Force met April 18 at Aurora Sinai Medical Center in Milwaukee to discuss mental health issues unique to Milwaukee.
Pete Carlson, president, Aurora Psychiatric Hospital, and senior vice president, behavioral health, spoke on behalf of the Milwaukee Health Care Partnership’s Behavioral Health Provider Work Group about the health systems’ collaborative efforts to address Milwaukee’s unique mental health needs and challenges. One of those efforts has been to increase the behavioral health capacity of private hospitals.
"Together, Milwaukee’s private health systems provided inpatient psychiatric services to 8,707 people or 73 percent of all psychiatric discharges in Milwaukee County in 2011," explained Carlson. "These systems also served over 10,000 individuals in need of psychiatric services through their emergency departments."
"The Provider Work Group initially prioritized the development of a work flow to transfer [Milwaukee County Mental Health Complex] inpatients, including emergency detentions, to private hospitals. This initiative resulted in improved efficiency allowing patients to more quickly access appropriate care settings," said Carlson. "In 2012, approximately 1400 patients transferred from the [Milwaukee County Mental Health Complex] to private hospital settings. This increased capacity made available through private hospitals has allowed [the Milwaukee County Mental Health Complex] to reconfigure and significantly reduce the number of inpatient beds from 124 to approximately 65."
Carlson also highlighted the serious shortages of mental health professionals in Milwaukee and the impact below-cost Medicaid reimbursement and administrative hurdles has on that shortage.
"There is a significant gap in outpatient access for Medicaid beneficiaries in Milwaukee due to shortages of psychiatrists, advanced practice psychiatric nurse practitioners and psychotherapists," said Carlson. "This shortage, which impacts both inpatient and outpatient capacity, is primarily due to the shortfall in compensation and administrative burdens providers experience when interfacing with Medicaid payers, such as authorization and denial issues."
Carlson also offered recommendations to the Task Force, including enacting the HIPAA Harmonization Bill.
"Wisconsin’s outdated mental health records law is a barrier to individuals with mental illness getting coordinated, integrated care. This barrier does not exist for other illnesses and perpetuates the stigma of mental illness," said Carlson.
Carlson also helped clarify some misconceptions about the HIPAA Harmonization proposal. "It is important to note that the HIPAA Harmonization proposal does not allow disclosure of psychotherapy notes without signed consent. Instead, the HIPAA Harmonization recommendation allows clinical summaries of an individual’s diagnosis, medication use and effectiveness, functional status, treatment plans, symptoms, prognosis and progress to be shared between treating providers and for quality improvement purposes without requiring patient consent," Carlson said.
Carlson also recommended that the Task Force consider using Milwaukee County’s redesign study as a model for developing a statewide mental health redesign. The Milwaukee Provider Work Group was one of the catalysts for the development of the Milwaukee redesign study.
Carolyn Glocka, president of Aurora Sinai Medical Center and Aurora St. Luke’s South Shore, welcomed the Task Force to Sinai Medical Center, and noted its community role in Milwaukee.
"As Milwaukee’s last remaining downtown hospital, Sinai cares for a large number of vulnerable and underserved populations," said Glocka. "More than 80 percent of our emergency cases were uninsured or covered by Medicaid last year. Often times, underserved patients will seek care in emergency departments for primary care needs, such as mental and behavioral health needs."
The next meeting of the Speaker’s Mental Health Task Force is May 9 in Polk County.
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SSM Health Care, one of the largest Catholic health systems in the country, and Dean Health Systems, a large multi-specialty physician group, have signed an agreement under which the physician-owned Dean and its subsidiaries would become part of SSM Health Care, pending the approval of Dean physician shareholders, the Wisconsin Insurance Office of the Commissioner of Insurance and other regulatory agencies. The transaction could close as soon as this summer. The terms will not be disclosed.
The two companies already have an established integrated delivery network that manages the health of populations in south central Wisconsin. Dean has expertise in managing physician practices, while SSM has geographic breadth and expertise in acute care. In addition, SSM and Dean jointly own an insurance company, Dean Health Plan.
"This is our opportunity to take the high quality/low cost model that SSM and Dean have developed in south central Wisconsin and expand it throughout the Midwest," said SSM Health Care President/CEO William P. Thompson. "We are committed to partnering with our physicians in other regions to improve the patient experience, lower the overall cost of health care, and focus on keeping people healthy."
"This transaction is being considered because it would help us become fully integrated and continue delivering value-based care," said Dean Health Systems President and CEO Craig Samitt. "For our patients, there would be very few changes, with the potential for many advantages as we strive, during this critical time, to shift the focus of care delivery to higher quality at a greater value."
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Wisconsin State Laboratory of Hygiene (WSLH) at UW-Madison and their public health partners recognize the important contributions of their clinical lab partners, including the lab services that are provided in Wisconsin’s hospitals. WSLH relies on its clinical laboratory partners for many things. Clinical laboratory professionals provide the diagnostic specimens that are the backbone of the state laboratory-based influenza and respiratory virus surveillance program. Submissions of isolates that cause enteric disease help detect foodborne and waterborne outbreaks. Clinical laboratory professionals play a critical role in emergency response by performing screening tests on suspicious isolates to rule out agents of bioterrorism. They also notify local and state public health authorities when organisms are isolated that are a public health threat—such as measles and tuberculosis—so public health staff can investigate and prevent further spread of disease.
"The hospital and health system labs are excellent partners with us in the early identification of diseases and outbreaks that can be of widespread concern in our state," said Dr. Peter Shult, director, WSLH Communicable Disease Division and Emergency Laboratory Response.
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Physical activity is a preventive factor for many adverse health conditions, such as heart disease, stroke, high cholesterol, depression, and bone and joint disease. In communities across Wisconsin, hospitals are dedicating resources and doing what they can to encourage people of all ages to stay active.
Community Health school nurse focuses on flexible outcomes
Diana McGuan, BSN, RN, teamed up with Kathleen Stack, MSW, social worker, at Ben Franklin Elementary School in Milwaukee to teach children yoga—the mindful exercise emphasizing the mind-body connection. McGuan is one of nine nurses at designated Milwaukee Public Schools and follows a coordinated school health model of care.
"We’re taking a comprehensive look at the school environment and working in partnership with administrators, teachers, students and families to make changes that will impact overall health," said Sara Siedenburg, school health nurse manager, Children’s Hospital of Wisconsin.
Community Health School Nurse Program nurses are trained in disease prevention. They provide direct care to students and screenings, including vision and hearing. For chronic illnesses - such as asthma, diabetes, seizures or sickle cell anemia - they monitor students’ lifestyles and recommend ways they can better manage their illnesses. The nurses also coordinate care with physicians, social workers and insurance companies.
In addition, the nurses collaborate with Children’s Hospital’s Community Health Outreach Education staff to provide education on a variety of health topics, including:
• Anger management
• rugs and alcohol use prevention
• Human growth and development
Yoga provides the children techniques to help them relax and calm pre-test jitters, builds focus and concentration, oxygenates the blood to get kids ready to learn and promotes a more positive attitude. Teachers benefit because their students are calmer and ready to learn. Studies have linked yoga with better learning and improved behavior.
"Once you’ve got a good thing going, you’ve got to keep it going," said Nurse Diana - as the children call her. "We have to advocate for every child and provide healthy resources for families."
Students had a large learning curve. They were able to learn but not master about five poses in the first three months. By January 2011, McGuan and Stack observed significant progress as students began to ask for specific poses by name, have mastery of the earlier poses and have readiness for introduction of new poses. Students also showed an improvement in flexibility because of their participation.
Now, McGuan and Stack are teaching second-graders and offering a one-time "Taste of Yoga" class to all of the students.
Children’s Hospital of Wisconsin, Milwaukee
Wheaton Franciscan Healthcare supports fitness in Oak Creek community
Oak Creek Mayor Steve Scaffidi was looking for a way to bring his city together in a positive way, following the tragic Sikh temple shooting in August. He wanted the community to do something together, so he approached area health-related businesses with an idea for a weight loss and fitness challenge. Wheaton Franciscan Healthcare – Franklin accepted the challenge and became an active partner and sponsor of the event.
Hundreds of participants showed up to weigh in during the kickoff event in November at Oak Creek High School. Between November 10 and February 10, area businesses sponsored a series of "flash fitness" events, whether it was a walk outside, a free zumba class, or a talk on nutrition. The Franklin Hospital promoted the event and sponsored a healthy eating seminar. Two Wheaton Franciscan Medical Group physicians, Jennifer Scheeler and Emily Musselman, championed the event and talked to participants about health issues at both the kickoff and the finale.
What participants found most comforting about the Franklin Hospital’s involvement in the challenge was its commitment to the community.
"Thank you, Franklin Hospital, for always being involved," said a resident who commented on Facebook. "The Fitness Challenge was awesome!"
Collectively, the community lost 899 pounds. Wheaton sponsored the finale and encouraged attendees to bring and donate clothes to Goodwill. Many shed substantial pounds and had plenty of clothes to donate.
"People truly want to improve their lives through healthy eating and exercise," said Oak Creek Mayor Steve Scaffidi, who lost 20 pounds during the challenge. "Through the support of Wheaton Franciscan Healthcare, we were able to reach out to the entire community and invite them to participate. I think people really felt a sense of belonging. We intend to build upon this challenge in the fall."
Wheaton Franciscan Healthcare- Franklin
Submit community benefit stories to Mary Kay Grasmick, editor, at email@example.com.
Read more about hospitals connecting with their communities at www.WiServePoint.org.
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