A Call To Care

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Leaving No One Behind  


Nurse Brenda Buchanan takes the blood pressure of Gladys Rogers at one of our Community-Based Chronic Disease Management clinics. 

Since 2007, Columbia St. Mary's Community-based Chronic Disease Management (CCDM) project has screened more than 6,000 people.

We have provided disease management to more than 1,200 people.

And 93 percent of survey respondents report overall health improvement after receiving care at a CCDM clinic.

Those results are incredible. These are people who, were it not for the CCDM project, would have gone without life-changing and life-saving care. They would have fallen through the cracks.

As a result of these successes, the program was recently recognized with an Advancing a Healthier Wisconsin (AHW) Excellence Award from the Medical College of Wisconsin. 

This award recognizes a collaborative, community-based health improvement project that has demonstrated the ability to build coalitions to successfully address pressing public-health issues.

The CCDM program (which is led by Dr. Jim Sanders, Associate Professor of Family and Community Medicine at the Medical College of Wisconsin, and Bill Solberg, Director of Community Services for Columbia St. Mary’s) is an innovative collaboration between Columbia St. Mary’s and the Medical College of Wisconsin to screen and manage chronic diseases – including hypertension, diabetes, obesity and smoking – among Milwaukee’s most vulnerable populations.

By establishing clinics in nontraditional locations – such as food pantries and churches – the CCDM program helps remove barriers to health services for low-income adults who are at risk of developing chronic diseases. And by offering screening, referral and management services, low-cost drugs, at-cost diabetic supplies and preventative education, CCDM clinics contribute to the prevention of chronic disease complications.

For years, Gladys Rogers was active in Columbia St. Mary’s community-based chronic disease clinics, helping spread life-saving information to her fellow congregants at the Greater Bethlehem Temple Church. But when she was downsized from her job in 2008, the longtime instructor became a patient.

“After my insurance lapsed, I wanted to be prideful and do everything out of pocket, but I soon realized money won’t cover everything,” says the 62-year-old. “And, of course, my chronic hypertension wasn’t going away.”

Having spent her whole life surrounded by the world of health care – from dealing with her own personal health issues as a child to witnessing her parents’ struggles later in life – Gladys knew the importance of maintaining a healthy lifestyle. But as other stresses in her life became more pronounced, her health took a back seat.

“My numbers were all out of whack,” she says.

So, Gladys sought out help at the very clinic she had long worked as an educator. Walking in the front door and being greeted with familiar faces immediately put Gladys at ease. There she met with a nurse who ran some tests, talked with her about the issues she faced, how to get them under control and suggested some medication along with lifestyle changes. Gladys still makes regular trips to the clinic once a month and her blood pressure numbers are now “near miraculous,” she says.

“They’re so well-controlled that when we did the blood pressure screenings at church I thought something was wrong. No way my numbers could be this good,” Gladys says, adding, “There are no words to express how important these clinics are in the community.” 

When we talk about health care that leaves no one behind, this is exactly what we mean. 


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Please watch this short video highlighting all the great work being done through our Community-Based Chronic Disease Management project.  


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