Program will track and monitor clinical measures to improve healthcare quality and identify and manage patients with hypertension (HTN); implement and improve team based care (TBC) to reduce cardiovascular disease(CVD) risk focusing on hypertension; link community resources and clinical services to support bi-directional referrals, self-management, and lifestyle change work for women at risk for CVD; and identify at risk women using Community Health Workers(CHW) and work towards the sustainability of CHW's. Project outcomes: increase detection and then HTN control, increase quality of care, and increase HBSS participation. Program will implement screening and interventions to reduce the number who are undiagnosed or managing HTN, and other risk factors for CVD for NBCCEDP eligible and evaluate outcomes. Activities will include: clinical services, risk reduction and CVD education, medical referrals medication, goal setting, targeted HBSS, identify social supports, identify and expand the Health Care Team (HCT), support bi-directional communications between HCT, management data collection, support clinical quality improvement, program management, and evaluation and outcome reporting. Between Core and Innovative strategy, Program plans to screen 3,100 women. Based on the new Minimum Data Elements (MDE) guidelines released for 2018, Program will adjust data collection with Med-IT data vendor. Additional evaluation for HTN medication therapy and other CVD risk factors will be provided, with alert values receiving follow-up within 7 days. For those needing medications, staff will identify low cost options. Results provided verbally and in writing, in plain language. Program plans to continue to refer clients to existing HBSS to include: Weight Watchers®, Curves Complete, Take Off Pounds Sensibly (TOPS), YMCA Self-Monitoring Blood Pressure program (Y-SMBP), health coaching with or without YMCA membership, or other approved HBSS. Program will co
ntinue to identify and gain CDC approval for other opportunities that provide flexibility and scheduling to fit the needs of clients with irregular schedules. Program will work to develop strategies between clinic and HBSSs to implement bi-directionally communication to ensure the client receives all services. Program will monitor and evaluate all program activities. Program will work with partners, health systems, Federally Qualified Health Center (FQHCs), and community resources. Leveraging work already underway to improve the quality of health care, Program will work with the following: 1)PA Pharmacists Association (PPA) to provide medication management services and referrals to clinics 2) Quality Insights (QI) on clinical workflow and EHR improvements focused on HTN 3), Health Care Improvement Foundation (HCIF) to provide health literacy focused trainings 4) The University of Pittsburgh Medical Center, Penn State Office of Rural Health, and other health system reach eligible women, 5) Create bi-directional referral systems with partners, 6) Work with the Tobacco Prevention and Control (TPC) Program to identify potential clients and provide services, and 7) In the Innovative component use CHWs, PNs, social workers, and Certified Insurance Navigators (CINs) to increase and engage women and the PA CHW Committee to establish standard training and core competencies for sustainability. The Program Management team will have regular meetings to discuss guidelines, barriers, program changes, etc. Program will continue to monitor changes to the Affordable Care Act (ACA) and other influential legislative changes that will impact the potential number of eligible women. Program will work with the CDC Project Officer to adjust and revise workplan activities throughout the five-year period. Program will leverage existing CVD risk reduction program efforts already underway within the Bureau of Health Promotion and Risk Reduction (BHPRR) to ensure no duplication of funding and
that outcomes are shared.