Project Abstract Summary
The burden of cardiovascular disease (CVD) and associated disease, cerebrovascular disease and diabetes, remains high in Minnesota. In 2016, 25.4% of deaths among Minnesota women were due to heart disease, stroke, or diabetes. Most importantly, this burden of disease is not shared equally. American Indians (AI) have the highest heart disease mortality in Minnesota, (187/116 per 100,000 AI/Whites respectively). Also, US-born African Americans have a 20% higher heart disease mortality rate compared to whites. Although Minnesota has outstanding health care delivery systems and overall better health status than many other states, Minnesota has substantial racial, ethnic and geographic health inequities and incidence of chronic disease relative to the rest of the country. Yet the risk-factors, morbidity and mortality associated with CVD are largely preventable and health disparities can be addressed.
The 1816 NOFO application provides an opportunity to address income, geographic, and racial disparities in CVD in Minnesota. The following proposed project builds on the extensive work of Sage programs (NBCCEDP, CRCCP, CCCP, and MCRS) as well as CVD programs within MDH and an extensive network of clinical and community support systems.
Purpose: The Minnesota Department of Health will implement and evaluate CVD screening and HBSS referral programs for low-income, uninsured or underinsured, and high-burden populations of women in Minnesota.
Outcomes: Long term outcomes are to: 1) to reduce disparities in target populations in CVD, 2) increase blood pressure control, 3) increase control of other CVD risk-factors, and 4) create sustainable structures such as learning circles and CHW-centered team based care in target communities and partner clinics. Intermediate outcomes include: 1) expanding learning circles to 10 target population communities, 2) increasing data sharing and utilization, through bi-directional feedback systems, among clinics, communities and Sage programs, 3) increasing engagement in self-management among patients with high blood pressure and high blood cholesterol, and 4) increasing participation in evidence-based lifestyle interventions among patients with CVD risk-factors, 6) increasing maintenance of health behaviors and lifestyle changes among at-risk women, and 7) developing an infrastructure to promote long-term sustainability for a community health worker model. Short term outcomes are: 1) identifying and targeting hard-to-reach and underserved women for CVD screening and referral, 2) enhancing referral, participation, and adherence to HBSS programs in traditional and community settings, 3) piloting new approaches to facilitate bi-directional referral mechanisms, 4) piloting learning circles to address health equity, and 5) increasing adherence to team-based care within clinics.
The overarching goals of SagePlus are to decrease CVD-associated morbidity and mortality, as well as CVD health disparities in Minnesota. To achieve these goals, SagePlus plans to extend CVD health screening and risk-assessment to 7,500 unique women over 5 years, provide a referral system for lifestyle change for at-risk women, and develop community structures to address health equity.
