California, CDC-RFA-DP18-1816
Project Abstract Summary
The proposed program, as detailed in this grant application, will build upon the CA WISEWOMAN (CAWW) Program’s expertise that has developed over the past twelve years, to address one of the leading causes of death for women, heart disease. CAWW has utilized a successful clinic-based model for all components of its program structure, incorporating clinic-based screening and risk reduction counseling followed by health coaching (HC) sessions. CAWW will continue to work with select clinic providers that have demonstrated reach and capacity to screen eligible women (low income, under- or uninsured, 40-64 years of age, eligible for California National Breast and Cervical Cancer Early Detection Program [CNBCCEDP]). These clinic providers are located in geographic regions of CA with the largest number of eligible women for CNBCCEDP (Every Woman Counts [EWC]) and who are at risk for cardiovascular disease (CVD).
CAWW will gather information from environmental scans, data sources and geographic information system (GIS), key clinic and community partners, and from lessons learned, to determine the available structured, evidence-based lifestyle programs (LSPs) that are currently delivered in the community. CAWW will enhance its existing database to include all CDC required reporting measures, as well as measures that will demonstrate effective short, intermediate, and long term program outcomes. The program will extend preventative health services to under-served women who are eligible for EWC services. The services will include assessment of cardiovascular risk factors and provision of services to reduce those risks through improved diet, physical activity, tobacco cessation, and medication adherence support, with a focus on the health systems and community-clinical links that are supportive of these preventative health services.
CAWW will partner with other CDC-funded programs that reside within the California Department of Public Health (CDPH) and the California Department of Health Care Services (DHCS), and non-CDC funded programs and organizations at the state, local, county, and community level. CAWW will collaborate with these programs in appropriate activities as the program focuses on three strategic areas: 1) Track and monitor clinical measures shown to improve healthcare quality and identify patients at risk for and with hypertension; 2) Implement team-based Care to reduce cardiovascular risk with a focus on hypertension control and management; and 3) Link community resources and clinical services that support bi- directional referrals, self-management, and lifestyle change for women at risk for cardiovascular disease.
The short-term and intermediate outcomes for the project period include: 1) Increased reporting, monitoring, and tracking of clinical data for improved identification, management, and treatment of women with hypertension; 2) Increased use of and adherence to evidence-based guidelines and policies related to team-based care; 3) Increased use of data systems to identify and refer at-risk women to appropriate healthy behavior support services; 4) Increased data sharing and utilization; 5) Increased engagement in self-management among women at risk for and with cardiovascular disease; 6) Increased participation in healthy behavior support services; and, 7) Improved and maintained healthy behavior and lifestyle changes.
The long-term outcomes the project will achieve at the end of the five-year project period include: 1) Increased blood pressure control; and, 2) Improved detection, prevention, and control of cardiovascular disease.
Estimated number of people to be served as a result of the award of this award: 9,000 (over 5 years).