Friday, April 4, 2025
4/4/2025
MN WISEWOMAN SagePlus - The Minnesota Department of Health’s (MDH) application for the WISEWOMAN (CDC-RFA-DP-23-0003) (MN SagePlus) will work in partnership with communities most affected by disparities, primary care clinics, health care systems and other partners to improve cardiovascular health (CVH) outcomes within our National Breast and Cervical Cancer Early Detection Program (Sage) eligible population (ages 35-64) with an emphasis on American Indians, African Americans, and other priority populations. While heart disease is the second leading cause of death in MN, and the direct cause of nearly 25 deaths each day.* NBCCEDP target populations fare even worse experiencing significant disparities in CVD mortality, morbidity, and risk factors that include unfair opportunities for them to get what they need to have optimal health due to structural racism. The proposed SagePlus program builds on the extensive work of Minnesota’s CDC funded projects (e.g. NBCCEDP, WISEWOMAN, Coverdell, National Cardiovascular Health Program) to create sustainable partnerships to: 1) Conduct CVD health screening and risk assessment and screening for social determinants of health and 2) to provide culturally appropriate HBSS and social services and supports to targeted populations addressing longstanding disparities in CVD caused by structural racism, unfair opportunity structures, and social determinants of health for targeted communities. We will plan to implement and evaluate the following strategies: • Establish and build on partnerships with primary care clinics, health systems, and community-based organizations in targeted geographic area where there are disparities. • Work with partners to implement culturally informed and evidence-based Healthy Behavior Support Services (HBSS) in clinic and community-based settings. • Identify, build, and implement networks of social services and supports that are grounded in the communities where participants live, work or frequent. • Work with partners to improve electronic health records (EHR) and health information technology (HIT) to enhance data collection to identify and track participants, conduct data exchange and streamline EHR efforts. • Identify and change policies and systems that advantage some populations over others using data, technical assistance, and quality improvement projects • Engage program stakeholders and partners to facilitate team-based care outside of the clinic setting. • Improve access to medical care and coordinate participants access to social need referrals and follow-up supporting communities in reducing health disparities and maximizing opportunities for optimal health outcomes. • Measure and report on outcomes to increase the number of participants in sustainable HBSS and networks of social services and supports, reduce CVH incidence among target populations, and utilize results for program improvement. With health equity as a foundation for our work, MDH SagePlus will work with clinic and community partners to provide services to 750 participants from targeted communities in the first year and will build on that number by at least 5% each year over the five-year grant period (2023-2028), ultimately reaching and providing services to over 4100 participants. * Vital Statistics 2013-2020. MN Center for Health Statistics, MDH.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).