Reducing cardiovascular risk and addressing social needs among Montana women aged 35-64 years using the WISEWOMAN model - The Montana Department of Public Health & Human Services’ (MT DPHHS) Cardiovascular Health Program (CVHP) is applying for the CDC-RFA-DP-23-003 (WISEWOMAN: Well-Integrated Screening and Evaluation of WOMen Across the Nation) to improve cardiovascular health in a focused population and address health equity. The work will focus on women ages 35-64 years who are low-income and uninsured or under-insured with emphasis on American Indians and women living in rural/frontier areas. The CVHP offices are located at 1400 Broadway Street, Cogswell Building, C314 B, Helena, MT 59601. The CVHP has the capability to serve this population and communities across Montana. The CVHP will improve the health of eligible Montanan women by achieving the outcomes described in this funding opportunity. For decades, the CVHP has provided heart disease and stroke prevention and management activities statewide - with a focus on hypertension and high cholesterol since 2009. This includes long-standing partnerships and well-trained, experienced staff. The CVHP will implement WISEWOMAN activities through a comprehensive, inclusive, and coordinated approach to expand cardiovascular prevention and health equity efforts in clinical and community settings. These activities will occur in three Chronic Disease (CD) regions (northwest, north central and southeast) with increased focus on priority populations, including those living in high burden areas. Continued surveillance and evaluation activities will monitor progress, analyze outcomes, perform quality improvement, and report success. With Strategies 1A and 1B, three WISEWOMAN-funded Coordinated Chronic Disease (CCD) contractors at county health departments will partner with three health systems in their CD regions. The health systems will use a social determinants of health (SDOH) screener, document Z codes in the electronic health record problem list for patients, and monitor referrals of patients to community-based programs addressing social services and support needs. They also will complete a cardiovascular risk assessment with WISEWOMAN-eligible patients. For Strategy 1C, the CCD contractors and partnering health systems will identify standardized processes for the WISEWOMAN program flow and implement bidirectional referrals. For Strategy 1D, the CCD contractors and health systems will monitor which healthy behavior support services (HBSS) and other services that WISEWOMAN participants enroll in and complete. Programs will be tailored to meet the needs of the population. For Strategy 1E, the health systems will analyze population health data to identify health care disparities. For Strategies 2A and 2B, the CCD contractors and partnering health systems will participate in a Cardiovascular Learning Collaborative, expand their multidisciplinary care team, and form a network of regional social services and support needs to address SDOH. For Strategies 3A-3C, the CCD contractors and health systems will use a bidirectional referral system like CONNECT to refer WISEWOMAN patients to HBSS (such as National Diabetes Prevention Program and Health Coaches for Hypertension Control), social services and support resources. They will also monitor enrollment and retention in these programs and services. For Strategy 3D, the CCD contractors and health systems will refer WISEWOMAN patients to programs such as the Supplemental Nutrition Assistance Program (SNAP), food pantries, and housing/transportation assistance. The proposed WISEWOMAN project will enhance communication and integration of MT health systems and community organizations to better address social services and support needs of WISEWOMAN-eligible women at higher risk of cardiovascular disease, particularly hypertension. These strategies also will help improve health outcomes and health equity long-term.
