North Carolina WELL-INTEGRATED SCREENING AND EVALUATION FOR WOMEN ACROSS THE NATION (WISEWOMAN)Program - The NC WISEWOMAN Program is administered by the NC Cancer Prevention and Control Branch within the Chronic Disease and Injury Section of the NC Division of Public Health (NC DPH). The purpose of the NC WISEWOMAN Program is to reduce the overall burden of cardiovascular disease and stroke in North Carolina. This will be achieved through the provision of high-quality preventative health services including cardiovascular screening, assessment of social support service needs, and referral to Healthy Behavior Support Services (HBSS) and by addressing the structured barriers and disparities experienced by the priority population. This will be conducted in partnership with the NC Breast and Cervical Cancer Control Program (BCCCP), the NC Community and Clinical Connections for Prevention and Health Branch (CCCPH), the NC Tobacco Prevention and Control Branch (TCPB), and other community resource centers. NC WISEWOMAN currently provides funding to 27 local health departments, community health centers, and FQHCs to provide cardiovascular screening, patient centered risk reduction counseling, diagnostic referral for medical follow-up, and lifestyle behavior change education. Through funding from this NOFO, NC WISEWOMAN will conduct strategies and activities aligned with the Centers for Disease Control and Prevention’s (CDC) guidelines to achieve the project period outcomes and reduce morbidity and mortality from cardiovascular disease. The following activities will be completed to meet the outcomes of the strategies: • Train local service providers on the proper implementation of the NC WISEWOMAN Program • Establish partnerships with community groups who support the identification of women among the priority population • Identify existing protocols used by local service providers for the use of EHR and HIT data to query, monitor, and track clinical social services needs • Develop a social services care plan and referral process for NC WISEWOMAN local service providers through a partnership with NCCARE 360 for the tracking and monitoring of social service referrals • Pilot a quality improvement process among local service providers to include aim statements, process modeling, gap analysis, and PDSA for the implementation of evidence-based interventions to address program enrollment, retention, and referral • Identify and increase health disparities data collection by local service providers • Expand capacity among community pharmacists to support SMBP and CVD education as part of team-based care for program participants • Engage local service providers in the use of community health workers to support care coordination for program participants • Leverage existing partnerships to build and maintain a social support services resource network across state, regional, and local organizations • Collaborate with community organizations that support referral to evidence based and evidence informed lifestyle behavior change programs • Provide patient navigation aids to address identified health disparities and social support needs among participants
