South Carolina Well-Integrated Screening and Evaluation of WOMen Across the Nation Program (WISEWOMEN) - The purpose of this initiative is to leverage technical and financial resources to support the South Carolina Department of Health and Environmental Control’s (SC DHEC) WISEWOMAN (SC WW) programmatic efforts. Given that the CDC-RFA-DP23-003 (WW Program) and CDC-RFA-DP23-004 (The National Cardiovascular Health Program, 2304) will be housed within the same division, DDHDM will use a synergistic approach and leverage common partnerships to improve cardiovascular health outcomes among all South Carolinians, specifically the WW Program participants, women ages 35 – 64 years old. The SC DHEC Central Office is located at 2600 Bull Street, Columbia, SC, 29201. SC’s application builds the accomplishments and outcomes achieved from previously funded CDC grants (1815, 1816,1817, and 2202). This application supports and expands efforts in applications recently submitted by the Division of Diabetes and Heart Disease Management (DDHDM) for CDC-funded cooperative agreements, DP 2304 and 2320). DHEC and DDHDM have a statewide presence, history, expertise, and experience in implementing federal grants which demonstrate our capacity to serve all South Carolinians. DDHDM’s WW Program will accomplish its work through the engagement of strategic partnerships with the South Carolina Office of Rural Health (SCORH), South Carolina Hospital Association (SCHA), AccessHealth SC (AHSC), and current SC WW provider sites. Current and future WW Providers will participate in a cardiovascular health learning collaborative (CHLC) with Access Health Networks focused on improving health outcomes for uninsured and underinsured adults with CVD. DDHDM will use a data-driven approach and GIS mapping to focus efforts on priority populations. The activities outlined in the work plan build upon the CHLC’s framework of linking a learning topic and the subsequent performance improvement coaching efforts, using Results Based Accountability. This approach will be used to yield equitable outcomes for the strategies. During the period of performance, some of the expected short-term outcomes for the strategies include 1) Increased number of underinsured and uninsured women, ages 35-64, who receive CVD risk assessment. 2) Increased use of EHR and HIT to query, monitor, and track clinical and social services and support needs data for improved identification, management, and treatment of participants at risk of CVD, particularly hypertension. 3) Increased use of standardized processes or tools to identify, assess, track, and address social service and support needs of WW participants.4) Increased use of metrics from program data to guide quality improvement activities to increase program enrollment, retention, and referrals to additional services. 5) Increased use of EHR, HIT, or program data to identify healthcare disparities and address health outcomes within WW their population. Additional intermediate outcomes anticipated by DDHDM are to increase the availability of WW providers in counties that have a high social vulnerability and reduce obesity rates among WW participants. Where possible, DDHDM will leverage partnerships (e.g., Best Chance Network) to maximize the reach of program implementation and data collection. The DDHDM implementation approach provides the necessary program management, coordination, and evaluation to manage CVD, effectively and efficiently, among the uninsured and underinsured. Additionally, the SC WW Program will partner with organizations such as the Supplemental Nutrition Assistance Program and affiliated partners, SC Alliance of YMCAs, to intentionally focus on improving blood pressure control through innovative and evidence-based community-driven approaches to increase resources and referral options that provide healthy behavior support services, social services, and other support needs. This proposal addresses the challenges of reducing health disparities and addressing health outcomes among women ages 35-64 in priority populations
