PA will target areas in need, provide CVD screenings, assess social service needs and assist referrals, provide lifestyle programs, and assist women and providers in addressing socioeconomic needs. - PA WISEWOMAN (Program) will track and monitor clinical measures to improve health, health care quality, and identify patients at risk for CVD, particularly those with hypertension; implement team-based care with a focus on hypertension, detection, and control through mitigation of social support barriers to improve outcomes; and link community and clinical services to support mitigation of social support barriers, support participation and completion of lifestyle change programs. Program staff will participate in statewide, local, and regional meetings with social service repositories to ensure all women and providers will have access to resources to help women with social service needs. The Program will work with organizations such as the Pennsylvania Office of Rural Health, PA Federally Qualified Health Centers Association, United Way, American Heart Association, Penn Medicine Health System Community Health Worker Program, Black Women’s Health Alliance, University of Pittsburgh, Quality Insights (QI), and others who provide services in areas of need. The Program will work with other areas including heart disease, tobacco, cancer, health equity, chronic disease epidemiology; Pitt evaluation team; and other internal and external stakeholders to collaboratively identify geographic areas with high needs through GIS mapping and data analysis. Providers will be engaged through release of an RFA, direct recruitment from QI’s network of 23-0004 clinical providers, and sole source contract to providers in specific geographic areas of need. Through this multi-faceted approach, at least 1,500 women will be engaged in clinical screenings, lifestyle programs, and social service assessments/referrals, all of which will be monitored through clinical records and the Med-IT data system. Providers will be trained, provided an updated data entry manual and training for staff and Community Health Workers (CHWs). MED-IT billing and MDE data is checked monthly to ensure quality data and accurate billing. Data and evaluation collected will serve as the basis for data-based decisions, quality improvement processes and evaluation activities over the five years. Both staff have completed training in PDSA, Lean, and worked on numerous quality improvement initiatives, which provides capacity for quality improvement work. Program will work with providers so services, social service assessments and referrals are tracked and available in EHR systems for the entire care team to access and use when developing and implementing care plans. Working with statewide, regional, and local social service repositories will show gaps and resources needed. Program will use a multicultural team of CHWs to assist women throughout the year so that women are empowered and can fully participate in healthy lifestyle programs. The CHWs will offer culturally and linguistically appropriate health coaching and engage women in other healthy lifestyle programs. Program will collaborate with other CVD staff that are rolling out programs in the same targeted geographic areas in need to ensure that there is no duplication of effort between programs. Providers will be offered training in the HHA-BPSM to offer to both WISEWOMAN and other patients. Enrolled women will have multiple connections with a CHW or clinical staff to help them with social services. Program will work with providers to establish referral process for services such as tobacco cessation, DPP, HHA-BPSM, or pharmacy medication management services so that they have a process to refer any patients with insurance to services. Assisting providers in creating local referral processes, will enable them to help all patients, not just WISEWOMAN. All activities will leverage work by other chronic disease, health equity, and other state or local efforts to eliminate duplication and adhere to program fidelity. Program will work with the CDC Project Officer to adjust and revise workplan activities throughout the five-year period.
