Competitive Grant Application for Funding Opportunity Number CDC-RFA-DP-23-0003 WISEWOMAN: Well-Integrated Screening and Evaluation of WOMen Across the Nation - Alabama WISEWOMAN (ALWW), the Division of Cancer Prevention and Control at the Alabama Department of Public Health will provide services to reduce risk factors for cardiovascular disease in women age 35-64 enrolled in the Alabama Breast and Cervical Cancer Early Detection Program (ABCCEDP). Specifically, ALWW will integrate innovative, evidence-based approaches to enhance hypertension management and control among ABCCEDP women.
ALWW screening will be conducted within three health systems at six clinic sites in areas of the state where heart disease and stroke are prevalent and in communities where analysis of overall health burden across population subgroups have been conducted. Screening sites include two Federally Qualified Health Centers and one County Health Department. Each of the six sites utilizes an electronic health record (EHR) with bi-directional referral capability. Each site has a long history of providing services to marginalized groups and minority populations. Target populations include African American and Hispanic women, women living in rural Alabama, who are uninsured and at or below 250 percent of the Federal Poverty Level.
ALWW utilizes a team-based care model, led by a licensed social worker. Services included a clinical health and social needs assessment, risk reduction counseling by a clinician, health coaching, and referrals to community agencies to help eliminate barriers to care and other social determinants of health. Social workers, housed at each clinic site, meet with participants immediately following risk reduction counseling and will review both clinical and social needs assessments, conduct health coaching, and will work with participant to develop a plan of action. During the six-month health coaching takes place, participants will meet with nutritionist, pharmacist, medication assistance workers, smoking cessation and all community agencies offering needed resources. All medical and community referrals will be followed with outcomes documented in the EHR. In addition, all locations will have monthly support groups, physical activities and other educational programs. At each support group or activity, weight and blood pressure values will be taken and entered into the EHR. All activities and literature will comply with health literacy and plain language standards.
