New from Quality Insights: WISEWOMAN, Healthy Woman - Assessing and Addressing the Health and Social Needs of Woman Ages 40-64 

Quality Insights is pleased to release the WISEWOMAN educational module, WISEWOMAN, Healthy Woman: Assessing and Addressing the Health and Social Needs of Women Ages 40-64.  The module is designed to help providers identify, assess, and address the relevant health and social needs of patients in the WISEWOMAN population. This newsletter will summarize the module and provide resources for both practices and patients.

Features in the module include:
  • Medical preventive services for the WISEWOMAN population
  • WISEWOMAN clinical recommendations
  • Relationship of health and social needs
  • Resources for assessing and addressing social needs
WISEWOMAN Dimensions of Health
The WISEWOMAN (Well-Integrated Screening and Evaluation for WOMen Across the Nation) program was created to help women understand and reduce their risk for heart disease and stroke by providing services to promote lasting heart-healthy lifestyles. Working with low-income, uninsured and underinsured women aged 40 to 64 years, the program provides heart disease and stroke risk factor screenings and services that promote healthy behaviors. The WISEWOMAN program currently is administered through CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) and is operated on a state-by-state basis.  Services provided by each WISEWOMAN program vary, but all are designed to promote lifelong heart-healthy lifestyle changes.

In Delaware, WISEWOMAN goals include tracking and monitoring clinical measures to improve healthcare quality and identify patients with hypertension; promote team-based care to reduce cardiovascular risk; and develop clinic/community links to support evidence-based lifestyle change for at-risk women.  Interventions are designed to address and connect dimensions of health at the individual patient, clinic, and community level.

Medical Preventive Services for the WISEWOMAN Population
The module includes a summary listing of medical preventive services identified by the U.S. Preventive Services Task Force (USPSTF) with A or B evidence grades.  An A grade assignment indicates that USPSTF recommends the service with high certainty that the net benefit is substantial.  A B grade indicates that there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. In both cases, the USPSTF suggests that practices offer or provide these services.
  • Providers can access the full set of recommendations by visiting the USPSTF website.
  • A printable PDF chart listing preventive services for well women is available from the Women’s Preventive Services Initiative. The site also offers an interactive well-woman chart that can be used with patients.
  • For a listing of women’s preventive care benefits covered by Marketplace health plans, visit Note that these services are covered without copayments or coinsurance and even when yearly deductibles are not met.
WISEWOMAN Clinical Interventions
WISEWOMAN offers support for implementation of team-based care to reduce cardiovascular disease risk with a focus on hypertension control and management, such as:
  • WISEWOMAN cardiovascular disease workflow
  • Clinical decision support in the electronic heath record
  • Evidence-based protocol for identification of patients with undiagnosed hypertension
  • Evidence-based protocol for self-measured blood pressure (SMBP) program
Qualifying patients can receive at no cost:
  • Home blood pressure monitors and training in proper use
  • Medication therapy management – evidence-based 1:1 consultations with a trained pharmacist
  • Fitbit devices (up to 20 available) with training by qualified bilingual health coach
Relationship of Medical and Social Needs
The National Association of Community Health Centers (NACHC) PRAPARE pilot analyzed the relationship between social determinants of health (SDOH) and outcomes and found: 
  • There is a positive correlation between the number of social determinant risks a patient faces and having hypertension.
  • Stress levels affect the likelihood of having hypertension control.
  • More complex patients face upward of ten social determinant risks.
To get started in assessing SDOH, consider adopting a standardized social needs screening tool, such as: Another option to assist with capturing data on the social needs of patients is the ICD-10 Z codes Z55-Z65. These codes identify non-medical factors that may influence a patient’s health status. Learn more in the module, or learn more from the American Hospital Association.
January 2021 CMS Guidance on SDOH 

The Centers for Medicare and Medicaid Services (CMS) issued guidance in January 2021 to state officials aimed at increasing adoption of strategies that address SDOH in Medicaid and the Children’s Health Insurance Program. CMS notes the growing shift toward alternative payment models and value-based care that has accelerated the interest in addressing SDOH. The guidance gives numerous examples of ways states “can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH."
Community-Based Resources for Meeting Patient Social Needs
  • DE 211 Helpline – A central resource available by phone or online that works collaboratively statewide to help Delawareans in need, by connecting them to appropriate resources that lead to acceptable resolution of identified concerns and advocate to reduce or eliminate gaps in services.
  • Supplemental Nutrition Assistance Education Program (DE SNAP-Ed) - The primary purpose of SNAP is to prevent the debilitating effects of hunger by providing nutrition assistance to millions of eligible individuals and families. The Supplemental Nutrition Program – Education (SNAP-Ed) is a research-based federal nutrition education and obesity prevention program.
  • Food$mart - Expanded Food and Nutrition Education Program (EFNEP) offers free nutrition education classes for people with limited resources and children 0-18 living at home.  Those eligible for SNAP, WIC, Head Start or free/reduced school lunches are eligible.
  • Delaware State Service Centers – The 15 State Service Centers located throughout Delaware offer family support services, including emergency assistance, community resource assistance, and information/referrals.
  • HelpIsHereDE – This site offers comprehensive information and resources on mental health and substance use, including prevention, treatment/recovery, and overdose prevention.
  • Delaware Food Pantries – maintains information about local food pantries, soup kitchens, food banks, and other food help.
  • Delaware Division of Services for Aging and Adults with Physical Disabilities – This state agency offers a comprehensive listing of services for older Delawareans and adults with physical disabilities.
  • Delaware Division of Public Health, Bureau of Health Equity -  Office of Women’s Health and Office of Minority Health
  • (formerly Aunt Bertha): is a free online social services search engine. It lists available services including food, housing, transportation, health care, finances, education, employment, legal aid, and goods/supplies. The services are based on ZIP code and allow for electronic referrals.
Learning Resources for Providers and Practices
To facilitate referrals to community organizations, Unite Delaware is a coordinated care network of health and social care providers. Partners in the network are connected through a shared technology platform, United Us, which enables them to send and receive electronic referrals, address people’s social needs, and improve health across communities. Unite Delaware enables providers to:
  • Easily refer and connect your clients to local services they need in the community.
  • Improve your clients’ health and well-being through strengthened collaboration with partners offering a wide array of services.
  • Track the outcomes of all referrals and services delivered for your clients.
  • Measure the impact of your organization and the services you deliver.
Unite Delaware
On-Demand Webinars 

Contact Us

For more details about the WISEWOMAN project,
please contact Sarah Toborowski.


This publication was supported by the Cooperative Agreement Number CDC-RFA-DP18-1816 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. Publication number DEDPH-WW-042021b
Copyright © 2023 Quality Insights, All rights reserved.

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