WISEWOMAN Drives Healthier Hearts and Lives

For more than 100 years, the nation’s leading cause of death has been heart disease – a range of chronic conditions that includes coronary artery disease, heart failure, arrhythmias, and valvular heart disease. Heart disease claims nearly 700,000 lives each year in the U.S. At the local level, heart disease remains a high priority clinical issue for hospitals and health departments, who look to safety net organizations like Zufall for cost-effective, preventive interventions.

A Disproportionate Burden

Although about 80 percent of heart disease cases are preventable, good heart health is harder to access for some groups of people. Women who earn low incomes and do not have health insurance are especially vulnerable to conditions like hypertension (high blood pressure), high cholesterol, obesity, and diabetes, putting them at  greater risk of heart disease.

In response, Zufall’s WISEWOMAN (Well-Integrated Screening and Evaluation for WOMen Across the Nation) program, established in 2022, systemically addresses heart disease among low-income, under-or-uninsured women aged 35-64. Authorized by Congress in 1993 and funded by the Centers for Disease Control and Prevention, WISEWOMAN integrates primary care, behavioral health, pharmacy, nutrition, and social needs. WISEWOMAN is considered one of the nation’s leading approaches to heart health in this vulnerable population.

Why Low-Income, Uninsured Women?

Consider Helen*, a patient with hypertension in her mid-40s and single mother of two at Zufall Health – Dover, to understand why this population is especially vulnerable to poor heart health. With a household income of $38,000 annually, Helen often experiences significant stress associated with her limited resources, putting strain on her cardiovascular health.

Prior to becoming a Zufall patient, Helen was uninsured and did not have a primary care provider who listened to her heart, measured her blood pressure and cholesterol levels, and counseled her on her weight. And because Helen is a woman, she’s less likely to be diagnosed and treated for heart disease. This is because heart disease in women is more likely to be “silent,” or to show no symptoms, and is poorly misunderstood relative to heart disease in men.

Zufall’s Approach

Since 2022, Zufall Health has enrolled more than 100 participants like Helen into its WISEWOMAN program, which combines the expertise of primary care physicians, a case manager, clinical pharmacists, a nutritionist, and behavioral health providers. The team works together to complete a Health Risk Assessment and develop a personalized care plan for each participant. They also address participants’ social barriers through referrals to patients in need of transportation, childcare, employment, housing, and food access.

Participants receive individualized tools and resources related to their goals including fitness watches, reusable water bottles, blood pressure monitors, food portion containers, full body scales, and food scales. They can also be referred to a number of lifestyle programs that provide intensive counseling on the connection between chronic disease and mental health, stress management, medication adherence, healthy eating, and physical activity.

According to VP of Quality Assurance and Clinical Risk Management Milibeth Castro, MPH, who leads the program, “Zufall’s WISEWOMAN program has already shown healthy progress in a short time. We have made great strides in the areas of nutrition education, A1C levels, blood pressure management, and weight loss.”

Zufall’s third year of WISEWOMAN funding concludes September 30, 2024, but Castro says that the health center plans to sustain the program beyond this date.

“WISEWOMAN is central to the Zufall mission and emblematic of our commitment to empowering underserved patients with the knowledge and they need to live healthier, happier lives. We look forward to the ongoing impact driven by this powerful program.”

*Name changed to protect patient privacy

Above: Zufall Health offers many healthy lifestyle activities to WISEWOMAN participants, including virtual cooking classes.