Missouri WISEWOMAN Program Manual

In conjunction with Health Coaching, the WISEWOMAN Program offers Healthy Behavior Support Services (HBSS), including referrals to LSPs and community-based resources, as part of a strategy to improve the health status of individuals participating in the WISEWOMAN Program. These services are funded through the provider’s LOA.

Missouri Tobacco Quitline

The CDC requires that all enrolled WISEWOMAN participants are assessed for tobacco use and that tobacco cessation services are promoted by WISEWOMAN providers. WISEWOMAN participants are assessed for tobacco use with the WISEWOMAN Assessment Form (tan) and referred for cessation services by following these steps:

• Participant will indicate her current smoking status, smoking cessation completion, if applicable, and readiness for behavior change on the WISEWOMAN Assessment Form (tan)
• Participants who report smoking/tobacco use and express interest in quitting, including identifying tobacco cessation as a priority during RRC and/or Health Coaching, should be given a referral to the Missouri Tobacco Quitline or another evidence-based tobacco cessation program
• WISEWOMAN suggests using the Ask, Advise and Refer method:
  • Ask every participant at each encounter about tobacco use and document their status
  • Advise every tobacco user to quit with a clear, strong, personalized health message about the benefits of quitting
  • Refer participants who are ready to quit tobacco within 30 days to the Missouri Tobacco Quitline
• Refer a participant to the Missouri Tobacco Quitline, which is free to anyone in Missouri, by calling 1-800-QUIT-NOW/1-800-784-8669 or registering online at http://www.quitnow.net/missouri
• Select the Tobacco Quitline LSP referral box and document the date of referral
• Smoking/tobacco cessation should be checked as a “topic” on the Health Coaching Reporting Form (peach) and discussion should be documented in the comments section
• A Diagnostic Office Visit can be billed and reimbursed through the WISEWOMAN Program for participants who wish to discuss tobacco cessation medication with a physician or practitioner

*Note: WISEWOMAN funds cannot be used for nicotine replacement therapies, but the Missouri Tobacco Quitline and other tobacco cessation resources often offer these therapies at little to no cost for participants*

Diabetes Prevention Program

The focus of a Diabetes Prevention Program (DPP) is to prevent type 2 diabetes among people at-risk for diabetes. This successful, standardized lifestyle intervention was developed to increase physical activity to a minimum of 150 minutes per week and reduce weight by a minimum of 7 percent, for population meeting eligibility criteria. Individual lifestyle coaches work with participants to help them achieve individualized, clearly defined weight loss and physical activity goals. The program focuses on self-management to achieve long-term improvements in diet and physical activity.

Referral Guidelines for DPP

Refer Wisewoman Participants to DPP Who:

• Indicate a readiness to change
• Agree DPP is an appropriate HBSS
• Have access to a local DPP
• Meet the DPP eligibility requirements as outlined in the CDC Diabetes Prevention Recognition Program Standards and Operating Procedures:
  • BMI of ≥25 kg/m2 or ≥22 kg/m2, if Asian
  • Elevated blood sugar/glucose is NOT a requirement for participation
  • Participant cannot have already been diagnosed with diabetes—if the participant had gestational diabetes, she may be eligible to participate
• Select the DPP LSP referral box and enter the referral date on the WISEWOMAN Screening Form (light pink)
• Fax a paper referral form to the WISEWOMAN Staff at 573-522-3023
• WISEWOMAN staff will send the referral to the appropriate DPP Coordinator

Nationally-Recognized DPP Providers

• Missouri’s recognized DPPs are listed here.
• To become a nationally-recognized program, providers should complete the application at the CDC website.

Criteria and Training to Provide DPP On-Site Include:

• Personnel must meet specific criteria for the responsibilities, skills, knowledge, and qualities to become a DPP Lifestyle Coach
• Lifestyle coaches may have other credentials (e.g. RD, RN and MA), but they are not required
• Diabetes Prevention Coordinator is designated to implement the program, supervise daily operations, provide support and guidance to coaches and ensure the program activities achieve quality performance outcomes
• Coach and coordinator may be the same individual

Course Content of DPP

DPP consists of two phases: a 16-session core curriculum and a 6-session maintenance/post-core phase. The 16-session core curriculum courses are typically delivered once per week and must be completed within 26 weeks. The remaining six post-core classes are each usually delivered once per month.

60-Minute, In-Person Sessions Include:

• Private weigh-in and review of self-monitoring records
• Discussions on various topics
• Identification of barriers
• Action planning

Completion of the DPP is defined as 9 of 16 core sessions and 3 of 6 maintenance/post-core. If a WISEWOMAN provider has a participant interested in DPP participation, but a class is not scheduled to start soon, the provider may choose to refer participants interested in DPP to Health Coaching sessions in the interim. Health Coaching can be conducted as an interim HBSS to keep the participant engaged and motivated until a DPP or other lifestyle program group becomes available. This option should be used if the participant’s screening visit is not conducted around the time that a new DPP class will begin the course.

Reimbursement for DPP

For individuals referred to DPP by the WISEWOMAN Program, the program fee is covered by WISEWOMAN and the reimbursement cap for DPP is $705.00 per year.

Weight Watchers

Weight Watchers (WW) is a diet plan first developed in the 1960s that encourages weight loss by making healthy food and lifestyle choices. The Weight Watchers plan is based upon the idea that dieting is only one part of a healthy lifestyle. The program stresses the importance of overall mental and physical health and well-being.

Weight Watchers does not forbid specific foods or tell people what to eat. There are also no pre-prepared meals or foods to purchase. Instead, people are encouraged to make healthier eating choices and to increase physical activity. Weight Watchers sponsors group meetings in locations throughout the world and online where members can offer each other encouragement, support and tips for making healthier lifestyle choices.

Referral Guidelines for Weight Watchers

• Participant indicates a readiness for change
• BMI >25kg/m2 or >22kg/m2, if Asian
• Participant must sign the Weight Watchers Consent Form at the time of her screening visit to participate in the program
• Select the Weight Watchers priority area box on the WISEWOMAN Screening Form (light pink)

Session Dosage and Delivery

• Weight Watchers participants will receive a 10 week prepayment coupon and an attendance sheet
• Local meeting registration fee will be waived
• Membership kit is provided at the first meeting with resources from Weight Watchers
• In order to receive the second set of ten-week prepayment coupons, the participant must attend and participate in 80% of the first ten meetings
• Once the participant has selected her preferred meeting, she will take the voucher to her next chapter meeting
• Weight Watchers chapter leader will take the voucher and have her complete a Weight Watchers membership application
• Voucher along with the membership application will be sent to the Weight Watchers corporate office
• Participant is responsible for presenting her attendance sheet at each weekly meeting and having the Weight Watchers leader sign off on her attendance
• If attending Weight Watchers online, the participant must share their app log-in information with the WISEWOMAN provider by creating an account with the provider in-person in the clinic
• Once the participant has attended 12 weekly sessions, she will then return to the WISEWOMAN provider clinic for a face-to-face visit, providing the attendance sheet to the health coach, which is faxed to the WISEWOMAN central office staff as a form of completion of the 12 weekly sessions
• Weekly attendance does not need to be recorded following the 12 week check-in, however it is encouraged as a motivator for the participant

Participant Follow-Up and Program Assessment

Participants must agree to actively participate in Health Coaching from the provider. This allows the provider to follow-up with the participant and see that the program is meeting the participant’s needs and address any concerns the participant may have.

Reimbursement for Weight Watchers

Weight Watchers services will be reimbursed every three months. The reimbursement cap for Weight Watchers is currently $800.00/year and it set based on grant budget.

Take Off Pounds Sensibly

Take Off Pounds Sensibly (TOPS) is the short name for TOPS Club, Inc.—the original nonprofit, noncommercial network of weight loss support groups and wellness education organization. Established in 1948 to champion weight loss support and success, TOPS has helped millions of people live healthier lives. TOPS offers tools and programs for healthy living and weight management, with exceptional group fellowship and recognition.

Weekly meetings include private weigh-ins and professionally prepared, informational chapter programs that feature up-to-date information on nutrition, exercise and healthy lifestyles. Programs provide positive reinforcement and motivation to adhere to food and exercise programs. TOPS does not sell foods, endorse products or push a one-size-fits-all meal plan. On the TOPS meal plan, you choose foods you enjoy in moderation. The flexible guidelines help you control calories while eating real food at home or in a restaurant.

Chapter locations vary and include; hospitals, churches, senior center settings, libraries and other community locations. Participants can find the local chapters by going to the website www.tops.org, clicking on “Find a Meeting” tab and entering her home zip code and a travel radius.

Referral Guidelines for TOPS

• Participant indicates a readiness for change
• BMI ≥25kg/m2 or ≥22kg/m2, if Asian
• Must be able to establish a healthy and responsible weight loss goal
• Select the TOPS LSP referral box and enter the referral date on the WISEWOMAN Screening Form (light pink)
• Participant must sign the TOPS Consent Form at the time of her screening visit to participate in the program
• Fax the signed consent form to the WISEWOMAN Staff at 573-522-3023
• Participant is provided with her signed voucher and the attendance/weigh-in sheet to take to her local chapter meetings

Obtaining a TOPS Voucher

Once a provider has recognized a participant qualifies for the TOPS program and the enrollment paperwork is complete, a TOPS voucher will be mailed to the clinic for pick up by the participant. Vouchers are valid for one grant year and the participant must continue to achieve goals and participate in health coaching to obtain additional vouchers. Please note that the membership voucher is not replaceable if lost and cannot be photocopied

Session Dosage and Delivery

• Participants choose to join a local chapter or become an online member
• Weekly meetings provide a supportive, educational environment
• Participants will have the option of attending the local chapter that is best for their schedule and comfort level
• Participants are encouraged to attend several different chapter meetings to find the best suited chapter for them
• Meetings are held at various times of the day and days of the week
• Initial visits are free of charge
• Once the participant has selected her preferred chapter, she will take the voucher to complete a TOPS membership application
• The voucher, along with the membership application, will be sent to the TOPS corporate office
• Participant is responsible for presenting her attendance sheet at each weekly meeting and having the TOPS leader sign off on her attendance
• Once the participant has attended 12 weekly sessions, she will then return to the WISEWOMAN provider clinic for a face-to-face visit
• The WISEWOMAN provider/health coach will obtain the attendance sheet from the participant and fax it to the WISEWOMAN central office staff as a form of completion of the 12 weekly sessions
• At the 12 week face-to-face session with the participant, the WISEWOMAN provider will provide the participant with the book Real Life: The Hands-on Pounds-Off Guide and food cards for her attendance to the TOPS program
• Weekly attendance does not need to be recorded following the 12 week check-in, however it is encouraged as a motivator for the participant
• If at any time the participant stops attending TOPS Chapter meetings regularly, the TOPS Chapter leader or another member may call or email the participant for follow-up

Reimbursement For TOPS

The WISEWOMAN Program will cover the yearly cost for the participant at $32.00 per year. The participant will be responsible for any minimal chapter dues of $5.00 monthly.

Eating Smart-Being Active

Eating Smart-Being Active (ESBA) is a research-based nutrition, food safety and food resource management education curriculum for low-income adults. All participant materials are available in English and Spanish. Curriculum activities include facilitated discussion and hands-on activities to allow participants to be actively engaged in the learning process and apply the newly learned information. Lessons include the latest research-based information from the Dietary Guidelines for Americans 2015-2020 and MyPlate.

Topics Covered Include:

• Physical activity
• Nutrition and healthy lifestyle choices
• Food preparation
• Saving money at the grocery store
• Eating a variety of healthy foods from all the food groups
• Food safety
• Reducing fat, sugar and salt
• Feeding children

ESBA is delivered by the University of Missouri Extension (UME). The UME is part of the national land-grant university and Cooperative Extension System that brings research-based knowledge and information to people in their homes, workplaces and communities to improve the lives of Missourians. The UME puts research into practice by providing high-value education programs and resources in the areas of agriculture and natural resources, home and consumer life, nutrition and health, families and youth, community and leadership, and business and workforce development.

Referral Guidelines for ESBA

• Participant indicates a readiness for change
• Select the ESBA LSP referral box and enter the referral date on the WISEWOMAN Screening Form (light pink)
• Fax the ESBA Referral Form [NEEDS LINK] to the WISEWOMAN Staff at 573-522-3023
• WISEWOMAN staff will send the referral to the appropriate UME
• UME receives the paper referral form and contacts the participant to set up the class and address any barriers the participant may have in regards to attendance

Session Dosage and Delivery

• Consists of 9 lessons, each 90 to 120 minutes in length
• Lessons are designed to be taught in sequential order, building on previous lesson content
• Completion of the ESBA program is defined as attending six (6) sessions, but attending all nine (9) sessions is encouraged
• ESBA provides incentives to the participant once they have completed the minimum of six (6) sessions
• Taught in either a one-on-one or in small group class (2-12 people) setting for maximum interaction among participants
• A variety of learning styles are incorporated into the lessons through the use of handouts, discussions, facilitated dialogue, demonstrations and hands-on performance of skills learned during class
• Curriculum is written for participants who may have a low literacy level

Participant Follow-Up and Program Assessment

• UME provides follow-up with participants who do NOT attend scheduled classes
• UME provides WISEWOMAN staff with a monthly attendance list
• UME makes attempts to call the participant after completion to gain follow-up information regarding the participant’s status and the success of the class
• UME also encourages the participant to follow-up for their annual WISEWOMAN screenings

Reimbursement for ESBA

WISEWOMAN providers do not receive reimbursement for ESBA services as this time. Providers make the referrals to ESBA and ESBA has a contract with MDHSS to provide and administer services. ESBA will send MDHSS an invoice for services provided and MDHSS will then reimburse ESBA.

Other Programs

Any additional HBSS options will require prior approval by the Missouri WISEWOMAN program.

Self-Monitoring Blood Pressure

Self-Monitoring Blood Pressure (SMBP) is the regular measurement of blood pressure by the patient outside the clinical setting, either at home or elsewhere. SMBP requires the use of a home blood pressure measurement device by the patient to measure blood pressure at different points in time. SMBP, plus clinical support, helps people with hypertension lower their blood pressure.

SMBP is a significantly more individualized program that focuses heavily on the participant’s blood pressure, when compared to other lifestyle programs. The individualization of the program allows for it to be adapted to the needs and motivation level of each participant. Coaching will be customized to the participant priority and willingness/ability to make change.

This coaching program is optimal for those who are not able to attend other programs due to barriers, such as transportation, inability to afford gas to travel and time conflicts. Telephone health coaching will be provided if that best accommodates the participant’s needs. The health coaches will help the participant use problem-solving skills to overcome barriers and will be a source of support and encouragement to the participant when working to reach goals. Health coaches will also be able to refer participants to community-based resources for assistance in overcoming barriers.

Referral Guidelines for SMBP

• Participant indicates a readiness for change
• Participants who have presented with disease level hypertension (≥130/80)
• Participants who need to closely monitor their HTN diagnosis (each clinic will utilize appropriate trained clinical staff to address medical issues such as hypertension and determine, based on screening and diagnostic visits, if the participant is a good candidate to enroll in SMBP)
• If the provider determines the participant would benefit from a SMBP program, the clinic will fill out the SMBP Referral Form (white), SMBP Initial Enrollment Form (white) and Patient Participation Agreement (white) then fax the forms to the WISEWOMAN staff at 573-522-3023
• WISEWOMAN clinics may operate SMBP within their clinic or they may refer the participant to a community SMBP Program that works with WISEWOMAN
  • If the clinic operates a SMBP, the clinic will then schedule the participant for a follow-up 2-3 days later to recheck the blood pressure and the participant will receive a blood pressure cuff and self-monitoring packet with tracking information
  • If the clinic does not operate a SMBP in their community, the WISEWOMAN central office staff will work with the clinic to determine a SMBP partner within the community to offer SMBP services\

Session Dosage and Delivery

• Consists of at least three or more in-person SMBP Blood Pressure Medical Follow-Up visits and three SMBP Health Coaching telephone calls until appropriate blood pressure goal is reached
• If blood pressure is not controlled, additional counseling will be available or other interventions will be considered
• During the in-person BP Follow-Up visits the participant will be trained in appropriate home blood pressure monitoring techniques, receive a home monitoring blood pressure cuff and receive tools to document the readings
• During the SMBP Health Coaching sessions, concerns over medications will be discussed with the participant and shared with the primary care provider, as needed
• Between visits the participant is asked to self-monitor and record their blood pressure twice daily, or as prescribed by physician
• Participant will be asked to bring these results and the device at the BP Medical Follow-Up visits and SMBP Health Coaching sessions in order to ensure proper utilization of the blood pressure device
• After the program has ended, participant will be allowed to keep the blood pressure monitor in order to continue self-monitoring

Participant Follow-Up and Program Assessment

• Within four weeks of completion of SMBP Health Coaching, the participant will receive a face-to-face Post Intervention Assessment to include two clinical BP readings and two SMBP readings and participants will be counseled on the use of community resources and potential challenges/barriers
• Six months after the program is complete, a Post Intervention Follow-Up telephone call will be made to the participant to address the participant’s blood pressure, medication adherence, any further needs the participant may have and reinforcement of community resources
• WISEWOMAN Fourth Follow-Up Assessment will be completed either face-to-face or via the telephone with the participant after the completion of three SMBP Health Coaching sessions

Reimbursement Guidelines for SMBP

Self-Monitoring Blood Pressure has a reimbursement cap dependent upon the budget. Please see the Reimbursement Guidelines section of the manual for specific reimbursement rates and CPT codes.

Community-Based Resources

Community-based resources supplement other HBSS, such as Health Coaching and LSP referrals, to reduce a woman’s CVD risk. For an individual woman, referral to community-based resources may be the most appropriate HBSS. WISEWOMAN participants should be referred to community-based resources to support identified goals. These resources may include programs that support chronic disease management, physical activity, nutrition and tobacco cessation. Providers should develop partnerships to offer community-based resources at low or no cost to women. Reimbursement for community-based resources and barrier-reduction tools will be utilized through LOA funding for HBSS and invoice submission to the WISEWOMAN staff. See the Reimbursement Section for detailed guidelines.

Community-based resources and barrier-reduction tools that are reimbursable through the WISEWOMAN program should only be offered and utilized once a participant shows commitment to the WISEWOMAN program and has attended at least three health coaching sessions within six months of enrollment

Fitness Center/Gym Membership and Fitness Classes

Fitness center/gym memberships or fitness classes for committed WISEWOMAN participants are eligible for reimbursement. Fitness center/gym memberships allow for participants to have the opportunity to work out in a safe environment that promotes successful lifestyle changes. Providers would have agreements with local fitness centers/gyms where participants could exercise. The provider would pay the initial fee for the participant and would be reimbursed by the WISEWOMAN Program. If a provider has a fitness center/gym that offers fitness classes on‐site or at another facility, the provider may be reimbursed for the cost of the membership or class cost for the WISEWOMAN participants.

Guidelines for Memberships Include:

• Participants who qualify may have a membership for a three‐month period
• Provider will need to follow-up with the fitness center/gym to assure the participant has attendance of 80% or greater for a three-month period to continue to qualify for an additional three‐month period
• Participants must also be participating in Health Coaching sessions