Heart disease is the leading cause of death in the United States, responsible for nearly 1 in every 3 deaths each year. While cardiovascular disease affects people across all populations, the burden is not shared equally.
Black adults die from heart disease at rates approximately 35% higher than the overall population.
Nearly 60% of Black women age 20 and older are living with some form of cardiovascular disease.
Black women experience earlier onset of heart disease, higher rates of hypertension, and worse outcomes than white women.
These disparities are not driven by individual behavior or biology. They are the result of structural racism, chronic stress, economic instability, unequal access to care, and persistent barriers to culturally responsive, high-quality healthcare.
In Wisconsin, heart disease remains the leading cause of death, accounting for more than 20% of all deaths statewide.
At the same time:
- Wisconsin has some of the largest racial health disparities in the nation, even as it ranks highly on overall health indicators.
- Black Wisconsinites experience higher rates of uncontrolled hypertension, a primary driver of heart disease and stroke.
- These disparities persist across income and education levels, underscoring that place-based advantage does not protect against racialized health inequity.
For Black women in Wisconsin, cardiovascular risk is shaped not only by clinical factors, but also by housing instability, food insecurity, caregiving burden, income volatility, and cumulative stress associated with racism and gender inequity.
Dane County is frequently ranked as one of the healthiest counties in Wisconsin. However, county-level averages obscure deep racial inequities—particularly for Black women.
Local data from Healthy Dane County show that:
- Black residents experience significantly higher rates of cardiovascular disease–related mortality compared to white residents, even after adjusting for age.
- Hypertension-related hospitalizations and emergency department visits are disproportionately concentrated among Black adults, reflecting gaps in prevention, continuity of care, and access to supportive resources.
- Black women are more likely to experience earlier onset and more severe cardiovascular complications, contributing to preventable illness and premature death.
These disparities persist despite Dane County’s overall health rankings, underscoring a critical reality: place-based advantage does not protect against racialized health risk.
The Social Delta Initiative exists to address this gap—by pairing direct support for women managing hypertension with systems-level change that reshapes how care is defined, delivered, and supported across the county.
A Systems-Change Approach to Women’s Heart Health
Social Delta is grounded in a simple but powerful premise: Improving heart health outcomes requires systems to learn from the people most impacted.
Decades of research—including findings from the County Health Rankings—demonstrate that most factors shaping health occur outside of the clinical setting, such as access to stable housing, nutritious food, income, social support, and freedom from chronic stress. At the same time, healthcare systems play a critical role in prevention, diagnosis, treatment, and ongoing management of cardiovascular disease.
Social Delta works at the intersection of these realities.
Rather than placing responsibility solely on individuals to navigate complex systems on their own, the initiative focuses on strengthening how systems understand, listen, and coordinate—both inside and outside the clinic. By centering community voice and lived experience, Social Delta helps partners better understand how care is experienced in real life and where opportunities exist to improve access, trust, continuity, and outcomes.
Partnerships That Make Systems Change Possible
This work is grounded in intentional, layered partnerships that operate at both the level of direct care and the level of systems learning and improvement.
Clinical Partnership: Access Community Health CentersAccess Community Health Centers (ACHC) serves as the primary clinical partner for the Reclaim Our Hearts program. Women enrolled in Reclaim Our Hearts are prioritized from ACHC’s patient population, enabling close coordination around referrals, data sharing, and continuity of care.
Through this partnership:
- Community Health Workers employed by The Foundation work closely with ACHC patients to help address social drivers of health, support appointment adherence, and navigate barriers to care; and
- insights from participants’ lived experiences are shared back with clinical teams to inform learning and quality improvement efforts.
This partnership strengthens the connection between community-based support and clinical care, while respecting the distinct roles each plays.
Systems Learning & Coordination: Dane County Heart Health Collaborative
ACHC is also an active member of the Dane County Heart Health Collaborative, a multi-sector partnership convened to advance equitable cardiovascular health across Dane County.The Collaborative brings together representatives from:
- health systems and clinical providers;
- public health agencies, including the Wisconsin Department of Health Services and Public Health Madison & Dane County;
- Community Health Workers and community-based organizations;
- the American Heart Association; and
- individuals with lived experience.
This forum creates structured opportunities for shared learning across systems—allowing insights from Reclaim Our Hearts participants and other community members to inform broader conversations about prevention, access, trust, and care delivery.
How Change Happens: Four Integrated Strategies
Social Delta centers the lived experiences of Black women managing hypertension—listening to their needs, challenges, and experiences of trust (or mistrust) in healthcare.
These insights are shared with Access Community Health Centers and with healthcare partners participating in the Dane County Heart Health Collaborative, creating real-time feedback loops that may inform improvements in care delivery, communication, and coordination.
Health outcomes are shaped far beyond medical visits.
Social Delta shares learnings with public and private payers, social service agencies, and community-based organizations—including hunger relief and economic support organizations—to strengthen how systems support people living with heart health conditions.
This cross-sector approach helps identify gaps, reduce friction, and improve alignment across systems that are too often siloed.
Social Delta also invests in community-level prevention and emergency preparedness.Through partnerships with the American Heart Association, the Foundation:
- serves as a community blood pressure hub, and
- provides access to CPR training and life-saving resources for participants and their families.
These efforts build practical, community-based capacity that can prevent emergencies—or save lives when emergencies occur.
Social Delta is committed to learning—not assumptions.Through ongoing evaluation, the initiative examines:
- what works,
- how it works,
- for whom it works, and
- under what conditions.
This learning is essential to scaling and sustaining the model beyond the life of the grant, informing future investments, and contributing to national conversations about equitable cardiovascular care.
From Systems Change to Direct Support: Reclaim Our Hearts
Reclaim Our Hearts is the free, participant-facing program within the Social Delta Initiative.Through Reclaim Our Hearts, women managing hypertension receive 15 months of no-cost, holistic support designed to strengthen heart health, trust in care, and overall well-being. Program elements include:
- Opportunities to build knowledge, confidence, and agency around heart health in ways that honor lived experience and whole-person wellness.
- Community Health Worker (CHW) support, focused on addressing social drivers of health, navigating systems, and supporting appointment adherence;
- Culturally grounded Heart Health Circles, which create space for education, peer connection, and shared learning;
- Virtual community and movement-based resources, offering accessible opportunities to build strength, reduce stress, and stay connected beyond in-person gatherings; and
Reclaim Our Hearts is not a standalone program. It is how systems change becomes tangible in women’s lives—and how women’s experiences, insights, and expertise inform broader systems transformation through the Social Delta Initiative.
A Model for Equity-Centered Change
The Social Delta Initiative is designed to do more than improve outcomes for one population. It is building a replicable, evidence-informed model for how communities and healthcare systems can partner to reduce inequities, restore trust, and save lives.This is systems change grounded in data, lived experience, and accountability.
