Category C CIO Project Plans.pdf

Project Title: Disability-Inclusive Preventive Health Screening Implementation Guide

Population of Focus: Category C: Public Health System Components

Population of Focus Description:

community-based organizations, community health centers, primary care providers, hospitals, and education organizations

Project Plan Details Project Purpose: An estimated over 65 million adults in the U.S. live with a disability. People with disabilities are disproportionately impacted by chronic and infectious disease as well as injury and mental health conditions. Preventive health screenings are a critical component of public health practice as they can result in early diagnosis and treatment, reduced medical costs, and prevention of early death. People with disabilities experience multiple barriers at the individual, interpersonal, societal, and community level to accessing medical services, including preventative health screenings.

The U.S. Preventative Services Task Force (UPSTF) makes evidence-based recommendations about preventative screenings. Based on a review of available evidence, UPSTF grades screenings based on their potential net health benefits.

UPSTF also publishes information practice considerations, importance of the recommendation, along with implementation resources and guides. These materials are critical for public health practitioners and other public health partners to effectively recommend and implement these screenings in their jurisdictions.

Although existing UPSTF tools are extensive, none include a focus on people with disabilities. For example, practice considerations do not address how screenings can be made accessible to people with disabilities, the data supporting the importance of individual recommendations does not include people with disabilities, it is not clear what existing data systems can be used to monitor uptake of recommendations among people with disabilities, and none of the existing implementation resource focus on how to implement recommendations in a way that is inclusive and accessible for people with disabilities. In addition, existing recommendations may require adjustments for particular sub-populations of people with disabilities, such as people with intellectual and developmental disabilities (IDD) or individuals with mobility limitations (ML).

The objective of this project is to increase the inclusion of people with disabilities into UPSTF recommended preventative health screenings with an “A” or “B” score by developing, and disseminating, a tailored Implementation Guide. These materials will provide much needed tools that will increase public health practitioner capacity to implement and evaluate UPSTF recommended preventative health screenings among people with disabilities.

CIO: NCBDDD

Division/Branch/Office /Unit:

Division of Human Development and Disability (DHDD)

Proposed FY24 Project Funding Total:

$300,000.00

Funding Appropriation:

75-24-0958

Funding Statutory Authority:

Public Health Service Act 317C [42 U.S.C. 247b-4]

Expected Project Length:

1 Year

Recipient Organizational Capacity:

The applicant organization should have the capacity to evaluate and synthesize existing disability literature; be familiar with preventative health recommendations from UPSTF; and capacity, expertise, and mechanisms to engage a Technical Assistance Group (TAG) to include people with lived disability experience; and capability to develop and disseminate an implementation guide and implementation resources focused on increase inclusion of people with disabilities into preventative health screening recommendations from UPSTF.

Recipient Program Experience:

The applicant should have experience synthesizing existing literature to make recommendations and revisions, developing and disseminating capacity building implementation guides and resources to support the uptake and evaluation of recommended public health interventions. Applicant should have knowledge and familiarity with UPSTF preventative health recommendations and knowledge and familiarity with working in disability inclusion.

Expectations for Collaboration:

It is expected that the partner will meet regularly (weekly or biweekly) with CDC collaborators/team to discuss the project. It is also expected that partners will engage with a range of public health organizations and organizations focused on people with disabilities to disseminate the implementation guide and implementation resources. Depending on the specific project activities, additional types of cross organization collaboration may be appropriate and acceptable to accomplish project work plan objectives and deliverables. The applicant is expected to collaborate with people with disabilities participating in a Technical Assistance Group (TAG) across project activities and to use best practices when developing, and working with, the TAG.

Expected Subcontractual Work and Criteria:

The applicant may need to subcontract out work depending on their internal capability. Specifically, the applicant may need to subcontract with an organization with subject matter expertise in disability and health and/or preventative health screening to support project activities.

General Instructions for Use of Funds:

Funds may be used for: salaries and wages, fringe benefits, consultant costs, supplies, other categories (meetings), total indirect costs, total direct costs.

Strategic Area: Policy and Programs

Strategic Area Details

Outcomes: Short-term: Increased awareness of best/promising practices and/or tools by populations of focus of CBA services and products;Intermediate: Increased awareness and understanding of recommended processes, policies, programs, and practices within the strategic areas;Intermediate: Enhanced skill and ability to support decision-processes, policies, programs, and practices within the strategic areas

Activities: (1) Establish a Technical Assistance Group (TAG) made up of a diverse group of people with lived experiences to review and provide feedback on approaches taken in the project, and on materials developed under Activities 2-8. All meetings with the TAG should be fully accessible.

(2) Build upon existing literature reviews about each UPSTF recommendation with an “A” or “B” score and develop a summary of data supporting the recommendation among people with disabilities. Data summary should include a description of the disparities among people with disabilities compared to people without disabilities for the particular health topic, and data on screening rates by disability status compared to people without disabilities for the particular health topic. Data summary should also include sub-analyses among people with IDD and ML.

(3) Building upon existing literature reviews about each UPSTF recommendation with an “A” or “B” score, and based on consultation from the TAG, develop a summary of adjustments or adaptations needed for people with disabilities to access screenings and overcome major barriers. Adaptations should focus on people with disabilities overall, and among people with IDD and ML.

(4) Building upon existing literature reviews about each UPSTF recommendation with an “A” or “B” score, and based on consultation with the TAG, develop practice considerations for people with disabilities (disability and IDD), with a focus on inclusion and accessibility. Practice considerations should focus on people with disabilities overall, and among people with IDD and ML.

(5) Identify existing population-based outcome indicators and data systems or sets (e.g., BRFSS, NHIS) that can be used to monitor and evaluate uptake of recommended screenings among people with disabilities. Data-systems identified should be ones that can allow for analyses among people with any disability, and/or among people with IDD and ML.

(6) Develop and disseminate implementation resources, including Clinician Summaries and Related Resources Tools, to support the implementation of UPSTF preventative health screening recommendations with an “A” or “B” score among people with disabilities. A sub-set of materials (e.g., infographics) should be developed in both English and Spanish. Capacity building resources should include sub-sections with implementation guidance for people with IDD and ML.

(7) Develop and disseminate a capacity building Implementation Guide that includes information developed through Activity 2-6 and provides a comprehensive resource for public health practitioners to increase the inclusion of people with disabilities into preventative health screening activities. A sub-set of materials included in the implementation guide should be developed in both English and Spanish. Materials should focus on people with disabilities overall, and among people with IDD and ML. Report should also include an introduction that provides a rationale for the project, including role of preventative health screening in secondary prevention efforts, existing disparities in access and utilization of preventative health screening among people with disabilities, and the potential for preventative health screenings to reduce morbidity and mortality.

(8) Conduct at least one, recorded, publicly accessible virtual sessions about the Implementation Guide and capacity building resources. Training should be fully accessible.

Process Measures: -number of people with lived experience on project advisory board

- minimum of 100 partner groups implementation guide shared with

- minimum of 30 clinician summaries developed

- minimum of 20 implementation resources, such as Infographics or Fact Sheets, developed

- number of partners implementation resources, such as clinician summaries and related resources tools, were shared with

- number of people attending virtual session about the Implementation Guide and capacity building resources

- minimum of 30 UPSTF recommendations with an “A” or “B” score with a summary of adjustments, adaptations, or modifications developed for people with disabilities

- minimum of 30 UPSTF recommendations with an “A” or “B” score with a summary of data supporting the recommendation developed among people with disabilities

- minimum of 30 UPSTF recommendations with an “A” or “B” score with practice considerations for people with disabilities developed

- number of existing data systems that can be used to monitor/track uptake of UPSTF recommendations with an “A” or “B” score among people with disabilities

Outputs: - Implementation guide

- Implementation resources, including clinician summaries and related resources tools

- Virtual, open-access, webinar

Budget Period Outcomes:

- Public health practitioners will have an increased capacity to implement, and evaluate, UPSTF preventative health screening recommendations with an “A” or “B” score among people with disabilities.

- People with disabilities will have increased inclusion, and access to, UPSTF recommended preventative health screening recommendations with an “A” or “B” score.

Outcome Measures: - At least 70% of webinar respondents report increase capacity to implement UPSTF recommended preventative health screening recommendations with an “A” or “B” score

- Clinician Summaries are developed for a minimum of 30 UPSTF recommended preventative health screening recommendations with an “A” or “B” score

- Implementation Guide includes implementation guidance for a minimum of 30 UPSTF recommended preventative health screening recommendations with an “A” or “B” score

- At least 20 implementation resources are developed

- Implementation guide shared with a minimum of 100 relevant partners or organizations

Project Title: Increasing Capacity to Implement Community-Based Interventions to Reduce Cancer Risk

Population of Focus: Category C: Public Health System Components

Population of Focus Description:

Public health professionals working within community-based organizations to address cancer risk factors

Project Plan Details Project Purpose: The purpose of this project is to gather, synthesize, and package foundational information about cancer risk and prevention that will ultimately be used to empower public health practitioners and community leaders to effectively implement evidence-based prevention strategies to reduce cancer risk. Using a health equity lens, the project will focus specifically on community-based strategies that help to reduce carcinogenic exposures and facilitate healthy behaviors where people are born, grow, work, live, and age.

This project builds on past efforts within CDC’s Division of Cancer Prevention and Control (DCPC) to inform the prevention work of the division, including conducting literature reviews, interviewing subject matter experts (SMEs), hosting webinars, convening expert meetings, and developing resources to inform public health action. This current project will use similar types of activities to increase understanding within DCPC of the science of cancer risk and prevention and to explore potential policies and practices to address a variety of cancer risk factors.

Additionally, the project will incorporate a community-engaged approach to identify effective ways to frame and share information about opportunities to reduce cancer risk.

During the first year of the project, we will focus our efforts on information gathering for four main topics:

1. Stress in adulthood and its association with cancer risk

2. Climate change and its intersection with cancer prevention and control

3. Toxicology and cancer biology of carcinogenic exposures

4. Alcohol use and its association with cancer risk

In subsequent years of the project, we may expand our efforts to encompass other cancer risk factors of interest.

CIO: NCCDPHP

Division/Branch/Office /Unit:

Division of Cancer Prevention and Control (DCPC)

Proposed FY24 Project Funding Total:

$600,000.00

Funding Appropriation:

Appropriations number 75-24-0948

Funding Statutory Authority:

Public Health Services Act; (PHS) 42 U.S.C. 241, 247(b), 317(k), 301(a), 311, (Note B)

Expected Project Length:

5 Years

Recipient Organizational Capacity:

To conduct the described work, the applicant should have the capacity to complete the following tasks or subcontract the work as needed:

• Conduct high-level reviews of the peer-reviewed literature (with a focus on review papers and meta-analyses) and provide written summaries of the findings for the CDC project staff.

• Host and provide all logistical support for virtual interviews with SMEs.

• Conduct qualitative analyses of the findings from the virtual interviews with SMEs.

• Host and provide all logistical support for up to 8 webinars, with each webinar lasting approximately 1 hour.

• Promote the webinars widely to community-based organizations and the public health workforce.

• Host and provide all logistical support for up to 4 workshops featuring SME presentations and group discussions for professional audiences.

• Develop and maintain a public-facing online space to house the webinars and other materials created through this project.

Recipient Program Experience:

To effectively conduct the described work, the applicant should have expertise in implementation science, community-level interventions for chronic disease prevention, health policy, behavioral science, health communication and social marketing, social determinants of health, health equity, and general public health practice. The applicant should also have an understanding of the influence of contextual factors (e.g., policies, systems, and environmental factors) on cancer causation and the prevalence of cancer risk factors. The applicant should have a strong understanding of CDC’s Principles of Community Engagement:

www.atsdr.cdc.gov/communityengagement/. The applicant should also demonstrate experience developing public health messages, particularly focusing on cancer prevention and control. Some of the applicant’s proposed staff will need to have experience planning and providing logistical support for virtual and in-person workshops and webinars (unless these activities are subcontracted out).

Expectations for Collaboration:

The recipient will be expected to work closely and collaboratively with the CDC team throughout the life of the project and in the context of each project-related activity. The recipient will be expected to collaborate with subject matter experts internal and external to CDC. The recipient will be expected to work closely with the CDC team to identify and recruit these subject matter experts to actively participate in interviews, webinars, and/or workshops. As described in the section on subcontractual work, the recipient will be expected to collaborate with another organization that has experience and expertise in the use of community-engaged approaches and may subcontract out additional aspects of the work as needed.

Expected Subcontractual Work and Criteria:

The recipient will be expected to subcontract with another organization that has demonstrated experience developing and delivering a community-engaged approach. This subcontract will be critical to the development (year 1) and implementation (year 2) of a strategic plan for a community-engaged approach to the alcohol-related work described in the list of activities and possibly additional community-engaged work in future years of the project. The recipient may subcontract out additional aspects of the work as needed.

General Instructions for Use of Funds:

Some project funds may be used for travel, as needed to accomplish the project activities as described in the project plan.

Strategic Area: Partnership Development and Engagement

Strategic Area Details

Outcomes: Short-term: Increased awareness of best/promising practices and/or tools by populations of focus of CBA services and products;Intermediate: Increased awareness and understanding of recommended processes, policies, programs, and practices within the strategic areas;Intermediate: Increased implementation and sharing of recommended processes, policies, programs, and practices within the strategic areas

Activities: The partnership-related activities will vary across the topics we address. For each topic, activities may include:

• Developing a strategic partnership plan that outlines opportunities for engaging both existing partners and potential new partner organizations in work on the given topic.

• Hosting virtual SME interviews and conducting qualitative analyses of the transcripts to identify key themes.

• Hosting webinars and/or workshops (virtual or in-person) for professional audiences that feature presentations by SMEs.

• Serving as a liaison between the CDC project team and external SMEs, including activities such as: facilitating communication, scheduling calls and meetings, and soliciting/compiling SME input for the development of communication products (e.g., manuscripts, one-pagers, slides) that may emerge from the project.

For topic 4 (alcohol consumption and cancer risk), year 1 activities also will include the development of a strategic plan for community engagement. CDC’s principles of community engagement are available online at www.atsdr.cdc.gov/communityengagement/. The awardee is expected to engage the communities of focus in the development of the strategic plan itself.

In year 2, the alcohol-related activities will focus on the implementation of the strategic plan developed in year 1. We anticipate that the plan may include stratification by demographic characteristics such as rural/urban, race and ethnicity, age, gender, and education or household income that would help to address relevant health disparities within the given community. The following paper provides an example of a community-engaged approach to message development and dissemination:

Norman N, Bennett C, Cowart S, et al. Boot camp translation: a method for building a community of solution. J Am Board Fam Med. 2013; 26(30):254-63.

Others have summarized Norman et al.’s work (e.g., Gautom P, Escaron AL, Garcia J, et al. Developing patient‑refined colorectal cancer screening materials:

application of a virtual community engagement approach. BMC Gastroenterology. 2023;23:179.).

Using a health equity lens, the strategic plan should identify which sociodemographically distinct communities the awardee plans to work with and why, identify the demographic characteristics by which they will stratify, and describe in detail how the awardee will:

1) Use the principles of community engagement to create messages about

a. The link between alcohol use and risk for various cancer types.

b. The health benefits, at both the individual and community level, of drinking less alcohol, including reduced cancer risk.

c. The evidence-based, community-level strategies shown to reduce alcohol consumption.

2) Use the principles of community engagement to create dissemination strategies for such messages, including communication channels, appropriate messengers, etc.

Process Measures: • Number of potential new partners identified

• Number of SME interviews scheduled and completed

• Numbers of webinars and workshops scheduled and completed

• Identification of demographic characteristics by which the alcohol-related activities for community engagement will be stratified

Outputs: • A written strategic plan for partner engagement

• Summary reports from the qualitative analyses of up to four series of virtual interviews with SMEs (9 or fewer interviews per topic) about the topic areas of focus for Year 1.

• Up to eight webinars featuring SME presentations related to the four topic areas of focus for Year 1.

• Up to four workshops featuring SME presentations and group discussions for professional audiences.

• A written strategic plan for community engagement, using a health equity lens, that describes in detail how the awardee will:

1) Use the principles of community engagement to create messages about:

a. The link between alcohol use and risk for various cancer types.

b. The health benefits, at both the individual and community level, of drinking less alcohol, including reduced cancer risk.

c. The evidence-based, community-level strategies shown to reduce alcohol use.

2) Use the principles of community engagement to create dissemination strategies for such messages, including communication channels, appropriate messengers, etc.

Budget Period Outcomes:

Increased partner engagement in work on the topics of interest for year one:

o Stress in adulthood and its association with cancer risk o Climate change and its intersection with cancer prevention and control o Toxicology and cancer biology of carcinogenic exposures o Alcohol use and its association with cancer risk

Outcome Measures: Measured increases in partner engagement on the topics of interest by the end of the budget period.

Strategic Area: Policy and Programs

Strategic Area Details

Outcomes: Short-term: Increased awareness of best/promising practices and/or tools by populations of focus of CBA services and products;Intermediate: Increased implementation and sharing of recommended processes, policies, programs, and practices within the strategic areas

Activities: The policy- and programs-related activities will vary across the topics we address. For each topic, activities may include:

• Conducting and summarizing the findings from high-level reviews of the peer-reviewed literature, with a focus on review papers and meta-analyses.

• Conducting environmental and policy scans to identify relevant policies, public health campaigns, research findings that provide new insight into cancer risk (e.g., emerging research on the link between different levels of alcohol use and health outcomes; new findings about the link between social connectedness and health outcomes), and other significant national or global events (e.g., the COVID-19 pandemic) that may have had an important influence on cancer risk factors (e.g., alcohol use) over time.

• Developing resources, including communication materials, for professional audiences and/or the general public.

Process Measures: • Draft list of review papers and meta-analyses on the topics of focus

• Draft list of potential resources that could be developed on the topics of focus

Outputs: • Summary reports from up to four high-level reviews of the peer-reviewed literature related to the four topic areas of focus for Year 1 (one review/summary per topic).

• Summary reports from up to four environmental and policy scans.

Budget Period Outcomes:

• Increased awareness and understanding of the state of the science on links between stress in adulthood and risk and progression of various cancer types.

• Increased awareness and understanding of the state of the science on how climate change intersects with cancer prevention and control.

• Increased awareness and understanding of the latest science on toxicology and cancer biology.

• Increased awareness and understanding about the link between alcohol use and cancer risk and community-level strategies to decrease alcohol use (e.g., limiting alcohol outlet density).

• Increased awareness and understanding of policies, public health campaigns, research findings that provide new insight into cancer risk, and other national or global events that may have had an important influence on cancer risk factors over time.

Outcome Measures: • Increases in interest among community-based organizations in programmatic activities related to the topics of focus.

Project Title: Million Hearts: Preventing Hearts Attacks and Strokes with Improved Blood Pressure Control

Population of Focus: Category C: Public Health System Components

Population of Focus Description:

Physicians

Project Plan Details Project Purpose: The purpose of this project is to work with and through physicians to prevent heart attacks and strokes by improving blood pressure outcomes. Through this project we want to 1) test evidence-informed process improvements and/or implement evidence-based process improvements (e.g., change ideas from the Hypertension Control Change Package and/or the Hypertension in Pregnancy Change Package) to improve cardiovascular health outcomes among patients; 2) discover and develop new tools and strategies needed to improve performance on process measures and blood pressure outcomes of interest, especially among patient populations of focus (e.g., pregnant and postpartum women with hypertension, people from racial/ethnic minority groups, people with lower incomes, and/or people who live in rural areas or other ‘access deserts.’); 3) scale and spread implementation of high impact change ideas by building a supportive ecosystem for optimal delivery of cardiovascular disease prevention services; 4) test and refine the ways electronic health record data may be used to monitor and drive improvements in blood pressure outcomes for patients with uncontrolled hypertension and pregnant and postpartum women with hypertension.

CIO: NCCDPHP

Division/Branch/Office /Unit:

Division for Heart Disease and Stroke Prevention (DHDSP)

Proposed FY24 Project Funding Total:

$1,000,000.00

Funding Appropriation:

Further Consolidated Appropriations Act, 2024 (P.L. 118-47)

Funding Statutory Authority:

Sec. 301(a) of the Public Health Service Act (42 U.S.C. 241(a)); Sec. 317(k)(2) of the Public Health Service Act (42 U.S.C. 247b(k)(2)) and Patient Protection and Affordable Care Act, 2010 (P.L. 111-148)

Expected Project Length:

5 Years

Recipient Organizational Capacity:

The applicant should have the ability to provide technical assistance to a variety of entities that support work physicians, including those working at community health centers. The applicant should have expertise in quality improvement work and implementation science physician processes and the health information technology infrastructure used by physicians. The applicant needs the capacity to document, track, and use clinical quality measures to inform implementation of process improvements. Expertise with health information technology and use of electronic health record data to describe and improve the quality of cardiovascular disease preventive services. The applicant needs the capacity to report blood pressure metrics bi-annually to CDC. Finally, the applicant needs the ability to work nationally with public and private partners to build the capacity of physicians in a variety of low resource environments to improve the cardiovascular health of racially, ethnically, and socioeconomically diverse patient populations that are disproportionately burdened with uncontrolled hypertension.

Recipient Program Experience:

The applicant should have a deep understanding of primary care physicians and how they operate with the support of primary care associations, health center controlled networks, and other public and private partners to provide quality anti-hypertensive care to patients. The applicant should have experience directing clinical quality improvement activities and promoting and scaling interventions.

Experience developing and publishing resources and peer-reviewed articles is also required. Ideally, the applicant would be familiar with Million Hearts evidence-based strategies, data metrics, quality improvement resources (e.g., Million Hearts change packages) and other translational and implementation science activities.

Expectations for Collaboration:

Collaboration with CDC is expected, especially in the development and analysis of priorities and evaluation of impact. Additionally, recipient would be expected to collaborate with other public health partners working on similar blood pressure control quality improvement projects or initiatives. CDC has historically worked successfully with the National Association of Community Health Centers (NACHC), primary care associations, health center controlled networks, and community health centers to produce outcomes that align with the aim of this project. Additional potential partners may include women's health care providers, population health management product developers, etc.), and with other federal agencies (e.g., Health Resources and Services Administration). The ideal candidate would have some history of engaging with scientific and programmatic collaborators of stature.

Expected Subcontractual Work and Criteria:

Applicant is expected to provide national oversight and support to the project, but much of the technical work will take place at subcontracted primary care.

Additional subcontracts may be needed to work with a clinical repository and a population health management system to test self-measured blood pressure monitoring clinical care process improvements. It may also be appropriate to subcontract for evaluation, writing, and/or other support activities.

General Instructions for Use of Funds:

Funds should be used to generate strategies and tools, collect data, produce, disseminate, and scale interventions. It is reasonable for some funds to be devoted to supporting national efforts (e.g., collaboration to support the widespread use of self-measured blood pressure monitoring, advancement of health IT solutions, increased access to and use of data to inform care processes, etc.). Travel is permissible but should be minimized for maximum impact. It would be helpful for the budget to be scalable. Funding to primary care practices should be carefully determined to optimize the project’s reach and to assess the degree to which capacity-building activities can be replicated in other regions with no or minimal supplemental resources. Funding to support resource development and communication activities is permissible. Overall, the funds should provide flexibility to work with at least 5 primary care networks with an anticipated reach of at least 500,000 adult patients.

Strategic Area: Organizational Capacity and Performance Improvement

Strategic Area Details

Outcomes: Short-term: Increased use of CBA services and products by populations of focus;Intermediate: Increased implementation and sharing of recommended processes, policies, programs, and practices within the strategic areas

Activities: • Develop an annual action plan with CDC to outline the focus for the upcoming year’s activities to test and implement, discover and develop, and scale and spread.

• Develop an evaluation plan with CDC that aligns with annual action plan.

• Recruit primary care practices to participate in the project.

• Support project participants in implementing evidence-based process improvements (e.g., change ideas from the Hypertension Control Change Package and/or the Hypertension in Pregnancy Change Package) to improve cardiovascular health outcomes (e.g., develop care processes to systematically diagnose and treat or refer pregnant and/or post-partum patients with hypertension, test health IT solutions to facilitate the bi-directional exchange of blood pressure measurements, etc.).

• Discover and develop new tools and strategies needed to improve performance on blood pressure outcomes of interest, especially among patient populations of focus (e.g., pregnant and postpartum women with hypertension, people from racial/ethnic minority groups, people with lower incomes, and people who live in rural areas or other ‘access deserts.’). An example of year one activities could be to bolster chronic care management services to help patients take and send their blood pressure measurements to their prescribing clinician(s).

• Scale and spread implementation of high impact change ideas by identifying needs for a supportive ecosystem for optimal delivery of cardiovascular disease prevention services (e.g., provide staffing to coordinate and align the work of national public and private partners to improve blood pressure control among African Americans, expand use of population health interventions to close gaps in the diagnosis and management of hypertension, identify and promote policies to facilitate the delivery of medication management services in trusted community-based settings with qualified clinical staff).

• Test and refine the ways electronic health record data may be used to monitor and drive improvements in blood pressure control outcomes, as deemed appropriate and timely. This includes working with population health management vendors to generate hypertensive disorders of pregnancy-related data reports.

• Test the connection between a clinical repository and a population health management system to benefit health centers and health center control networks implementing self-measured blood pressure monitoring.

• Capture, clean, and report quality improvement data bi-annually.

Process Measures: • # of primary care networks engaged in the project (≥5)

• # of practices engaged in the project

• # of adult patients reached (≥500,000)

• % of data-reporting entities that have completed electronic health record data extraction, validation, cleaning, normalization, aggregation, and descriptive analysis (100%)

• % of data-reporting entities that have completed reporting specified data (100%)

Outputs: • Spreadsheet with the primary care practice participants and prospective number of lives impacted by the project.

• Summary of workflows and/or ecosystem parameters to be changed for optimal impact.

• Report of resources used by contracted organizations networks (e.g., funds, staffing needs, space, equipment, etc.) to implement process improvements.

• New tools or resources, as needed, to facilitate implementation of change ideas to improve blood pressure control.

• Report of clinical quality measures and other metrics of interest from project participants.

Budget Period Outcomes:

• Increased implementation of existing and emerging Million Hearts® evidence-based strategies to improve blood pressure control.

• More pregnant and postpartum women with hypertension, people from racial and ethnic minority groups, people with lower incomes, and people living in rural areas or other access deserts receive clinical guideline-recommended care to lower their risk for having a heart attack or stroke.

• Increased awareness and communication of approaches taken or planned by public and private national partners to improve blood pressure control

Outcome Measures: • At least 500,000 adult patients are at lower risk for having a heart attack or stroke.

Project Title: Million Hearts: Preventing Hearts Attacks and Strokes with Community Health Centers

Population of Focus: Category C: Public Health System Components

Population of Focus Description:

Physicians

Project Plan Details Project Purpose: The purpose of this project is to work with and through physicians to prevent heart attacks and strokes. Through this project we want to discover and develop new tools and strategies needed to improve performance on cardiovascular disease prevention, especially among patient populations of focus (e.g., pregnant and postpartum women with hypertension, people from racial/ethnic minority groups, people with lower incomes, and people who live in rural areas or other ‘access deserts.’).

CIO: NCCDPHP

Division/Branch/Office /Unit:

Division for Heart Disease and Stroke Prevention (DHDSP)

Proposed FY24 Project Funding Total:

$850,000.00

Funding Appropriation:

Further Consolidated Appropriations Act, 2024 (P.L. 118-47)

Funding Statutory Authority:

Sec. 301(a) of the Public Health Service Act (42 U.S.C. 241(a)); Sec. 317(k)(2) of the Public Health Service Act (42 U.S.C. 247b(k)(2)) and Patient Protection and Affordable Care Act, 2010 (P.L. 111-148)

Expected Project Length:

5 Years

Recipient Organizational Capacity:

The applicant should have the ability to develop resources to improve the quality of care provided at primary care practices, including community health centers, to prevent heart attacks and strokes. The applicant should have expertise in knowing the care processes involved in the delivery of quality cardiovascular disease preventive services (e.g., systematic protocol use, medication intensification, medication adherence, delivery of care in partnership with pharmacists and community health workers, population health management systems, and other types of care processes). Knowledge of how primary care teams can leverage health information technology solutions, electronic health record data, and tools to automate communication with patients is required.

Finally, the applicant needs the ability to work strategically with public and private partners to align national efforts to improve cardiovascular health outcomes.

Recipient Program Experience:

The applicant should have experience working with primary care practices, including community health centers, and know how they operate with the support care networks (e.g., primary care associations, health center controlled networks, and other public and private partners) to provide quality cardiovascular disease preventive services. Experience applying implementation science is a requirement. Experience developing new and innovative approaches to resolve issues in care processes is also requested. Ideally, the applicant would be familiar with Million Hearts® evidence-based strategies, data metrics, quality improvement resources (e.g., Million Hearts® change packages) and other translational and implementation science activities.

Expectations for Collaboration:

Collaboration with CDC is expected, especially in the development and analysis of priorities and evaluation of impact. Additionally, recipient would be expected to collaborate with other public health partners working on similar quality improvement projects or initiatives. CDC has historically worked successfully with the National Association of Community Health Centers (NACHC), primary care associations, health center controlled networks, and community health centers to produce outcomes that align with the aim of this project. Additional potential partners may include women's health care providers, population health management product developers, patient engagement platforms, and with other federal agencies (e.g., Health Resources and Services Administration).

Collaboration with Million Hearts Partners, at large, is also expected (e.g., Million Hearts Partner Calls, Million Hearts learning platforms, etc.).

Expected Subcontractual Work and Criteria:

Applicant is expected to provide national oversight and support to the project.

Subcontracts with primary care networks, including health center control networks and primary care associations, and possibly individual practices or health centers, may be necessary to test innovative solutions and develop resources that may be shared with other partners. It may also be appropriate to subcontract for evaluation, writing, media development, and/or other support activities.

General Instructions for Use of Funds:

Funds should be used to develop and test new tools and strategies that can be used to improve performance on cardiovascular disease prevention indicators of progress. It is reasonable for some funds to be devoted to supporting national organizations and/or health centers, health center controlled networks, and primary care associations to test systems. Travel is permissible but should be minimized for maximum impact. Funding to support resource development and communication activities is permissible.

Strategic Area: Organizational Capacity and Performance Improvement

Strategic Area Details

Outcomes: Intermediate: Increased awareness and understanding of recommended processes, policies, programs, and practices within the strategic areas

Activities: • Develop an annual action plan and evaluation plan with CDC to outline the focus for the upcoming year’s activities, target goals, and data to be collected to ensure goals are met (e.g., LDL messages from labs, patient text messaging platforms)

• Test the use of electronic health record systems and automated communication platforms to improve performance on clinical quality measures as deemed appropriate and timely.

• Discover and develop new tools and strategies needed to improve performance on the ABCS of cardiovascular disease prevention, especially among patient populations of focus (e.g., pregnant and postpartum women with hypertension, people from racial/ethnic minority groups, people with lower incomes, and people who live in rural areas or other ‘access deserts.’).

Process Measures: • # of primary care networks engaged in testing new tools or strategies

• # of patients reached and impacted

Outputs: • Report on discoveries made from testing new tools or strategies.

• Data showing the impact of automated communication platforms and other outreach resources on patient engagement indicators of interest.

• Development of new tools and/or strategies

Budget Period Outcomes:

• Increased implementation of existing and emerging Million Hearts® practice-based or evidence-informed strategies to prevent heart attacks and strokes

• Increased patient engagement in their cardiovascular disease preventive care

• Improved efficiency in the delivery of clinical guideline-recommended cardiovascular disease preventive care

Outcome Measures: • Hundreds of thousands of patients benefit from receiving increased delivery of clinical guideline-recommended cardiovascular disease preventive care

Project Title: Training Decision-Makers to Increase Physical Activity Through Community Design

Population of Focus: Category C: Public Health System Components

Population of Focus Description:

State and local affiliates (including YMCA affiliates) and decision-makers who develop policies, plans and systems that affect physical activity, transportation, land use and healthy community design planning. State and local champions (including YMCA affiliates) who educate decisionmakers and communities on the policies, programs, and practices supportive of physical activity, active transportation and healthy community design planning.

Project Plan Details Project Purpose: This project will support national partnership efforts across public health and other sectors to support the goals of Active People, Healthy Nation to increase implementation of equitable and inclusive evidence-based strategies that support physical activity.

This project will support the equitable implementation of transportation and land use policies, systems, and environmental changes to increase physical activity through community design. The goal of this project is to support state, local, and tribal decision-makers and professionals from transportation, land use planning, housing and economic development, public transit, and parks and recreation to partner with public health practitioners. This project should align/support the Division of Nutrition, Physical Activity, and Obesity’s priority strategy – community design for physical activity. It should also  These cross-sectoral partnerships are intended to implement land use and transportation policies, plans, and programs, system changes, and environmental changes to increase equitable access to places for safe physical activity.

The project will support the analysis of existing data and development of a series of complimentary products to the State Report Cards on Support for Walking, Bicycling, and Active Kids and Communities (2022 State Report Cards | Safe Routes Partnership) that aligns with Division of Nutrition, Physical Activity, and Obesity’s (DNPAO’s) priority strategy – community design for physical activity – and builds the capacity of practitioners and decision makers involved in transportation policies, plans and system changes. It should also reinforce significant national public health policy statements supporting walking, including the Surgeon’ General’s Call to Action to Promote Walking and Walkable Communities and the Physical Activity Guidelines for Americans. The State Report Cards are updated biannually with data from all 50 states and are used to educate practitioners and decision makers about the importance of policies and practices that support activity-friendly communities, and to help guide planning and decision-making. Complimentary products provide a more in-depth analysis on specific indicators or topics in the State Report Cards. These are developed in off years in collaboration with CDC to support uptake of the Report Cards, and to build capacity of states to plan and make decisions based on data to create activity-friendly communities (e.g., trend analyses on indicators, success stories/state profiles of how the Report Card was used to inform changes, etc.).

Through the development of these products and related efforts, the recipient will be expected to facilitate collaborations to support Active People, Healthy Nation and its network. The recipient will be asked to support or contribute to efforts to build awareness and support for Active People, Healthy Nation with routine communications, networking, and strategic engagement.

CIO: NCCDPHP

Division/Branch/Office /Unit:

Division of Nutrition, Physical Activity, and Obesity (DNPAO)

Proposed FY24 Project Funding Total:

$699,000.00

Funding Appropriation:

75-24-0948

Funding Statutory Authority:

Public Health Service Act , Title 42, Sections 307 and 301 U.S.C. 241I and 241 (a).

Expected Project Length:

5 Years

Recipient Organizational Capacity:

The applicant must show significant organizational experience and knowledge in promoting healthier communities, be a nationally recognized leader in the areas of physical activity and healthy communities, have long-standing credibility and relationships in communities throughout the country, have credibility with the intended target audiences and identified collaborators, and have locations throughout the nation.

The applicant should demonstrate a proven track record in successful program management, meeting program goals, and advancing healthier communities.

The applicant must have an established network of state affiliates with a coordinated engagement strategy aligned with the applicant’s national strategy.

The organization must have an existing portfolio and efforts in promoting physical activity and promoting healthier communities focused on promoting safe and accessible places for physical activity through community design.

The organization should have credibility among national organizations working to promote evidence-based physical activity strategies as well as credibility among state and local decision-makers, as well as public health, land use planning and transportation professionals, with experience working with other sectors.

The organization must have experience in advancing policy and system change at local, state, tribal, and national levels, catalyzing support for healthy communities (i.e., housing, zoning, planning, land use, economic development, transportation), addressing equity issues in land use policies and regulations, addressing equity issues in active transportation, and have extensive expertise working with communities to improve support for walking, bicycling, or taking transit to essential destinations like homes, workplaces, schools, parks, health care or food outlets. The organization must have experience and expertise in providing actionable recommendations that state and local decision makers can use to upend the status quo and build a transportation system that helps make more people healthier.

The organization must have experience in promoting and building the capacity within states and communities for sustainable, equitable, walkable development.

The organization must have experience creating and disseminating resources and tools needed to drive change in development and mobility policies in communities. The organization must understand the importance of affordable housing, the need for vibrant local economies, and how to affordably connect people to jobs and services.

The organization must have at least five years of experience successfully engaging local and/or state public health, transportation and land use planning officials or practitioners to address active transportation and land use issues.

The organization should have capacity to engage with state and local decisionmakers and state and local public health, planning and transportation professionals. An established capacity of working with decisionmakers and champions at state and local levels to use data from The State Report Cards and related tools to make…