cdc-rfa-dp15-1508amend1publication.pdf

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable

Populations

CDC-RFA-DP15-1508

Application Due Date: 05/15/2015

Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

CDC-RFA-DP15-1508

TABLE OF CONTENTS

Part I. Overview Information

Federal Agency NameA.

Funding Opportunity TitleB.

Announcement TypeC.

Agency Funding Opportunity NumberD.

Catalog of Federal Domestic Assistance (CFDA) NumberE.

Dates F.

Executive Summary G.

Part II. Full Text

Funding Opportunity Description A.

Award Information B.

Eligibility Information C.

Required Registrations D.

Review and Selection Process E.

Award Administration Information F.

Agency Contacts G.

Other Information H.

Glossary I.

Part I. Overview Information Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Send Me Change Notifications Emails" link to ensure they receive notifications of any changes to CDC-RFA-DP15-1508. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) B. Funding Opportunity Title:

Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations C. Announcement Type: New - Type 1 This announcement is only for non-research domestic activities supported by CDC. If research is proposed, the application will not be considered Research for this purpose is defined at http://www.cdc. gov/od/ science/ integrity/ docs/cdc- policy- distinguishing- public- health- research- nonresearch. pdf.

D. Agency Funding Opportunity Number:

CDC-RFA-DP15-1508

E. Catalog of Federal Domestic Assistance (CFDA) Number:

93.946 F. Dates:

1. Due Date for Letter of Intent (LOI): N/A

2. Due Date for Applications: 05/15/2015, 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Date for Informational Conference Call: 04/02/2015 CDC/DRH will host one webinar for prospective applicants. This webinar will provide information about the FOA and will answer questions pertinent to preparing applications in response to this FOA. The conference line can hold up to 100 callers.

Webinar Date: April 2, 2015 at 1:00pm (EST) Call-in Number: 1-888-790-3525 passcode: 5823026 URL: https://www.mymeetings.com/nc/join/ Conference number: PW1977435 Audience passcode: 5823026

G. Executive Summary:

1. Summary Paragraph:

This program is a new five-year initiative to 1) enhance publicly funded health centers’ capacity to provide youth-friendly sexual and reproductive health services and 2) increase the number of youth accessing sexual and reproductive health services by (a) working with youth-serving systems to develop strategies to refer and link vulnerable youth to care and (b) increasing awareness of the health centers’ services in the local community through communication efforts. All proposed strategies and approaches should contribute to the long-term outcomes of reduction in teen pregnancy and births. Sexual and reproductive health services includes services such as sexual health assessment, contraceptive and/or sexual health counseling, health exams (e.g. pelvic exam, pap test), insertion of or prescription of contraception or IUD, STD screening and/or treatment and HIV testing.

Vulnerable youth include those at risk of health disparities due to low socioeconomic status (SES), race/ethnicity, exposure to social determinants negatively affecting health (e.g., poor housing, poor education, stressful neighborhood environment, high community unemployment, etc.), being out of school, living in foster care, homelessness, having experienced trauma or abuse, geography (e.g., remote rural areas with limited services, marginalized urban communities), involvement with juvenile justice, substance abuse, being a pregnant/expecting teen or a teen parent. Thus, vulnerability is not limited to race/ethnicity.

This funding opportunity announcement (FOA) supports: 1) the implementation of evidence-based clinical recommendations and youth-friendly best practices; and 2) the development and institutionalization of referral and linkage mechanisms from systems serving vulnerable youth to publicly funded health centers providing sexual and reproductive health services.

Applicants will develop and implement strategies within a network of publicly funded health centers and youth-serving systems.

a. Eligible Applicants: Open Competition

b. FOA Type: Cooperative Agreement

c. Approximate Number of Awards: 3

d. Total Project Period Funding: $9,750,000

e. Average One Year Award Amount: $650,000

f. Number of Years of Award: 5

g. Estimated Award Date: 09/30/2015

h. Cost Sharing and / or Matching Requirements: N

Part II. Full Text

A. Funding Opportunity Description

1. Background

a. Overview

There has been significant progress in teen pregnancy prevention in all 50 states and among all racial/ethnic groups. However, U.S. rates of teen childbearing remain far higher than in other comparable countries. In 2013, there were 274,641 births to teen girls aged 15-19 (26.6 births per 1,000 girls), representing a 10% drop from the 2012 rate. Although birth rates have dropped for all races and ethnicities, the rates for African American, Hispanic and Native American teens are over twice the rates of white and Asian American youth. In addition, geographic differences exist. Birth rates are highest in the southern and southwestern states and lowest in the Northeast; rates have been declining in rural area, but not as quickly as in suburban and urban areas.

Increased access to and use of quality youth-friendly sexual and reproductive health services among sexually active teens could significantly reduce teen pregnancy. However, sexual and reproductive health services are often not youth-friendly. A key barrier noted by youth is that services are often not delivered in a ‘youth-friendly’ manner. Many teens are concerned about lack of confidentiality and the high cost of services, or they have limited education on and access to contraception. Recent studies have also found wide variation in practices regarding providing contraceptive services to younger clients in publicly funded family planning facilities. Common challenges to providing contraceptive and long-acting reversible contraceptives (LARCs) to younger clients include: limited trained staff, high upfront costs of some contraceptive methods, inconvenient clinic hours, staff concerns about the safety of IUD or implant use among teens, and limited availability of provider training on LARC insertion.

Organizations such as the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend providing adolescents with youth-friendly care and ensuring reproductive health visits begin during early adolescence and include reproductive health counseling, screening for sexual activity, anticipatory guidance/delay counseling when appropriate, the provision of contraception, and screening for sexually transmitted infections (STIs). Nevertheless, recent research and lessons learned https://foa.grantsolutions.gov/announcementmodule/www.grants.gov https://foa.grantsolutions.gov/announcementmodule/www.grants.gov http://www.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf http://www.grants.gov https://www.mymeetings.com/nc/join/ through two current cooperative agreements, one cooperative agreement with CDC and the Office of Adolescent Health and another cooperative agreement with CDC and the Office of Population Affairs (OPA)) demonstrate that many clinics serving adolescents in communities with high teen birth rates are not adhering to these new recommendations. Health system-level changes focused on ensuring that publicly funded clinics provide adolescents with accessible, affordable, and evidence-based reproductive health care are necessary to improve utilization of sexual and reproductive health services by adolescents (youth aged 15-19).

In addition to the work needed to improve the quality of sexual and reproductive health care at publicly funded health centers, connecting youth from youth-serving systems (e.g., juvenile justice, foster care, and other social services) with quality care is also important. Studies show that youth who become involved with systems such as juvenile justice and foster care are at high risk for early sexual debut, inconsistent use of condoms and other contraceptives, pregnancy, and sexually transmitted diseases (STDs). Barriers to these youth accessing reproductive health services include 1) the absence of reproductive health-related policies within the youth-serving systems or the failure to fully implement such policies (e.g. screening/evaluation upon entry into juvenile justice facility), 2) lack of collaboration between different youth-serving systems and health care, and 3) limited information provided to youth on sexual health and development. Coordinated efforts, partnerships with health centers, and system-level changes within youth-serving systems are needed to develop sustainable interventions that will link vulnerable youth to quality sexual and reproductive health services on an ongoing basis.

b. Statutory Authorities

This program is authorized under Section 317K of the Public Health Service Act, 42U.S.C. 247b-12 and Section 301(a) of the Public Health Service Act, 42 U.S.C. 241(a).

c. Healthy People 2020

This cooperative agreement supports Healthy People 2020 objectives related to: Family Planning (FP) and Sexually Transmitted Disease (STDs).

FP-3 Increase the proportion of publicly funded family planning clinics that offer the full range of FDA-approved methods of contraception, including emergency contraception, onsite FP-6 Increase the proportion of females at risk of unintended pregnancy or their partners who used contraception at most recent sexual intercourse FP-7 Increase proportion of sexually experienced persons who received reproductive health services FP-8 Reduce pregnancies among adolescent females FP-11 Increase the proportion of sexually active persons aged 15 to 19 years who use condoms and hormonal or intrauterine contraception to both effectively prevent pregnancy and provide barrier protection against disease STD-1 Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections STD-6 Reduce gonorrhea rates This site is accessible at: http://www.healthypeople.gov

d. Other National Public Health Priorities and Strategies

The mission of CDC’s Division of Reproductive Health (DRH) is to promote optimal reproductive and infant health and quality of life by influencing public policy, health care practice, community practices, and individual behaviors through scientific and programmatic expertise, leadership, and support. Addressing issues surrounding teen pregnancy is an important component of this mission. Specifically, the activities to be conducted under the proposed FOA addresses two key strategic areas of focus of DRH within the priority area of Women’s Reproductive Health: Teen Pregnancy Prevention and Family Planning Methods, Services, and Use. Within CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), this FOA aligns well with the goal to “Achieve equity in health by eliminating racial and ethnic disparities and achieving optimal health for all Americans,” and strategy to enhance epidemiology and surveillance (provide states and communities with the necessary expertise to collect data and information and to develop and deploy effective interventions).

Teen pregnancy prevention is one of the President’s priorities. The President’s budget for fiscal year (FY) 2010 proposed a new Teenage Pregnancy Prevention (TPP) initiative to address high teen pregnancy rates by replicating evidence-based models and testing innovative strategies. On December 16, 2009, the President signed the Consolidated Appropriations Act, 2010 (Public Law 111-117) providing support for this teen pregnancy prevention program. In addition, teen pregnancy prevention has been named a Winnable Battle at CDC. See more information on CDC’s winnable battles at: http://www.cdc.gov/about/cdcdirector/winnablebattles.html

e. Relevant Work

This Funding Opportunity Announcement (FOA) builds on CDC’s existing work and expertise in the delivery of quality reproductive health services. Reproductive health services includes services such as sexual health assessment, contraceptive and/or sexual health counseling, health exams (e.g. pelvic exam, pap test), insertion of or prescription of contraception or IUD, STD screening and/or treatment and HIV testing. Through the CDC-OPA cooperative agreement and the CDC-OAH cooperative agreement, funded grantees gained experience in multiple-components of a community-wide teen pregnancy prevention initiative, including community mobilization; the implementation of evidence-based prevention programs; the establishment of strong community-clinic referral linkages for adolescents; and building the capacity of health center partners to provide quality sexual and reproductive health care for adolescents. Specifically, this FOA incorporates the lessons learned from our previous cooperative agreements, yet targets improving the quality of, and linking youth to, sexual and reproductive health services. This FOA also supports the dissemination and use of important CDC guidelines and recommendations, including the Quality Family Planning Services Recommendations, US Selected Practice Recommendations for Contraceptive Use (SPR), and US Medical Eligibility Criteria for Contraceptive Use (MEC).

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/QFP.htm http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htm http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

2. CDC Project Description

a. Approach

Activities Short-Term Outcomes Intermediate Outcomes

Distal Outcomes

Plan for the initiative and conduct needs assessment Establish a key partnership team and partner with a national training and technical assistance provider Strengthen clinical services and improve the quality of care Strengthen youth-serving systems and linking youth to care Develop and implement system change

Support and maintain an active key partnership team

Leaders are supportive of the teen pregnancy prevention (TPP) initiative within their systems Leaders are engaged and committed to implementing the TPP initiative Leaders have dedicated staff time or other resources to the TPP initiative TPP efforts are coordinated across systems Collaborative network with other health care services

Maintain a strong health care system

Health center leaders and staff are knowledgeable about

Youth are reached by TPP efforts

Receive information through health communications and outreach efforts Receive referrals to health care networks Participate in EBIs

Youth show increases in knowledge of and intentions to use contraceptive and reproductive health services More youth receive contraceptive and reproductive health services at health care network partners More youth receive

Fewer teen pregnancies, teen births, and STDs among vulnerable youth*

Better long-term educational and employment outcomes for youth and better outcomes for their children*

Sustained efforts* http://www.healthypeople.gov/ http://www.cdc.gov/about/cdcdirector/winnablebattles.html http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/QFP.htm http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htm http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm system change approaches Develop and implement health communication and outreach efforts and supportive of implementation of evidence-based guidelines and youth-friendly best practices Health center staff are knowledgeable about and support broader TPP efforts within their system Evidence-based guidelines and youth-friendly best practices are implemented with high quality for vulnerable youth

Maintain strong youth services system integration of TPP

Youth service providers are knowledgeable about and supportive of TPP efforts within their systems Established formal linkages with reproductive health services TPP referral and linkage strategies are implemented EBIs are implemented with high quality

Maintain a strong linkage and referral system

Established linkage and referral systems between youth-service systems and health care systems

Implement health communication efforts across and within systems

More youth receive contraceptive methods including highly effective contraception More youth take protective action*

Use contraception* Delay sexual activity*

*These outcomes are not measured during the project period.

All items in bold are expected to be achieved during the project period.

i. Purpose

This FOA aims to reduce teen pregnancy through increased access to and use of sexual and reproductive health services among youth aged 15 to 19 in the context of publicly funded health centers (e.g., Federally Qualified Health Centers, community health centers, health departments, Title X clinics). This will be accomplished by: 1) increasing health centers' capacity to provide youth-friendly sexual and reproductive health services; and 2) increasing the number of youth accessing sexual and reproductive health services through working with youth-serving systems to link vulnerable youth to care, and increasing awareness of the health centers’ services in the community.

ii. Outcomes

Short-term

1. Stronger (or enhanced) collaborative core leadership team; supportive leadership within publicly funded health centers and youth service systems

Increase health center and youth service system leadership capacity to a) support the TPP initiative and b) engage and commit to implementing the TPP initiative Increase coordination of TPP efforts across systems through formal partnership agreements between health centers and youth-serving systems

2. Stronger (or enhanced) health care system that offers youth friendly clinical services (e.g., FQHC, Title X clinics) Establish and maintain referral and linkage systems between youth service systems and health care systems Increase health center staff knowledge about, support for, and provision of youth friendly reproductive health services and for implementation of evidence-based clinical guidelines Implement and maintain the use of evidence-based clinical guidelines and youth friendly best practices by clinic partners Increase health center staff knowledge about and support for TPP efforts within their system

3. Enhanced youth service systems integration and coordination Establish and maintain formal linkages with health care services Increase youth service providers’ knowledge about and support for TPP efforts within their system Implement and maintain high-quality, evidence-based interventions (EBIs) for TPP for vulnerable youth Implement health communication efforts within and across youth-serving systems

Intermediate outcomes

4. Increased number of youth reached by TPP efforts

Receive information through health communication or other outreach efforts Receive referrals to health care centers Participate in evidence-based teen pregnancy prevention interventions, when applicable

5. Increased number of youth who show increases in knowledge of and intentions to use sexual and reproductive health services Increase knowledge of and intention to access reproductive health services among youth reached by TPP efforts Increase knowledge of and intention to use contraceptive methods among youth reached by TPP efforts

6. Increased number of youth who visit health care network partners for sexual and reproductive health services

Increase in the number of youth who visit health care network partners for sexual and reproductive health services Increase the number of youth who receive sexual and reproductive health services at visits to health care network partners

7. Increased number of youth who receive moderately or highly effective contraception Increase in the number of youth who receive moderately effective contraception (i.e., pill, depo, patch, ring) Increase in the number of youth who receive highly effective contraception (i.e., IUD, contraceptive implant)

8. Increasing number of youth who take protective action (will not be measured) Increase use of contraception (including dual method use) Delay sexual activity

Long-term outcomes (will not be measured) Fewer teen pregnancies, teen births and STDs among vulnerable youth Better long-term educational and employment outcomes for youth and better outcomes for their future children Efforts to prevent teen pregnancy and birth are sustained among awardee communities

iii. Strategies and Activities

Awardees will be responsible for designing, implementing, and evaluating strategies and activities focused on: 1) improving the capacity of publicly funded health care centers to provide quality, youth-friendly sexual and reproductive health services, including the full range of contraceptive services; 2) increasing the capacity of youth-serving systems to address teen pregnancy prevention and connect vulnerable youth needing sexual and reproductive health services to local health centers providing youth-friendly services; and 3) increasing awareness of the youth-friendly clinical services through communication efforts in the community and among partnering youth-serving systems.

The first year of the project will be dedicated to planning and assessment, and developing or strengthening partnerships, followed by four years of implementation and evaluation activities.

Activities conducted as part of this FOA will fall into the following categories: Planning and Assessment, Partnerships, Strengthening Clinical Services and Improving the Quality of Care, Strengthening Youth-Serving Systems and Linkages to Care, System Change Approaches, and Communications. All strategies and activities will be evaluated with the routine collection of performance measures and site-specific evaluation plans.

Planning and Assessment

• Staffing

During the first three months of receiving funds, awardee must hire or subcontract with all required staff. CDC can assist awardee post-award to identify appropriate staff and subcontractors. Prior approval is required by PGO for all key personnel (PD, PI, business official) and new contract awards. The following staff will comprise the implementation team: Project Coordinator, Evaluator, Program Technical Assistance (TA) Provider, and Clinical TA Provider. (A subcontracted clinical training provider will also be required. More information on the clinical training provider below in the Partnerships section.) The implementation team will work with all partners in this project and will collaborate with other awardees and CDC program staff. A description of the qualifications required and duties for each staff member is provided below.

Project Coordinator: This staff person will be responsible for managing the planning, coordination, implementation, monitoring, and reporting associated with the program, and for establishing relationships with all partner organizations and health centers. This individual must have previous experience in program coordination or management, and knowledge of health care settings and policies is strongly desired. The project coordinator must be on staff at the awardee organization. 1.0 FTE required.

Evaluator: This individual will carry out all evaluation activities required as part of this project. At least .50 FTE will be required. The evaluator can be on staff at the awardee organization or be contracted through another organization. The evaluator will work with clinical staff and youth-serving system staff to ensure timely and accurate collection of data, to analyze data and to provide evaluation data to program staff for continuous quality improvement (CQI) purposes, and prepare reports for CDC. The evaluator will also be responsible for timely submission of performance measure data to CDC as requested.

Technical Assistance (TA) Providers (Program and Clinical): Within the first three months of receiving funds, awardee must identify, hire or subcontract with a Program TA provider and a Clinical TA provider. It is recommended that awardees work with the CDC Project Officer post-award to select appropriate TA providers. If applicant proposes to contract with a specific TA provider in application, a Memorandum of Understanding (MOU) must be included with the application.

Program TA provider (at least .50 FTE) will work with youth-serving systems and health centers. The individual will provide training and technical assistance (T&TA) on adolescent sexual and reproductive health and the development of a referral and linkage system between partnering clinics and youth-serving systems. In addition, the Program TA provider will develop annual TA plans for each youth-serving system partner; monitor linkage relationships; work with the evaluator to ensure accurate and timely data collection from youth-serving system partners; and provide ongoing TA on implementation and CQI throughout the initiative. Time dedicated to the project should decrease in Years 3-5 (less than .50FTE required) as capacity and infrastructure is built within the youth-serving systems. Program TA provider must have:

Previous experience working with youth-serving systems that have been proposed as partners in this application (schools, foster care, juvenile justice, housing authority) Previous experience providing training and technical assistance to organizations on adolescent sexual and reproductive health and teen pregnancy prevention Previous experience working with youth-serving systems to develop referral systems to link youth to health services Previous experience conducting CQI and using data to enhance programs

Clinical TA provider (at least .50 FTE) will provide T&TA to health center or clinic staff to increase their capacity to provide youth-friendly sexual and reproductive health services; to provide access to the full range of contraceptive methods; and to ensure the implementation of youth-friendly clinical best practices. The Clinical TA provider will develop annual TA plans for each health center/or clinic partner; work with the evaluator to ensure accurate and timely data collection from health center partners;

provide ongoing TA on implementation and CQI throughout the initiative. Time dedicated to the project should decrease in Years 3-5 (less than .50 FTE required) as capacity and infrastructure is built within the health center. Clinical TA provider must have:

At least 3 years of previous experience developing and providing training and technical assistance to health centers on topics including but not limited to:

youth-friendly clinical best practices, quality family planning guidelines, evidence-based clinical practices, expanding clinic capacity to serve larger numbers of youth, delivering culturally and linguistically competent care and billing practices to maximize reimbursement for contraceptive services Previous experience providing TA to a variety of practice settings, including but not limited to Title X clinics, FQHCs, community health clinics, pediatricians, school-based health centers and health departments.

• Needs Assessment During the first 6 months of the project period, awardee must develop, implement, and analyze results of a comprehensive needs assessment of the local community where health center and youth-serving system partners reside. For quality assurance and improvement purposes, assessments of health centers and youth-serving systems must be conducted within three months of partnership establishment and annually thereafter (specific timeframes determined by CDC). Results of needs assessments will inform T&TA provided by the grantee to health center and youth-serving system partners.

Community needs assessment should contain information including but not limited to data on: demographics and number of youth in the community, teen pregnancy and birth rates, STD/HIV rates, community knowledge of clinical services and the range of contraceptive services available to youth, community perception of teen pregnancy as an issue in their community, etc. Awardee can work with CDC project officer to determine level and method of data collection for needs assessment purposes.

Assessment of health centers will be completed using a CDC-developed needs assessment tool and will assess the range and quality of services provided to adolescents at a given health center. Assessment tool will be developed and receive approval from the Office of Management and Budget (OMB), under the Paperwork Reduction Act (PRA).

Assessment of youth-serving systems should include: number and demographics of youth within the system, current pregnancy prevention activities, knowledge of sexual and reproductive health services, knowledge of youth-friendly clinical services as well as clinical services available in the area for referral, assessments of current referral and linkage strategies and opportunities to establish new referrals and linkages. An assessment tool with core questions will be developed by CDC. Assessment tool will be developed and receive approval from OMB, under the PRA. Focus groups with youth and staff in the system(s) are examples of methods that might be used to collect this information.

• Development of Technical Assistance Plans, Tools, and Training material

By the start of Year 2, awardee must develop a detailed implementation plan, based on needs assessment results, and determine necessary tools and trainings to use, adapt or develop to meet the needs of the partners. By the start of Year 2, awardee must:

Subcontract with trainers that can provide training on evidence-based teen pregnancy prevention strategies and programs, if the expertise is not available internal at the awardee organization and is needed by partner organizations.

Adapt or develop training and technical assistance materials to build the capacity of health center partners and youth-serving systems (can be done in collaboration with subcontractor).

Develop an individualized technical assistance plan (TA plan) for each health center and youth-serving system partner. TA plans must be updated annually and based on annual assessments.

• Continuous Quality Improvement (CQI)

Awardee must continuously monitor progress through continuous quality improvement processes (e.g., Plan-Do-See-Act (PDSA), Getting to Outcomes (GTO)).

Partnerships

Within 6 months of receiving funding, awardee must establish a key partnership team with 1) a network of publicly funded health centers that provide sexual and reproductive health services to youth in the community, and 2) youth-serving systems that serve large numbers of vulnerable youth. Health center(s) and youth-serving system(s) should be located in geographic proximity to each other to ensure effective referral and linkages between the two systems. Each partner should have at least two representatives committed to this project.

A leader with decision-making capacity must be a part of the key partnership team and must participate in leadership meetings and trainings as appropriate.

A designated staff person/coordinator at each partnering agency must have time dedicated to this project and be a key contact for awardee agency. Awardee funds can be used to support staff time at each of these agencies, including evaluation and data collection activities.

Awardee must submit a Memorandum of Understanding (MOU) with each proposed partner at time of application submission. MOU must include 1) specific roles and responsibilities of each partner, 2) names and titles of individuals who will be committed to this project, 3) a description of how progress will be measured, and 4) the amount of funding that will be included in these sub-awards. MOU must explicitly state that partner will collect and submit data required for evaluation purposes.

Throughout the project, awardee must:

Host meetings between health centers and youth-serving systems so all participating staff are aware of services and staff at each organization to facilitate more effective referral and linkage relationships.

Host annual partnership meeting/training with leaders and key staff from the health centers and youth-serving systems

Awardee must partner with a national or regional organization with expertise in adolescent sexual and reproductive health that has the ability to provide training and on site TA to clinical TA providers and health center partners on topics including but not limited to: evidence-based clinical guidelines, youth-friendly clinical best practices, tiered contraceptive counseling, electronic medical records, data collection, and CQI processes. The regional or national organization must have previous experience developing and providing training and TA to a range of health centers, including Title X clinics, FQHCs, and health departments. Funds from this cooperative agreement must be used to subcontract training and technical assistance provision from this training organization as needed. The selection of this organization will be subject to CDC approval.

Strengthen Clinical Services and Improve the Quality of Care

By the start of year 2, awardee must form and develop leadership teams within each health center partner to 1) ensure implementation of youth-friendly clinical best practices, 2) regularly review and monitor data (at least every two months), and 3) encourage buy-in from frontline and clinical staff.

Awardee must provide T&TA to leaders and staff on youth-friendly clinical best practices and evidence-based guidelines. Evidence-based guidelines include the latest guidance from the US SPR, the US MEC, and the recommendations for providing quality family planning services. A list of youth-friendly clinical best practices will be provided by CDC. Training to health center partners will be facilitated by the clinical TA provider and the contracted training organization. Training and TA provided will cover topics including but not limited to:

Evidence-based, youth-friendly clinical best practices supported by CDC. Example practices include:

Same day, next day, or walk-in appointments are available for adolescents Appointments available at times convenient for adolescents (after school, weekends) Sexual health assessment done at every visit Wide range of contraceptives available, including LARCs, without barriers Quick start method for initiating hormonal contraception and IUD Provide contraception without unnecessary prerequisite exams or testing Provide STD and HIV testing Low- or no-cost services are available for adolescents Confidential sexual and reproductive health care is available to adolescents without need for parental or caregiver consent, as applicable by jurisdiction Have systems in place to facilitate billing third-party payers for sexual and reproductive health care services provided Have a counseling area that provides both visual and auditory privacy Have an examination room that provides visual and auditory privacy

Increasing health center staff knowledge, skills, and attitudes in tiered contraceptive counseling, sexual health history taking, and working with youth. Contraceptive counseling should include providers and youth working together to select a method that best fits the youth’s current needs.

Increasing staff capacity to deliver culturally and linguistically competent care.

Increasing capacity of the health center to increase patient load and to serve additional youth referred from youth-serving systems Increasing provider knowledge, skills, and comfort in all contraceptive methods, including LARC insertion procedures Working with management and fiscal staff to review billing procedures and reimbursements from third-party payers Conducting evaluation and CQI processes Clinic-based evidence-based teen pregnancy prevention programs (EBPs). EBPs can be found at: http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/programs.html #.U5iV2HbD-70

Strengthen Youth-Serving Systems and Linking Youth to Care

Identify potential opportunities and staff in positions to create and improve opportunities to assess sexual health history and to provide referrals and linkages to care. Youth-serving systems will be required to provide referrals to youth to health center partners for sexual and reproductive health services, including but not limited to contraceptive services and STD testing and/or treatment.

Provide T&TA to leaders of youth-serving systems to implement teen pregnancy prevention efforts, including conducting sexual health assessments and referring and linking youth to youth-friendly sexual and reproductive health services.

Provide T&TA to identified staff who work directly with the youth in the youth-serving systems (i.e., case workers, social workers, probation officers, nurses, health education teachers) on basic sexual and reproductive health, sexual and reproductive health services provided in the community, cultural competency, adolescent development, and how to make an effective referral to health centers partners.

Provide T&TA to implement teen pregnancy prevention evidence-based interventions (EBI) if implementation of an EBI is feasible and appropriate for the youth-serving system partner. Awardee may contract with a training organization for EBP specific trainings if internal capacity is not available. EBPs can be found at: http://www.hhs.gov/ash/oah/oah-initi atives/teen_pregnancy/db/programs.html#.U5iV2HbD-70 If youth-serving system has an existing health center, T&TA on strengthening the clinical services and quality of care provided at the on site health center are expected. See activities above in Strengthen Clinical Services and Improve the Quality of Care.

System Change Approaches

Enhance health centers’ infrastructure and capacity for the institutionalization of evidence-based guidelines and youth-friendly clinical best practices. This may include the development or strengthening of clinical standard operating procedures, the development or reinforcement of policies to ensure youth sexual and reproductive health needs are addressed at every visit, or supporting and implementing environmental changes such as extended clinic times to accommodate youths’ schedules.

Develop youth-serving systems’ infrastructure and capacity to assess and address the sexual and reproductive health needs of youth in their population to effectively refer and link youth to care and to ensure continuity of care. This may include the development or strengthening of policies and standard operating procedures to conduct a sexual health assessment of all youth within the system, the development of a referral and linkage system to permit partnering health centers, and supporting and providing staff training on sexual and reproductive health.

http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/programs.html#.U5iV2HbD-70 http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/programs.html#.U5iV2HbD-70 http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/programs.html#.U5iV2HbD-70 http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/programs.html#.U5iV2HbD-70

Build the infrastructure for implementing and evaluating a referral and linkage system between health center partners and youth-serving systems, with the ability to track youth who are linked to care.

Communications

Develop, implement, and evaluate focused health communication efforts. Health communication efforts, including targeted communications campaigns, should be designed to promote the youth-friendly services of the partner clinics; raise awareness of teen pregnancy prevention and the range of contraceptive methods, including LARC; and increase the number of youth accessing sexual and reproductive health services. Communication activities include but are not limited to development of marketing materials (including social media) for health center partners, patient education materials, and parent education materials. Communication materials must be approved by CDC and should undergo audience testing prior to dissemination.

Communication activities should support strategies and activities in this FOA, but will not be the focus of this cooperative agreement. No more than 10% of funding should go toward communication efforts.

1.Collaborations

Required partnerships are listed above under Partnerships in the Strategies and Activities section.

Awardee will be required to collaborate with other awardees under this cooperative agreement.

a. With CDC-funded programs:

Awardees are encouraged to collaborate with other CDC-funded programs in their jurisdiction that serve the target audience and that have a role in achieving the outcomes sought through this FOA. Awardees must plan their activities so that their efforts complement other CDC-funded programs operating within the community. These partnerships are optional. Other CDC-funded programs include programs funded by:

• CDC Division of Adolescent and School Health

• CDC Division of HIV/AIDS Prevention

• CDC Division of Violence Prevention

• CDC Division of STD Prevention

b. With organizations external to CDC:

Awardees are encouraged to collaborate with other federal agencies and their grantees, if appropriate. These partnerships are optional and include but not limited to the following:

• Centers for Medicare and Medicaid Services (CMS)

• Grantees of the HHS Office of Adolescent Health (OAH)

• Office of Population Affairs (OPA) Title X grantees

• HRSA federally qualified health centers Other collaborations may include state or local teen pregnancy prevention organizations, state and local health departments, departments of juvenile justice, social service agencies, foster care agencies, departments of education, national organizations with a focus on teen pregnancy prevention, community health clinics, faith-based organizations, organizations serving LGBT youth, health insurers, state primary care associations, university/academic institutions, or non-traditional partners (e.g., parks and recreation, transportation, public safety, housing, workforce development).

2. Target Populations

Strategies and activities in this cooperative agreement will target youth accessing or eligible for publicly funded health centers and those in youth-serving systems. Publicly funded health centers include health departments, community health centers, federally qualified health centers, and Title X clinics. Youth-serving systems participating in the project should serve large numbers of vulnerable youth. System types include but are not limited to juvenile justice, foster care, education, or social services.

Vulnerable youth are at risk of health disparities due to low socioeconomic status (SES), race/ethnicity (with respect to high pregnancy rates among teens who are Black or African-American, Hispanic or Latino, Native Hawaiian or other Pacific Islander, American Indian and Alaska Native), exposure to social determinants negatively affecting health (e.g., poor housing, poor education, stressful neighborhood environment, high community unemployment, etc.), being out of school, living in foster care, homelessness, experiencing trauma or domestic violence, geography (e.g., remote rural areas with limited services, marginalized urban communities), involvement with juvenile justice, substance abuse, being a pregnant/expecting teen or a teen parent. (Adapted from CDC Office of Minority Health and Health Equity, HHS Office of Adolescent Health, and John Snow, Inc.)

Applicant must demonstrate that they are located in a state with a teen birth rate higher than the 2013 national average (26.6 births per 1,000 female adolescents aged 15-19) and that health centers and youth-serving system partners are located in an area (county/city) with teen birth rates above the national average. Applicant must use data to describe the youth accessing the health centers and youth-serving systems and the need for teen pregnancy prevention strategies proposed in this FOA. Census tract or county-level data can be used to demonstrate vulnerability, as well as vital statistics data, and data from local health surveys and hospitals, among other sources.

a. Inclusion

This FOA will include all youth within a given youth-serving system and health center, which may or may not include youth with disabilities, non-English speaking youth, lesbian, gay, bisexual, and transgender (LGBT) youth, and youth with low health literacy.

iv. Funding Strategy (for multi-component FOAs only)

N/A

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy

Evaluation and performance measurement data will be used to demonstrate the achievement of program outcomes and to build the evidence base on efforts to refer and link vulnerable youth to sexual and reproductive health services. CDC will work with awardees to: (1) ensure accurate reporting on CDC performance and outcome measures as specified in this FOA, (2) develop and implement community-specific evaluation plan(s), and (3) finalize measures and assist with the identification of data collection approaches. The evaluation will provide data on the progress awardees are making in implementing their strategies and their progress in achieving the project-period outcomes related to reducing teen pregnancy through increased access and use of quality sexual and reproductive health services among youth aged 15 to 19.

Awardees are required to (1) collect and report on outcome measures as reflected in the FOA, (2) report on performance measures as outlined below, and (3) develop and implement an evaluation plan that addresses implementation of strategies and progress on performance measures. The performance measures described below are not exhaustive and additional performance measures will be developed as appropriate during the first 6 months of the cooperative agreement. CDC will obtain approval of all developed measures through the Office of Management and Budget and awardees will be required to report on all approved measures. Applicants should allocate at least 10% of their total funding award toward evaluation efforts and performance monitoring.

CDC will manage and synthesize the required outcome performance measure data submitted by awardees. Throughout the 4 years of the project implementation period, CDC will work individually and collectively with the awardees to answer the following evaluation questions based on the program logic model.

1. To what extent have formal agreements (MOU/MOA) been established between youth-serving systems and health care centers?

2. What resources did health center and youth-serving system partner organizations contribute to the initiative?

3. How many health center network partners have formal agreements (MOU/MOA) to participate in a health care network and on a partnership team?

4. What planned and actual procedures were used to foster partnerships between health centers and youth-serving system?

5. To what extent were planned training and technical assistance provided to health center leaders as planned?

6. What proportion of health center leaders and staff received training in youth-friendly services and best practices?

7. To what extent have health center leaders and staff knowledge about and support of evidence-based clinical guidelines, youth-friendly services and TPP strategies increased?

8. To what extent have health center partners implemented evidence-based guidelines and youth-friendly best practices?

9. Has the number of youth visits that include sexual and reproductive health services increased for health care network partners?

10. Have health care centers increased the number of youth who receive moderately effective contraceptive methods (i.e., pill, patch, ring) and highly effective methods (i.e., IUD, implants)?

11. To what extent were planned training and technical assistance provided to youth-serving systems as planned?

12. What proportion of youth-serving system leaders and staff received training in TPP strategies?

13. To what extent have youth-serving system leaders and staff knowledge about and support of TPP strategies increased?

14. To what extent have youth-serving systems implemented TPP strategies to refer and actively link youth to services?

15. What number and proportion of youth were reached by at least one TPP strategy in the youth-serving system?

16. Have youth-serving systems increased the number of youth they refer and link to health centers for reproductive health services?

17. Has the number of youth who visit health care centers for reproductive health services after referrals from youth-serving systems increased?

18. To what extent have youth-serving systems implemented evidence-based teen pregnancy prevention interventions to delay sexual activity and increase use of sexual and reproductive health services for youth? (If EBIs are implemented)

19. To what extent have youth increased their knowledge of and intentions to use contraceptive and reproductive health services?

20. What planned and actual health communication efforts were used to attract youth to the health centers?

21. What proportion of youth who received contraceptive services (i.e., moderately to highly effective contraceptive methods) were reached through health centers’ communication efforts?

Process measures: CDC will work with awardees to identify, develop, and report on process measures that describe strategies that are implemented to refer and link youth to reproductive health services. Strategies and measures must be included in the awardee evaluation plan. The awardee will be required to manage the collection and reporting of process measure data to CDC for all health centers and youth-serving systems.

Outcome and…