CDC-RFA-DP20-2002.pdf

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Public Health and Health Systems Partnerships to Increase Colorectal Cancer Screening in

Clinical Settings

CDC-RFA-DP20-2002

Application Due Date: 03/17/2020

Public Health and Health Systems Partnerships to Increase Colorectal Cancer Screening in

Clinical Settings

CDC-RFA-DP20-2002

TABLE OF CONTENTS

Part I. Overview Information A. Federal Agency Name B. Funding Opportunity Title C. Announcement Type D. Agency Funding Opportunity Number E. Assistance Listings (CFDA) Number F. Dates G. Executive Summary

Part II. Full Text A. Funding Opportunity Description B. Award Information C. Eligibility Information D. Application and Submission Information E. Review and Selection Process F. Award Administration Information G. Agency Contacts H. Other Information I. Glossary

Part I. Overview Information Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Subscribe" button link to ensure they receive notifications of any changes to CDC-RFA- DP20-2002. 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) / Agency for Toxic Substances and Disease Registry (ATSDR) B. Notice of Funding Opportunity (NOFO) Title:

Public Health and Health Systems Partnerships to Increase Colorectal Cancer Screening in Clinical Settings C. Announcement Type: New - Type 1 This announcement is only for non-research activities supported by CDC. If research is proposed, the application will not be considered. For this purpose, research is defined at https ://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf.

Guidance on how CDC interprets the definition of research in the context of public health can be found at https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html (See section 45 CFR 46.102(d)).

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP20-2002

E. Assistance Listings (CFDA) Number:

93.800 F. Dates:

1. Due Date for Letter of Intent (LOI): 02/05/2020

2. Due Date for Applications: 03/17/2020, 11:59 p.m. U.S. Eastern

Standard Time, at www.grants.gov.

3. Date for Informational Conference Call:

01/29/2020 Informational Conference Calls for Potential Applicants: CDC will conduct two (2) informational conference calls for interested applicants on January 29, 2020 at 11:00 AM and 3:00 PM Eastern Standard Time. The calls will last no longer than an hour and a half.

Conference call lines are limited, so we encourage those who can to call in together from one line/location.

Call-in information:

Toll-free Number: 1-866-510-1407 Toll Number: 1-517-968-2548 Participant Passcode: 80681704

G. Executive Summary:

https://www.grants.gov https://www.grants.gov https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html https://www.grants.gov

1. Summary Paragraph:

This announcement provides funds to recipients to partner with health systems and individual primary care clinics to implement evidence-based interventions (EBIs) to increase colorectal cancer (CRC) screening uptake among applicant defined populations age 50-75 years that have CRC screening rates lower than the national, regional, or local rate. Recipients will: 1) establish partnerships with health systems and primary care clinics to implement at least two of four EBIs recommended in The Community Guide (client reminders, provider reminders, reduction of structural barriers, and provider assessment and feedback); 2) establish partnerships with organizations that provide expertise to support the implementation of EBIs in primary care clinics; 3) conduct a formal assessment of each clinic's capacity/readiness to implement EBIs;

4) utilize the clinic assessment to select appropriate EBIs to implement; 5) provide resources to partner clinics to provide and support completion of follow-up colonoscopies after a positive or abnormal screening test; and 6) collect and submit high-quality clinic-level data including baseline and annual CRC screening rates.

a. Eligible Applicants: Open Competition

b. NOFO Type: Cooperative Agreement

c. Approximate Number of Awards: 35

d. Total Period of Performance Funding: $110,000,000

e. Average One Year Award Amount: $500,000

f. Total Period of Performance Length: 5

g. Estimated Award Date: 06/30/2020

h. Cost Sharing and / or Matching Requirements: N Cost sharing or matching funds are not required for this program. Although no statutory matching requirements for the NOFO exists, leveraging other resources and related ongoing efforts to promote sustainability is strongly encouraged.

Part II. Full Text A. Funding Opportunity Description

Part II. Full Text

1. Background

a. Overview Colorectal cancer (CRC) is the second leading cause of death from cancer in the United States.

There is substantial evidence that screening for CRC reduces the incidence of and death from this disease. Screening for CRC can both detect disease early when treatment is more effective and prevent cancer by finding and removing precancerous polyps. Of individuals diagnosed with early stage CRC, more than 90% live five or more years.

The U.S. Preventive Services Task Force recommends screening average risk adults age 50-75 years for CRC with either: 1) fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, 2) multi-target stool DNA (also referred to as FIT-DNA) every 1 or 3 years, 3) colonoscopy every 10 years, 4) computed tomographic colonography (CTC) every 5 years, 5) flexible sigmoidoscopy every 5 years, or 6) flexible sigmoidoscopy every 10 years with FIT annually.

Despite strong evidence that screening for CRC is effective, only 68.8% of age-eligible adults report being up-to-date with CRC screening. Approximately 22 million adults have never been screened or are not up-to-date with screening. Individuals age 50-64 years, men, racial and ethnic minorities, those who do not live in a city, and people with lower educational attainment and annual household income are less likely to be screened. Lower rates of screening directly contribute to disparities in CRC morbidity and mortality.

Barriers to CRC screening include lack of a provider recommendation, lack of awareness, not having a choice of tests, the absence of systematic processes to identify patients due for screening and to support them through the screening process, lack of transportation, language barriers, and lack of access to health care systems during normal working hours. The Community Guide (https ://www.thecommunityguide.org/topic/cancer) has identified evidence-based interventions (EBIs) that address many barriers to CRC screening. These include interventions to increase community demand (client reminders), interventions to increase community access (e.g., reducing structural barriers through alternative screening sites or hours, addressing transportation barriers, providing translation services), and interventions to increase provider delivery of screening services (provider reminders, provider assessment and feedback). The Community Guide also recommends multi-component interventions which combine two or more intervention approaches (e.g. combining interventions to increase community demand with interventions to increase provider delivery), or two or more interventions to reduce structural barriers. Patient navigators (people trained to assist patients with navigating the health care system) often provide services that overlap with or support these EBIs, particularly the reduction of structural barriers (e.g., assisting with appointment scheduling, reminding patients to complete tests, arranging transportation or language translation services, providing education about screening).

To address barriers to CRC screening, this program will support public health and health system partnerships to implement EBIs recommended by The Community Guide to increase and improve the quality of CRC screening and follow-up testing. Using data to identify high-need populations and the health systems serving them and implementing combinations of these EBIs will result in increased CRC screening rates and ultimately decreased CRC incidence and mortality.

b. Statutory Authorities This program is authorized under section 301(a) of the Public Health Service Act, [42 U.S.C section 241(a)], as amended.

c. Healthy People 2030 This program is directly related to the Healthy People 2020 Cancer (HP-C) Focus Area: a) Reduce the age-adjusted annual rate of cancer mortality per 100,000 population; b) Reduce the colorectal cancer death rate (HP-C5); c) Increase the proportion of adults who receive a colorectal https://www.thecommunityguide.org/topic/cancer https://www.thecommunityguide.org/topic/cancer cancer screening based on current guidelines (HPC-16).

d. Other National Public Health Priorities and Strategies This program supports using evidence-based strategies to increase uptake of colorectal cancer screening tests, particularly among populations with low colorectal cancer screening rates, and that align with the following national plans and guidelines:

The Community Guide https://www.thecommunityguide.org/topic/cancer The National Partnership for Action to End Health Disparities https://www.minorityhealth.hhs .gov/npa/

e. Relevant Work

The Colorectal Cancer Control Program (CRCCP): In 2015 CDC funded 30 recipients to implement the CRCCP. Recipients partnered with health systems to implement EBIs in primary care clinics serving populations with low annual household incomes and low CRC screening rates. Recipients focused on four priority EBIs from The Community Guide (client reminders, reducing structural barriers, provider reminders, provider assessment and feedback) and several supporting activities (small media, patient navigation, provider education, health information technology). Six of the recipients received funding to provide direct screening services to average risk, low-income, uninsured and underinsured people. https://www.cdc.gov/cancer/crccp/

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

Strategies Short-term Outcomes

Intermediate Outcomes

Long-term Outcomes

Establish partnerships with health system/primary care clinics Establish partnerships to support implementation of evidence-based interventions (EBIs) Conduct implementation

Increased clinic-level

CRC

screening rates

Increased number of cancers prevented

Increased diagnosis of early stage

CRC

Reduced CRC incidence and mortality https://www.thecommunityguide.org/topic/cancer https://www.minorityhealth.hhs.gov/npa/ https://www.minorityhealth.hhs.gov/npa/ https://www.cdc.gov/cancer/crccp/ readiness assessment of partner primary care clinics Implement EBIs Facilitate patients' linkage to follow-up colonoscopy Data quality, program monitoring and evaluation

i. Purpose The purpose of this program is to implement EBIs in primary care clinics that provide clinical services to populations with low CRC screening rates to increase clinic-level CRC screening rates.

ii. Outcomes As displayed in the logic model, the key outcome of this program by the end of the period of performance is:

1) Increased clinic-level CRC screening rates.

Over time, increased screening is expected to result in the intermediate outcomes of increased number of cancers prevented, increased diagnosis of early stage CRC, and ultimately the long-term outcomes of decreased CRC incidence and mortality among the population reached by program activities.

iii. Strategies and Activities Applicants must propose activities for all strategies as outlined in the logic model. All applicants, including those that are regional in scope or are national organizations must identify a target population(s) in one state, tribe, tribal organization, or territory, and implement all required program activities in the selected state, tribe, tribal organization, or territory.

1. Establish partnerships with health system/primary care clinics Primary care clinic partners can include, but are not limited to: Federally qualified health centers (FQHCs), other publicly funded entities that provide primary care services, or private entities that provide primary care services. Recipients are required to collaborate with primary care clinics to implement the recipient’s proposed strategies and activities in individual clinics. Recipients may also partner with health systems that are comprised of several primary care clinics (hereafter referred to as health systems), however recipients should plan to implement program strategies and activities at the clinic level.

a. Use data to identify priority populations and select appropriate primary care clinics to implement the CRCCP

i. Utilize data (e.g., cancer registry, Behavioral Risk Factor Surveillance System, HRSA UDS, other state or local data sources) to identify and describe a defined target population(s) age 50-75 years that has a CRC screening rate lower than the state or national overall screening rate, or known screening rate for that population.

ii. Utilize data (e.g., HRSA UDS, clinic location data, other state or local data sources) to identify primary clinic partners that serve the applicant defined target population.

b. Establish formal agreements with primary care clinics or health systems

i. Strengthen existing or establish new formal partnership agreements (e.g., memorandum of agreement, contract) with identified primary care clinics or health system partners (health system or individual clinic) that serve the applicant’s defined target population to facilitate implementation of EBIs to increase CRC screening within the identified clinics.

2. Establish partnerships to support implementation of EBIs

a. Collaborate with partners to support program implementation and data monitoring

i. Partnerships to support clinic implementation of EBIs include but are not limited to: health care plans, health care networks, hospitals, non-profit organizations, primary care associations, health center controlled networks, payers and insurers, regional medical associations, and professional organizations.

ii. Identify partners that have expertise in implementing EBIs in primary care clinics (e.g., expertise in clinic workflow or process mapping, assessment of clinic readiness to implement EBIs, quality improvement, data management, data quality, use of electronic health record data for population management, implementation of EBIs in clinic settings).

iii. Identify partners that have experience implementing interventions for identified target populations and in clinic settings.

iv. Establish formal agreements (e.g., memorandum of agreement, contract) with the identified partners.

3. Conduct implementation readiness assessment of partner primary care clinics

a. Conduct formal assessment of each clinic’s capacity/readiness to implement EBIs and identify needed data system improvements and EBIs for implementation

i. Prior to implementation of EBIs, an implementation readiness assessment of each clinic must be performed. The purpose of the implementation readiness assessment is to document the clinic's current CRC screening process, the quality of CRC screening data in the electronic health record (EHR), and available clinic resources in order to 1) guide the selection of EBIs to address identified gaps and opportunities, and 2) identify and conduct any needed quality improvement activities prior to implementation of EBIs (e.g., improving the quality of EHR screening data). CDC will review the results of the implementation readiness assessment prior to the implementation of EBIs in the clinic.

The readiness assessment should include, at a minimum:

1. Calculation of the baseline CRC screening rate in the clinic;

2. Process or workflow mapping of the CRC screening process (e.g., how the clinic identifies who is due or overdue for screening; how patients are notified that they are due for screening; how and by whom CRC screening tests are ordered; how people receive their CRC screening test kit or order; how people are referred for colonoscopy;

how the clinic tracks completion of ordered or referred tests; how the clinic ensures that people with an abnormal test receive appropriate follow-up testing);

3. An assessment of the clinic’s EHR (e.g., how and where CRC screening test information is captured, how CRC screening rates are calculated, validation of the CRC screening rate through manual record review);

4. An assessment of EBIs currently used by the clinic to determine implementation quality;

5. An assessment of clinic resources and capacity available to support EBI implementation (e.g., staff, leadership support).

ii. The completed assessment should be used in collaboration with clinic staff to identify gaps and opportunities for improving the clinic screening process, identify opportunities to improve EHR data quality, select appropriate EBIs to address identified gaps, and develop a plan to implement the selected EBIs.

iii. Applicants must describe their implementation readiness assessment tool and how they will conduct the clinic implementation readiness assessments.

4. Implement EBIs (evidence-based interventions)

a. Implement multiple EBIs in partner health systems/clinics consistent with clinics’ implementation readiness assessments

i. Recipients must implement at least two of the four required EBIs described below in each partner clinic, and should choose interventions based on the results of the clinic implementation readiness assessment.

ii. The required EBIs include:

1.Provider Assessment and Feedback – Interventions that evaluate provider performance in delivering or offering screening to patients (assessment) and presentation of information to providers about their performance in providing screening services (feedback).

2. Provider Reminders – Reminders inform health care providers it is time for a client’s cancer screening test (called a “reminder”) or that a client is overdue for screening (called a “recall”).

3. Client (or patient) Reminders – Written (letter, postcard, email) or telephone messages (including recorded/automated messages) advising people that they are due for screening. Client reminders can be general to reach the overall target population or tailored with the intent to reach one specific person based on characteristics unique to that person, related to the outcome of interest, and derived from an individual assessment.

4. Reducing Structural Barriers – Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening (e.g., inconvenient clinic hours, lack of transportation).

b. Utilize patient navigation to support delivery of EBIs

i. Patient navigators may be used to help patients overcome barriers and support adherence to screening completion (e.g., ensuring return of FITs), follow-up testing (colonoscopy), and initiation of cancer treatment if relevant, and to support implementation of required clinic-based EBIs.

ii. Existing small media materials may be used, or adapted for use, to support implementation of patient navigation and client reminder interventions.

c. Provide support to clinics to implement EBIs

i. Develop a plan or protocol for how the recipient will provide implementation support to primary care clinics for data monitoring and EBI implementation. The plan/protocol should include, but not be limited to: types of support to be provided, organizations delivering support to primary care clinics, anticipated amount of implementation support to be delivered, and change in types and amount of implementation support over time for a given primary care clinic.

ii. Recipients must monitor and support implementation in each clinic (e.g., bi-weekly conference calls, site visits, or other methods to meet with clinics to assess progress, and identify and resolve problems).

iii. Recipients should identify and collaborate with a CRC screening champion that work within the clinic or parent health system.

5. Facilitate patients’ linkages to follow-up colonoscopy

a. Provide resources to partner clinics to pay for follow-up colonoscopies

i. Recipients may use limited funds with CDC approval to pay for follow-up colonoscopies for asymptomatic uninsured or underinsured adults age 50-75 who are screened for colorectal cancer by their partner clinics. Funds may not be used to pay for colonoscopies to evaluate or diagnose symptomatic patients.

ii. Recipients may use awarded funds to pay for a colonoscopy following a positive or abnormal fecal immunochemical test (FIT), fecal occult blood test (FOBT), sigmoidoscopy, computed tomographic colonography (CTC), or multi-target stool DNA test (mts-DNA) if these tests were ordered or performed by a partner clinic (e.g., a clinic in which the recipient is implementing EBIs and clinic-level data are being reported on screening rates) for the purpose of screening asymptomatic adults for CRC. Colonoscopies provided by the program should meet national quality standards.

iii. Reimbursement for colonoscopy may not exceed the Medicare rate (the reimbursement rate by the federal government as established by the Centers for Medicare and Medicaid Services).

iv. The Federal government is the payor of last resort. Awarded funds must be used as the payment of last resort and may not supplant other available sources of payment for colonoscopy.

v. Recipients must report, in aggregate, for follow-up colonoscopies paid for with CRCCP funds: the number of patients provided a follow-up colonoscopy, the final test results (cancer, adenomatous polyp, non-adenomatous polyp, other abnormal finding, or normal), the number of patients referred for cancer treatment, and the number of patients that start cancer treatment as part of the CDC required clinic data.

vi. Applicants must describe how they will secure treatment resources for patients diagnosed with cancer or those needing additional evaluation or treatment.

vii. All applicants must describe how they will facilitate linkage to follow-up colonoscopy regardless of whether or not the applicant intends to use awarded funds to support this activity.

b. Provide support to patients to facilitate the completion of follow-up colonoscopies

i. Patient navigators may be used to facilitate screening and reduce barriers to colonoscopy completion regardless of the source of payment for the colonoscopy (e.g., educating patients about the procedure, assisting with scheduling, providing instructions for bowel preparation, providing appointment reminders, assisting with transportation or translation services, other related activities).

6. Data quality, program monitoring and evaluation

a. Plan and conduct program monitoring and evaluation

i. Recipients must have staff with expertise in evaluation, data collection, data management, and data reporting.

ii. Participate in an annual CDC-led grantee survey, as directed by CDC.

iii. Conduct process and outcome evaluation to assess all program activities, including clinic-level EBI implementation and screening rate changes. Monitoring implementation can serve as an early detection system to identify implementation problems allowing for mid-course corrections.

iv. Develop and submit annual monitoring and evaluation results in a report that summarizes key findings and describes how results have been used for program improvement, best practices that have been identified, and success stories.

b. Collect high quality clinic-level data on implementation and outcomes

i. Recipients must be able to report a baseline and annual data record, as defined by CDC, for each clinic that includes:

1. Characteristics of health systems/clinics and their patient populations;

2. The EBIs that are implemented;

3. The total number of adults age 50-75 years assigned to the clinic that are eligible for CRC screening;

4. Of the total number of adults age 50-75 years served by the clinic, the number that received an appropriate CRC screening test within the recommended time frame;

5. The CRC screening prevalence (referred to as CRC screening rate) for each clinic (number of adults age 50-75 years that received an appropriate CRC screening test within the recommended time frame/total number of adult age 50-75 years served by the clinic who are eligible for CRC screening) prior to implementation of any EBIs.

6. Annual CRC screening rate for each clinic;

7. The number of patients given a FIT or FOBT kit and the percentage of patients that returned a kit to the clinic;

8. The number of patients with a positive or abnormal screening test and percentage that completed a follow-up colonoscopy;

9. The total number of colonoscopies paid for with CDC CRCCP funds;

10. Final results of colonoscopies paid for with CDC CRCCP funds (in aggregate, the number of colonoscopies provided and the final results [cancer, adenomatous polyp, non-adenomatous polyp, other abnormal finding, or normal], the total number of patients diagnosed with CRC and percent starting treatment).

ii. Recipients must have expertise in, or partner with an organization that has expertise in, extracting population health data from electronic health records (EHRs) and in improving the quality of data entered into and extracted from EHRs.

iii. Recipients should validate each clinic’s reported EHR CRC screening rate through manual chart review within the first year of a clinic’s participation in the program, and if discrepancies exist, identify and address issues to improve data quality.

c. Use monitoring data for quality and program improvement

i. Routinely analyze clinic and other program monitoring data to assess data quality and identify areas for quality improvement.

ii. Regularly review clinic data, including screening rate (e.g., monthly, quarterly), implementation successes and challenges, and other program monitoring data with partner clinics to monitor progress and improve implementation of EBIs.

iii. Participate in CDC-led data review process.

iv. Conduct data-driven planning to maximize program resources.

1. Collaborations

a. With other CDC programs and CDC-funded organizations:

Recipients are expected to collaborate with CDC-funded programs that are currently funded in the recipient’s state, county, city, Tribe or tribal organization, or territory to coordinate program activities to avoid duplication of effort. Relevant CDC-funded programs may have established partnerships with organizations that can support the applicant’s proposed activities, may be implementing EBIs in health systems, or may provide data that inform program activities.

Relevant CDC-funded programs include:

National Breast and Cervical Cancer Early Detection Program (https://www.cdc.gov/cancer /nbccedp/) National Comprehensive Cancer Control Program (https://www.cdc.gov/cancer/ncccp/) https://www.cdc.gov/cancer/nbccedp/ https://www.cdc.gov/cancer/nbccedp/ https://www.cdc.gov/cancer/ncccp/

National Program of Cancer Registries (https://www.cdc.gov/cancer/npcr/) WISEWOMAN program (https://www.cdc.gov/wisewoman/index.htm) The Cancer Prevention and Control Network (https://www.cpcrn.org/ )

b. With organizations not funded by CDC:

Recipients are required to collaborate with primary care clinics to implement program activities.

To demonstrate organizational capacity to establish partnerships with primary care clinics, applicants must provide a signed Letter of Support (LOS) from:

• At least two separate primary care clinics that provide services to adults (applicant will provide two separate LOS);

OR

• One health care system with at least two primary care clinic sites that provide services to adults (e.g., a Federally Qualified Health Center could be considered a health system and may have multiple primary care clinic sites) (applicant may provide one LOS from the health care system describing both clinics).

Each letter from the health system or clinic should describe:

• The approximate number of adults age 50-75 years currently served by the clinic;

• The clinic’s current CRC screening rate (the percentage of adults up-to-date with CRC screening);

• The clinic’s willingness to participate in a detailed clinic assessment and to implement the recommended EBIs;

• The clinic’s ability and willingness to submit required data to the applicant.

The information should be provided for each proposed clinic partner (e.g., if submitting one LOS from a health system, then the information above should be provided for each clinic expected to participate in the program).

Recipients are also expected to collaborate with organizations that support the implementation of EBIs in primary care clinics. If the applicant proposes such collaborations, then a Letter of Support should be provided for each proposed partner organization. Each letter should describe the organizations proposed role in implementation of the program and the expertise that they will provide (e.g., using EHR data for population management, data quality improvement, EBI implementation and/or practice quality improvement, evaluation support).

Each letter of support should be dated within 3 months of the application due date. Applicants must upload the LOS as PDF files at www.grants.gov under “Other Attachment Forms” and name the file “Letters of Support" .

2. Target Populations The target population is average risk adults age 50-75 years who are eligible for CRC screening as recommended by the U.S. Preventive Services Task Force and have a CRC screening rate that https://www.cdc.gov/cancer/npcr/ https://www.cdc.gov/wisewoman/index.htm https://www.cpcrn.org/ https://www.grants.gov/ is lower than the average screening rate in the proposed geographic area.

All applicants, including those that are regional in scope or are national organizations, must identify a target population(s) in one state, tribe, tribal organization, or territory, and implement all required program activities in the selected state, tribe, tribal organization, or territory.

Applicants must describe:

• The geographic area in which program activities will be implemented (e.g., statewide, a specific region of a state, in a city, in a county, or other geographic unit);

• The approximate number of unscreened (people who have never been screened or are overdue for screening) people age 50-75 years in the proposed geographic area;

• The percentage of the population in the proposed geographic area living in an urban or rural area (as defined by the U.S. Census Bureau at https://www.census.gov/programs-surve ys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html) or frontier and remote areas (as defined by the U.S. Department of Agriculture at https://www.ers.usda.gov/data-products/frontier-and-remote-area-codes/).

Recipients must plan to implement the program in primary care clinics that serve adults age 50-75 years and have a CRC screening rate that is lower than the local or state screening rate.

Recipients should prioritize clinics with a CRC screening rate of <60%.

The impact of the program is a function of both the number of persons reached and the increase in clinic-level CRC screening rates. Consequently, recipients are encouraged to use resources efficiently by partnering with clinics that serve large numbers of the target population. However, public health is responsible for ensuring appropriate populations in less populated areas also benefit from the program.

a. Health Disparities Recipients should prioritize clinics that reach populations known to have lower CRC screening rates including, but not limited to, rural populations, racial and ethnic minorities, people with low annual household incomes, people who are uninsured, or people with lower levels of educational attainment. Recipients should also prioritize populations for whom there may be limited data about CRC screening test use but are known to have limited access to care or poorer health outcomes (e.g., non-English speaking populations, sexual and gender minorities, people with physical or mental health disabilities).

iv. Funding Strategy No more than one applicant per state, tribe, tribal organization, or U.S. territory will be awarded CRCCP funds, up to a maximum of 35 awards. All applicants, including those that are regional in scope or are national organizations must identify a target population(s) in one state, tribe, tribal organization, or territory, and implement all required program activities in the selected state, tribe, tribal organization, or territory.

b. Evaluation and Performance Measurement https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html https://www.ers.usda.gov/data-products/frontier-and-remote-area-codes/

i. CDC Evaluation and Performance Measurement Strategy Evaluation and performance measurement help demonstrate achievement of project outcomes;

build a stronger evidence base for specific interventions; clarify applicability of the evidence base to different populations, settings, and contexts; and, drive continuous improvement. Evaluation and performance measurement can also determine if the intended populations are reached and program impact is achieved. CDC’s evaluation strategy is grounded in the CDC Evaluation Framework for Public Health, MMWR, September 18, 1999, Vol. 48 / No. RR-11. CDC requires ongoing evaluation and performance measurement under this NOFO. CDC expects recipients to maintain sufficient staffing and analytic capacity to meet these requirements.

Recipients are required to report data to CDC on a regular basis so that CDC can monitor progress toward achieving specific outcomes of the NOFO. These data include a clinic-level record (data submitted for each clinic) collected at baseline when a clinic is recruited into the program and annually, thereafter. The clinic-level data includes the measure "clinic CRC screening rate among adults age 50-75 years" which will be used to measure progress towards the outcome of interest (increased clinic-level screening rates). Additionally, recipients will complete an annualrantee survey administered by CDC, a quarterly program monitoring update, and an annual evaluation report. Data collected includes information about the characteristics of partner health systems, the number and type of implementation partners, EBIs implemented, linkages to follow-up colonoscopy, and recipient data quality and monitoring activities. These CDC data reporting requests are subject to review and approval by the Office of Management and Budget (OMB). CDC will finalize a set of performance measures in consultation with recipients within 6 months of award.

Based on required data reported to CDC, CDC will calculate performance measures to assess implementation progress and determine whether increases in CRC screening rates are achieved.

CDC will produce reports, including comparative reports, based on these data and disseminate them to recipients in a timely manner. CDC will use these reports to foster discussions with recipients about data quality, program challenges and successes, improvements in intervention strategies, and untapped opportunities. CDC will conduct, at a minimum, an annual data review aimed at continuous program quality improvement.

Special Studies CDC may request that recipients participate in special studies including ones to examine the cost effectiveness of EBIs and other program activities. These studies will require collection of cost data and, in some cases, additional implementation and outcome data. Recipients will also participate in qualitative interview studies to improve understanding of program implementation.

Success Stories CDC may request that recipients submit success stories periodically describing successful partnerships, implementation of EBIs, best practices, data quality improvement efforts, and challenges that were successfully addressed. Success stories may also include information about partnerships, strategies or interventions that were not successful and required a redirection of program efforts.

Recipient-specific Evaluation and Monitoring Activities In addition to reporting clinic data and completing the annual grantee survey, recipients will conduct their own monitoring and evaluation activities to support on-going program improvement and assess program effectiveness. CDC expects all recipients to analyze and use their clinic and other program data for continuous program improvement and to inform replication and sustainability.

Recipients typically collect additional data and information that are not sent to CDC but are critical to tracking EBI implementation and program progress, and informing internal procedures.

Recipients should not consider the data required by CDC, or any reports produced by CDC, as sufficient alone for program monitoring and evaluation.

The specific number and types of evaluations conducted by a recipient will vary based on their program scope and approach, but it is expected that major program components will be evaluated during the period of performance. Moreover, recipients are encouraged to conduct or participate in more in-depth evaluations of selected program activities to characterize program efficiencies, effectiveness, and cost-effectiveness. Recipients are encouraged to contribute to the practice-based evidence for CRC screening programs.

ii. Applicant Evaluation and Performance Measurement Plan Applicants must provide an evaluation and performance measurement plan that demonstrates how the recipient will fulfill the requirements described in the CDC Evaluation and Performance Measurement and Project Description sections of this NOFO. At a minimum, the plan must describe:

How applicant will collect the performance measures, respond to the evaluation questions, and use evaluation findings for continuous program quality improvement.

How key program partners will participate in the evaluation and performance measurement planning processes.

Available data sources, feasibility of collecting appropriate evaluation and performance data, and other relevant data information (e.g., performance measures proposed by the applicant)

Plans for updating the Data Management Plan (DMP), if applicable, for accuracy throughout the lifecycle of the project. The DMP should provide a description of the data that will be produced using these NOFO funds; access to data; data standards ensuring released data have documentation describing methods of collection, what the data represent, and data limitations; and archival and long-term data preservation plans. For more information about CDC’s policy on the DMP, see https://www.cdc.gov/grants/additionalrequirements/ar-25.html.

Where the applicant chooses to, or is expected to, take on specific evaluation studies, they should be directed to:

Describe the type of evaluations (i.e., process, outcome, or both).

Describe key evaluation questions to be addressed by these evaluations.

Describe other information (e.g., measures, data sources).

Recipients will be required to submit a more detailed Evaluation and Performance Measurement https://www.cdc.gov/grants/additionalrequirements/ar-25.html plan, including a DMP, if applicable, within the first 6 months of award, as described in the Reporting Section of this NOFO.

The evaluation plan should include a program logic model specific to the recipient's program, and specify process and outcome evaluation questions, methods, analysis, and how results will be used and disseminated. Ideally, the evaluation plan is updated annually to reflect evaluation findings, current program context, and current priorities.

A DMP will not be required.

c. Organizational Capacity of Recipients to Implement the Approach Applicants must describe their organizational capacity to carry out the strategies and activities outlined in the logic model. At a minimum, applicants must:

• Demonstrate their ability to form successful partnerships with health systems, primary care clinics, and other organizations;

• Demonstrate their ability to implement EBIs within health systems and primary care clinics;

• Have (or have access to) expertise in CRC screening including familiarity with CRC screening tests; the facilitators and barriers to screening; and knowledge of CRC incidence, mortality, and screening rates in the proposed target geographic area;

• Have (or have access to) expertise in quality improvement, data quality improvement, and accessing and using population data from EHRs;

• Have (or have access to) expertise in program evaluation, including use of program data for program quality improvement.

Applicants can describe their organizational capacity to implement the program by providing:

• A description of a program in which the applicant partnered with a health care system or clinic to implement an intervention, including a detailed description of the applicant’s role in the project or program;

• The results of the program or project implemented in the health care system or clinic including the number of people reached, the type of intervention, the type of data collected, and the outcomes. (For example, the applicant partnered with clinic A to implement client reminders reaching 1,000 people which resulted in an increase in the clinic CRC screening rate from 45% to 50%);

• A detailed description of how the applicant has partnered with other organizations to support the implementation of a project or program, including a description of the role the partner(s) played in implementation;

• A description of how the applicant or their partner has accessed and used data from EHRs and any data quality improvement activities the applicant or partner undertook to improve the quality of the data;

• A description of a project or program evaluation that the applicant conducted and how the results were used for program improvement.

If the applicant proposes partnering with external organizations to provide specific areas of expertise (e.g., evaluation, data quality improvement), the applicant should clearly describe:

• The type of expertise the partner organization will provide;

• The activities the proposed partner will implement;

• The partner organization’s capacity and previous experience providing the type of expertise proposed to primary care clinics.

Applicants should identify and maintain staff to manage the program. At a minimum, applicants should identify:

• Staff to manage the program;

• Staff with appropriate experience to conduct program evaluation;

• Staff with experience in working with primary care clinics and service delivery;

• Staff with appropriate skills to collect and report clinic data.

d. Work Plan Strategy: (Example: Establish partnerships with health system/clinics)

Period of performance outcome: Outcome measure:

Objective

Activities Process Measures Person Responsibl e

Deadline for Completio n

Baseline *if applicable

Target *if applicable

EXAMPLE:

Recruit two additional clinics to begin needs assessment and implementati on process

EXAMPLE:

Identify potential clinics using data Work with partners who can help broker new relationship Prepare recruitment materials Schedule and hold

EXAMPLE:

REACH: # of clinics recruited, # patients age 50-75

CHARACTERISTIC

S: Size of clinics, Types of clinics, geographic location, primary test used % clinics with MOU or contract

EXAMPL

E:

Program Director Program Manager

EXAMPL

E:

December

EXAMPL

E:

2 current clinics participa-ting

EXAMPL

E:

4 total clinics participa-ting initial recruitment meetings with interested clinics Begin administrati ve process for securing formal agreements

Applicants must provide a detailed work plan that covers the first year of the period of performance and a high-level plan for subsequent years. At a minimum, the work plan must demonstrate how the strategies, activities, and staffing/partnerships work together to achieve program outcomes. Information on performance measures, data sources, and data collection should be included. Please use the template above when describing your work plan.

e. CDC Monitoring and Accountability Approach Monitoring activities include routine and ongoing communication between CDC and recipients, site visits, and recipient reporting (including work plans, performance, and financial reporting).

Consistent with applicable grants regulations and policies, CDC expects the following to be included in post-award monitoring for grants and cooperative agreements:

Tracking recipient progress in achieving the desired outcomes.

Ensuring the adequacy of recipient systems that underlie and generate data reports.

Creating an environment that fosters integrity in program performance and results.

Monitoring may also include the following activities deemed necessary to monitor the award:

Ensuring that work plans are feasible based on the budget and consistent with the intent of the award.

Ensuring that recipients are performing at a sufficient level to achieve outcomes within stated timeframes.

Working with recipients on adjusting the work plan based on achievement of outcomes, evaluation results and changing budgets.

Monitoring performance measures (both programmatic and financial) to assure satisfactory performance levels.

Monitoring and reporting activities that assist grants management staff (e.g., grants management officers and specialists, and project officers) in the identification, notification, and management of high-risk recipients.

CDC will use performance measure and evaluation data/information reported by recipients (aggregate clinic data, recipient surveys, case studies, success stories, and other data) to assess progress towards achieving the priority program outcome, increasing clinic CRC screening rates.

CDC will use the clinic and survey data to calculate performance measures to assess implementation progress and determine whether increases in CRC screening rates are achieved.

CDC will produce reports, including comparative reports, based on these data and disseminate those to recipients in a timely manner. CDC will use these reports to foster discussions with recipients about data quality, program improvement strategies, opportunities, and successes. CDC will conduct, at a minimum, an annual data review process aimed at continuous program quality improvement.

In addition to periodic conference calls and site visits, CDC will provide, at minimum, annual summary reports of recipient and aggregate program data.

f. CDC Program Support to Recipients (THIS SECTION APPLIES ONLY TO

COOPERATIVE AGREEMENTS)

CDC will provide technical assistance to recipients through a variety of mechanisms described below.

CDC will:

• Provide a data dictionary of required clinic data elements, related data collection forms, and a guidance document on measuring CRC screening rates;

• Provide a web-based system to enter clinic data;

• Provide training on the clinic data and how to use the web-based data entry system;

• Provide recipient results from CDC monitoring and evaluation activities including updates on key performance and outcome measures;

• Provide technical assistance to improve the quality of EBI implementation and data quality;

• Provide programmatic technical assistance;

• Assign a program consultant to each recipient;

• Work with recipients to solve challenges identified in evaluation and monitoring activities through conference calls, site visits, reverse site visits, and webinars;

• Provide resources to support EBI implementation and high-quality data collection;

• In person trainings and meetings.

CDC will provide opportunities for peer-to-peer information sharing between recipients regarding best practices, lessons learned, and evaluation results through meetings, webinars, sharing of success stories, teleconferences, sharing of materials via webpages, and other mechanisms as appropriate.

B. Award Information

1. Funding Instrument Type: Cooperative Agreement CDC's substantial involvement in this program appears in the CDC Program Support to Recipients Section.

2. Award Mechanism: U58

3. Fiscal Year: 2020

4. Approximate Total Fiscal Year Funding: $22,000,000

5. Approximate Period of Performance Funding: $110,000,000

This amount is subject to the availability of funds.

Estimated Total Funding: $110,000,000

6. Approximate Period of Performance Length: 5 year(s)

7. Expected Number of Awards: 35

8. Approximate Average Award: $500,000 Per Project Period

9. Award Ceiling: $900,000 Per Project Period

This amount is subject to the availability of funds.

10. Award Floor: $350,000 Per Project Period

11. Estimated Award Date: 06/30/2020

12. Budget Period Length: 12 month(s)

Throughout the project period, CDC will continue the award based on the availability of funds, the evidence of satisfactory progress by the recipient (as documented in required reports), and the determination that continued funding is in the best interest of the federal government. The total number of years for which federal support has been approved (project period) will be shown in the “Notice of Award.” This information does not constitute a commitment by the federal government to fund the entire period. The total period of performance comprises the initial competitive segment and any subsequent non-competitive continuation award(s).

13. Direct Assistance Direct Assistance (DA) is not available through this NOFO.

C. Eligibility Information

1. Eligible Applicants Eligibility Category: State governments

County governments City or township governments Special district governments Independent school districts

Public and State controlled institutions of higher education Native American tribal governments (Federally recognized) Public housing authorities/Indian housing authorities Native American tribal organizations (other than Federally recognized tribal governments) Nonprofits having a 501(c)(3) status with the…