dp1514amendmentpublication.pdf

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Paul Coverdell National Acute Stroke Prevention

CDC-RFA-DP15-1514

Application Due Date: 04/27/2015

Paul Coverdell National Acute Stroke Prevention

CDC-RFA-DP15-1514

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-DP15-1514. 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:

Paul Coverdell National Acute Stroke Prevention 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-DP15-1514

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

93.946 F. Dates:

1. Due Date for Letter of Intent (LOI): 03/27/2015

2. Due Date for Applications: 04/27/2015, 11:59 p.m. U.S. Eastern

Standard Time, at www.grants.gov.

3. Date for Informational Conference Call: 03/16/2015 Call time will be from 3:00-4:00 PM EST Dial: 800-369-2199 participant code 6534641

G. Executive Summary:

1. Summary Paragraph:

Stroke is the 4th leading cause of death in the U.S. and a leading cause of severe disability, and yet, stroke is preventable. To date, there has been little development of integrated stroke care across the continuum from onset of stroke through early pre-hospital care, Emergency Department (ED) and hospital care, and transition to post-hospital care, rehabilitation, and recovery.

During 2012-2014, the CDC provided funding to 5 states to engage in pre-hospital Emergency Medical Services (EMS) quality improvement as well as post-hospital transitions of care (TOC). Based on this work, we have learned that partnerships between EMS and EDs are critical to providing timely acute stroke care;

and that the early post-hospital period is a vulnerable time for patients discharged to home. Building on this knowledge gained, we see a need to further improve the quality of transition from hospital to home, reintegration with the patient’s primary care provider and access to community resources, enhanced patient and caregiver education, and ongoing rehabilitation and secondary prevention. Further, community education to prevent first stroke may be effective in addressing race/ethnic disparities in stroke mortality.

This comprehensive approach to a stroke system of care requires multiple partnerships throughout clinical and community participants.

a. Eligible Applicants: Limited

b. FOA Type: Cooperative Agreement 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.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf http://www.grants.gov

c. Approximate Number of Awards: 6

d. Total Project Period Funding: $24,000,000

e. Average One Year Award Amount: $790,000

f. Number of Years of Award: 5

g. Estimated Award Date: 06/30/2015

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

Consistent with the cited authority for this announcement and applicable grants regulations, sources for cost sharing or matching may include complementary foundation funding, other U.S. government funding sources including programs supported by HHS or other agencies (e.g., Department of Agriculture, Department of Education, Department of Housing and Urban Development, Department of Transportation, Environmental Protection Agency, U.S. Park Service) and other funding sources. Applicants should coordinate with multiple sectors such as public health, transportation, education, health care delivery, and agriculture.

Part II. Full Text A. Funding Opportunity Description

1. Background

a. Overview

Stroke is largely preventable, yet nearly 800,000 strokes and transient ischemic attacks (TIAs) occur each year, leading to ~130,000 deaths annually, and significant morbidity in survivors. To address this public health burden, CDC has initiated and progressively expanded the Paul Coverdell National Acute Stroke Program since 2001 to the present to improve quality of care for acute stroke patients from stroke onset through hospital discharge through organized quality improvement activities. During the 2012-2014 Coverdell Program, initial partnerships with Emergency Medical Services (EMS) began with the goal of improving EMS pre-hospital care for acute stroke and development of EMS data collection for acute stroke quality improvement (QI) data, linking that data with hospital data to improve EMS education on acute stroke, and improving the relationship between EMS and ED hospital staff to improve acute stroke care.

Similarly, initial efforts to identify needs in post-hospital transition of care (TOC) identified opportunities to improve the transition from hospital to next care setting, patient education, and access to community resources post discharge, re-integration with primary care providers, and prevention of early complications post discharge from hospital. To build on existing successful activities of this program, this project will address improving the quality of care (QoC) provided by pre-hospital care providers, emergency department and in-hospital care providers, and early post-hospital care providers to maximize recovery from stroke and prevention of secondary stroke and stroke complications. This FOA will focus on: Community Education, EMS, Acute Care, Recovery, and Ongoing Secondary Prevention, as seen in the figure of the components of a stroke system of care. The specific aims of this FOA include: • Improved systems of stroke care through coordination of stroke prevention and care activities (primarily secondary stroke prevention but also elements of primary prevention), reduced time to treatment, improved transitions from EMS to ED, and improved transitions from hospital to home and return to primary care provider. • Improved EMS QoC; improved ED and hospital QoC as measured by adherence to established guidelines for care and quality metrics. • Improved cholesterol, hypertension, and tobacco control; improved early medication adherence post-hospital; improved access to community services and rehabilitation; improved receipt and understanding of on-going post-stroke care; reduced 30-day hospital readmissions and 30-day mortality understanding of on-going post-stroke care; reduced 30-day hospital readmissions and 30-day mortality following acute stroke. • Development and use of integrated data collection systems that can link across the continuum of care for EMS, hospital, and post-hospital care to address data-driven QI in these different care settings. • Strengthen statewide infrastructure to reduce the burden of stroke morbidity and mortality, and eliminate disparities in care for stroke.Care coordination across care settings is a major component of the National Quality Strategy (Conway, JAMA 2013), yet to date there are limited quality measures that address these transitions of care across settings, especially measures that address the unique needs of stroke patients or measures that address patient reported outcomes. This FOA will address this important area for acute stroke patients by identifying and patient needs in the early post-discharge period.

b. Statutory Authorities

This program is authorized under Section 317(k)(2) of the Public Health Services Act (PHS Act), 42 U.S.C. 247b(k)(2) as amended.

c. Healthy People 2020

This FOA addresses the Healthy People 2020 Heart Disease and Stroke focus areas of:

HDS-3 Reduce stroke deaths HDS-6 Increase the proportion of adults who have had their blood cholesterol checked within the preceding 5 years HDS-7 Reduce the proportion of adults with high total blood cholesterol levels Reduce the proportion of adults with high total blood cholesterol levels HDS-17 (Developmental) Increase the proportion of adults aged 20 years and older who are aware of and respond to early warning symptoms and signs of a stroke HDS-19.3 (Developmental) Acute reperfusion therapy within 3 hours from symptom onset for patients with strokes (Developmental) Acute reperfusion therapy within 3 hours from symptom onset for patients with strokes HDS-20.2 (Developmental) Increase the proportion of adults who have had a stroke who have their low-density lipoprotein (LDL)-cholesterol at or below recommended levels HDS-21 (Developmental) Increase the proportion of adults with a history of cardiovascular disease who are using aspirin or antiplatelet therapy to prevent recurrent cardiovascular events.

HDS-23 (Developmental) Increase the proportion of adult stroke survivors who are referred to a stroke rehabilitation program at discharge.

d. Other National Public Health Priorities and Strategies

Long Term Objective 5.4: Reduce death and disability due to heart disease and stroke.

5.4.1b: Reduce the age-adjusted annual rate per 100,000 population of: Stoke-related deaths.

5.4.2: Increase the age-adjusted proportion of persons age 18+ with high blood pressure who have it controlled (<140/90).

5.4.3: Maintain the age-adjusted proportion of persons age 20+ with high total cholesterol (>=240mg/dL) at no higher than its current rate.

e. Relevant Work

This work builds on the previous work of the Paul Coverdell national Acute Stroke Registry and Project (02045 2004 Supplement, DP07-705, DP12-1203). In DP12-1203, in-hospital quality of care improvement continued as in DP07-705, and initial work was done in pre-hospital quality improvement as well as identifying areas in transitions of care post-hospital that could benefit from quality improvement interventions. Additional references for the Coverdell Program can be found at http://www.cdc.gov/dhdsp/programs/stroke_registry.htm

2. CDC Project Description

a. Approach

i. Purpose

This FOA will fund state health departments to develop comprehensive stroke systems of care which will improve the quality of care for acute stroke patients, improve recovery, improve adherence to post-stroke guidelines, and reduce complications, readmissions, and early mortality for acute stroke patients. These projects will be data-driven across pre-hospital, hospital, and post-hospital care, with linkable data across care settings for quality improvement purposes; will require support from EMS entities, hospitals, and post-stroke clinical care providers; and enhance post-stroke prevention through improved risk factor control as indicated by guidelines.

ii. Outcomes

The project is expected to achieve the following outcomes for the 5-year FOA project period:

Short Term Outcomes (1-2 Years)

1. Increased public awareness of signs and symptoms of stroke and knowledge of appropriate activation of emergency medical systems.

2. Maintenance of existing broad reach and/or increase the state-wide reach of the stroke system of care. As an example, if awardee already has a geographically broad reach or a high proportion of state stroke cases at participating program hospitals, this should be maintained and expanded as appropriate for their state. For awardees that do not have a broad state-wide program, the awardee is expected to increase the reach of their program.

3. Increased data usage and sharing between components of the stroke care system that will result from having an integrated/linked data platform for pre-hospital data, in-hospital data, and early post-discharge data. While not required, linking with Medicare or other similar data for even longer term outcomes is optional for further understanding of post-stroke patient care needs.

a. Improved reliability and validity of data as determined through annual data validation of select and highly important data elements, as well as quarterly data quality reviews.

4. Increased workforce capacity and scientific knowledge for stroke surveillance within stroke systems of care. Providing resources, tools, guidance, and technical assistance to EMS and hospital stroke care providers will increase the knowledge, skills, and abilities of these providers in providing evidence-based stroke care.

a. Increased implementation of quality improvement (QI) strategies for acute stroke care across the continuum of stroke care (EMS care, hospital care, and early post-hospital care).

b. Increase efficiencies and effectiveness of pre-hospital, in-hospital, and post-hospital stroke care practices and resources (e.g. reduced door-to-needle time, increased use of thrombolytic therapy).

c. Increased pre-notification of hospitals by EMS of suspected stroke patients.

5. Improved patient and caregiver receipt of education on ongoing post-stroke care needs.

Intermediate Outcome (3+ years) Stroke Systems of Care

1. Reduced time to treatment for acute stroke events.

2. Improved transition of care from emergency services to hospital emergency department (ED)

3. Improved transition of care from hospital to home, which may include reintegration with primary care provider, access to community resources, enhanced patient/caregiver education, and ongoing rehabilitation and secondary prevention.

Stroke Care

1. Improved quality of EMS care for possible stroke patients

2. Improved quality of acute and sub-acute ED and hospital stroke care as measured by adherence to established guidelines for care and quality metrics

3. Improved defect free care for acute stroke patients Health Outcomes

1. Improved tobacco control/reduction in smoking post stroke.

2. Improved medication adherence post-discharge.

3. Reduced 30-day hospital readmissions and ED visits for stroke-related complications after stroke.

4. Reduced 30-day mortality after acute stroke.

Long Term Outcomes

1. Reduced disparities in stroke care, death, and disability should result from adherence to stroke care guidelines.

iii. Strategies and Activities

The following primary strategies and activities are required to assist in the implementation of this FOA. The applicant may include additional strategies/activities.

1. Coordinate and/or promote public stroke prevention messaging.

2. Coordinate Partnerships by establishing/maintaining a steering committee for the program that will advise and guide the work of the program and establish program partnerships within 6 months of being awarded.

a. Steering committee should have a least one stroke clinician (stroke physician, stroke coordinator, stroke nurse) with knowledge of acute stroke care guidelines and practice; a person with special knowledge of post-stroke care needs of stroke patients discharged to home (could be the same person as the stroke clinician or an additional person); and an EMS professional with knowledge of pre-hospital stroke care.

b. Establish or maintain partnership with any existing state stroke coalitions, initiatives, or stroke professional organizations.

c. Establish or maintain a partnership with state and/or regional EMS Directors.

3. Recruit local/regional EMS systems and hospitals.

a. Recruit at least 1 local or regional EMS system in Year 1 to participate in EMS data collection for quality improvement, engage in quality improvement activities, and focus on improving the transition of patients from EMS to Emergency Department (ED). Recruit additional local or regional EMS systems each year for the duration of the funding period.

b. Recruit hospitals to participate in in-hospital data collection for quality improvement, engage in quality improvement activities, and focus on improving the transition of patients from EMS to ED.

c. Recruit at least 3 hospitals or integrated healthcare systems (e.g. accountable care organizations, integrated in-patient/out-patient healthcare systems) by Year 2 to participate in the activities listed in 3.b. (recruitment), and also participate in post-hospital data collection for 30 day follow-up, that will support improving the early post-discharge transition from hospital to home. Increase hospital participation each year for the duration of the funding period. Note: CDC will provide technical assistance and guidance on reasonable increase per year.

4. Establish data infrastructure by implementing an integrated data management system for measurement, tracking, and assessment of quality of care.

a. Establish and maintain data collection system(s) for pre-hospital data, in-hospital, post-hospital follow-up data as specified by CDC. Note: CDC will provide guidance and technical assistance for functional requirements and options for developing data collection systems.

b. Develop and implement data linkages at the individual record level between the pre-, in-, and post-hospital settings.

c. Conduct annual analysis of data quality. Note: CDC will provide guidance on expectations for this activity.

d. Submit data to CDC according to CDC guidelines. Awardee’s are advised that CDC will be developing a data sharing policy for Coverdell data collected under this Funding Opportunity Announcement that will be in accordance with CDC’s data sharing policy and guidelines as required by the Office of Management and Budget.

5. Analyze and use data to improve care AND transitions of care (EMS-Hospital, Hospital-Home) through the following activities:

a. Provide feedback to EMS and hospitals on quality of care using performance measures of care.

Notes:

--CDC will provide guidance on performance measures of care --Performance measures of care refer to measures that track the quality of care delivered to stroke patients.

These measures are distinct from the performance measures of the FOA that are intended to track progress and outcomes of the FOA. See section CDC Evaluation and Performance

Measurement Strategy for further details.

b. Provide feedback to hospitals on 30-day outcomes.

c. Identify gaps in care in all settings (i.e. EMS, hospital, post-hospital) and address them through systematic quality improvement (QI) methods and interventions. Example QI methods include: PDSA, Lean, Six Sigma.

d. Identify methods, models, systems, and/or processes, to improve transitions and patient outcomes post-discharge to home.

e. Disseminate select findings from data collection efforts.

6. Coordinate stroke care QI efforts

a. Provide stroke care quality improvement (QI) efforts (e.g. training, technical assistance, QI training programs, education, workshops, site visits, etc.) that demonstrate coordination between care providers in different care settings (e.g., EMS-Hospital; Hospital-Primary Care Provider; Community-Clinical linkages) as well as within-in care setting QI.

b. Provide resources, tools, guidance, technical assistance, customized data results feedback, coaching to program partners (hospitals, EMS) to improve quality of care.

c. Promote the use of stroke protocols and team-based care appropriate to various care settings.

7. Development of sustainability plan and/or mechanisms to support ongoing coordinated stroke care systems by end of Year 3 and update/revise yearly as needed.

1.Collaborations

Applicants are required to collaborate with CDC funded programs as well as other organizations external to

CDC.

Collaborations and strategic partnerships are crucial to implement program strategies and sustain outcomes.

They allow for more efficient use of existing resources and exchange of information between experts working in various areas of public health and other sectors. Applicants are encouraged to use evidence-based collaboration models as appropriate (e.g., PRECEDE/PROCEED model or Mobilizing for Action through Planning and Partnerships [MAPP]).)

a. With CDC-funded programs:

1. Awardees are expected to engage with applicable subject matter experts within the CDC’s Division for Heart Disease and Stroke Prevention (DHDSP). DHDSP will provide technical assistance, communication, facilitation, and additional support to fully enhance the project.

2. Awardees are expected to engage in network collaborations with other awardees under this funding opportunity.

3. Applicants are expected to work with other applicable units within the Health Department to advance program outcomes. Depending on the Health Department organizational structure, this may include Heart Disease and Stroke Prevention programs, EMS units, or healthcare quality improvement programs.

b. With organizations external to CDC:

Successful applicants are expected to establish/maintain/expand collaboration with: EMS entities within their state; state-based stroke councils or initiatives within their state if such exists; stroke professional organizations within their state if such exist; acute care hospitals; major stroke partners, academic partners, and stakeholders in their state that are related to stroke, other non-Federal partners, and Quality Improvement Organizations (QIOs)External collaborations are required, and should be supported by MOUs or letters of support that detail the partner’s specific commitment to the strategies and activities supporting the desired outcomes. (Letters of support should be included as Appendices).

2. Target Populations

Target populations include acute stroke patients (intracerebral hemorrhage, ischemic stroke, potential acute stroke patients, and patients presenting with a transient ischemic attack (TIA).

a. Inclusion

All individuals diagnosed with an acute stroke (ischemic stroke or intracerebral hemorrhage) or transient ischemic attack (TIA) presenting to acute care hospitals or emergency departments, and all individuals presenting to EMS with a potential acute stroke or TIA. CDC encourages but does not require the inclusion of patients presenting with stroke in pregnancy (including peripartum stroke). CDC encourages the inclusion of patients with acute stroke or TIA that are in ED boarding. CDC strongly encourages the inclusion of patients presenting with subarachnoid hemorrhage.

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

N/A

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy

b. Evaluation and Performance Measurement:

In an effort to continue to build evidence around effective stroke care strategies across the system of care, applicants must evaluate the implementation and impact of the strategies and disseminate findings of these evaluations over the course of the project period. Evaluation and performance measures are directly linked to the program process and outcome objectives and strategies. Evaluation findings will be used to refine and improve program activities. Findings will also demonstrate the value and impact of the program on improving public health outcomes. CDC will work with successful applicants through the five-year project period to demonstrate program impact through process evaluation, and short and intermediate-term outcome evaluation. Process evaluation methods will be used to assess the extent to which planned program activities have been implemented and have led to desired programmatic outcomes and to demonstrate the feasibility and sustainability of the strategies. Short and intermediate term outcome evaluation will assess whether the project activities are leading to intended long-term outcomes, as well the as reach and impact of the program. CDC will work with awardees to ensure appropriate dissemination of program impact and lessons learned.

Evaluation findings will (1) contribute to the continuous program and quality improvement of program efforts, (2) contribute to the evidence base for coordinating stroke care in all settings, (3) document and share lessons learned to support replication of program strategies in other states, and (4) inform future funding opportunities at CDC.

CDC will use a three-pronged evaluation approach. Awardees are required to (1) report on CDC outcome performance measures as specified in this FOA, (2) develop and implement a state-specific evaluation plan, and (3) participate as requested in a cross-site evaluation (as resources permit).

i. CDC Evaluation and Performance Measurement Strategy:

CDC will work with awardees to operationalize the required performance measures and assist with the identification of sound data collection approaches and/or the availability of existing data collection instruments. CDC will manage and synthesize the required performance measure data submitted by awardees. In addition, CDC will work with awardees to jointly refine process performance measures that will be used to monitor progress toward the outcomes specified in the Logic Model.

Note:

• The following performance measures are intended to track progress and outcomes of the FOA. The performance measures of care refer to measures that track the quality of care delivered to stroke patients.

Therefore there are two separate sets of measures specified in the FOA.

• CDC will work with awardees on full measure specifications post-award. Proposed process and outcome performance measures include:

Process-level Performance Measures

Public Awareness 1. # and types of activities that promote public awareness on signs and symptoms and appropriate emergency response

Partnerships 2. # of partnerships and types of partnerships between state Coverdell Program and other stroke-related entities

Recruitment 3. # of local or regional EMS agencies recruited to participate in state Coverdell activities

4. # of hospitals recruited to participate in state Coverdell activities (in-hospital care; post-hospital care)

Data Infrastructure

5. % of EMS agencies that submit data to an integrated data management system for the purposes of the Coverdell program’s EMS data-driven QI activities and performance monitoring for potential acute stroke patients.

6. % of hospitals that submit data to an integrated data management system for the purposes of the Coverdell program’s in-hospital data-driven QI activities and performance monitoring for acute stroke patients.

7. % of hospitals that submit 30-day post discharge data to an integrated data management system for the purposes of the Coverdell program’s in-hospital data-driven QI activities and performance monitoring for acute stroke patients.

8. Submission of annual chart re-abstraction results according to CDC guidelines

Data Use 9. # of and types of reports created using quality of care data from EMS and hospitals

10. # and type of systematic QI methods/interventions implemented by EMS agencies as a result of quality of care data reports

11. # and type of systematic QI methods/interventions implemented by hospital staff as a result of quality of care data reports

12. # and type of systematic QI methods/interventions implemented by hospital staff as a result of quality of care data reports to improve transition of care from hospital to home

Quality Improvement

13. # and type of stroke QI efforts implemented by state Coverdell program for EMS and hospital staff

14. % of EMS agencies that have participated in stroke QI efforts implemented by state Coverdell program

15. % of hospitals that have participated in stroke QI efforts implemented by state Coverdell program

Sustainability 16. Sustainability plan submitted to CDC by end of Year 3

17. Revisions/updates to sustainability plan in years 4 & 5 as necessary

Short-Term Outcome Performance Measures

Public Awareness 18. % of patients with acute stroke presenting to an ED that arrive by

EMS

19. % of patients with acute stroke who arrive within 3 hours of time last known to be well

Reach 20. % of state acute stroke admissions in participating hospitals

21. % of state acute stroke patients transported by EMS agencies participating in state Coverdell program

Data Linkage 22. Proportion of EMS agencies that have data linked to in-hospital data

23. % of EMS run sheets entered into in-hospital data collection tool

Data Reliability/ Validity

24. % concordance between original abstractor and re-abstractor for each specified data element.

25. % missing data for select data elements by calendar quarter.

26. # of cases with improbable dates/times by calendar quarter

Workforce Capacity

27. # and type of trainings provided to EMS and to hospital stroke professionals

28. Proportion of EMS and hospital stroke professionals with improved scores in pre and post tests administered during training events

Stroke Care 29. % of hospitals that implemented changes in stroke care practices

30. % of EMS agencies that implemented changes in stroke care practices

31. % (or #) of hospital QI interventions that resulted in an improvement in a select performance measure of care

32. % (or #) of EMS QI interventions that resulted in an improvement in a select performance measure of care

33. % of hospitals with improvement in a select performance measure of care

34. % of EMS agencies with improvement in a select performance measure of care

Patient Education 35. % of patients and/or caregiver that received educational materials during the hospital stay addressing all stroke education areas (i.e.

activation of emergency medical system, follow-up after discharge, medications adherence, risk factors, signs and symptoms of stroke)

36. % of hospitals implementing the use of teach back (or other methods) to determine patient and/or caregiver understanding of stroke education

Intermediate Outcome Performance Measures

Systems of Stroke Care

37. Median door-to-needle time by calendar quarter

38. % of patients with door-to-needle time within 60 minutes by calendar quarter

39. % of EMS-hospital teams reporting use of feedback from hospital to

EMS

40. % of stroke patients that had a follow-up appointment scheduled prior to hospital discharge

Stroke Care 41. % adherence to Coverdell patient-level performance measures of care for EMS

42. % adherence to Coverdell patient-level performance measures of care for in-hospital and transition of care

43. % of patients with defect-free in-hospital care

44. % of patients with defect-free care by EMS

45. # of EMS, in-hospital, or TOC performance measures with significant race (black, white) or gender disparities

Health Outcomes 46. % of patients identified as smokers on hospital admission for acute stroke who are still smoking at 30-days post hospital discharge

47. % adherence to discharge medications at 30 days (for each medication class: antihypertensive, statins, anticoagulant, antiplatelet)

48. % of patients readmitted within 30 days after hospital discharge for acute stroke (crude, and risk-adjusted for demographics and stroke severity)

49. % of patients presenting to the emergency department within 30 days after hospital discharge for acute stroke (crude, and risk-adjusted for demographics and stroke severity)

50. 30-day mortality rate after acute stroke by stroke type (crude, and risk-adjusted for demographics and stroke severity)

For the

Draft patient-level performance measures of care (Draft data dictionary available upon request)

Draft EMS Measures

1 % of stroke transports with an on-scene time < 15 minutes

2 % of stroke transports with a blood glucose checked and recorded

3 % of stroke transports where EMS called in a stroke alert pre-notification

4 % of stroke transports that had a stroke screen completed and recorded

5 % of stroke transports that had a documented the time last known to be well

6 % of stroke transports that had a documented time of discovery

7 % of stroke transports that had a thrombolytic stroke check completed and documented

8 % of stroke transports where EMS diagnosis agreed with hospital diagnosis

Hospital Measures (potentially different measures for acute stroke ready hospitals)

1 VTE prophylaxis provided by end of hospital day 2

2 Antithrombotic medication by end of hospital day 2

3 Antithrombotic medication at discharge cross-site evaluation (as resources permit), CDC will: lead the design, work with funded sites to coordinate data collection, oversee analysis, and oversee reporting for this effort. The cross-site evaluation of funded programs will focus on implementation processes and the extent to which the FOA-identified outcomes have been achieved.

4 % of ischemic stroke patients that arrive by 2 hours of time last known well and are treated with IV tPA by 3 hours of last known well

5 Dysphagia screening performed and passed prior to food, fluids, or medication by mouth

6 Anticoagulation on discharge for patients with atrial fibrillation/flutter

7 Statin medication provided on discharge

8 Smoking cessation counseling and/or treatment provided

9 Assessed for rehabilitation needs

10 Stroke Education: Patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.

11% ischemic stroke patients with initial NIHSS score recorded

12 Median door-to-needle time

13 % patients with door-to-needle time ≤ 60 minutes

Draft Transition of Care (TOC) Measures

1 % of stroke patients discharged to home who have died by 30 days

2 % of stroke patients who were seen in ED within 30 days of discharge

3 % of stroke patients who were readmitted to the hospital within 30 days of discharge

4 % of stroke patients reporting blood pressure (BP) > 140 systolic or > 90 diastolic among those checking their BP at home

5 % of stroke patients checking the BP at home

6 % of stroke patients reporting 2 or more falls within 30 days of discharge

7 % of stroke patients who stopped taking medications since discharge

8 % of stroke transports where EMS diagnosis agreed with hospital diagnosis

9 % of stroke patients that had a follow-up appointment scheduled prior to discharge

ii. Applicant Evaluation and Performance Measurement Plan

Evaluation and performance measurement are a critical component of this work. Applicants must provide an overall description program evaluation plans and performance measurement in a manner that is consistent with the CDC evaluation and performance measurement strategy. Applicants are encouraged to work with professional evaluators (either internal or external) to meet the evaluation requirements of this FOA. In developing evaluation and performance measurement plans, applicants are encouraged to use the following resource: CDC Framework for Program Evaluation in Public Health (Centers for Disease Control and Prevention. Framework for Program Evaluation in Public Health. MMWR 1999; 48,No. RR-11) (www.cdc.gov/eval). At a minimum, the evaluation and performance measurement plan must:

• Describe commitment to allocate at least 10% of the total funding award to evaluation activities.

• Describe how key program partners will be engaged in the evaluation and performance measurement planning processes

• Describe the type of evaluations to be conducted (i.e. process and/or outcome)

• Describe key evaluation questions to be answered

• Describe how reach of the proposed strategies will be measured

• Describe potentially available data sources and feasibility of collecting appropriate evaluation and performance data

• Describe how evaluation findings will be used for continuous program improvement and quality improvement

• Describe how evaluation and performance measurement results will be shared with CDC

• Describe how evaluation and performance measurement results will be disseminated beyond CDC

c. Organizational Capacity of Awardees to Execute the Approach

Applicants must provide:

1. Evidence that they have the organizational capacity to facilitate the program strategies and activities and meet the project period outcomes by describing their program staffing structure, the role of each proposed staff member or relevant contractor, their relevant skills, and the percent time expected of each staff for each major objective proposed in the work plan.

2. Evidence that they have the organizational capacity to hire adequate staff or contractors to meet the project period outcomes.

3. Evidence that they have the organizational capacity to execute contracts as necessary for fulfilling requirements of this FOA.

4. Evidence that the have organizational capacity that encompasses and includes stroke clinical experts, state EMS entities, and quality improvement expertise. A list of proposed staff and steering/coordinating committee members along with their CVs and letters of support or Memorandums of Understanding from each. Experts in acute stroke care, EMS officials or entities, and hospital stroke coordinators or nursing, and experts in post-stroke care are strongly advised to be members of the program’s steering committee (see section 2.a.1 under iii. Strategies and Activities).

5. Evidence of relevant experience relevant to the work of this FOA.

6. Evidence of the ability to collect linkable data from EMS, hospitals, and data on up to 30-days post-hospital care, and submit this as de-identified limited data to CDC through CDC’s secure data systems on a quarterly basis.

d. Work Plan

The applicant is required to provide a general program work plan for the five-year program and a detailed description of their first year plan. The work plan should include outcomes, program strategies, activities, and specific, measurable, achievable, realistic, and time-phased objectives. For each major objective, the assigned staff should be delineated and their estimated percentage time should be included.

The work plan must include at a minimum:

1. Program strategies to be used during the first year of the project period. While the work plan for year one should have sufficient detail of proposed activities, the activities for years 2-5 can be in general terms sufficient to address not only short term outcomes, but also intermediate outcomes.

2. Activities for the first year of the project period; the activities must be in alignment with the proposed objectives and program strategies and activities,

3. Outcomes for the first year of the project period

4. Specific, measureable, achievable, realistic, and time-phased objectives for the first year of the project period.

5. Timeline for the first year of the project period.

6. Budget and budget narrative for the first year of the project period including expenses necessary to achieve progress and success in pre-hospital, hospital, and post-hospital settings.

Note: Proposed work-plan may be adjusted post-award, to better address DHDSP’s priorities.

The following is a sample work plan template. You are not required to use it.

Project Period Outcome: [from Outcomes section and/or logic model]

Outcome Measure:

[from Evaluation and Performance Measurement section]

Or

SMART Outcome Objective:

[should draw on measures in Evaluation and performance Measurement section]

Strategies/Activities Process Measure[from Evaluation and Performance Measurement section]

Or

SMART Outcome Objective:

[should draw on measures in Evaluation and performance Measurement section]

Responsible Position/Party

Completion Date

1.

2.

3.

e. CDC Monitoring and Accountability Approach Monitoring activities include routine and ongoing communication between CDC and awardees, site visits, and awardee 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 awardee progress in achieving the desired outcomes.

Ensuring the adequacy of awardee 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:

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

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

Working with awardees 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.

Other activities deemed necessary to monitor the award, if applicable.

These activities may include 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 grantees.

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

AGREEMENTS)

CDC will provide technical assistance (TA) that supports the required activities and anticipated program outcomes. This TA will encompass partnership development, data collection and linkage, quality improvement for pre-hospital, in-hospital, and post-discharge care for acute stroke patients. Specifically, CDC will provide TA on the development of data collection platforms if necessary and will specify required data collection. Quality of care metrics will be determined by CDC with input from awardees.

CDC will implement multiple venues for information sharing with awardees, including lessons learned, promising and challenging practices, evaluation results, etc. through a combination of conferences, guidance, material development, webinars, conference calls, and working groups related to this cooperative agreement.

B. Award Information

1. Funding Instrument Type: Cooperative Agreement CDC's substantial involvement in this program appears in the

CDC Program Support to Awardees Section.

2. Award Mechanism:

3. Fiscal Year: 2015 Estimated Total Funding: $24,000,000

4. Approximate Total Fiscal Year Funding: $4,740,000

5. Approximate Project Period Funding: $24,000,000

6. Total Project Period Length: 5 year(s)

7. Expected Number of Awards: 6

8. Approximate Average Award: $790,000 Per Budget Period

9. Award Ceiling: $800,000 Per Budget Period

10. Award Floor: $700,000 Per Budget Period

11. Estimated Award Date: 06/30/2015 Throughout the project period, CDC will continue the award based on the availability of funds, the evidence of satisfactory progress by the awardee (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 project period comprises the initial competitive segment and any subsequent non-competitive continuation award(s).

12. Budget Period Length: 12 month(s)

13. Direct Assistance Direct Assistance (DA) is available through this FOA.

C. Eligibility Information

1. Eligible Applicants Eligibility Category: State governments

Special district governments

2. Additional Information on Eligibility

The award ceiling for this FOA is $800,000. CDC will consider any application requesting an award higher than this amount as non- responsive and it will receive no further review. If a pre-application is required, then specify here and include it in the special eligibility requirements section. (http:// www.hhs.gov/ asfr/ ogapa/ aboutog/ hhsgps107.pdf)

3. Justification for Less than Maximum Competition

The purpose of this FOA is to fund state health departments to develop comprehensive stroke systems of care which will improve the quality of care for acute stroke patients, improve access to rehabilitation and recovery, improve adherence to post-stroke guidelines, and reduce complications, readmissions, and early mortality for acute stroke patients. These projects will be data-driven across pre-hospital, hospital, and post-hospital care, with linkable data for quality improvement purposes; will require support from EMS entities, hospitals, and post-stroke clinical care providers; and enhance post-stroke prevention through improved blood pressure control, cholesterol management, use of antithrombotics as indicated by guidelines.

State health departments are the only agencies who are uniquely positioned to develop strong state level task forces to develop these stroke systems of care that can be used to focus on an comprehensive approach to improving quality of care at all points along the continuum of care that will have the largest reach and impact on decreasing morbidity and mortality from stroke, reducing disparities in the delivery of care, and improving outcomes.

http://www.hhs.gov/asfr/ogapa/aboutog/hhsgps107.pdf

4. Cost Sharing or Matching Cost Sharing / Matching Requirement:

No

Cost sharing or matching funds are not required for this program. Although no statutory matching requirement for this FOA exists, leveraging other resources and related ongoing efforts to promote sustainability is strongly encouraged.

Consistent with the cited authority for this announcement and applicable grants regulations, sources for cost sharing or matching may include complementary foundation funding, other U.S. government funding sources including programs supported by HHS or other agencies (e.g., Department of Agriculture, Department of Education, Department of Housing and Urban Development, Department of Transportation, Environmental Protection Agency, U.S. Park Service) and other funding sources. Applicants should coordinate with multiple sectors such as public health, transportation, education, health care delivery, and agriculture.

5. Maintenance of Effort

Maintenance of effort is not required for this program.

D. Required Registrations

Additional materials that may be helpful to applicants: http://www.cdc.gov/od/pgo/funding/docs/Financial ReferenceGuide.pdf.

1. Required Registrations An organization must be registered at the three following locations before it can submit an application for funding at www.grants.gov.

a. Data Universal Numbering System: All applicant organizations must obtain a Data Universal Numbering System (DUNS) number. A DUNS number is a unique nine-digit identification number provided by Dun & Bradstreet (D&B). It will be used as the Universal Identifier when applying for federal awards or cooperative agreements.

The applicant organization may request a DUNS number by telephone at 1-866-705-5711 (toll free) or Internet at http:// fedgov.dnb.com/webform/displayHomePage.do. The DUNS number will be provided at no charge.If funds are awarded to an applicant organization that includes sub-awardees, those sub-awardees must provide their DUNS numbers before accepting any funds.

b. System for Award Management (SAM): The SAM is the primary registrant database for the federal government and the repository into which an entity must submit information required to conduct business as an awardee. All applicant organizations must register with SAM, and will be assigned a SAM number. All information relevant to the SAM number must be current at all times during which the applicant has an application under consideration for funding by CDC. If an award is made, the SAM information must be maintained until a final financial report is submitted or the final payment is received, whichever is later. The SAM registration process usually requires not more than five business days, and registration must be renewed annually. Additional information about registration procedures may be found at www.SAM.gov.

c. Grants.gov: The first step in submitting an application online is registering your organization through www.grants.gov, the official HHS E-grant website. Registration information is located at the "Get Registered" option at www.grants.gov.

All applicant organizations must register with www.grants.gov. The one-time registration process usually takes not more than five days to complete. Applicants must start the registration process as early http://www.cdc.gov/od/pgo/funding/docs/FinancialReferenceGuide.pdf http://www.cdc.gov/od/pgo/funding/docs/FinancialReferenceGuide.pdf http://www.grants.gov http://fedgov.dnb.com/webform/displayHomePage.do https://www.SAM.gov http://www.Grants.gov http://www.grants.gov usually takes not more than five days to complete. Applicants must start the registration process as early as possible.

2. Request Application Package Applicants may access the application package at www.grants.gov.

3. Application Package Applicants must download the SF-424, Application for Federal Assistance, package associated with this funding opportunity at www.grants.gov. If Internet access is not available, or if the online forms cannot be accessed, applicants may call the CDC PGO staff at 770-488-2700 or e-mail PGO PGOTIM@cdc.gov for assistance. Persons with hearing loss may access CDC telecommunications at TTY 1-888-232-6348.

4. Submission Dates and Times If the application is not submitted by the deadline published in the FOA, it will not be processed. PGO personnel will notify the applicant that their application did not meet the deadline. The applicant must receive pre-approval to submit a paper application (see Other Submission Requirements section for additional details). If the applicant is authorized to submit a paper application, it must be received by the deadline provided by PGO.

a. Letter of Intent Deadline (must be emailed or postmarked by) Due Date…