FINAL GHWIC Implementation Guide_508_4-4-2024.pdf

A Cultural Approach to Good Health and Wellness in Indian Country (GHWIC)

Healthy Tribes Program Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Division of Population Health

GHWIC DP24-0025 Implementation Guide

March 2024

Table of Contents

Background

GHWIC strategies and activities

Cultural practices

Background

Cultural practices example activities

Cultural practices resources

Community-clinical linkages

Background

Required chronic disease prevention, management, and control activities

Required diabetes prevention activities

Required team-based care activities

Example activities and available resources

Commercial tobacco cessation example activities

Commercial tobacco cessation resources

Diabetes prevention example activities

Diabetes prevention resources

Diabetes self-management example activities

Diabetes elf-management resources

High blood pressure example activities

High blood pressure resources

Physical activity example activities

Physical activity resources

Nutrition example activities

Nutrition resources

Oral health example activities

Oral health resources

Team-based care example activities

Team-based care resources

Policy, systems, and environmental changes (PSE) example activities

PSE resources

Glossary

Background

A Cultural Approach to Good Health and Wellness in Indian Country (GHWIC), DP24-0025, builds on previous and current GHWIC, Tribal Epidemiology Centers Public Health Infrastructure (TECPHI), and Tribal Practices for Wellness in Indian Country (TPWIC) programs. Input was also received from recipients and CDC’s Tribal

Advisory Committee (TAC) that helped shape the new notice of funding opportunity (NOFO). The new cultural approach is designed to be a more sustainable approach to chronic disease prevention, management, and control.

GHWIC is a collaborative effort of six (6) divisions within CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). It is administered by the Healthy Tribes program, Division of Population

Health. The divisions supporting GHWIC include the following:

• Division of Diabetes Translation

• Division for Heart Disease and Stroke Prevention

• Division of Nutrition, Physical Activity, and Obesity

• Division of Oral Health

• Division of Population Health

• Office on Smoking and Health

Purpose The purpose of this implementation guide is to help you develop work plans and implement activities that are aligned with the GHWIC logic model and meet the required outcomes.

You are encouraged to engage your community members to develop your work plan. This helps make sure your work plan addresses the needs of your community and builds on community assets. You are encouraged to work with your current partners and develop new partnerships to plan, implement, and evaluate your work plan.

Engaging partners helps supplement your efforts. They may be able to support items that can’t be covered by the cooperative agreement. Also, keeping them engaged may help sustain your program when the federal funds go away.

Important considerations when using this guide The guide is organized by chronic diseases and their risk factors. Each section provides the required activities as outlined in the NOFO, example activities, and resources, but is not an exhaustive list.

Links to non-federal government organizations found in this document are provided solely as a service to the https://www.grants.gov/search-results-detail/335074 https://www.grants.gov/search-results-detail/334873 https://www.grants.gov/search-results-detail/334873 https://www.cdc.gov/tribal/consultation-support/tac/index.html https://www.cdc.gov/tribal/consultation-support/tac/index.html https://wcms-wp.cdc.gov/diabetes/index.html https://www.cdc.gov/dhdsp/ https://www.cdc.gov/chronicdisease/resources/publications/aag/dnpao.htm https://www.cdc.gov/oralhealth/index.html https://www.cdc.gov/chronicdisease/resources/publications/aag/population-health.htm https://www.cdc.gov/tobacco/ reader. These links do not constitute an endorsement of these organizations or their programs by CDC or the

Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization sites listed in this document.

Section Links:

• Cultural Practices

• Commercial Tobacco Cessation

• Diabetes Prevention

• Diabetes Self-management

• High Blood Pressure

• Physical Activity

• Nutrition

• Oral Health

• Team-based Care Example Activities

• Policy, System, and Environmental Changes (PSE) Example Activities

• Glossary

Post-award technical assistance In addition to the information and resources in this guide, recipients will receive technical assistance from CDC project officers, evaluators, and subject-matter experts to finalize their work plans. Technical assistance is also available if you have questions or concerns implementing your work plan. We intend to have monthly calls with all recipients and conduct site visits as needed. If you need technical assistance, please make your request with your project officer.

GHWIC strategies and activities

One goal of the GHWIC NOFO is to create community engagement through shared cultural experiences.

These experiences will lay the foundation for a more comprehensive, holistic approach to health and wellbeing that will help prevent, manage, and control chronic diseases.

We designed the strategies and activities to meet you where you are. Over the course of the five years, you will be implementing each of the strategies and activities in your component’s logic model. If you are already doing any of these activities, we want you to continue doing that work. We want you to build on what’s already in place and establish new systems and programs over the course of the 5-year period of performance.

Cultural practices Background AI/AN culture and traditions have been severely disrupted by colonialism, loss of land, racial discrimination, and policies such as assimilation, relocation, and tribal termination. This has resulted in historical trauma, continued intergenerational trauma, as well as health, social, and economic inequities, which have put AI/AN populations at higher risk for chronic diseases. AI/AN communities have innate strengths and resilience rooted in tribal culture and traditional ways of life. Evidence suggests that centering culture, language, and traditions to chronic disease prevention, management, and control is impactful, enables new partnerships, and increases participation in public health events.

CDC supports work to improve cultural connectedness and social connectedness among community members. Higher levels of social connectedness suggest better community outcomes, ranging from population health, resilience, and prosperity.1 We emphasize culture and tradition as the foundation for all GHWIC efforts.

Cultural practices required activity

• Implement family-centered community activities that respect, support, teach, build upon, celebrate, and strengthen cultural practices and teachings. These might include Native language, seasonal cultural events, and intergenerational programs.

Cultural practices example activities

• Establish community programs to plant, raise, gather, harvest, or preserve traditional healthy foods.

• Establish intergenerational mentorship programs to share cultural heritage (e.g., language, ceremonies, stories, places, and crafts).

• Engage community members of all ages in traditional practices (e.g., beading, sewing, basket-making, 1 Office of the Surgeon General (OSG). (2023). Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community. US Department of Health and Human Services.

games, stories).

• Implement a program to enhance, reclaim, and/or restore the community's Native language.

• Distribute a calendar of seasonal cultural and traditional events to encourage community participation.

• Invite knowledge-bearers to share cultural expertise with community.

Cultural practices resources

• Health effects of Indigenous language use and revitalization: a realist review

(https://doi.org/10.1186/s12939-022-01782-6). This article describes language use and revitalization as protective factors in the health of Indigenous population.

Community-clinical linkages

Background CDC supports work to establish partnerships among clinical, social, and community-based services and programs to prevent, manage, and control chronic diseases and their risk factors. CDC requires efforts to screen, test, and refer community members with, or at risk of chronic diseases to the appropriate provider for care and treatment or to programs for self-management or self-monitoring.

Required chronic disease prevention, management, and control activities

• Engage community members of all ages in traditional and contemporary wellness activities focused on chronic disease prevention. These might include community walking programs, healthy eating classes, virtual wellness classes.

• Develop a new or expanded coordinated system for screening, testing, and making referrals for community members to community, clinical, and social, services and programs for chronic disease prevention, management, and control.

• Identify or offer culturally appropriate programs for preventing and managing chronic diseases that you can refer community members to. These might include the National Diabetes Prevention Program

(National DPP), blood pressure (BP) monitoring, and family healthy weight programs.

• Recruit clinical and social service providers to participate in your community clinical linkages program.

• Implement systems for screening, testing, and making referrals to clinical, social, and community-based services and resources for chronic disease prevention, management, and control.

https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Health%20effects%20of%20Indigenous%20language%20use%20and%20revitalization:%20a%20realist%20review

Required diabetes prevention activities

• Diabetes screening o Screen tribal members at risk for diabetes using the American Diabetes Association/CDC

Prediabetes Risk Test. Refer those at risk to a health care provider for blood glucose testing and a type 2 diabetes prevention program. See options in the next required activity.

• Type 2 diabetes prevention. Pick one of the following based on your community’s needs:

o Establish a new (or maintain an existing) CDC-recognized, culturally relevant version of the National

DPP lifestyle change program for adult tribal members with prediabetes using the PreventT2 curriculum.

o Establish a new (or maintain an existing) community selected, evidence-informed type 2 diabetes prevention program using elements of the National DPP PreventT2 curriculum. This could include

“Eat Well to Prevent T2,” “Commit to Change,” “Coping with Challenges,” “Support,” and other modules.

• *Note: Individuals whose blood glucose levels are in the diabetes range should be referred to a diabetes self-management education and support (DSMES) program.

Required team-based care activities

• Promote the implementation of team-based care teams to include community, social, and clinical service providers. Examples of providers include community health workers (CHWs), community health representatives (CHRs), patient navigators, social workers, pharmacists, and dentists.

• Engage multidisciplinary teams to improve team-based care coordination and provide more comprehensive and holistic care.

• Facilitate referrals from health care settings to community and social services for patients reporting health and social economic needs.

https://www.cdc.gov/prediabetes/takethetest/ https://www.cdc.gov/diabetes/prevention/resources/curriculum.html https://www.cdc.gov/diabetes/prevention/resources/curriculum.html https://www.cdc.gov/diabetes/prevention/resources/curriculum.html https://diabetes.org/diabetes/a1c/diagnosis https://wcms-wp.cdc.gov/diabetes-toolkit/php/index.html

Example activities and available resources

Commercial tobacco cessation example activities

• Form partnerships and establish a referral system to a commercial tobacco cessation program that includes counseling (e.g., one-on-one, group, or quitline) and nicotine treatment therapy.

• Form partnerships (e.g., community members, youth, healthcare partners) for mass communication

(e.g., radio, newspaper, digital media) on available services (e.g., quitlines, local clinic’s commercial tobacco cessation program).

• Help establish a pharmacist-led commercial smoking cessation clinic that provides counseling and medication therapy services under a collaborative practice agreement (CPA).

• Provide commercial tobacco treatment intervention training for healthcare professionals, paraprofessionals, and community members to deliver cessation interventions and lead health systems change.

Commercial tobacco cessation resources

• Keep it Sacred (https://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-v-commercial/) This

National Native Network website provides resources for culturally tailored commercial tobacco use prevention and cessation effort.

• Red Lake Indian Health Service pharmacist-led smoking cessation clinic

(https://aphanet.pharmacist.com/sites/default/files/audience/APhAPromisingPracticesTobCess_RedLake

IHS.pdf) This resource summarizes commercial tobacco cessation services at Red Lake Indian Health

Service.

• American Indian Commercial Tobacco Program (https://aiquitline.com/) This site offers resources for commercial tobacco cessation and mass media campaigns.

• Quitlines and Other Cessation Support Resources (https://www.cdc.gov/tobacco/patient-care/quitlines-other/index.html)This resource describes commercial tobacco cessation support resources to include https://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-v-commercial/ https://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-v-commercial/ https://aphanet.pharmacist.com/sites/default/files/audience/APhAPromisingPracticesTobCess_RedLakeIHS.pdf https://aphanet.pharmacist.com/sites/default/files/audience/APhAPromisingPracticesTobCess_RedLakeIHS.pdf https://aphanet.pharmacist.com/sites/default/files/audience/APhAPromisingPracticesTobCess_RedLakeIHS.pdf https://aiquitline.com/ https://aiquitline.com/ https://www.cdc.gov/tobacco/patient-care/quitlines-other/index.html https://www.cdc.gov/tobacco/patient-care/quitlines-other/index.html https://www.cdc.gov/tobacco/patient-care/quitlines-other/index.html quitlines, text messaging support, web-based support, smartphone apps, etc.

• American Indian and Alaska Native People Encounter Barriers to Quitting Successfully

(https://www.cdc.gov/tobacco/health-equity/aian/quitting-tobacco.html) This provides examples of strategies that communities can use when encountering barriers.

• Rural Tobacco Control and Prevention Toolkit (https://www.ruralhealthinfo.org/toolkits/tobacco)This provides evidence-based examples, best practices, and resources to implement a tobacco control and prevention program.

• Program Infrastructure in Tobacco Prevention and Control

(https://www.cdc.gov/tobacco/stateandcommunity/guides/pdfs/program-infrastructure.pdf)This resource identifies how to establish a strong infrastructure for your community's commercial tobacco control program.

• The Community Guide on Tobacco Use: Mass-Reach Health Communication Interventions

(https://www.thecommunityguide.org/findings/tobacco-use-mass-reach-health-communication-interventions.html) This provides evidence of the effectiveness of mass-reach health communication interventions implemented with a comprehensive commercial tobacco control program.

• SmokefreeNATIVE.gov (https://smokefree.gov/tools-tips/text-programs/quit-for-good/smokefreenative?utm_source=IHS&utm_medium=website&utm_campaign=SFNative) This resource is a free text messaging program to help American Indians and Alaska Natives quit smoking commercial tobacco.

Diabetes prevention example activities

• Partner with a tribal clinic/health care facility to ensure policies are in place to refer individuals with prediabetes or at high risk for type 2 diabetes to the National DPP lifestyle change program.

• Establish a new CDC-recognized National DPP lifestyle change program (where the population can support one).

• Partner with a CDC-recognized program offered virtually or nearby to offer a culturally tailored option appropriate for your community.

• Market the program with community-appropriate activities and messages.

• Involve CHRs to provide individualized assistance to help participants enroll in the program and stay engaged over time.

• Apply to become a Medicare Diabetes Prevention Program supplier.

• Build the infrastructure to support billing Medicare, Medicaid, and other insurers for program services

(where applicable) to promote long-term sustainability.

• Modify the program to improve convenience, appeal, and sustainability (e.g., train a community member as a lifestyle coach, incorporate traditional foods and physical activity, involve family members or caretakers).

https://www.cdc.gov/tobacco/health-equity/aian/quitting-tobacco.html/ https://www.cdc.gov/tobacco/health-equity/aian/quitting-tobacco.html/ https://www.ruralhealthinfo.org/toolkits/tobacco https://www.cdc.gov/tobacco/stateandcommunity/guides/pdfs/program-infrastructure.pdf https://www.cdc.gov/tobacco/stateandcommunity/guides/pdfs/program-infrastructure.pdf https://www.thecommunityguide.org/findings/tobacco-use-mass-reach-health-communication-interventions.html https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/(https:/www.thecommunityguide.org/findings/tobacco-use-mass-reach-health-communication-interventions.html) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/(https:/www.thecommunityguide.org/findings/tobacco-use-mass-reach-health-communication-interventions.html) https://urldefense.us/v3/__https:/smokefree.gov/tools-tips/text-programs/quit-for-good/smokefreenative?utm_source=IHS&utm_medium=website&utm_campaign=SFNative__;!!Og_tST9LxTiQE1I!o-2vPp7iquaxzGVwn-QuyyQhqPNY1H9aL4JoJm1vqIeCwMjrt4o7RhREjiydOK_kKvZU3D1AFT4hrukb0Ner9cFvPjh6pYIITNN71JM$ https://smokefree.gov/tools-tips/text-programs/quit-for-good/smokefreenative?utm_source=IHS&utm_medium=website&utm_campaign=SFNative https://smokefree.gov/tools-tips/text-programs/quit-for-good/smokefreenative?utm_source=IHS&utm_medium=website&utm_campaign=SFNative

• Help participants overcome barriers to participation in the program (e.g., healthy food vouchers, transportation). (Additional guidance coming from CDC.)

• Consider program modifications to help improve convenience, appeal, and sustainability (e.g., offering sessions at convenient times, having a community member trained as a lifestyle coach, incorporating traditional foods or forms of physical activity, inviting family members or caretakers to join).

Diabetes prevention resources

• National DPP Customer Service Center (https://nationaldppcsc.cdc.gov/s/ This allows you to access training materials, toolkits and videos for delivering the National DPP).

• Integrating Culture and History to Promote Health and Help Prevent Type 2 Diabetes in American

Indian/Alaska Native Communities: Traditional Foods Have Become a Way to Talk About Health

(https://doi.org/10.5888/pcd17.190213) This article describes the Traditional Foods Project that addresses type 2 diabetes by focusing on traditional foods, physical activity, and social support.

• Learning about the National DPP | CDC (https://www.cdc.gov/diabetes/prevention/about.htm) The

National DPP is a partnership of public and private organizations working to build the infrastructure for nationwide delivery of an evidence-based lifestyle intervention for adults with prediabetes to prevent or delay onset of type 2 diabetes.

• Education Materials and Resources (Online Catalog) | Division of Diabetes Treatment and Prevention

(DDTP) (https://www.ihs.gov/diabetes/education-materials-and-resources/) This IHS website provides free, culturally relevant materials to prevent and treat diabetes and diabetes-related conditions.

• National Diabetes Prevention Program Standards and Operating Procedures (DPRP)

(https://nationaldppcsc.cdc.gov/s/article/DPRP-Standards-and-Operating-Procedures) This resource provides the standards and operating procedures for the National DPP.

• CDC Native Diabetes Wellness Program (https://www.cdc.gov/diabetes/ndwp/index.html) This program honors a balance between cultural practices and sciences in Indian Country to promote health and help prevent type 2 diabetes. Includes the Eagle Books.

Diabetes self-management example activities

• Refer community members with diabetes to a Diabetes Self-Management Education and Support

(DSMES) program.

https://nationaldppcsc.cdc.gov/s/about-the-customer-service-center https://nationaldppcsc.cdc.gov/s/ https://doi.org/10.5888/pcd17.190213 https://doi.org/10.5888/pcd17.190213 https://doi.org/10.5888/pcd17.190213 https://www.cdc.gov/diabetes/prevention/about.htm https://www.ihs.gov/diabetes/education-materials-and-resources/ https://www.ihs.gov/diabetes/education-materials-and-resources/ https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf https://www.cdc.gov/diabetes/ndwp/index.html

Diabetes self-management resources

• Diabetes Self-Management Education and Support (DSMES)

(https://www.cdc.gov/diabetes/dsmes/dsmes-living-with-diabetes.html) This resource describes strategies and available support to manage diabetes.

• Diabetes self-management education and support (DSMES) | IHS

(https://www.ihs.gov/diabetes/clinician-resources/soc/dsme1/) This IHS Division of Diabetes Treatment and Prevention website offers diabetes self-management education resources for clinicians and educators.

• Integrating Diabetes Self-Management Education and Support into Your SDPI Diabetes Best Practice

(https://www.ihs.gov/sites/sdpi/themes/responsive2017/display_objects/documents/DSME.pdf) This resource is designed for clinicians/educators who want to integrate DSMES into Special Diabetes

Program for Indians (SDPI) activities and services.

• Development of an American Indian Diabetes Education Cultural Supplement: A Qualitative Approach

(https://www.frontiersin.org/articles/10.3389/fpubh.2022.790015/full) This article describes the approaches on the development, implementation, and testing of culturally informed health education for

AI/AN populations.

• Physicians Committee for Responsible Medicine (https://www.pcrm.org/good-nutrition/healthy-communities/native-american-resources) This website provides resources for ancestral plant-based foods to treat, reverse, and prevent type 2 diabetes.

• The DSMES Toolkit (https://wcms-wp.cdc.gov/diabetes-toolkit/php/index.html) The DSMES toolkit is a comprehensive resource for achieving success in diabetes self-management education and support.

• Division of Diabetes Translation (https://wcms-wp.cdc.gov/diabetes/index.html) This CDC resource highlights ways you and your family can manage type 2 diabetes together.

High blood pressure example activities

• Partner with a health clinic to create referrals to a Self-Measured Blood Pressure (SMBP) monitoring program.

https://www.cdc.gov/diabetes/dsmes/dsmes-living-with-diabetes.html https://www.cdc.gov/diabetes/dsmes/dsmes-living-with-diabetes.html https://www.ihs.gov/diabetes/clinician-resources/soc/dsme1/ https://www.ihs.gov/diabetes/clinician-resources/soc/dsme1/ https://www.ihs.gov/sites/sdpi/themes/responsive2017/display_objects/documents/DSME.pdf https://www.ihs.gov/sites/sdpi/themes/responsive2017/display_objects/documents/DSME.pdf https://www.frontiersin.org/articles/10.3389/fpubh.2022.790015/full https://www.frontiersin.org/articles/10.3389/fpubh.2022.790015/full https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Physicians%20Committee%20for%20Responsible%20Medicine https://www.pcrm.org/good-nutrition/healthy-communities/native-american-resources https://www.pcrm.org/good-nutrition/healthy-communities/native-american-resources https://wcms-wp.cdc.gov/diabetes-toolkit/php/index.html https://wcms-wp.cdc.gov/diabetes/index.html https://millionhearts.hhs.gov/tools-protocols/tools/smbp.html

• Support a local health center SMBP Program that provides the following:

• Training on how to use a home blood pressure monitor.

• Education on how to accurately measure blood pressure (e.g., preparation, positioning).

• A system where home blood pressure values are relayed from the patient back to the clinical care team

(e.g., Electronic Health Records, log sheet).

• Ongoing, direct support to those community members using SMBP.

• Education for community members on behaviors that trigger high blood pressure.

• Partner with health centers, social or community organizations to offer activities and education on preventing high blood pressure (e.g. DASH Eating Plan, healthy weight and physical activity programs, smoking cessation).

• Create a referral system to a local pharmacy to support medication adherence, which may include medication counseling, motivational interviewing, and education.

• Integrate SMBP orientation into lifestyle education classes.

• Use SMBP to enhance services for existing chronic disease programs offered in the community.

Highlight the benefits of implementing team-based care in health systems as an effective way to improve blood pressure control.

High blood pressure resources

• Dietary Approaches to Stop Hypertension (DASH) (https://www.nhlbi.nih.gov/education/dash-eating-plan) This is an eating plan with a proven record of helping people lower their blood pressure.

• Self-Measured Blood Pressure Monitoring (SMBP) Implementation Toolkit

(https://www.nachc.org/resource/smbp-toolkit_final-2/) This toolkit is designed to help organizations implement self-measured blood pressure monitoring (SMBP) successfully into their care processes and workflows.

• Self-Measured Blood Pressure (https://millionhearts.hhs.gov/files/MH_SMBP.pdf) This document provides action steps and resources for public health practitioners on self-measured blood pressure monitoring.

• Best Practices for Health Disease and Stroke Prevention and Management (https://hdsbpc.cdc.gov/s/)

This website provides full guidance on addressing heart disease and stroke prevention and management.

• Tailored Pharmacy-Based Interventions to Improve Medication Adherence

(https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm). This website provides pharmacy-based interventions to support adherence to medications prescribed to prevent heart disease.

• Hypertension Management Program (HMP) Toolkit (https://www.cdc.gov/dhdsp/pubs/toolkits/hmp-toolkit/index.htm) This CDC toolkit for clinicians aims to improve the quality of patient care and decrease the number of patients with uncontrolled hypertension.

https://www.nachc.org/wp-content/uploads/2023/07/Self-Measured-Blood-Pressure-Toolkit_3.9.2023_FINAL.pdf https://www.cdc.gov/bloodpressure/prevent.htm https://www.nhlbi.nih.gov/education/dash-eating-plan https://www.cdc.gov/healthyweight/index.html https://www.cdc.gov/tobacco/ https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm https://www.thecommunityguide.org/findings/heart-disease-stroke-prevention-team-based-care-improve-blood-pressure-control.html?ACSTrackingID=USCDCCG_25-DM113679&ACSTrackingLabel=New%20Publication%20Features%20Cost-effectiveness%20Evidence%20for%20Team-based%20Care%20to%20Improve%20Blood%20Pressure%20Control&deliveryName=USCDCCG_25-DM113679 https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Dietary%20Approaches%20to%20Stop%20Hypertension%20(DASH)%20(https:/www.nhlbi.nih.gov/education/dash-eating-plan https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Dietary%20Approaches%20to%20Stop%20Hypertension%20(DASH)%20(https:/www.nhlbi.nih.gov/education/dash-eating-plan https://www.nachc.org/resource/smbp-toolkit_final-2/ https://www.nachc.org/resource/smbp-toolkit_final-2/ https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Self-Measured%20Blood%20Pressure https://millionhearts.hhs.gov/files/MH_SMBP.pdf https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm https://www.cdc.gov/dhdsp/pubs/toolkits/hmp-toolkit/index.htm https://www.cdc.gov/dhdsp/pubs/toolkits/hmp-toolkit/index.htm

• Heart Disease and Stroke Prevention (https://www.cdc.gov/dhdsp/index.htm) This website provides program and evaluation guides, videos, and tips for implementing heart disease and stroke prevention programs.

• WISE WOMAN Program (https://www.cdc.gov/wisewoman/). This program was created to help women reduce their risk for heart disease and stroke by providing services to promote lasting heart-healthy lifestyles.

• Prevent High Blood Pressure (https://www.cdc.gov/bloodpressure/prevent.htm) This website provides ways to lower the risk for heart disease and stroke by practicing healthy living habits.

• Honoring the Gift of Heart Health: A Heart Health Educator's Manual for American Indians | NHLBI, NIH

(https://www.nhlbi.nih.gov/resources/honoring-gift-heart-health-heart-health-educators-manual-american-indians) This manual provides guidance on sessions, worksheets, handouts, and other resources to promote heart health to individuals, family, and communities.

• Cardiovascular Disease: Self-Measured Blood Pressure Monitoring

(https://www.thecommunityguide.org/media/pdf/OnePager-CVD-SMBP.pdf)

The Community Preventive Services Task Force (CPSTF) recommends self-measured blood pressure

(SMBP) monitoring interventions to improve blood pressure outcomes in patients with high blood pressure.

Physical activity example activities

• Encourage employers to establish a worksite wellness program, or improve one, to include physical activity programs.

• Work with tribal leaders to designate land for physical activity (e.g., walking trails, sports fields, walking/biking paths to community places).

• Increase access to safe places for physical activity.

• Establish a community-wide walking club.

• Implement the Just Move It campaign to promote physical activity.

• Offer cultural games, traditional dancing, and canoeing to increase physical activity.

• Host POWWOW Sweats.

Physical activity resources

• Active People, Healthy NationSM

(https://www.cdc.gov/physicalactivity/activepeoplehealthynation/index.html) This national campaign aims to move people from inactive to some activity every day. Includes evidence-based strategies to improve equitable and inclusive access to safe places for physical activity.

• Just Move It https://www.nihb.org/public_health/just_move_it.php) This national campaign from the

National Indian Health Board is designed to promote physical activity for American Indians and Alaska https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Heart%20Disease%20and%20Stroke%20Prevention https://www.cdc.gov/dhdsp/index.htm https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Prevent%20High%20Blood%20Pressure%20(https:/www.cdc.gov/bloodpressure/prevent.htm) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Honoring%20the%20Gift%20of%20Heart%20Health:%20A%20Heart%20Health%20Educator's%20Manual%20for%20American%20Indians%20|%20NHLBI,%20NIH%20(https:/www.nhlbi.nih.gov/resources/honoring-gift-heart-health-heart-health-educators-manual-american-indians) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Honoring%20the%20Gift%20of%20Heart%20Health:%20A%20Heart%20Health%20Educator's%20Manual%20for%20American%20Indians%20|%20NHLBI,%20NIH%20(https:/www.nhlbi.nih.gov/resources/honoring-gift-heart-health-heart-health-educators-manual-american-indians) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Honoring%20the%20Gift%20of%20Heart%20Health:%20A%20Heart%20Health%20Educator's%20Manual%20for%20American%20Indians%20|%20NHLBI,%20NIH%20(https:/www.nhlbi.nih.gov/resources/honoring-gift-heart-health-heart-health-educators-manual-american-indians) https://www.thecommunityguide.org/media/pdf/OnePager-CVD-SMBP.pdf https://www.thecommunityguide.org/media/pdf/OnePager-CVD-SMBP.pdf https://hncpartners.org/ https://www.cdc.gov/physicalactivity/activepeoplehealthynation/index.html https://www.nihb.org/public_health/just_move_it.php

Natives. The website provides information on starting a program in your community.

• Nutrition, Physical Activity, and Obesity within American Indian and Alaska Native Populations

(https://www.cdc.gov/healthytribes/nutrition-activity-obesity.html) This website highlights strategies to encourage physical activity among your clients and in your community.

• CDC-Recognized Family Healthy Weight Programs | Overweight & Obesity |

(https://www.cdc.gov/obesity/strategies/family-healthy-weight-programs.html) This website provides ready-to-use, evidence-based programs for children who have overweight or obesity and their families.

• Obesity Education Opportunities for Healthcare Professionals (https://www.aap.org/en/patient-care/institute-for-healthy-childhood-weight/obesity-education-opportunities-for-healthcare-professionals/)

This website consists of modules, webinars, and podcasts to increase the knowledge and understanding of obesity.

Nutrition example activities

• Encourage employers to establish a worksite wellness program, or improve one, to include nutrition programs.

• Establish healthy fruits and vegetables incentive programs.

• Partner with health care providers to offer produce prescription programs.

• Offer lessons on preparing and consuming plant-based snacks, garden-based nutrition, and traditional foods.

• Share traditional foods recipes.

• Host hands-on food demonstrations and taste tests.

• Host events to teach about traditional food sources.

• Hold healthy cooking classes with traditional and contemporary foods to increase healthier meals.

• Hold workshops on hunting, gathering, fishing, and preparing and preserving foods.

• Share cultural teachings and practices about traditional healthy foods to promote health, sustenance, and sustainability.

Nutrition resources

• Nutrition, Physical Activity, and Obesity within American Indian and Alaska Native Populations

(https://www.cdc.gov/healthytribes/nutrition-activity-obesity.html) This website suggests strategies to encourage physical activity among your clients and in your community.

• Nourishing Native Foods & Health (https://www.firstnations.org/our-programs/nourishing-native-foods-health/) This First Nations website highlights their programs and resources for improving access to healthy foods and building sustainable food systems in the community.

• Nutrition. Division of Nutrition, Physical Activity, and Obesity (https://www.cdc.gov/nutrition/index.html)

This website houses resources such as dietary guidelines, strategies, toolkits, and factsheets.

https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/CDC-Recognized%20Family%20Healthy%20Weight%20Programs%20|%20Overweight%20&%20Obesity%20|%20%20(https:/www.cdc.gov/obesity/strategies/family-healthy-weight-programs.html) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/CDC-Recognized%20Family%20Healthy%20Weight%20Programs%20|%20Overweight%20&%20Obesity%20|%20%20(https:/www.cdc.gov/obesity/strategies/family-healthy-weight-programs.html) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Obesity%20Education%20Opportunities%20for%20Healthcare%20Professionals%20(https:/www.aap.org/en/patient-care/institute-for-healthy-childhood-weight/obesity-education-opportunities-for-healthcare-professionals/) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Obesity%20Education%20Opportunities%20for%20Healthcare%20Professionals%20(https:/www.aap.org/en/patient-care/institute-for-healthy-childhood-weight/obesity-education-opportunities-for-healthcare-professionals/) https://www.cdc.gov/healthytribes/nutrition-activity-obesity.html https://www.cdc.gov/healthytribes/nutrition-activity-obesity.html https://www.firstnations.org/our-programs/nourishing-native-foods-health/ https://www.firstnations.org/our-programs/nourishing-native-foods-health/ https://www.cdc.gov/nutrition/index.html

• Priority Nutrition Strategy: Fruit and Vegetable Voucher Incentives and Produce Prescriptions | Nutrition |

(https://www.cdc.gov/nutrition/state-and-local-strategies/priority-incentives-prescriptions.html) This website offers example activities and resources to implement fruit/vegetable/produce incentive and prescription programs in your community.

• First National Development Institute: Nourishing Native Foods & Health

(https://www.firstnations.org/our-programs/nourishing-native-foods-health/) This website provides tools and resources that focus on sustainable food systems that improve health and strengthen food security.

• Priority Breastfeeding Strategy: Continuity of Care (https://www.cdc.gov/breastfeeding/priority-breastfeeding-strategy.html) This website includes activities and resources for building support for breastfeeding in your community.

Oral health example activities

• Encourage dental professionals to perform blood pressure screenings and make referrals to health care clinics, primary care providers, and community organizations.

• Increase oral health awareness through the Early Childhood Caries Collaborative, an Indian Health

Service initiative.

• Implement a public awareness campaign about the importance of oral health.

• Work with tribal governments to implement water fluoridation programs.

Oral health resources

• American Academy of Pediatrics: Oral Health Campaign Toolkit (https://www.aap.org/en/news-room/campaigns-and-toolkits/oral-health/) This Protect Tiny Teeth toolkit contains materials for education and clinical resources in oral health.

• Indian Health Service Dental Portal (https://www.ihs.gov/doh/) The Indian Health Service Dental Portal contains oral health materials and resources from the IHS Division of Oral Health, which includes a

November 2022 Oral Health Report of AI/AN adult dental patients

(https://www.ihs.gov/doh/documents/surveillance/2021-2022 IHS Oral Health Survey Data Brief.pdf).

• Native Oral Health Network-Southern Plains Tribal Health Board (https://spthb.org/programs/our-grants/native-oral-health-network/). This website provides a platform for resources, peer support, and community engagement.

• Oral Health in America (https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-

America-Advances-and-Challenges.pdf) This report is intended to provide a road map on how to improve the nation’s oral health and draws primarily on information from public research and evidence-based practices.

• Oral Health in Healthcare Settings to Prevent Pneumonia Toolkit | HAI | CDC

(https://www.cdc.gov/hai/prevent/Oral-Health-Toolkit.html) This toolkit promotes oral healthcare to https://www.cdc.gov/nutrition/state-and-local-strategies/priority-incentives-prescriptions.html https://www.cdc.gov/nutrition/state-and-local-strategies/priority-incentives-prescriptions.html https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/First%20National%20Development%20Institute:%20Nourishing%20Native%20Foods%20&%20Health%20%20(https:/www.firstnations.org/our-programs/nourishing-native-foods-health/) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/First%20National%20Development%20Institute:%20Nourishing%20Native%20Foods%20&%20Health%20%20(https:/www.firstnations.org/our-programs/nourishing-native-foods-health/) https://www.cdc.gov/breastfeeding/priority-breastfeeding-strategy.html https://www.cdc.gov/breastfeeding/priority-breastfeeding-strategy.html https://www.ihs.gov/doh/index.cfm?fuseaction=ecc.packetnew file:///C:%5CUsers%5Cgpk9%5COneDrive%20-%20CDC%5CDocuments%20-%20NCCDPHP-HealthyTribes%5CNOFO-DEVELOPMENT-All-Things-NOFO%5C_GHWIC-2024%5CImplementation%20Guides%5CCleared%20Version%5CAmerican%20Academy%20of%20Pediatrics:%20Oral%20Health%20Campaign%20Toolkit%20(https:%5Cwww.aap.org%5Cen%5Cnews-room%5Ccampaigns-and-toolkits%5Coral-health%5C) file:///C:%5CUsers%5Cgpk9%5COneDrive%20-%20CDC%5CDocuments%20-%20NCCDPHP-HealthyTribes%5CNOFO-DEVELOPMENT-All-Things-NOFO%5C_GHWIC-2024%5CImplementation%20Guides%5CCleared%20Version%5CAmerican%20Academy%20of%20Pediatrics:%20Oral%20Health%20Campaign%20Toolkit%20(https:%5Cwww.aap.org%5Cen%5Cnews-room%5Ccampaigns-and-toolkits%5Coral-health%5C) https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Indian%20Health%20Service%20Dental%20Portal%20(https:/www.aap.org/en/news-room/campaigns-and-toolkits/oral-health/) https://www.ihs.gov/doh/ https://www.ihs.gov/doh/documents/surveillance/2021-2022%20IHS%20Oral%20Health%20Survey%20Data%20Brief.pdf https://spthb.org/programs/our-grants/native-oral-health-network/ https://spthb.org/programs/our-grants/native-oral-health-network/ https://www.cdc.gov/hai/prevent/Oral-Health-Toolkit.html https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf https://www.cdc.gov/hai/prevent/Oral-Health-Toolkit.html https://www.cdc.gov/hai/prevent/Oral-Health-Toolkit.html prevent healthcare-associated pneumonia in hospital and long-term care settings.

Team-based care example activities

• Expand health care teams by including Community Health Workers (CHW)

• Partner with local clinic pharmacists and physician champion(s) to implement a Collaborative Practice

Agreement (CPA) that provides pharmacists the authority to initiate, monitor, modify, and discontinue drug therapy for chronic diseases (e.g., diabetes, high blood pressure, high blood cholesterol, commercial smoking cessation).

• Partner with local clinics and community-based organizations to implement a referral system to connect patients to classes and programs related to healthy eating, active living, chronic disease self-management, and health-related social services.

• Partner with pharmacists to identify barriers to, and improve, medication adherence strategies.

• Conduct health education and outreach efforts for patients at increased risk for chronic diseases and their risk factors.

Team-based care resources

• Team-Based Care to Improve Blood Pressure Control – Heart Disease and Stroke Best Practices

Clearninghous (https://hdsbpc.cdc.gov/s/article/Team-Based-Care-to-Improve-Blood-Pressure-Control)

This is an article on the best practices to implement team-based care.

• Community Health Workers (CHW) Inclusion Checklist

(https://archive.cdc.gov/www_cdc_gov/dhdsp/pubs/toolkits/chw-checklist.htm) This checklist can help facilitate and strengthen relationships between CHWs and health care providers. The checklist is structured into 4 phases: planning, implementation, evaluation, and sustainability.

• Collaborative Drug Therapy Management (CDTM) (https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-

Based-Care.pdf) This guide is to empower community pharmacists and physician champion(s) to initiate collaborative practice agreements (CPAs).

• Community-Clinical Linkages for the Prevention and Control of Chronic Diseases

(https://www.cdc.gov/dhdsp/pubs/docs/ccl-practitioners-guide.pdf) This guide presents resources for public health practitioners to use when implementing the strategy and examples of community-clinical linkages. Public health practitioners can use these examples as models for community-clinical linkages in their areas.

• Tailored Pharmacy-Based Interventions to Improve Medication Adherence

(https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm)This website provides resources to support adherence to medications prescribed to prevent and manage chronic conditions such as cardiovascular disease (CVD).

https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf https://hdsbpc.cdc.gov/s/article/Team-Based-Care-to-Improve-Blood-Pressure-Control https://archive.cdc.gov/www_cdc_gov/dhdsp/pubs/toolkits/chw-checklist.htm https://archive.cdc.gov/www_cdc_gov/dhdsp/pubs/toolkits/chw-checklist.htm https://cdc.sharepoint.com/teams/NCCDPHP-HealthyTribes/Shared%20Documents/NOFO-DEVELOPMENT-All-Things-NOFO/_GHWIC-2024/Implementation%20Guides/Draft%20Implementation%20Guide/Collaborative%20Drug%20Therapy%20Management%20(CDTM) https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf https://www.bing.com/ck/a?!&&p=a1e455a2a37009a8JmltdHM9MTcwNjQ4NjQwMCZpZ3VpZD0xYjQzYmY4Ny05YjkwLTYxMmQtMGNhNy1hYjk3OWFkYzYwZTcmaW5zaWQ9NTIxMQ&ptn=3&ver=2&hsh=3&fclid=1b43bf87-9b90-612d-0ca7-ab979adc60e7&psq=CCL+referral+system&u=a1aHR0cHM6Ly93d3cuY2RjLmdvdi9kaGRzcC9wdWJzL2RvY3MvY2NsLXByYWN0aXRpb25lcnMtZ3VpZGUucGRm&ntb=F https://www.cdc.gov/dhdsp/pubs/docs/ccl-practitioners-guide.pdf https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm

• Creating Patient-Centered Team-based Primary Care [PDF – 2 MB]

(https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf). This paper proposes a conceptual framework and offers strategies to support patient-centered team-based care in primary care settings.

• Implementation Considerations for Team-Based Care (https://hdsbpc.cdc.gov/s/article/Implementation-

Considerations-for-Team-Based-Care) This resource provides implementation guidance and resource links for team-based care.

• Screening for Social Needs: Guiding Care Teams to Engage Patients

(https://www.aha.org/toolkitsmethodology/2019-06-05-screening-social-needs-guiding-care-teams-engage-patients).This resource includes strategic considerations for implementing a social needs screening program.

Policy, systems, and environmental changes (PSE)

Background CDC supports work to establish policy, systems, and environmental changes that make healthier choices the easy choice. PSE changes also support sustainability of your efforts after federal funding ends. CDC requires Component 2 recipients to provide training, technical assistance, and support to all Tribes, Villages, UIOs, and other tribal entities in their award area to establish PSEs that promote health and prevent chronic diseases and their risk factors.

Required PSE activities (Component 2)

Assist all Tribes, Villages, UIOs, and other tribal entities in your award area in establishing policies that promote healthier behaviors, such as commercial smokefree air, worksite wellness, and public locations for physical activity.

Provide technical assistance, training, and resources to all Tribes, Villages, UIOs, and other tribal entities in your award area on these evidence-based PSE changes.

Assist all Tribes, Villages, UIOs, and other tribal entities in your award area in increasing awareness among community members and leaders about how PSE changes promote health and encourage healthier behaviors.

Policy, systems, and environmental changes (PSE) example activities

• Assess PSE interests and needs of Tribes, Villages, UIOs, and other tribal entities.

https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf https://hdsbpc.cdc.gov/s/article/Implementation-Considerations-for-Team-Based-Care https://www.aha.org/toolkitsmethodology/2019-06-05-screening-social-needs-guiding-care-teams-engage-patients https://www.aha.org/toolkitsmethodology/2019-06-05-screening-social-needs-guiding-care-teams-engage-patients https://www.aha.org/toolkitsmethodology/2019-06-05-screening-social-needs-guiding-care-teams-engage-patients

• Invite experts to provide culturally appropriate policy training.

• Conduct American Indian Adult Tobacco surveys to understand the impact of commercial tobacco control activities on Tribes/Villages/UIOs/other tribal entities.

• Educate community…