Foa_Content_of_CDC-RFA-DP-23-0003_Revised.pdf

Centers for Disease Control and Prevention

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH

PROMOTION

WISEWOMAN: Well-Integrated Screening and Evaluation of WOMen Across the Nation

CDC-RFA-DP-23-0003

05/30/2023

Table of Contents A. Funding Opportunity Description

B. Award Information

C. Eligibility Information

D. Application and Submission Information

E. Review and Selection Process

F. Award Administration Information

G. Agency Contacts

H. Other Information

I. Glossary

Part I. Overview

Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Subscribe" button link to ensure they receive notifications of any changes to CDC-RFA-DP- 23-0003. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) / Agency for Toxic Substances and Disease Registry (ATSDR) B. Notice of Funding Opportunity (NOFO) Title:

WISEWOMAN: Well-Integrated Screening and Evaluation of WOMen Across the Nation C. Announcement Type: New - Type 1:

This announcement is only for non-research activities supported by CDC. If research is proposed, the application will not be considered. For this purpose, research is defined at https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52- 2.pdf. Guidance on how CDC interprets the definition of research in the context of public health can be found at https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr- 46/index.html (See section 45 CFR 46.102(d)).

New-Type 1

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP-23-0003

E. Assistance Listings Number:

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

93.436 F. Dates:

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

05/01/2023

2. Due Date for Applications:

05/30/2023 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call:

WISEWOMAN: Well-Integrated Screening and Evaluation of WOMen Across the Nation

Applicant Informational Webinar

Tuesday, April 11, 2023

3:00pm - 4:00pm ET

Click the link below to join the webinar:

https://cdc.zoomgov.com/j/1611247473?pwd=cUpic1ViVEs3VU5NcHplY3JENXJJUT09

Or join by phone:

US: +1 669 254 5252 or

+1 646 964 1167 or

+1 646 828 7666 or

+1 415 449 4000 or

+1 551 285 1373 or

+1 669 216 1590

Webinar ID: 161 124 7473

Passcode: 08483154

Additional information about this and other DHDSP funding opportunities may be found at:

https://www.cdc.gov/dhdsp/funding-opps/index.htm

Questions about this NOFO may be submitted via email: WISEWOMAN23-0003@cdc.gov

Responses will be posted to the NOFO informational website.

G. Executive Summary:

1. Summary Paragraph This notice of funding opportunity (NOFO) aims to improve cardiovascular health in a specific population with a focus on advancing health equity. It will support the implementation and evaluation of a core set of evidence-based strategies proven to reduce heart disease and stroke rates through early detection and treatment of hypertension and high cholesterol in low-income, uninsured, and underinsured participants ages 35 to 64.

https://www.grants.gov/ https://cdc.zoomgov.com/j/1611247473?pwd=cUpic1ViVEs3VU5NcHplY3JENXJJUT09 https://www.cdc.gov/dhdsp/funding-opps/index.htm mailto:WISEWOMAN23-0003@cdc.gov

An applicant must propose a comprehensive work plan for year one and a high-level work plan for all years of the project that addresses hypertension in alignment with the broad evidence-based, evidence-informed strategies indicated. There must be a demonstration of how key health equity concepts: health inequities and disparities, social determinants, and unfair opportunity structures, factor into the design and implementation of program activities.

This NOFO requires that an applicant collaborates with partners with expertise and services to address the social needs of participants to promote blood pressure control and other healthy behaviors.

The use of Geographic Information Systems (GIS), or other Geo-mapping tools, will be required to identify priority populations where heart disease and stroke are prevalent and use data to propose criteria for selecting health systems and communities in which to work based on a robust analysis of overall health burden across population subgroups.

a. Eligible Applicants:

Open Competition

b. Funding Instrument Type:

CA (Cooperative Agreement)

c. Approximate Number of Awards

d. Total Period of Performance Funding:

$110,000,000

e. Average One Year Award Amount:

$650,000

f. Total Period of Performance Length:

5 year(s)

g. Estimated Award Date:

August 30, 2023

h. Cost Sharing and / or Matching Requirements:

Yes Recipient financial participation is required for this program in accordance with the authorizing legislation. Section 1502(a) and (b)(1), (2), and (3) of the PHS Act, as amended, requires matching funds from non-Federal sources in an amount not less than one dollar for every three dollars of Federal funds, a ratio of 3:1, awarded under this program. However, Title 48 of the US Code 1469a (d) requires DHHS to waive matching fund requirements for Guam, U.S. Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands up to $200,000.

The match requirement may include third-party in-kind contributions, as well as expenditures from the grantee. The matching funds may be cash, in-kind or donated services or equipment.

Public Law 93-638 authorizes tribal organizations contracting under the authority of Title I to use funds received under the Indian Self-Determination Act as matching funds.

Matching funds may not include: 1) payment for treatment services or the donation of treatment services; 2) services assisted or subsidized by the Federal government; or 3) the indirect or overhead costs of an organization. All costs designated as meeting the match requirement must be documented by the applicant and will be subject to audit. Documentation of appropriate matching is to be provided in the detailed budget and narrative justification.

Part II. Full Text

A. Funding Opportunity Description

1. Background

a. Overview CDC’s Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program is at the forefront of the nation’s efforts to improve cardiovascular health for low-income, uninsured, and underinsured participants. Congress authorized the WISEWOMAN program in 1993 to extend the preventive health services offered to participants of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The intent is to expand services to NBCCEDP participants aged 35-64 to address cardiovascular health concerns in a population made vulnerable through social determinants of health.

Extensive scientific evidence links non-medical factors, including economic opportunities and systemic racism, with poor health outcomes and increased mortality rates. These factors, commonly referred to as social determinants of health, also explain long-standing disparities in cardiovascular health across racial and ethnic groups and between men and women.

Cardiovascular disease (CVD) is the leading cause of death in the US and stroke is the 5th leading cause. In 2020, about 1 in 5 adults who died from CVD were younger than 65 years old.

CVD accounts for about 1 in 3 deaths per year in women. In 2020, the age-adjusted CVD death rate among women was 183.9/100,000. Hypertension, which is the leading risk factor for CVD is prevalent among non-Hispanic Black and Hispanic women at 56.7% and 36.8%, respectively.

While improvements in CVD mortality have been made and life expectancy has increased for all Americans, women continue to experience a disproportionately high mortality rate, and health inequities by race and ethnicity persist. For example, Black and Native American women experience higher rates of total cardiovascular disease, coronary disease and stroke deaths when compared to white women.

Increased efforts to target risk factors and achieve equitable outcomes through culturally-focused interventions are urgently needed. Better health outcomes in priority populations can be achieved by implementing interventions that disrupt health disparities that are compounded by social conditions. The American Heart Association notes that clinicians should consider factors that affect individuals, such as the social determinants of health, to inform treatment decisions. Public health interventions that focus on advancing health equity are critical.

The current cooperative agreement, CDC-RFA-DP18-1816 (2018-2023), funds 30 recipients in 27 states and three Tribal organizations. It prioritizes activities encouraging women to become informed, active participants in CVD self-management by self-monitoring blood pressure with clinical support, maintaining a healthy diet, engaging in physical activity, and smoking cessation.

Given the importance of health equity, this new NOFO will continue the nation’s efforts to improve cardiovascular health for low-income, uninsured, and underinsured participants aged 35-64. Further, it will address social and economic factors to help program participants achieve the best health possible by addressing social needs and the effect of unfair opportunity structures.

b. Statutory Authorities Title XV, Section 1509 of the Public Health Service Act (PHS Act) (42 U.S.C. 300n-4a). Section 1502 of the PHS Act (42 U.S.C. 300l) and the FY 2023 Consolidated Appropriations Act (Pub.

L. 117-328, Div. H). Because WISEWOMAN is a sister program with the National Breast and Cervical Cancer Early Detection Program, eligible applicants must have received a grant pursuant to Section 1501 of the PHS Act (42 USC 300k).

c. Healthy People 2030 Healthy People 2030 objectives related to Heart Disease and Stroke:

https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke

HDS-01: Improve cardiovascular health in adults HDS-02: Reduce coronary heart disease deaths HDS-03: Reduce stroke deaths HDS-04: Reduce the proportion of adults with high blood pressure HDS-05: Increase control of high blood pressure in adults HDS-06: Reduce cholesterol in adults HDS-07: Increase cholesterol treatment in adults HDS-D07: Increase the proportion of adults whose risk for atherosclerotic cardiovascular disease was assessed

d. Other National Public Health Priorities and Strategies CMS Framework for Health Equity 2022-2032:

https://www.cms.gov/files/document/cms-framework-health-equity.pdf HHS Equity Action Plan: https://www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf HRSA Strategic Plan FY23: https://www.hrsa.gov/about/strategic-plan Million Hearts® 2027: https://millionhearts.hhs.gov/index.html The Guide to Community Preventive Services:

https://www.thecommunityguide.org/topics/heart-disease-stroke-prevention.html The Surgeon General’s Call to Action to Control Hypertension:

https://www.hhs.gov/sites/default/files/call-to-action-to-control-hypertension.pdf

e. Relevant Work WISEWOMAN began as research program designed to compare the efficacy of lifestyle interventions (LSIs) and usual care in reducing CVD risk in a priority population. It evolved into cooperative agreements funding organizations focused on service delivery and evaluating the feasibility of implementing evidence-informed LSIs in local settings. Beginning in 2008, a series https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke https://www.cms.gov/files/document/cms-framework-health-equity.pdf https://www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf https://www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf https://www.hrsa.gov/about/strategic-plan https://millionhearts.hhs.gov/index.html https://www.thecommunityguide.org/topics/heart-disease-stroke-prevention.html https://www.hhs.gov/sites/default/files/call-to-action-to-control-hypertension.pdf of 5-year NOFOs (CDC-RFA-DP08-804, CDC-RFA-DP13-1302, and CDC-RFA-DP18-1816) were funded to prioritize delivery of CVD screenings and providing LSIs. This shifted to engaging women in becoming informed, active participants in CVD self-management, and providing referrals to healthy behavior support services in 2013. This new NOFO, CDC-RFA- DP23-0003, builds upon CDC-RFA-DP18-1816 while centering health equity.

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

Strategies and Activities

Short-Term Outcomes Intermediate Outcomes

Long-Term Outcomes

Strategy 1: Track and Monitor Clinical Measures Shown to Improve Health and Wellness, Health Care Quality, and Identify Patients at Risk of and with CVD, Particularly Hypertension.

1A. Provide cardiovascular disease (CVD) risk assessment to under- and uninsured participants in the priority age range of 35- 64 years during the baseline, follow-up, and reassessment office visits, as appropriate.

Increased number of under- and uninsured participants, ages 35- 64, who receive CVD risk assessment.

1B. Use electronic health record (EHR) and health information technology (HIT) data to query, monitor, and track clinical and social services and support needs data for improved identification, management, referrals, Increased use of EHR and HIT to query, monitor, and track clinical and social services and support needs data for improved identification, management, and treatment of

Improved blood pressure control among

WISEWOMAN

participants.

Reduced disparities in blood pressure control among

WISEWOMAN

Increased utilization of social services and support among

WISEWOMAN

Improved cardiovascular health.

Reduced disparities in cardiovascular health.

treatment, and outcomes of those at risk of CVD, particularly hypertension.

participants at risk of CVD, particularly hypertension.

1C. Use standardized procedures to identify social services and support needs of participants and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc.

Increased use of standardized processes or tools to identify, assess, track, and address social service and support needs of participants.

1D. Use metrics from program data to guide quality improvement activities, e.g., Plan Do Study Act (PDSA) cycles, participant and partner feedback, etc., to increase program enrollment, retention, and referrals to additional services.

Increased use of metrics from program data to guide quality improvement activities to increase program enrollment, retention, and referrals to additional services.

1E. Use EHR, HIT or program data to identify health care disparities and address health outcomes within their

WISEWOMAN

population.

Increased use of EHR, HIT, or program data to identify health care disparities and address health outcomes within their WISEWOMAN population.

Strategy 2: Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on Hypertension Prevention, Detection, Control, and Management through the Mitigation of Social Support Barriers to Improve Outcomes.

participants at high risk of CVD.

2A. Engage program participants, health professionals, community health workers, social workers, patient navigators, pharmacists, and other members of the care team in community settings outside of health care facilities to enhance participant follow-up and communication and coordination among the care team.

Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address patient needs.

2B. Build and maintain a network of state, regional, and local social services and support based on social determinants of health within the recipient’s jurisdiction.

Increased multidisciplinary partnerships with a network of state, regional, and local social services and support.

Strategy 3: Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow-up Systems Aimed at Mitigating Social Support Barriers and Supporting Participation in and Completion of Lifestyle Change Programs for Participants at Risk of and with CVD.

3A. Identify, enhance, or build systems that facilitate provider and community bidirectional referrals to support medical follow-up, healthy behavior support

Increased data sharing and utilization through a bidirectional feedback mechanism.

services (HBSS), and social services and support.

3B. Collaborate with community groups who represent and serve the priority population, provide evidence-informed HBSS, and refer participants to those

HBSS.

Increased referrals to evidence-based and evidence-informed

HBSS.

3C. Use evidence-based and evidence-informed strategies to ensure participants are actively engaged in HBSS.

Increased participation in and completion of

HBSS.

3D. Refer participants to appropriate social services and support;

track and monitor use.

Increased referrals to and utilization of social services and support.

i. Purpose The purpose of the WISEWOMAN program is to extend preventive health services to achieve optimal cardiovascular health for participants ages 35-64 who are participants of the CDC-funded National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The program helps participants understand and reduce their risk of cardiovascular disease and benefit from early detection and treatment. With health equity as a guiding principle, WISEWOMAN provides culturally-informed risk factor screenings and program services that are mindful of the social determinants of health.

ii. Outcomes Recipients are expected to achieve the following outcomes by the end of the period of performance:

Short-term outcomes by strategy Strategy 1:

Increased number of under- and uninsured participants, ages 35-64, who receive CVD risk assessment.

Increased use of electronic health records (EHR) and health information technology (HIT) to query, monitor, and track clinical and social services and support needs data for improved identification, management, and treatment of participants at risk of CVD, particularly hypertension.

Increased use of standardized processes or tools to identify, assess, track, and address the social services and support needs of participants.

Increased use of metrics from program data to guide quality improvement activities to increase program enrollment, retention, and referrals to additional services.

Increased use of EHR, HIT, or program data to identify health care disparities and address health outcomes within their WISEWOMAN population.

Strategy 2:

Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address patient needs.

Increased multidisciplinary partnerships with a network of state, regional, and local social services and support.

Strategy 3:

Increased data sharing and utilization through a bidirectional feedback mechanism.

Increased referrals to evidence-based and evidence-informed healthy behavior support services (HBSS).

Increased participation in and completion of HBSS.

Increased referrals to and utilization of social services and support.

Intermediate outcomes

Improved blood pressure control among WISEWOMAN participants.

Reduced disparities in blood pressure control among WISEWOMAN participants.

Increased utilization of social services and support among WISEWOMAN participants at high risk of CVD.

iii. Strategies and Activities Applicants must address ALL strategies listed below.

Strategy 1: Track and Monitor Clinical Measures Shown to Improve Health and Wellness, Health Care Quality, and Identify Patients at Risk of and with Cardiovascular Disease (CVD), Particularly Hypertension.

1A.Provide CVD risk assessment to under- and uninsured participants in the priority age range of 35-64 years during the baseline, follow-up, and reassessment office visits, as appropriate.

1B. Use electronic health record (EHR) and health information technology (HIT) data to query, monitor, and track clinical and social services and support needs data for improved identification, management, referrals, treatment, and outcomes of those at risk of CVD, particularly hypertension.

1C. Use standardized procedures to identify social support needs of participants and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc.

1D. Use metrics from program data to guide quality improvement activities, e.g., PDSA cycles, participant and partner feedback, etc., to increase program enrollment, retention, and referrals to additional services.

1E. Use EHR, HIT, or program data to identify health care disparities and address health outcomes within their WISEWOMAN population.

Strategy 2: Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on Hypertension Prevention, Detection, Control, and Management through the Mitigation of Social Support Barriers to Improve Outcomes.

2A. Engage program participants, health professionals, community health workers, social workers, patient navigators, pharmacists, and other members of the care team in community settings outside of health care facilities to enhance participant follow-up and communication/coordination among the care team.

2B. Build and maintain a network of state, regional, and local social services and support based on social determinants of health within the recipient’s jurisdiction.

Strategy 3: Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow-up Systems aimed at Mitigating Social Support Barriers and Supporting Participation in and Completion of Lifestyle Change Programs for Participants at Risk of and with Cardiovascular Disease (CVD).

3A. Identify, enhance, or build systems that facilitate provider and community bidirectional referrals to support medical follow-up, healthy behavior support services (HBSS), and social services and support.

3B. Collaborate with community groups who represent and serve the priority population, provide evidence-informed HBSS, and refer participants to those HBSS.

3C. Use evidence-based and evidence-informed strategies (EBS/EIS) to ensure participants are actively engaged in HBSS.

3D. Refer participants to appropriate social services and support; track and monitor use.

WISEWOMAN Program Flow: WISEWOMAN is a direct services program, which requires providers to follow a specific program flow in order to ensure appropriate identification, assessment, and referral of participants. The following program flow chart describes the process of providing WISEWOMAN cardiovascular disease (CVD) risk assessments and access to healthy behavior support services to those enrolled in the program. Participant eligibility is determined by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

Health care providers assess individuals for cardiovascular risk and based on risk factors and results from the patient-centered risk reduction counseling, individuals receive referrals to healthy behavior support services (evidence-based lifestyle programs, health coaching, and community-based resources) that support bidirectional referrals, self-management, and lifestyle change. Recipients are expected to work with health care providers that have systems in place to optimize control of hypertension and other CVD risk factors through the use of electronic health records and health information technology, delivery system designs, decision support, and team-based care. This program flow aligns with the program strategies of tracking and monitoring clinical measures, implementing team-based care, and linking community and clinical services.

The diagram displays a continuum of care from the funded recipient’s perspective. As the participant progresses through the program flow, the participants’ clinical and social needs are assessed. The participant may be referred to new or additional social services and support at any step.

Program Flow Definitions:

Eligible Participants: Participants of the CDC-funded National Breast and Cervical Cancer Early Detection Program (NBCCEDP) ages 35-64.

Baseline Assessment (Clinical Health and Social Needs Assessments): The initial baseline assessment may be an integrated office visit with NBCCEDP. This visit includes a cardiovascular health risk and social needs assessment that is completed at baseline and the subsequent reassessments. Results must be reported in participant data files. Health assessment completion facilitates immediate patient-centered, risk-reduction counseling which is particularly valuable in the absence of lab work. In conjunction with clinical care, a social needs assessment is conducted to identify the program participant’s social needs and determine an appropriate referral to a network of social services and support partners.

Risk Reduction Counseling: Every program participant must receive a cardiovascular disease baseline risk assessment and reassessment, interpretation of the results, and appropriate recommendations in accordance with national clinical care guidelines. In a team-based care approach, it is critical that participants understand their CVD and health assessment findings. In the WISEWOMAN model, the participant is a crucial member of the health team. Participation facilitates increased self-management behavior, a critical component to becoming effective and informed managers of their health and health care.

The participant must receive CVD assessment information verbally and in writing using health literacy and plain language standards. If complete screening results are unavailable, programs should use the participant’s health risk assessment results to provide initial risk reduction counseling. Risk reduction counseling should include motivational interviewing to encourage the participant to change behaviors and lifestyle.

Effective motivational interviewing requires active listening by the interviewer, asking open questions, affirmation of the participant’s strengths, and support for strategies for maintenance or change. Immediate and ongoing support of needs identified in the social needs assessment must be provided.

Healthy Behavior Support Services (HBSS) Referrals: Healthy behavior support services (HBSS) include evidence-based lifestyle programs, health coaching, and community-based resources. Health care team members refer participants to appropriate HBSS that support the identified participant goals and helps reduce CVD risk. This referral typically occurs during risk reduction counseling but may also occur during a lifestyle program or health coaching session. Program participants will continue to have access to immediate and ongoing social services and support based on identified social needs.

HBSS Attendance: Once the program participant attends the referred HBSS, the participant will continue to have access to immediate and ongoing social services and support based on identified social needs.

HBSS Completion: Upon completion of the HBSS series, program participant will continue to have access to ongoing social services and support based on the participant’s identified social needs, priorities, and preferences to support sustaining results. New or social support service referrals may be made at this time.

Post-HBSS Follow-Up: At the completion of health coaching series or lifestyle programs, a follow-up assessment is conducted to assess the participant’s progress, short-term health outcomes, reinforce health goals, and facilitate ongoing social support needs.

Reassessment (Clinical Health and Social Needs Assessment): Clinical health and social needs reassessments are conducted after the baseline assessment to determine participant’s health outcomes, existing needs, priorities, and preferences to support continued participation in the WISEWOMAN program and allows the participant to continue through the WISEWOMAN program flow.

Social Services and Support Network and Referrals: The Social Services and Support Network is comprised of social service and support partner organizations which address social risk factors that inhibit a participant’s involvement and completion of HBSS.

Recipient coordination and management of the social service network is informed by data related to social risk factors identified within the programmatic jurisdiction. Social services and support referrals are based on care coordination systems that link program participants to social services and support that contribute to optimal health outcomes. It should be noted that these do not always occur linearly but can occur at different phases of the program. These services should address the needs identified by the participant and care team members and include, but not be limited to, services that address social risk factors broadly within the programmatic jurisdiction, such as inadequate housing, food assistance, and lack of transportation.

o Referrals are a system with essential elements and coordinated processes including:

an organizing entity that coordinates and tracks outcomes for all referrals to social services and support;

a network of community resources and partners who can address the social determinants of health;

a bidirectional or closed-loop referral mechanism to document community services and feedback of the primary care provided; and a data collection mechanism to track outcomes.Note: WISEWOMAN Program Directors or Program Managers should identify a state, regional, and local coordinator who will be responsible for garnering all social services and support to which participants would be referred and making connections to other programs and resources.

Recipients must establish, implement, and use a data system that collects all required minimum data elements (MDE) and other program data for program monitoring and reporting. MDEs are a set of standardized data variables tailored to this NOFO and capture consistent and complete participant information throughout the WISEWOMAN program flow. These are used to describe, monitor, and assess individual and program progress. Additional guidance will be provided to successful applicants post award.

1. Collaborations

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

An applicant’s collaborative efforts should be tied to the jurisdiction’s overarching heart disease and stroke prevention plan. Recipients should establish collaborative, strategic partnerships with other CDC-funded programs within and outside the state health departments, tribes and tribal organizations and community-based organizations. This will allow for more efficient use of existing resources. This will also allow for the exchange of information among experts working in various areas of public health and other sectors. At a minimum, partnerships must be established with heart disease and stroke, tobacco, cancer (especially the NBCCEDP), diabetes, and nutrition and physical activity programs. These include but are not limited to other CDC-funded heart disease and stroke programs such as The National Cardiovascular Health Program, The Innovative Cardiovascular Health Program, Paul Coverdell National Acute Stroke Program, Good Health and Wellness in Indian Country (GHWIC), and Community Health Workers for COVID Response and Resilient Communities, and the Million Hearts® initiative.

An applicant is encouraged to use a variety of data and technologies to establish an achievable health equity goal. It is also important that an applicant identify and leverage opportunities and partnerships that will help address unfair opportunity structures and the social determinants of health. This will enhance the recipient’s work with other state health department programs that address related chronic diseases or their underlying risk factors.

b. With organizations not funded by CDC:

Applicants are expected to describe and demonstrate the ability to collaborate with a variety of public and private partners to leverage resources and maximize reach and impact and utilize bidirectional referral systems. Collaborative partners can include entities from many sectors.

Successful applicants will be required to collaborate with partners and agencies that serve the priority population of interest or work with the identified communities of interest. For example, they may partner with health systems to improve heart disease screening, management, medical follow-up and HBSS referrals to improve cardiovascular health.

An applicant should consider establishing strategic partnerships with community health centers including Federally Qualified Health Centers, Health Center Controlled Networks, Regional Extension Centers, state Rural and Primary Care Associations, health plans, health systems, providers and hospitals, managed care organizations, Medicaid/HRSA, Indian Health Service providers, American Indian/Alaska Native tribal governments and/or tribally designated organizations. Recipients should identify and establish strategic partnerships that are tailored to the social determinants needs of the priority population, informed by data and community champions (e.g. focus groups, input from community members and coalitions, faith-based and cultural organizations, LGBTQ+ organizations, social justice organizations, people with disabilities orgs, shelters, reproductive health support orgs, substance rehabilitation centers, employment assistance organizations, language service groups, tribal organizations and governments).

Applicants are expected to describe and demonstrate collaborations with organizations that support heart disease prevention, physical activity, healthy food choices, chronic disease self-management, and smoking cessation. Recipients are also expected to collaborate with organizations to provide resources appropriate for underserved sub-populations that address participant barriers to accessing care and changing behavior (e.g., transportation, mental health, housing resources).

Recipients will be expected to establish contracts with HBSS providers who can provide culturally and linguistically appropriate services, telehealth, virtual, in-person lifestyle programs, and health coaching services to which participants may be referred.

It is also strongly recommended that recipients collaborate with non-traditional partner agencies and organizations (e.g., Federal Office of Rural Health Policy, Department of Transportation, and Department of Housing and Urban Development) to reach more underserved individuals and to coordinate access to social needs referrals and follow-up (e.g., establishing or participating on coalitions and reducing duplication). Recipients should establish or continue strategic partnerships that support the Division for Heart Disease and Stroke Prevention (DHDSP) goals with professional organizations; businesses; not-for-profit organizations, such as the American Heart Association; community-based organizations; for-profit organizations; non-governmental organizations; state and local governments; community advocates and members; and other partners that may have a vested interest in improving cardiovascular health.

Recipients will be expected to work with Quality Improvement Organizations/Quality Improvement Networks or other health care quality improvement entities to enhance patient care and improve health systems.

Letters of support, memoranda of understanding (MOU), or memoranda of agreement (MOA) with a firm commitment from providers and partners that outline the relationship, needs, and resources provided should be included in the application. Letters or Memoranda must be dated within 45 days of the application. Applicants must file the MOU or MOA, as appropriate, name the file “MOUs/MOAs”, and upload it as a PDF file at www.grants.gov

2. Target Populations Per Congressional support via statutory language, the priority population is low-income persons ages 35-64 years who are uninsured or under-insured and eligible to participate in NBCCEDP.

Applicants must focus program activities in locations where the population experiences disparities in CVD risk factors, morbidity, and mortality. Applicants are required to describe their location of focus, using available data, such as race, ethnicity, census geography, socioeconomic status, social vulnerability, health literacy, screening rates, and cardiovascular disease incidence, prevalence, and mortality. Applicants must prioritize eliminating health disparities and advancing health equity in these locations. An applicant must describe the health equity challenges in these locations, how they propose to address them through various strategies, and how progress will be measured. An applicant should also describe how they propose to engage communities in these locations, influence the environments, and empower individuals so that services are accessible and culturally appropriate. The planning process should engage organizations serving the population and population representatives.

Among the populations that will benefit from this funding are low-income persons, rural and frontier populations, and those experiencing health disparities within the following population subgroups: the uninsured or under-insured, geographically or culturally isolated, medically under-served, racial, ethnic, and/or cultural minorities, including African Americans, Alaska Natives, American Indians, Asian Americans, Hispanics, Pacific Islanders, and those with disabilities.

a. Health Disparities Applicants are expected to advance health equity among priority populations to prevent and mitigate the impact of heart disease and stroke to improve health outcomes, and increase life expectancy and quality of life among program participants. Advancing health equity can be accomplished in part through understanding how health disparities and health inequities exist within cardiovascular health. Cardiovascular disparities are compounded by variations in disease rates and the effects of unfair opportunity structures which influence social determinants of health. Some of these effects include but are not limited to a lack of access to preventive and treatment services among disproportionately affected populations.

iv. Funding Strategy Funding provided will range from $500,000 to $2,000,000 with an average award of $650,000.

Award amounts will be based on priority populations which for this NOFO are low-income persons ages 35-64 years who are uninsured or under-insured with heart disease and stroke risk factors and eligible to participate in NBCCEDP. Consideration will be given to the geographic area where the applicant’s work is proposed, along with prior experience and organizational capacity.

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy https://www.grants.gov/

Recipients are required to work with professional evaluators (either internal or external) to meet the evaluation and performance reporting requirements of this NOFO by identifying these efforts in the workplan, evaluation plans, and budget. Therefore, CDC strongly recommends allocating at least 10% of the total funding award to evaluation and performance monitoring and to consider both development and implementation costs. For information on developing an evaluation plan, please refer to the 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) https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm

Evaluation and performance measurement help demonstrate program accomplishments, strengthen the evidence for strategy implementation, and guide program improvement for CDC and recipients.

Throughout the five-year cooperative agreement, CDC will work individually and collectively with recipients to track the implementation of recipient strategies and activities and assess progress on achieving the five-year NOFO outcomes. Both the process and outcome evaluation will seek to answer the following overarching evaluation questions:

Process (Implementation) Evaluation:

To what extent have recipients increased the reach of the program strategies to prevent and control cardiovascular disease?

To what extent has program strategy implementation led to improved health outcomes among the identified population(s) at high risk of cardiovascular disease?

What factors were associated with effective implementation of the program strategies?

What factors were associated with identifying and addressing social services and support needs and social determinants of health for populations at high risk of cardiovascular disease?

To what extent can the implemented program strategies be sustained after the NOFO ends?

Outcome Evaluation:

To what extent have the implemented program strategies contributed to a measurable change in health outcomes, health equity, and health systems in a defined community, population, organization, or system?

To what extent have the program strategies contributed to reduced health care disparities and improved health outcomes within populations at high risk of cardiovascular disease?

CDC will use an evaluation approach that consists of (1) ongoing monitoring and evaluation through the collection and reporting of performance measures, (2) a CDC-led comprehensive evaluation, and (3) recipient-led evaluations.

Performance measures developed for this program correspond to the strategies and outcomes described in the logic model. Recipients will report all short-term and intermediate measures.

Recipients are not required to report long-term measures. CDC will work with recipients on https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm operationalizing and further defining each performance measure, and guidance will be provided prior to the first reporting period. Performance measures will be reported annually to CDC, and CDC will manage and analyze the data to assess recipient program progress, respond to broader technical assistance needs, and report to partners. CDC will analyze performance measure data annually and develop aggregate performance measure reports to be disseminated to recipients and other key partners, including federal partners, other funded and non-funded partners, and policymakers, as appropriate. These aggregate findings may also be presented during site visits and recipient meetings. In addition to performance measures reported by recipients, CDC will track additional measures relevant to the program through national datasets or comprehensive evaluation activities.

For the comprehensive evaluation activities, CDC will lead the design, data collection, analysis, and reporting. CDC will engage recipients in developing and implementing the evaluation and recipients will be asked to participate in comprehensive evaluation activities such as surveys, interviews, case studies, and other data collection efforts. Recipients may also be asked to participate in special studies led by CDC that further explore specific components of the program or across DHDSP-funded programs . An appropriate level of guidance and support will be provided to the recipients to ensure their effective participation in the comprehensive evaluation. CDC will use findings from these evaluation efforts to refine its technical assistance and, in turn, maximize and sustain program outcomes. Evaluation findings will be shared with recipients on a regular basis.

For recipient-led evaluations, CDC will assist recipients in developing and implementing evaluation plans that are useful for recipient-level program improvement and for the overall evaluation of the program. For all components of the evaluation, CDC and recipients will only collect data that will be analyzed and used.

CDC will provide recipients with guidance for developing evaluation plans and reporting performance measures and evaluation results. CDC will also provide ongoing evaluation technical assistance and ensure that the tools and services provided best meet the needs of the recipients. All information will be stored using a secure system. All evaluation findings produced by CDC and recipients, where appropriate, will contribute to: (1) continuous improvement of quality and effectiveness of program strategies; (2) the evidence base; (3) documentation and sharing of lessons learned to support replication and scaling of these program strategies; and (4) future funding opportunities supported by CDC.

The data collected by CDC for performance measurement and evaluation are directly related to the implementation of the strategies and/or the desired outcomes indicated in the logic model.

The data collected for this NOFO for performance measurement and comprehensive evaluation do not include any personally identifiable information. Data being collected are strictly related to the implementation of the NOFO strategies and shall be used for assessing and reporting progress and for other pertinent program improvement actions. All performance measure data will be stored using a secure data system. Recipients will report their performance measure data annually and will only have access to their data. Over the five-year period of performance, data will be secured with limited access to authorized CDC program and evaluation staff to the extent allowed under applicable federal law. CDC will aggregate data across all recipients to publish annual and summative reports. Applicants should submit a Data Management Plan (DMP). A sample template provided by NCCDPHP can be found at: https://www.cdc.gov/chronicdisease/programs-impact/nofo/index.htm. Applicants are not required to use the sample template; however, all elements included in the template must be addressed.

Recipients must establish, implement, and use a data system that collects all required minimum data elements (MDE) and other program data for program monitoring and reporting. MDEs are a set of standardized data variables tailored to this NOFO and capture consistent and complete participant information throughout the WISEWOMAN program flow. These are used to describe, monitor, and assess individual and program progress. Additional guidance will be provided to successful applicants post award.

The table below aligns with the logic model and shows the relationship between the overarching focus areas, specific strategies, outcomes, and performance measures. Recipients are required to address all strategies and report all short term and intermediate performance measures.

Strategies and Activities Short-Term Outcomes and Measures

Intermediate Outcomes and Measures

Strategy 1: Track and Monitor Clinical Measures Shown to Improve Health and Wellness, Health Care Quality, and Identify Patients at Risk of and with Cardiovascular Disease (CVD), Particularly Hypertension.

1A. Provide CVD risk assessment to under- and uninsured participants in the priority age range of 35-64 years during the baseline, follow-up, and reassessment office visits, as appropriate.

Increased number of under- and uninsured participants, ages 35-64, who receive CVD risk assessment.

Tracked via MDE data 1B. Use electronic health record (EHR) and health information technology (HIT) data to query, monitor, and track clinical and social services and support needs data for improved identification, management, referrals, treatment, and outcomes of

Increased use of EHR and HIT to query, monitor, and track clinical and social services and support needs data for improved identification, management, and treatment of participants at risk of CVD, Improved blood pressure control among

WISEWOMAN

participants.

PM #7: # and % of

WISEWOMAN

participants with known hypertension who have achieved or are currently maintaining blood pressure control.

Reduced disparities in blood pressure control among WISEWOMAN participants

PM #8: # and % of

WISEWOMAN

participants, reported by race and ethnicity, with known https://www.cdc.gov/chronicdisease/programs-impact/nofo/index.htm those at risk of CVD, particularly hypertension.

particularly hypertension.

PM #1: # and % of WISEWOMAN providers with a protocol for using EHR and HIT data to query, monitor, and track clinical data to identify, manage, refer, and treat patients at risk of CVD, particularly hypertension.

1C. Use standardized procedures to identify social services and support needs of participants and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc.

Increased use of standardized processes or tools to identify, assess, track, and address social services and support needs of participants.

PM #2: # and % of WISEWOMAN providers using standardized processes or tools to identify, assess, track, and address social services and support needs of

WISEWOMAN

participants.

1D. Use metrics from program data to guide quality improvement activities, e.g., PDSA cycles, participant and partner feedback, etc., to increase program enrollment, retention, and referrals to additional services.

Increased use of metrics from program data to guide quality improvement activities to increase program enrollment, retention, and referrals to additional services.

Tracked via Project Officer documentation

1E. Use EHR, HIT or program data to identify health care disparities and

Increased use of EHR, HIT or program data to identify health care hypertension who have achieved or are currently maintaining blood pressure control.

Increased utilization of social services and support among WISEWOMAN participants at high risk of

CVD

Tracked via MDE data.

address health outcomes within their WISEWOMAN population.

disparities and address health outcomes within their WISEWOMAN population.

PM #3: # and % of WISEWOMAN providers using standardized processes or tools to identify and address health…