Foa_Content_of_CDC-RFA-DP-23-0005.pdf

Centers for Disease Control and Prevention

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH

PROMOTION

The Innovative Cardiovascular Health Program

CDC-RFA-DP-23-0005

05/23/2023

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- 23-0005. 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:

The Innovative Cardiovascular Health Program C. Announcement Type: New - Type 1:

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

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP-23-0005

E. Assistance Listings Number:

93.426 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

F. Dates:

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

04/22/2023

2. Due Date for Applications:

05/23/2023 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call:

The Innovative Cardiovascular Health Program

Applicant Informational Webinar

Tuesday, March 28, 2023 3:00pm - 4:00pm ET

Click the link below to join the webinar:

https://cdc.zoomgov.com/j/1600868630?pwd=Z3BZV0VLaWRiSHp4TlRRcDlYY0E3QT09

Or join by phone:

US: +1 669 254 5252 or

+1 646 828 7666 or

+1 646 964 1167 or

+1 551 285 1373 or

+1 669 216 1590 or

+1 415 449 4000

Webinar ID: 160 086 8630 Passcode: 74072053

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

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

Programmatic questions about this NOFO may be submitted via email:

InnovativeCVH@cdc.gov

Responses will be posted to the NOFO informational website.

G. Executive Summary:

1. Summary Paragraph This NOFO focuses on comprehensive efforts to identify and respond to health care disparities in cardiovascular disease (CVD) and improve related outcomes, specifically for those with hypertension and high cholesterol.

https://www.grants.gov/ https://cdc.zoomgov.com/j/1600868630?pwd=Z3BZV0VLaWRiSHp4TlRRcDlYY0E3QT09 https://www.cdc.gov/dhdsp/funding-opps/index.htm mailto:InnovativeCVH@cdc.gov

Proposed interventions must assess and address the disparities and inequities in communities at highest risk, where there is a particular need for equity-focused health system interventions to prevent, detect, control, and manage hypertension and high cholesterol.

Populations of focus for this award are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO. Applicants must provide details in the Target Population section of the Project Narrative that clearly demonstrate the methodology and data sources used for identifying the population of focus at the census tract level. CDC will work with successful applicants post award to offer confirmation and approval of identified populations through technical assistance with revising workplan, evaluation plan, and budget.

a. Eligible Applicants:

Open Competition

b. Funding Instrument Type:

CA (Cooperative Agreement)

c. Approximate Number of Awards

d. Total Period of Performance Funding:

$105,000,000

e. Average One Year Award Amount:

$950,000

f. Total Period of Performance Length:

5 year(s)

g. Estimated Award Date:

August 30, 2023

h. Cost Sharing and / or Matching Requirements:

No Part II. Full Text

A. Funding Opportunity Description

1. Background

a. Overview Unequal socioeconomic conditions and unfair opportunity structures have long existed and contribute to poor health outcomes in minority and ethnic populations and geographically and economically disadvantaged communities. Poverty, inferior housing and health care, and other debilitating social conditions are endemic to some communities, including Non-Hispanic Black (NHB), Hispanic, and Native American communities.

Research highlights the high prevalence of cardiovascular disease (CVD), including hypertension, high cholesterol, and stroke in these groups. CVD is the leading cause of death in the US and stroke is the 5th leading cause with an estimated 1 in 9 health care dollars spent treating CVD. Despite significant decreases in CVD rates in the last 20 years, NHB continue to have higher CVD mortality rates than Non-Hispanic Whites (NHW). In 2019, NHB women and men younger than 65 were 2.0 and 1.3 times more likely to experience premature death from CVD than their NHW counterparts. In 2020, NHB had the highest heart disease mortality rates at

228.6 per 100,000 and stroke at 56.8 per 100,000.

Uncontrolled hypertension is the primary contributor to morbidity and mortality rate disparities in CVD between NHB and other racial and ethnic groups. In 2019, NHB had more than double the age-adjusted death rates (56.7) attributable primarily to hypertension compared to NHW (25.7).

Of the 1 in 2 US adults with hypertension, only 26.1% have controlled blood pressure. By age 55, the cumulative incidence of hypertension reaches almost 76% in NHB men and women, compared to 54.5% and 40.0% among NHW men and women, respectively. Moreover, NHB had a 1.5 to 2 times higher risk for hypertension after adjustment for other factors, regardless of baseline blood pressure. Among NHB adults who did not report a hypertension diagnosis, a larger proportion (28%) were unaware of hypertension (BP ≥140/90 mm Hg) compared to NHW adults (16%). Despite the similar rate of hypertension treatment, only one-third of NHB adults had their blood pressure controlled, in contrast to 45.0% of NHW adults. These data clearly indicate that NHB bear the greatest burden of CVD among US adults.

The outcomes are as stark in other CVD-related illnesses. Although the prevalence of high cholesterol in NHB is comparable to or lower than in NHW, racial-ethnic disparities occur at every level of diagnosis and management. The disparities present in low screening rates, fewer prescriptions, and medication adherence. Unsatisfactory control of high cholesterol among NHB stems from the same adverse social conditions that hinder the control of hypertension.

Interventions must include an understanding of individual and community factors that influence a healthy diet, losing weight, being physically active, and medication adherence to address the disparities and inequities. There is a need for equity-focused health system interventions to prevent, detect, control, and manage hypertension and high cholesterol. Building on lessons from the previous work, this NOFO focuses on comprehensive efforts to identify and respond to health care disparities and improve CVD-related outcomes, specifically for those with hypertension and high cholesterol.

Populations of focus for this NOFO are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO.

b. Statutory Authorities This program is authorized by Section 30l(a) of the Public Health Service Act [42] U.S.C.

Section 241(a) 93.426.

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 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

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 This NOFO builds on the accomplishments and outcomes achieved through the Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke (CDC-RFA-DP18-1815) (https://www.cdc.gov/chronicdisease/about/foa/1815/index.htm) and the Diabetes and Heart Disease & Stroke Prevent Programs-Innovative State and Local Public Health Strategies to Prevent and Manage Diabetes and Heart Disease and Stroke (CDC- RFA-DP18-1817) (https://www.cdc.gov/chronicdisease/programs-impact/supported/index.htm) NOFOs.

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

Strategies and Activities Short-Term Outcomes Intermediate- Term Outcomes

Long-Term Outcomes 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 https://www.cdc.gov/chronicdisease/about/foa/1815/index.htm https://www.cdc.gov/chronicdisease/programs-impact/supported/index.htm

Strategy 1. Track and Monitor Clinical Measures Shown to Improve Health and Wellness, and Health Care Quality Within Approved Populations of Focus with Hypertension and High Cholesterol.

1A. Advance the adoption and use of electronic health records (EHR) and health information technology (HIT) to identify, track, and monitor clinical and social services and support needs measures to address health care disparities and health outcomes within approved populations of focus.

Increased use of EHRs and HIT to report, monitor, and track clinical data and social services and support needs to improve detection of health care disparities and the identification, management, and treatment within approved populations of focus.

Improved cardiovascular health

Reduced disparities in cardiovascular health

1B. Promote the use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify the social services and support needs within approved populations of focus and monitor and assess the referral and utilization of those services, such as the need for transportation, housing, childcare, etc.

Increased use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify, assess, track, and address the social services and support needs within approved populations of focus.

Strategy 2: Implement Team-Based Care to Prevent, Detect, Control, and Manage Hypertension and High Cholesterol Within Approved Populations of Focus.

2A. Advance the use of health information systems that support team-based care to monitor and address hypertension and high cholesterol within approved populations of focus.

Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within approved

2B. Assemble or create multidisciplinary teams to identify social services and support needs within approved populations of focus.

Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address social services and support needs within approved populations of focus.

Improved blood pressure control among populations within partner health care and community settings.

Reduced disparities in blood pressure control among populations within partner health care and community

Increased utilization of social support services among approved populations of focus.

2C. Build and manage a coordinated network of multi-disciplinary partnerships that address identified barriers and needs within approved populations of focus, related to their social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing).

Increased multidisciplinary partnerships that address identified barriers and social services and support needs within approved

Strategy 3: Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow- Up Systems Aimed at Mitigating Social Services and Support Barriers for Optimal Health Outcomes Within Approved Populations of Focus.

3A. Create and enhance community-clinical links to identify social determinants of health {(SDOH) (e.g., housing, transportation, access to care, and community resources)} and respond to the individual social services and support needs within approved populations of focus.

Increased community clinical links to identify and respond to social support needs within approved populations of

3B. Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social needs leading to optimal health outcomes within approved populations of focus.

Increased engagement of CHWs (or their equivalents) to provide a continuum of care by extending clinical interventions and addressing social services and support needs within

3C. Promote the use of self-measured blood pressure monitoring with clinical support within approved populations of focus.

Increased use of SMBP with clinical support within

i. Purpose This NOFO focuses on comprehensive efforts to identify and respond to health care disparities and improve health outcomes, specifically for those with hypertension and high cholesterol. Populations of focus for this NOFO are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO.

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 use of EHRs and HIT to report, monitor, and track clinical data and social services and support needs to improve detection of health care disparities and the identification, management, and treatment within approved populations of focus.

Increased use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify, assess, track, and address the social services and support needs within approved populations of focus.

Strategy 2:

Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within approved populations of focus.

Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address social services and support needs within approved populations of focus.

Increased multidisciplinary partnerships that address identified barriers and social services and support needs within approved populations of focus.

Strategy 3:

Increased community clinical links to identify and respond to social services and support needs within approved populations of focus.

Increased engagement of CHWs (or their equivalents) to provide a continuum of care by extending clinical interventions and addressing social services and support needs within approved populations of focus.

Increased use of SMBP with clinical support within approved populations of focus.

Intermediate outcomes

Improved blood pressure control among populations within partner health care and community settings.

Reduced disparities in blood pressure control among populations within partner health care and community settings.

Increased utilization of social support services among approved populations of focus.

iii. Strategies and Activities Applicants must address all strategies.

Strategy 1. Track and Monitor Clinical Measures Shown to Improve Health and Wellness, Health Care Quality, and Identify Patients with Hypertension and/ High Cholesterol.

1A: Advance the adoption and use of electronic health records (EHR) and health information technology (HIT) to identify, track, and monitor clinical and social services and support needs measures to address health care disparities and health outcomes within approved populations of focus.

1B: Promote the use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify the social services and support needs within approved populations of focus, and monitor and assess the referral and utilization of those services, such as the need for transportation, housing, childcare, etc.

Strategy 2: Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on Hypertension and High Cholesterol Prevention, Detection, Control, and Management.

2A: Advance the use of health information systems that support team-based care to monitor population health with a focus on health disparities, hypertension, and high cholesterol within approved populations of focus.

2B: Assemble or create multidisciplinary teams to identify social service and support needs within approved populations of focus.

2C: Build and manage a coordinated network of multidisciplinary partnerships that address identified barriers and needs within approved populations of focus, related to their social services and support needs (e.g., childcare, transportation, language assistance, food assistance, and housing).

Strategy 3: Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow-Up Systems Aimed at Mitigating Social Support Barriers for Optimal Health Outcomes.

3A: Create and enhance community-clinical links to identify SDOH (e.g., housing, transportation, access to care, and community resources) and respond to the individual social services and support needs within approved populations of focus.

3B: Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social services and support needs leading to optimal health outcomes within approved populations of focus.

3C: Promote the use of self-measured blood pressure monitoring with clinical support within approved populations of focus.

This NOFO will require recipients to collaborate or partner with a heart disease and stroke learning collaborative (LC) or similar entity. If one does not exist, recipients will be required to create an LC. Post-award technical assistance will facilitate connections with existing and new LCs in a given jurisdiction, including but not limited to the state level LC that is required under CDC-RFA-DP-23- 0004: The National Cardiovascular Health Program.

An applicant should describe its history of establishing or partnering with multi-sectoral learning collaboratives (LCs) and collaborating with organizations with a history of working with approved populations of focus who are impacted by the high prevalence of CVD, with specific emphasis on hypertension and high cholesterol exacerbated by health inequities and disparities, social determinants, such as low incomes, poor health care, and unfair opportunity structures.

For the purposes of this NOFO, an LC is defined as a group of public health entities, health care providers, and community leaders and their partners with experience working to address and implement evidence-based or evidence-informed practices for CVD prevention, detection, control, and management within approved priority populations of focus. The applicant must describe how entities on the LC have a history of collaborating to achieve sustainable change and improvement in the areas outlined in the NOFO. The LC is expected to facilitate communication and the exchange of ideas between health systems, community health organizations, and public health entities. It will leverage technical and financial resources to support programs to improve cardiovascular health outcomes.

An LC may be an alliance of public health entities, housing, commerce, and transportation agencies, health systems, health care providers, clinical quality improvement organizations, health information technology experts, public and private payers, pharmacists, mental and behavioral health professionals, community-based health care professionals, community organizations, safety net providers, health departments, tribal organizations and others. These partners may also directly intervene on a clinical or community basis to address the social determinants of health (SDOH).

The LC serves as a hub focused on developing innovative approaches to improve overall cardiovascular health and is equipped to apply those approaches to the mitigation of SDOH and other associated risk factors within the approved populations of focus.

The goals of a heart disease and stroke learning collaborative are:

Prioritizing populations and communities with the highest prevalence of CVD, with a focus on advancing health equity.

Serving populations and communities affected disproportionately by CVD, specifically high blood pressure, high blood cholesterol, or stroke, due to unfair opportunity structures and SDOH, such as limited access to health care, inadequate or poor quality of health care, or economic instability.

Achieving optimal health outcomes within the approved populations of focus

To achieve these goals:

Recipients must ensure the LC employs culturally informed, evidence-based, and evidence-informed interventions and approaches that address social services and support needs to advance universal health equity goals.

Recipients must be able to document, explain, and report on the effects of efforts to address the impact of racism and other social injustices on cardiovascular health outcomes, specifically high blood pressure, high blood cholesterol, and stroke.

Recipients will be required to use Geographic Information System (GIS) mapping technology to identify and include in the action plan census geographies with priority populations with the highest prevalence rates and at the highest risk of developing cardiovascular disease. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO. Recipients will be expected to design and implement strategies using EHR and HIT to detect and mitigate health care disparities and utilize quality improvement techniques resulting in optimal health outcomes.

These interdisciplinary partnerships must have a demonstrated history of successfully and effectively serving the approved populations of focus and their communities, by creating and enhancing community-clinical links.

The interdisciplinary team must have demonstrated experience in responding to SDOH and social services and support needs. Referrals must include agencies in the community that serve the approved population of focus and provide safety net services.

LC partnerships must strengthen efforts to expand care teams to include health care providers, 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 follow-up, communication, and coordination among identified communities and populations.

Members of the LC must examine existing policies that are barriers to optimal health outcomes and engage in mitigation strategies aimed at system-level changes that reduce health and health care disparities and improve community conditions.

Post award technical assistance provided by CDC will ensure successful applicants adhere to the requirement for facilitating connections with any relevant existing and new LCs in a given jurisdiction, including but not limited to the state level LC that is required under CDC-RFA-DP- 23-0004: The National Cardiovascular Health Program.

Post-award technical assistance provided by CDC to successful applicants will ensure LCs develop detailed action plans that complement the work plan and lists key partners the first of which must be in place within the first 90 days, that also lists key partners.

During the Period of Performance, recipients are also charged with ensuring the LC focuses on:

Increasing the percentage of patients 18–85 years of age who have had a hypertension diagnosis and among those diagnosed, blood pressure was adequately controlled during the measurement year.

Testing models for collaboration between public health, health care, and community partners.

Deploying a quality improvement process to affect practice and policy at all levels of the system.

Ensuring newly established LCs and partnerships with existing LCs have at least 51% of participating collaborators and partners that have demonstrated history and experience working with and representing the interests of approved populations of focus.

Ensuring a dedicated staff person is identified, as evidenced by explicit inclusion in the work plan and budget, who will focus on health inequities and build relationships at the designated levels to decrease health care disparities and advance health equity.

1. Collaborations

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

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 also will allow for the exchange of information among experts working in various areas of public health and other sectors. Recipients are expected to partner, where appropriate, with other CDC-funded heart disease and stroke programs and initiatives, including but not limited to The National Cardiovascular Health Program, WISEWOMAN, Paul Coverdell National Acute Stroke Program, Good Health and Wellness in Indian Country, Community Health Workers for COVID Response and Resilient Communities, and the Million Hearts® initiative.

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. Applicants should submit letters of support from organizations and entities that will have a role in helping to achieve specific NOFO activities and outcomes. Letters must be dated within 45 days of the application. These files should be named "MOUs/MOAs.applicant name" and uploaded as a PDF file at www.grants.gov.

b. With organizations not funded by CDC:

An applicant should describe its history of establishing or partnering with multi-sectoral learning collaboratives (LC) and collaborating with organizations with a history of working with approved populations of focus who are impacted by the high prevalence of CVD, with specific emphasis on hypertension and high cholesterol exacerbated by health inequities and disparities, social determinants, such as low incomes, poor health care, and unfair opportunity structures.

Proposed collaborations must be relevant for all NOFO strategies. These organizations may include employers, hospitals, non-profit agencies, other federal, state, or local government agencies, tribes or tribal organizations, professional associations (state medical society, other medical specialty associations, etc.), quality improvement organizations housing, commerce, and/or transportation agencies, healthcare providers, health information technology experts, public and private payers, pharmacists, mental and behavioral health professionals, community-based health care professionals, community organizations, safety net providers, and others.

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. Applicants must submit letters of https://www.grants.gov/ support from organizations and entities that will have a role in helping to achieve specific NOFO activities and outcomes. Letters must be dated within 45 days of the application. These files must be named "MOUs/MOAs.applicant name" and uploaded as a PDF file at www.grants.gov.

2. Target Populations Populations of focus for this NOFO are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO. Priority populations should include those affected disproportionately by hypertension and high cholesterol due to socioeconomic or other factors, including inadequate access to care, poor quality of care, or low income.

a. Health Disparities One of the four Healthy People 2030 Foundational Health Measures is eliminating health disparities. This NOFO will address the challenges and health inequities in chronic disease risk factors and conditions that populations at high risk for CVD experience. These efforts will help determine the public health impact of programs intended to improve specific risks, conditions, and barriers experienced by populations living with high levels of disease burden for high blood pressure and high cholesterol.

Recipients are expected to advance health equity among priority populations to prevent and mitigate the impact of heart disease and stroke to improve health outcomes, increase life expectancy and quality of life within approved populations of focus. 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 lack of access to preventive and treatment services among racial and ethnic minority populations and geographically and economically disadvantaged communities.

An applicant must offer a plan that prioritizes eliminating CVD health disparities and advancing health equity in these locations. The plan must describe the health equity challenges in these locations, detail proposals to address those challenges through various strategies and show how progress will be measured. Applicants 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. Organizations serving the population, and representatives of the population, should be engaged in planning processes.

iv. Funding Strategy Funding provided will range from $650,000 to $1,200,000, with an average award of $950,000.

Award amounts will be based on priority populations which for this NOFO are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level. Consideration of the geographic area where work is proposed, along with prior experience and organizational capacity.

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy

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 period of performance, 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):

1. To what extent have recipients increased the reach of program strategies to improve cardiovascular disease within approved populations of focus?

2. What factors or components were associated with effective implementation of program strategies and learning collaboratives?

3. What factors were associated with identifying and addressing social services and support needs and social determinants of health within approved populations of focus?

Outcome Evaluation:

1. To what extent have the implemented strategies and learning collaboratives contributed to a measurable change in health outcomes within approved populations of focus?

2. What innovative strategies implemented by recipients can be replicated and/or scaled?

CDC will use an evaluation approach that facilitates recipient-conducted rigorous evaluations of innovative strategies, as well as collection and reporting of data that assess the program across recipients. This will include (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 performance measures. Recipients are not required to report long term measures. CDC will work with recipients on operationalizing and further defining each performance measure, and guidance will be provided prior to the first reporting period. Performance measures will be reported semi-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 funders, recipients, and partners. CDC will analyze performance measure data semi-annually and develop aggregate performance measure reports to be disseminated to recipients and other key partners, including federal partners, 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 national evaluation activities.

For the CDC-led 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 national 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 program improvement and for the overall evaluation of the program. Recipients will be expected to conduct rigorous evaluations that will demonstrate their progress addressing the health and social services and support needs within approved populations of focus.

For all components of the evaluation, CDC and recipients will only collect data that will be analyzed and used. CDC will provide evaluation technical assistance and ongoing evaluation guidance on recipient-level evaluation and performance measures. Evaluation technical assistance will be provided using a customized approach to ensure that tools and services provided meet the needs of the recipients. All data will be reported via a secure system. All evaluation findings produced by CDC and recipients will contribute to: continuous program and quality improvement of program efforts, the evidence base, documentation and sharing of lessons learned to support replication and scaling of program strategies, and 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 and 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. Recipients will report performance measure data semi-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 regular reports. Applicants should submit a Data Management Plan (DMP). A 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.

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 Short-Term Outcomes and Performance Measures https://www.cdc.gov/chronicdisease/programs-impact/nofo/index.htm.

Strategy 1. Track and Monitor Clinical Measures Shown to Improve Health and Wellness, and Health Care Quality Within Approved Populations of Focus, and Identify Patients with Hypertension and High Cholesterol.

Increased use of EHRs and HIT to report, monitor, and track clinical data and social services and support needs to improve detection of health care disparities and the identification, management, and treatment within approved populations of focus.

1A. Advance the adoption and use of electronic health records (EHR) and health information technology (HIT) to identify, track, and monitor clinical and social services and support needs measures to address health care disparities and health outcomes within approved populations of

Measure 1A:

# and % of clinics or health care systems that have policies/protocols in place requiring the use of EHRs and standardized clinical quality measures to track hypertension control measures by race, ethnicity, and other populations of focus.

Increased use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify, assess, track, and address the social services and support needs within approved populations of focus.

1B. Promote the use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify the social services and support needs within approved populations of focus and monitor and assess the referral and utilization of those services, such as the need for transportation, housing, childcare, etc.

Measure 1B:

# and % of clinics or health care systems that use standardized processes or tools to identify, assess, track, and address the social services support needs within approved populations of focus.

Strategy 2: Implement Team-Based Care to Prevent, Detect, Control and Manage Hypertension and High Cholesterol Within Approved Populations of Focus.

Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within approved populations of focus.

2A. Advance the use of health information systems that support team-based care to monitor and address hypertension and high cholesterol

Measure 2A:

# and % of clinics or health systems that have policies or protocols in place requiring the use of clinical data from EHRs or HIT to support communication within the care team to coordinate care for hypertension and high cholesterol within approved populations of

Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address social services and support needs within approved populations of focus. 2B. Assemble or create multidisciplinary teams to identify social services and support needs

Measure 2B:

# of adults, within approved populations of focus, served by clinics or health systems that use multidisciplinary care teams that adhere to evidence-based guidelines.

Increased multidisciplinary partnerships that address identified barriers and social services and support needs within approved populations of focus.

2C. Build and manage a coordinated network of multidisciplinary partnerships that address identified barriers and needs within approved populations of focus, related to their social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing).

Measure 2C:

# and type of social services within the recipient's network that address social needs within approved population of focus.

Strategy 3: Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow-Up Systems Aimed at Mitigating Social Services and Support Barriers for Optimal Health Outcomes Within Approved Populations of Focus.

Increased community clinical links to identify and respond to social services and support needs within approved populations of focus.

3A. Create and enhance community-clinical links to identify social determinants of health {(SDoH) e.g., housing, transportation, access to care, and community resources} and respond to the individual social services and support needs

Measure 3A:

# of adults within approved populations of focus, who are referred to lifestyle change programs or social services and support..

3B. Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social services and support needs leading to optimal health outcomes

Increased engagement of CHWs (or their equivalents) to provide a continuum of care by extending clinical interventions and addressing social services and support needs within approved populations of focus. Measure 3B:

# of CHWs (or their equivalent) who engage with community organizations to provide a continuum of care by extending clinical interventions and addressing social services and support needs within approved

Increased use of SMBP with clinical support within approved populations of focus. 3C. Promote the use of self-measured blood pressure monitoring with clinical support within approved populations of focus

Measure 3C:

# of adults within approved populations of focus who participate in SMBP with clinical support.

Intermediate Outcomes Intermediate Required Performance Measures Improved blood pressure control among populations within partner health care and community

# and % of adults within partner health care and community settings with known hypertension who have achieved or are currently maintaining blood pressure control.

Reduced disparities in blood pressure control among populations within partner health care and community settings.

# and % of adults within partner health care and community settings, reported by race, ethnicity, and approved population of focus, with known hypertension who have achieved or are currently maintaining blood pressure control.

Increased utilization of social and support services within populations of focus with hypertension and high cholesterol.

# and % of adults, within approved populations of focus, who were referred to social support services and accessed those services.

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

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

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

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

Plans for updating the Data Management Plan (DMP) as new pertinent information becomes available. If applicable, throughout the lifecycle of the project. Updates to DMP should be provided in annual progress reports. The DMP should provide a description of the data that will be produced using these NOFO funds; access to data;

data standards ensuring released data have documentation describing methods of collection, what the data represent, and data limitations; and archival and long-term data preservation plans. For more information about CDC’s policy on the DMP, see https://www.cdc.gov/grants/additional-requirements/ar-25.html.

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

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

Describe key evaluation questions to be addressed by these evaluations.

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

Recipients will be required to submit a more detailed Evaluation and Performance Measurement plan, including a DMP, if applicable, within the first 6 months of award, as described in the Reporting Section of this NOFO.

In addition, to enable the required rigorous evaluations, recipients will identify relevant measures and previously untapped data sources (e.g., health system, electronic health record systems, surveys, etc.), and where appropriate, develop partnerships to enhance current data systems to improve the comprehensiveness of monitoring approaches.

The applicant's evaluation and performance measurement plans should:

Ensure that the evaluation questions align with the purpose of this NOFO to improve hypertension control within approved populations of focus.

Describe an evaluation design that is rigorous enough to clearly document the innovative approaches to the proposed strategies and the contribution of the strategies to outcomes outlined in the logic model. This design should include a clear description of indicators, data sources, data collection methods, analysis plans, and dissemination activities.

Describe access to performance measure data (e.g., hypertension control within approved populations of focus) and how the applicant will meet the requirements to report performance measure data to CDC semiannually.

https://www.cdc.gov/grants/additional-requirements/ar-25.html

Describe how and how much of the total funding will be allocated to evaluation and performance measurement. CDC strongly recommends allocating at least 15% to evaluation and performance measurement.

Describe how GIS is used to identify populations of focus in census geographies disproportionately impacted by cardiovascular disease.

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 15% 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.