Foa_Content_of_CDC-RFA-DP-24-0059.pdf

Centers for Disease Control and Prevention

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH

PROMOTION

Mississippi Delta Health Collaborative

CDC-RFA-DP-24-0059

06/17/2024

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- 24-0059. 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:

Mississippi Delta Health Collaborative

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 purposes of this NOFO, research is defined as set forth in 45 CFR 75.2 and, for further clarity, as set forth in 42 CFR 52.2 (see eCFR :: 45 CFR 75.2 -- Definitions and https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR- 2007-title42-vol1-sec52-2.pdf. In addition, for purposes of research involving human subjects and available exceptions for public health activities, please see 45 CFR 46.102(l) (https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section- 46.102#p-46.102(l)).

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP-24-0059

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.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section-46.102#p-46.102(l) https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section-46.102#p-46.102(l)

E. Assistance Listings Number:

93.816

F. Dates:

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

04/18/2024

2. Due Date for Applications:

06/17/2024 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call:

Not Applicable

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 among adults in the 18-county Mississippi Delta Region.

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

The successful applicant will achieve this by implementing policy, systems, and environmental changes that impact health systems and clinical settings, as well as in communities across the 18-county MS Delta Region. This NOFO requires that the applicant collaborates with partners with expertise and services to address the social services and support needs of participants to promote blood pressure control and other healthy behaviors.

a. Funding Instrument Type:

CA (Cooperative Agreement)

b. Approximate Number of Awards

c. Total Period of Performance Funding:

$15,750,000

d. Average One Year Award Amount:

$3,150,000

e. Total Period of Performance Length:

5 year(s)

f. Estimated Award Date:

August 30, 2024

g. Cost Sharing and / or Matching Requirements:

No Cost sharing or matching funds are not required for this program.

https://www.grants.gov/

Although no statutory matching requirement for this NOFO exists, leveraging other resources and related ongoing efforts to promote sustainability is strongly encouraged.

Part II. Full Text

A. Funding Opportunity Description

1. Background

a. Overview The Mississippi Delta is a historically and culturally rich region of the United States. But for all its cultural wealth, there is a poverty of health and health care in the region. Residents of the 18-county region contend with persistent poor health outcomes compounded by challenges to attaining preventive services and care, poor quality of care, and stagnant opportunity structures, particularly as it relates to cardiovascular disease (CVD).

Roughly 1 in 10 (9.9% ≈ 28.6 million) adults in the US have at least 1 type of CVD, including coronary heart disease, heart failure, or stroke. This number excludes hypertension, a risk factor for and cause of CVD, but not a type of CVD. However, hypertension is a critical risk factor for stroke. An estimated 120 million American adults (48.1%) have it, most (3 in 4) don’t have it controlled, and 1 in 5 adults is unaware they have hypertension.

CDC WONDER data from 2018 to 2021 reveals 3,603,594Americans died from heart disease (ICD-10 codes I-00 to I-99), reflecting a crude mortality rate of 273.7 per 100,00 individuals.

During the same time, 44,415 Mississippians died of heart disease with a crude mortality rate of

373.9 per 100,00 individuals. However, in the 18-county Mississippi Delta region, 7, 942 individuals died of heart disease with a crude mortality rate of 367.3 per 100,000. Furthermore, 2021 CDC PLACES data document crude prevalence in Mississippi for the following health conditions at their highest levels, or the top 20% quantile: coronary heart disease (8.4% to 19.8%); high blood pressure (37.7% to 73%); high cholesterol (38% to 52%); and stroke (5.3% to 10.5%). Moreover, 13 counties within the 18-county MS Delta Region reflect these crude prevalences for all of these conditions and include Bolivar, Coahoma, Holmes, Humphreys, Issaquena, Leflore, Quitman, Sharkey, Tallahatchie, Warren, Washington, and Yazoo counties.

The persistence of these outcomes in the Delta is attributable to modifiable CVD conditions and risk factors, such as hypertension, high cholesterol, coronary heart disease, COPD, chronic kidney disease, diabetes, and stroke. To sufficiently address these conditions, interventions must include evidence-based and practice-based approaches that are innovative and tailored to the unique challenges and strengths of the 18-county MS Delta Region. These interventions must be rooted in strategies focused on health systems, team-based care, and linkages to community resources and clinical services that address the social conditions contributing to CVD prevalence in the MS Delta Region.

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 among adults in the 18-county Mississippi Delta Region.

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

The successful applicant will achieve this by implementing policy, systems, and environmental changes that impact health systems and clinical settings, as well as in communities across the 18-county MS Delta Region. This NOFO requires that the applicant collaborates with partners with expertise and services to address the social needs of participants to promote blood pressure control and other healthy behaviors.

b. Statutory Authorities Sec 317(a) of the Public Health Service Act 42 U.S.C. Section 247b(a).

c. Healthy People 2030 Healthy People 2030 objectives related to 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

• Heart Disease and Stroke Prevention Funding Opportunities

• CMS Framework for Health Equity 2022-2032

• HHS Equity Action Plan

• HRSA Strategic Plan FY2

• Million Hearts® 2027

• The Guide to Community Preventive Services

• The Surgeon General’s Call to Action to Control Hypertension

e. Relevant Work This cooperative agreement builds on the accomplishments and outcomes achieved in the health care systems and community-clinical linkage arenas in previous iterations of the MS Delta Health Collaborative (MDHC) NOFO, including DP16-1612 and DP19-1907, which emphasized implementation of population-wide and priority population approaches to prevent and control hypertension among adults in the 18-county Mississippi Delta Region and supported innovation, to explore, evaluate, and document novel approaches to addressing critical gaps in programmatic knowledge in the MS Delta Region.

https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke https://www.cdc.gov/dhdsp/funding-opps/index.htm 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.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://grants.gov/search-results-detail/283749 https://grants.gov/search-results-detail/316017

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

Bold indicates period of performance outcome.

All strategies refer to individuals and patients within the 18-county MS Delta Region

Strategies Short Term Outcomes Intermediate Term Outcomes

Long Term Outcomes

Strategy 1: Track and Monitor Clinical Measures Shown to Improve Health and Wellness and Health Care Quality Within Populations with and at the Highest Risk of 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 populations with and at the highest risk of 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 populations with and at the highest risk of hypertension and high cholesterol.

1B. Promote the use of standardized processes or tools, such as GIS or other mapping tools, to identify social services and support needs within populations with and at the highest risk of hypertension and high cholesterol, 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 populations with and at the highest risk of

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 services and

Improved cardiovascular health.

Reduced disparities in cardiovascular health.

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

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

Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within populations with and at the highest risk of hypertension and high cholesterol.

2B. Expand the existing coordinated network of multidisciplinary partnerships that address identified social services and support needs (e.g., childcare, transportation, language assistance, food assistance, and housing) within populations with and at the highest risk of hypertension and high cholesterol.

Increased multidisciplinary partnerships that address identified social services and support needs within populations with and at the highest risk of

2C. Promote the adoption of Medication Therapy Management (MTM) by community pharmacists and clinical providers to manage hypertension, high cholesterol, and lifestyle modification.

Increased use of MTM by community pharmacists and clinical providers to support the management of hypertension, high cholesterol, and lifestyle modification.

support within populations with and at the highest risk of hypertension and high cholesterol.

2D. 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, and collaboration among the care team.

Improved participant care and follow-up through care team communication, coordination, and collaboration.

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

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 individual social services and support needs within populations with and at the highest risk of hypertension and high cholesterol.

Increased community clinical links to identify SDOH and respond to individual social services and support needs within populations with and at the highest risk of

3B. Deploy and integrate Community Health Workers (CHW; or their equivalents) to provide a continuum of care and services that extend the benefits of clinical interventions and address social services and support needs leading to optimal health outcomes within populations with and at the highest risk of hypertension and high cholesterol.

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 populations with and at the highest risk of

3C. Promote the use of self-measured blood pressure (SMBP) monitoring with clinical support within populations with and at the highest risk of hypertension through referrals to the community-based National Healthy Heart Ambassador Blood Pressure Self- Monitoring (HHA-BPSM) Program and other lifestyle change programs to increase control of hypertension and high cholesterol.

Increased use of SMBP to promote self-management within populations with and at the highest risk of hypertension.

3D. Promote the development, adoption, and implementation of policies, systems, and environmental efforts to increase support for and reinforce healthy behaviors to improve overall health outcomes.

Increased development, adoption, and implementation of policies, systems, and environmental efforts to increase support for and reinforce healthy behaviors to improve overall health outcomes.

i. Purpose This cooperative agreement builds on lessons learned from previous MDHC NOFOs. It focuses on policy, systems, and environmental changes that impact clinical and community settings and lifestyle changes that reduce uncontrolled blood pressure and CVD within the Mississippi Delta Region.

ii. Outcomes Short-term outcomes by strategy

Strategy 1: Track and Monitor Clinical Measures Shown to Improve Health and Wellness, and Health Care Quality Within Populations with and at the Highest Risk of 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 populations with and at the highest risk of hypertension and high cholesterol.

• Increased use of standardized processes or tools, such as GIS or other mapping tools, to identify, assess, track, and address the social services and support needs within populations with and at the highest risk of hypertension and high cholesterol.

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

• Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within populations with and at the highest risk of hypertension and high cholesterol.

• Increased multidisciplinary partnerships that address identified social services and support needs within populations with and at the highest risk of hypertension and high cholesterol.

• Increased use of Medication Therapy Management (MTM) by community pharmacists and clinical providers to support the management of hypertension, high cholesterol, and lifestyle modification.

• Improved participant care and follow-up through care team communication, coordination, and collaboration.

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

• Increased community clinical links to identify SDOH and respond to individual social services and support needs within populations with and at the highest risk of hypertension and high cholesterol.

• 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 populations with and at the highest risk of hypertension and high cholesterol.

• Increased use of SMBP to promote self-management within populations with and at the highest risk of hypertension.

• Increased development, adoption, and implementation of policies, systems, and environmental efforts to increase support for and reinforce healthy behaviors to improve overall health outcomes.

Cross-Cutting Intermediate Outcomes

• Improved blood pressure control within populations with and at the highest risk of hypertension and high cholesterol.

• Reduced disparities in blood pressure control within populations with and at the highest risk of hypertension and high cholesterol.

• Increased utilization of social services and support within populations in the Mississippi Delta with and at the highest risk of hypertension and high cholesterol.

iii. Strategies and Activities Applicant must describe their approach for addressing all strategies.

Strategy 1: Track and Monitor Clinical Measures Shown to Improve Health and Wellness and Health Care Quality Within Populations with and at the Highest Risk of 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 populations with and at the highest risk of hypertension and high cholesterol.

• 1B. Promote the use of standardized processes or tools, such as GIS or other mapping tools, to identify the social services and support needs within populations with and at the highest risk of hypertension and high cholesterol 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 the Prevention, Detection, Control, and Management of Hypertension and High Cholesterol.

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

• 2B. Expand the existing coordinated network of multidisciplinary partnerships that address identified social services and support needs (e.g., childcare, transportation, language assistance, food assistance, and housing) within populations with and at the highest risk of hypertension and high cholesterol.

• 2C. Promote the adoption of MTM by community pharmacists and clinical providers to manage hypertension, high cholesterol, and lifestyle modification.

• 2D. 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 healthcare facilities to enhance participant follow-up and communication, coordination, and collaboration among the care team.

Strategy 3: Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow-up Systems Aimed at Mitigating Social Services and Support Needs 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 individual social services and support needs.

• 3B. Promote and integrate CHWs (or their equivalents) to provide a continuum of care and services that extend the benefits of clinical interventions and address social services and support needs, leading to optimal health outcomes within populations with and at the highest risk of hypertension and high cholesterol

• 3C. Promote the use of self-measured blood pressure monitoring with clinical support within populations with and at the highest risk of hypertension through referrals to the community-based National Healthy Heart Ambassador Blood Pressure Self-Monitoring Program and other lifestyle change programs to increase control of hypertension and high cholesterol.

• 3D. Promote the development, adoption, and implementation of policies, systems and environmental efforts to increase support for and reinforce healthy behaviors to improve overall health outcomes.

To maximize the reach of federal funding, the applicant must ensure that proposed efforts are complementary and not duplicative of other efforts in the 18-county MS Delta Region, including, but not limited to CDC-RFA-DP23-0003: Well-Integrated Screening and Evaluation of WOMen Across the Nation, CDC-RFA-DP23-0004:The National Cardiovascular Health Program, CDC- RFA-DP23-0005: The Innovative Cardiovascular Health Program, and other CDC-funded chronic disease prevention and management programs.

1. Collaborations

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

The applicant should establish collaborative, strategic partnerships with other CDC-funded programs within and outside the state health departments, tribes, and tribal organizations to allow for the efficient use of existing resources. This will allow for the exchange of information among experts working in various areas of public health and other sectors. Related CDC-funded programs include but are not limited to the WISEWOMAN Program (CDC-RFA-DP-23-0003), The National Cardiovascular Health Program (CDC-RFA-DP-23-0004), The Innovative Cardiovascular Health Program (CDC-RFA-DP-23-0005), Good Health and Wellness in Indian Country (GHWIC), Community Health Workers for COVID Response and Resilient Communities, the Million Heart® Initiative, and other CDC-funded chronic disease prevention and management programs. The applicant should also link to strategies and collaborations described in the State Chronic Disease Plan, as appropriate.

This NOFO will require the recipient to collaborate or partner with the heart disease and stroke learning collaborative established at the state level, which is required under The National Cardiovascular Health Program. The applicant is encouraged to engage and garner support from both internal and external partners with varied expertise. Applicant should describe how they will collaborate with CDC-funded programs and health equity subject-matter experts.

https://grants.gov/search-results-detail/342953 https://grants.gov/search-results-detail/342953 https://grants.gov/search-results-detail/342935 https://grants.gov/search-results-detail/342936 https://grants.gov/search-results-detail/342936 https://grants.gov/search-results-detail/342953 https://grants.gov/search-results-detail/342935 https://grants.gov/search-results-detail/342936 https://grants.gov/search-results-detail/342936 https://grants.gov/search-results-detail/349788 https://grants.gov/search-results-detail/349788 https://grants.gov/search-results-detail/330543 https://grants.gov/search-results-detail/330543 https://millionhearts.hhs.gov/index.html

If the applicant chooses to submit a MOA/MOU, the document should be saved as a PDF file with a title beginning with "MOA" or "MOU," and uploaded as a PDF file at www.grants.gov.

b. With organizations not funded by CDC:

The applicant should describe its history of establishing or partnering with multisectoral learning collaboratives (LC) and collaborating with organizations with a history of working with populations impacted by a high prevalence of cardiovascular disease (CVD), with specific emphasis on hypertension and high cholesterol exacerbated by health inequities and disparities, and social determinants, such as low incomes, poor health care, and unfair opportunity structures.

This NOFO will require the recipient to collaborate or partner with the heart disease and stroke learning collaborative established at the state level, which is required under The National Cardiovascular Health Program.

The applicant is required to collaborate with partners and agencies that serve the priority population of interest or work with the identified communities of interest. The applicant is expected to collaborate with a variety of public and private partners to leverage resources and maximize state-wide reach and impact. The applicant should describe proposed collaborations relevant to strategies in the NOFO. These partners may include local, regional, or state health entities, health care Quality Improvement (QI) entities, hospitals, health systems, health care providers, safety net providers, Federally Qualified Health Centers (FQHC)/Rural Health Clinics and Centers (RHC)/Community Health Centers, employers, non-profit agencies, other federal, state, or local government agencies (e.g., State Medicaid Agency, State Employee Benefit Agency, etc.), tribes or tribal organizations, professional associations (e.g., a state medical society, medical specialty associations, etc.), housing, commerce, or transportation agencies, health information technology experts, public and private payers, mental and behavioral health professionals, pharmacists (community and clinical pharmacists, pharmacy schools, and professional pharmacy organizations), the community-based workforce organizations (including community health workers, community health representatives, social workers, patient navigators, etc.), and others to advance program outcomes. Additionally, collaborations may center on shared data, partner organizations, stroke coalitions, intervention settings/locations, community-based organizations, and Electronic Health Records/Health Information Technology-focused entities.

The applicant must describe meaningful collaboration with state-level Offices of Health Equity, Offices of Minority Health, or their equivalent. If an agency does not have this resource, efforts should be made to locate an organization at the state or regional level that possesses this expertise, including expertise in health equity.

Letters of support and MOAs/MOUs are not required but strongly encouraged. These should be submitted as a part of the complete application, and include a firm commitment from partner organizations, along with the role the partner will play in achieving the NOFO’s outcomes. The application will be evaluated based on the strength and quality of collaborations.

If the applicant chooses to submit a Letter of Support, it should be saved as a PDF file with the title, "Letter of Support," and uploaded as a PDF file at www.grants.gov

If the applicant chooses to submit a MOA/MOU, the document should be saved as a PDF file with a title beginning with "MOA" or "MOU," and uploaded as a PDF file at www.grants.gov http://www.grants.gov http://www.grants.gov

2. Population(s) of Focus 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 among adults in the 18-county Mississippi Delta Region.

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

Emphasis should be placed on achieving maximum reach and impact across these populations.

The applicant must offer a plan that prioritizes eliminating CVD health disparities and advancing health equity throughout the 18-county MS Delta Region. 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.

This NOFO, including funding and eligibility, is not limited based on, and does not discriminate on the basis of race, color, national origin, disability, age, sex (including gender identity, sexual orientation, and pregnancy) or other constitutionally protected statuses.

a. Health Disparities The goal of health equity is for everyone to have a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.

Broadly defined, social determinants of health are non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces (e.g., racism, climate) and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. See content below and in other sections (e.g., Approach, Collaborations, Populations of Focus) for information on how this specific NOFO affects social determinants of health.

A health disparity is a preventable difference in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by populations that have been socially, economically, geographically, and environmentally disadvantaged. Health disparities are inextricably linked to a complex blend of social determinants that influence which populations are most disproportionately affected by these diseases and conditions.

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 of those with and at the highest risk of CVD within populations across the 18-county MS Delta Region. 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 hypertension and high cholesterol.

The applicant is expected to advance health equity among priority populations to prevent and mitigate the impact of heart disease and stroke, improve health outcomes, and increase life expectancy and quality of life among adults across the 18-county MS Delta Region. Advancing health equity can be achieved partly by understanding how health disparities and inequities exist within cardiovascular health. Cardiovascular health 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 in racial and ethnic minority populations.

iv. Funding Strategy The applicant is strongly encouraged to sub-award 50% of awarded funds to local and regional entities to contribute to the work, provide leadership and technical assistance to selected MS Delta Region communities, and ensure overall coordination or programmatic implementation efforts.

The applicant is further strongly encouraged to allocate at least 15% of its total funding award to evaluation and performance monitoring.

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 cooperative agreement, CDC will work with the recipient to track the implementation of 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 the strategies and activities increased the number of people in the communities in the region receiving quality care for heart disease and stroke prevention and management?

2. What factors or components of the strategies and activities were associated with effective implementation that expanded reach and improved outcomes?

3. What factors were associated with identifying and addressing social services and support needs and social determinant of health?

4. To what extent were data from the recipient-led and CDC-led evaluation used to improve program implementation and ensure strategies and activities were leading to the intended effect?

Outcome Evaluation:

1. To what extent have the strategies and activities conducted for this cooperative agreement contributed to measurable changes in health outcomes for residents in the Mississippi Delta regions?

2. To what extent are the strategies and activities sustainable within the communities?

CDC will use an evaluation approach that consists of (1) ongoing monitoring and evaluation through the collection and reporting of performance measure data, (2) a CDC-led evaluation, and

(3) a recipient-led evaluation.

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 measure data. Recipient is not required to report long term measures. CDC will work with the recipient on operationalizing and further defining each performance measure.

Performance measure data will be reported annually to CDC, and CDC will manage and analyze the data to assess recipient program progress, respond to technical assistance needs, and to ensure transparency and accountability for funding. CDC will analyze performance measure data annually and develop performance measure reports to be disseminated to the recipient and other key partners, including federal partners, other funded and non-funded partners, and policymakers, as appropriate. These findings may also be presented during site visits and recipient meetings. In addition to performance measure data reported by the recipient, CDC will track additional measures relevant to the program through national datasets or CDC-led evaluation activities.

For the CDC-led evaluation activities, CDC will lead the design, data collection, analysis, and reporting. CDC will engage the recipient in developing and implementing the evaluation The recipient will be required to participate in the evaluation activities and to respond to provide data that contributes to the evaluation. An appropriate level of guidance and support will be provided to ensure 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 on a regular basis.

For the recipient-led evaluation, CDC will assist in developing and implementing evaluation plans that are useful for program improvement and for the overall evaluation of the program.

The recipient is required to develop a robust evaluation plan and to report evaluation results to CDC annually.

CDC will provide evaluation technical assistance and guidance for developing evaluation plans and reporting performance measure data and evaluation results. For all components of the evaluation, CDC and the recipient will only collect data that will be analyzed and used. All evaluation findings produced by CDC and the recipient, 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 the desired outcomes indicated in the logic model. The data collected for this NOFO for performance measurement and national 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. The recipient 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 analyze performance measure data to publish annual and summative reports. The applicant 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 . Applicant is not required to use the sample template; however, all elements included in the template must be addressed.

The recipient will be expected to use a data system that collects all required data elements and other program data that is specific to selected health systems engaged in NOFO activities. The recipient must include de-identified program data related to known social determinants of health and social service and support needs. Examples include, but are not limited to housing, transportation, access to care, and community resources. These data will be used to capture consistent and complete information throughout the NOFO and for program monitoring and reporting. Additional guidance will be provided to the recipient 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. The recipients are required to address all strategies and report all short term and intermediate performance measure data.

Short-Term Outcomes Performance Measures 1A. 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 populations with and at the highest risk of hypertension and high cholesterol.

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.

1B. 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 populations with and at the highest risk of hypertension and high cholesterol

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 populations with and at the highest risk of hypertension and high cholesterol.

2A. Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within populations with and at the highest risk of 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 populations with and at the highest risk of hypertension and high cholesterol.

2B. Increased multidisciplinary partnerships that address identified social services and support

Measure 2B: # and type of partnerships established with traditional and https://www.cdc.gov/chronicdisease/programs-impact/nofo/index.htm https://www.cdc.gov/chronicdisease/programs-impact/nofo/index.htm needs within populations with and at the highest risk of hypertension and high cholesterol nontraditional partners for the purposes of addressing social service and support needs within populations with and at highest risk of hypertension and high cholesterol.

2C. Increased use of MTM by community pharmacists and clinical providers to support the management of hypertension, high cholesterol and lifestyle modification.

Measure 2C: # of adults receiving MTM to manage high blood pressure, high cholesterol, and lifestyle modification.

2D. Improved participant care and follow-up through care team communication, coordination, and collaboration.

Measure 2D: # of adults served by clinics or health systems using a protocol for communication, coordination and collaboration among the care team that enhances engagement and follow up of program participants.

3A. Increased community clinical links to identify SDOH and respond to individual social services and support needs within populations with and at the highest risk of hypertension and high cholesterol.

Measure 3A# of adults within populations with and at highest risk of hypertension and high cholesterol who are referred to an evidence-based and evidence-informed lifestyle change program or social services and support.

3B. 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 populations with and at the highest risk of hypertension and high cholesterol

Measure 3B: # of CHWs (or their equivalent) who collaborate beyond the clinical environment to address social services and support needs within populations with and at the highest risk of hypertension and high cholesterol.

3C. Increased use of SMBP to promote self-management within populations with and at the highest risk of hypertension.

Measure 3C: # of adults within populations with and at the highest risk of hypertension using SMBP tied to clinical support.

3D. Increased development, adoption, and implementation of policies, systems and environmental efforts to increase support for and reinforce healthy behaviors to improve overall health outcomes.

Tracked via Project Officer Documentation and Recipient Qualitative Reporting

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

• Measure 4: # and % of adults within partner health care and community settings with known hypertension who have achieved blood pressure control.

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

• Measure 5: # and % of adults within partner health care and community settings, reported by race, ethnicity, and other population of focus, with known hypertension who have achieved blood pressure control.

Increased utilization of social services and support within populations with and at the highest risk of hypertension and high cholesterol.

• Measure 6: # and % of adults, within populations with and at the highest risk of hypertension and high cholesterol, 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 applicant will collect the performance measures, respond to the evaluation questions, and use evaluation findings for continuous program quality improvement, including, as applicable to the award, how findings will contribute to reducing or eliminating health disparities and inequities.

• 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).

• How evaluation findings will be disseminated to communities and populations of interest in a manner that is suitable to their needs.

• 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).

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

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, the applicant's evaluation and performance measurement plans should:

• Describe data collection approaches, measures, and data sources.

• Align each evaluation question with the approach, instruments/data sources, and timeline.

• Propose analyses for at least two time points (baseline and follow-up), and assess program impact on any intended health disparate populations.

• Describe how much of the overall funding amount will be allocated to evaluation and performance measurement.

• Describe how the applicant will work with professional evaluators (either internal or external) to meet the evaluation and performance measurement requirements.

The applicant should demonstrate a clear plan 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).

For the detailed Evaluation and Performance Measurement Plan due 6 months post award, CDC will work closely with the recipient to develop the detailed plan to ensure that it is appropriate for the activities conducted as part of this cooperative agreement, for compliance with the monitoring and evaluation guidance established by CDC, or other guidance otherwise applicable to this cooperative agreement. CDC will provide additional guidance for developing the Evaluation and Performance Measurement Plan.

c. Organizational Capacity of Recipients to Implement the Approach The applicant must demonstrate the organizational…