Foa_Content_of_CDC-RFA-DP-24-0060.pdf

Centers for Disease Control and Prevention

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH

PROMOTION

Paul Coverdell National Acute Stroke Program

CDC-RFA-DP-24-0060

06/10/2024

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- 24-0060. 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:

Paul Coverdell National Acute Stroke 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 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-24-0060

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:

93.810

F. Dates:

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

05/10/2024

2. Due Date for Applications:

06/10/2024 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call:

CDC-RFA-DP24-0060: Paul Coverdell National Acute Stroke Program -Applicant Informational Webinar Date: April 29th, 2024 Time: 3:00 PM EST Join by Computer:

https://cdc.zoomgov.com/j/1603128767?pwd=OEgvdGlTbzhqME5pL1ZlaEpnSnRTUT09

Join by Phone: Dial (for higher quality, dial a number based on your current location):

+1 669 254 5252 US (San Jose) +1 646 964 1167 US (US Spanish Line) +1 646 828 7666 US (New York) +1 551 285 1373 US (New Jersey) +1 669 216 1590 US (San Jose) +1 415 449 4000 US (US Spanish Line) Webinar ID: 160 312 8767 Passcode: 64934939

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: coverdell24- 0060@cdc.gov

Questions and responses will be posted to the NOFO informational website within 72 hours of receipt so that all applicants have access to any information shared.

G. Executive Summary:

1. Summary Paragraph This NOFO aims to improve equity and quality in stroke prevention and care with a focus on those at highest risk of stroke. Recipients will use funding to:

1) prevent strokes through HTN detection and control,

2) improve stroke care through enhanced data collection, and

3) strengthen linkages between clinical and community resources for those at the highest risk of stroke.

https://www.grants.gov/ https://cdc.zoomgov.com/j/1603128767?pwd=OEgvdGlTbzhqME5pL1ZlaEpnSnRTUT09 https://www.cdc.gov/dhdsp/funding-opps/index.htm mailto:coverdell24-0060@cdc.gov

These objectives will be realized by creating or aligning with a learning collaborative (LC) or stroke coalition. The LC will address clinical and social services and support needs from prevention to in-hospital to post-discharge. Data systems will be used to monitor in-hospital quality of care. Community-clinical links will be strengthened to address stroke prevention through messaging, education, and post-discharge in home and rehab settings.

This NOFO recommends the use of CDC data sources, i.e., CDC WONDER and CDC PLACES.

CDC WONDER 2018-2021 data helped identify states with a crude stroke mortality rate of at least 55.9 per 100,000, for adults aged 18 years or older, with mortality identified via the ICD-10 codes for cerebrovascular disease (stroke), i.e., I60-I69. CDC PLACES can help identify stroke prevalence at the census tract level. Applicants must propose activities in communities most burdened by stroke as evidenced by crude stroke prevalence at the census tract level that is at least 1.5 times greater than crude stroke prevalence for the corresponding county.

a. Funding Instrument Type:

CA (Cooperative Agreement)

b. Approximate Number of Awards

c. Total Period of Performance Funding:

$38,875,000 This amount is subject to the availability of funds.

PLEASE NOTE: The Year 1 Budget Period is 9 months, i.e., September 30, 2024 through June 29, 2025. The Year 1 funding award will represent a full 12-month total award.

d. Average One Year Award Amount:

$650,000 This amount is subject to the availability of funds.

e. Total Period of Performance Length:

5 year(s)

f. Estimated Award Date:

August 30, 2024

g. Cost Sharing and / or Matching Requirements:

No Although no statutory matching requirement for this NOFO exists, applicants are encouraged to leverage other resources and related ongoing efforts to promote sustainability.

Part II. Full Text

A. Funding Opportunity Description

1. Background

a. Overview

An estimated 9.4 million adults living in the United States (US) aged 20 years or older have had a stroke, and every year, more than 795,000 adults in the United States have a stroke. On average, one American has a stroke every 40 seconds and dies from a stroke every 3 minutes and 14 seconds. These data are disturbing, as 80% of strokes are preventable.

Prevention begins with implementing equity-focused systems and interventions to assist in detecting and managing cardiovascular disease (CVD) in populations at the highest risk and mitigating systemic social conditions that contribute to the increased prevalence of CVD. An estimated 1 in 10 (9.9% ≈ 28.6 million) adults in the US have at least one type of CVD, including coronary heart disease, heart failure, or stroke. This estimate excludes hypertension, a risk factor for and cause of CVD but not a type of CVD. However, hypertension or high blood pressure is a critical risk factor for stroke. An estimated 120 million American adults (48.1%) have hypertension, and 1 in 5 adults are unaware they have it. High blood cholesterol, smoking, obesity, and diabetes also contribute to stroke risk.

Heart disease, stroke, and their modifiable risk factors disproportionately affect the US population based on race or ethnicity, social factors, and geography. The overall age-adjusted stroke death rate for all individuals in the US was 41.1 per 100,000 in 2021. Non-Hispanic Blacks had the highest age-adjusted stroke death rate among all races and ethnicities at 59.6 per 100,000 for the same year.

In 2001, Congress provided funding to CDC to establish the Paul Coverdell National Acute Stroke Registry, named after the late US Senator Paul Coverdell of Georgia, who suffered a fatal stroke in 2000. In 2012, the program expanded and became the Paul Coverdell National Acute Stroke Program. The aim has been to support the implementation of comprehensive stroke prevention and management strategies across the continuum of care, from the onset of stroke symptoms through rehabilitation and recovery. In subsequent years, Congress has directed DHDSP to continue to strengthen and expand evidence-based heart disease and stroke prevention activities focused on high-risk populations. As directed, this iteration will address the needs of those at the highest risk of stroke, which includes those who have experienced a stroke and those with uncontrolled or undiagnosed hypertension.

b. Statutory Authorities Section 317(k)(2) of the Public Health Services Act [42 USC 247b(k)(2) as amended].

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

HDS-01: Improve cardiovascular health in adults HDS-03: Reduce stroke deaths HDS-05: Increase control of high blood pressure in adults HDS-D04: Increase the proportion of stroke patients who get IV reperfusion therapy within 3 hours of symptom onset https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke

HDS-D05: Increase the proportion of adult stroke survivors who participate in rehabilitation services

HDS-D06: Increase the proportion of people with strokes who get mechanical thrombectomy within 16 hours of symptom onset

d. Other National Public Health Priorities and Strategies

• Division for Heart Disease and Stroke Prevention Funding Opportunities

• CMS Framework for Health Equity 2022-2032

• HHS Equity Action Plan •HRSA Strategic Plan FY23

• Million Hearts® 2027

• The Guide to Community Preventive Services

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

e. Relevant Work This NOFO builds on the accomplishments and outcomes achieved in CDC-RFA-DP21-2102, including the implementation of comprehensive stroke systems across the continuum of care, improved quality of care and prevention services, and reduced early mortality for acute stroke patients. This NOFO also builds on efforts to "Link Community Resources and Clinical Services" under CDC-RFA-DP18-1815, CDC-RFA-DP18-1816, and CDC-RFA-DP18-1817, which all worked to identify, enhance, and build systems that facilitate provider and community bidirectional referrals to support identification of and referrals for those with risk factors for CVD and those with CVD.

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

Strategies Short Term Outcomes

Intermediate Term Outcomes

Long Term Outcomes

Strategy 1: Track, monitor, and assess clinical and social services and support needs measures and referrals across the stroke continuum of care for those who have experienced a stroke, those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension, and to identify health care disparities.

Reduced strokes within partner, health care and community settings, for those

Improved cardiovascula r health.

Reduced disparities in 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.cdc.gov/bloodpressure/CTA.htm https://grants.gov/search-results-detail/327722 https://grants.gov/search-results-detail/305355 https://grants.gov/search-results-detail/301358 https://grants.gov/search-results-detail/301197

1A. Leverage electronic health records (EHRs) and health information technology (HIT) to identify those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

Increased use of EHR and HIT to identify those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

1B. Use standardized procedures to identify clinical and social services and support needs for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension to monitor and assess referrals and use of those services through a bidirectional referral system.

Increased use of standardized procedures to identify, monitor, and assess clinical and social services and support needs, and to provide referrals to those services and assess their utilization through a bidirectional referral system.

1C. Use metrics from EHR, HIT, and program data to guide quality improvement activities, e.g., Plan Do Study Act (PDSA) cycles, participant and partner feedback, etc.

Increased use of metrics from EHR/ HIT and program data to guide quality improvement activities.

1D. Describe, monitor, and assess statewide data across the stroke continuum of care within proposed service areas for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

Increased monitoring and assessment of statewide data across the stroke continuum of care and within proposed service areas for those who have experienced a stroke and those at the highest risk of stroke due to at the highest risk of stroke.

Reduced disparities in strokes within partner, health care and community settings, for those

Increased utilization of social and support services within partner, health care and community settings for those cardiovascula r health.

undiagnosed or uncontrolled hypertension.

Strategy 2: Promote the implementation of a team-based care approach across the stroke continuum of care for those who have experienced a stroke and those at the highest risk of stroke, focusing on hypertension prevention, detection, control, and management through the mitigation of barriers to social services and support needs to improve outcomes.

2A. Promote the use of standardized procedures among the care team, to include both clinical and community-based entities and individuals, across the stroke continuum of care to identify participants’ social services and support needs and track, monitor, and assess the referral and use of those services, such as food assistance, housing, childcare assistance, transportation, etc.

Increased number of individuals with identified social services and support needs referred to those services using standardized procedures among the care team, to include both clinical and community-based entities and individuals, across the stroke continuum of care.

2B. Implement data-driven changes to the stroke continuum of care in proposed service areas to improve the efficiency and quality of care among the care team, to include both clinical and community-based entities and individuals, from emergency medical service (EMS) and emergency departments, during in-patient care, through discharge, and to improve transitions of care among settings through systematic Quality Improvement (QI) methods and interventions.

Expanded collection and use of data elements across the stroke continuum of care to improve efficiency and quality of care among the care team, to include both clinical and community-based entities and individuals.

2C. Engage health care professionals, pharmacists (community and clinical pharmacists, pharmacy schools, and professional pharmacy organizations), the community-based workforce (including community health workers, community health representatives, social workers, patient navigators, etc.), other care team members, and individuals who have experienced a stroke or are at risk of stroke in both health care and community settings to improve communication, coordination, and collaboration among the care team.

Increased number of individuals served by clinics, health systems, and in community settings that use care teams comprised of both clinical and community expertise to prevent stroke.

Strategy 3: Link individuals to community resources and clinical services to support bidirectional referrals, self-management, and lifestyle changes for those who have experienced a stroke and those at the highest risk of stroke and to mitigate barriers to social services and support needs to improve outcomes.

3A. Establish and strengthen partnerships with relevant state or local stroke coalitions, learning collaboratives, initiatives, community-based organizations, non-governmental organizations, professional organizations, providers, and health systems that provide support for those who have experienced a stroke and those at the highest risk of stroke across the continuum of care.

Increased number of newly established and strengthened partnerships that provide support for those who have experienced a stroke and those at the highest risk of stroke across the stroke continuum of care.

3B. Facilitate the engagement of the community-based workforce (including community health workers, community health representatives, social workers, patient navigators, etc.) in managing community resources and clinical services that support those who have experienced a stroke and those at the highest risk of stroke across the continuum of care to improve outcomes.

Increased engagement of the community-based workforce (including community health workers, community health representatives, social workers, patient navigators, etc.) across the stroke continuum of care to manage community resources and clinical services for those who have experienced a stroke and those at the highest risk of stroke.

3C. Promote and coordinate appropriate messaging and education to increase the prevention and awareness of stroke across the continuum of care.

Increased reach of stroke prevention messaging and education across the stroke continuum of care.

i. Purpose This NOFO aims to 1) prevent strokes through HTN detection and control, 2) improve stroke care through enhanced data collection, and 3) strengthen linkages between clinical and community resources for those at the highest risk of stroke. Recipients will create or align with a learning collaborative (LC) or stroke coalition to address clinical and social services and support needs across the continuum of care. Data systems will be used to monitor in-hospital quality of care and community-clinical links will be strengthened to ensure that prevention and post discharge needs are addressed.

ii. Outcomes Short-term outcomes by strategy

Strategy 1:

• Increased use of EHR and HIT to identify those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

• Increased use of standardized procedures to identify, monitor, and assess clinical and social services and support needs, and to provide referrals to those services and assess their utilization through a bidirectional referral system.

• Increased use of metrics from EHR/HIT and program data to guide quality improvement activities.

• Increased monitoring and assessment of statewide data across the stroke continuum of care and within proposed service areas for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

Strategy 2:

• Increased number of individuals with identified social services and support needs referred to those services using standardized procedures among the care team, to include both clinical and community-based entities and individuals, across the stroke continuum of care.

• Expanded collection and use of data across the stroke continuum of care to improve efficiency and quality of care among the care team, to include both clinical and community-based entities and individuals.

• Increased number of individuals served by clinics, health systems, and in community settings that use care teams comprised of both clinical and community expertise to prevent stroke.

Strategy 3:

• Increased number of newly established and strengthened partnerships that provide support for those who have experienced a stroke and those at the highest risk of stroke across the stroke continuum of care.

• Increased engagement of the community-based workforce (including community health workers, community health representatives, social workers, patient navigators, etc.) across the stroke continuum of care to manage community resources and clinical services for those who have experienced a stroke and those at the highest risk of stroke.

• Increased reach of stroke prevention messaging and education across the stroke continuum of care.

Intermediate-term Outcomes

• Reduced strokes within partner, health care and community settings for those at the highest risk of stroke.

• Reduced disparities in strokes within partner, health care and community settings for those at the highest risk of stroke.

• Increased utilization of social and support services within partner, health care and community settings for those at the highest risk of stroke.

iii. Strategies and Activities Applicants must describe their approach to address all strategies and activities.

Recipients must implement all strategies and activities below.

Strategy 1: Track, monitor, and assess clinical and social services and support needs measures and referrals across the stroke continuum of care for those who have experienced a stroke, those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension, and to identify health care disparities.

• 1A. Leverage electronic health records (EHRs) and health information technology (HIT) to identify those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

• 1B. Use standardized procedures to identify clinical and social services and support needs for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension to monitor and assess referrals and use of those services through a bidirectional referral system.

• 1C. Use metrics from EHR, HIT, and program data to guide quality improvement activities, e.g., Plan Do Study Act (PDSA) cycles, participant and partner feedback, etc.

• 1D. Describe, monitor, and assess statewide data across the stroke continuum of care within proposed service areas for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension.

Strategy 2: Promote the implementation of a team-based care approach across the stroke continuum of care for those who have experienced a stroke and those at the highest risk of stroke, focusing on hypertension prevention, detection, control, and management through the mitigation of barriers to social services and support needs to improve outcomes.

• 2A. Promote the use of standardized procedures among the care team, to include both clinical and community-based entities and individuals, across the stroke continuum of care to identify participants’ social services and support needs and track, monitor, and assess the referral and use of those services, such as food assistance, housing, childcare assistance, transportation, etc.

• 2B. Implement data-driven changes to the stroke continuum of care in proposed service areas to improve the efficiency and quality of care among the care team, to include both clinical and community-based entities and individuals, from emergency medical service (EMS) and emergency departments, during in-patient care, through discharge, and to improve transitions of care among settings through systematic Quality Improvement (QI) methods and interventions.

• 2C. Engage health care professionals, pharmacists (community and clinical pharmacists, pharmacy schools, and professional pharmacy organizations), the community-based workforce (including community health workers, community health representatives, social workers, patient navigators, etc.), other care team members, and individuals who have experienced a stroke or are at risk of stroke in both health care and community settings to improve communication, coordination, and collaboration among the care team.

Strategy 3: Link individuals to community resources and clinical services to support bidirectional referrals, self-management, and lifestyle changes for those who have experienced a stroke and those at the highest risk of stroke and to mitigate barriers to social services and support needs to improve outcomes.

• 3A. Establish and strengthen partnerships with relevant state or local stroke coalitions, learning collaboratives, initiatives, community-based organizations, non-governmental organizations, professional organizations, providers, and health systems that provide support for those who have experienced a stroke and those at the highest risk of stroke across the continuum of care.

• 3B. Facilitate the engagement of the community-based workforce (including community health workers, community health representatives, social workers, patient navigators, etc.) in managing community resources and clinical services that support those who have experienced a stroke and those at the highest risk of stroke across the continuum of care to improve outcomes.

• 3C. Promote and coordinate messaging and education to increase the prevention and awareness of stroke across the continuum of care.

This NOFO will require recipients to collaborate or partner with a heart disease and stroke learning collaborative (LC) or stroke coalition to facilitate communication and share best practices for addressing the needs of communities disproportionately affected by the high prevalence of stroke. If one does not exist, recipients will be required to create an LC or coalition. Post-award technical assistance will facilitate connections with existing and new LCs or stroke coalitions 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.

Emphasis should be on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies in this NOFO. Applicants must also propose a process to support the collection and analysis of in-hospital stroke data for those who have had a stroke, ensuring post-discharge follow-up in rehabilitation or other community-supportive recovery services.

For the purposes of this NOFO, a heart disease and stroke LC or stroke coalition, is defined as a group of public health entities, health care providers, 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 LC or stroke coalition must be a regional or statewide group or similar entity.

Additional information regarding the LC, it's composition and requirements are included below.

The LC or stroke coalition serves as a central 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.

A heart disease and stroke LC or stroke coalition may be an alliance of public health entities, housing, commerce, 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 social determinants of health.

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

• Facilitating communication and idea exchanges between health systems, community health organizations, and public health entities. LCs should leverage technical and financial resources to support programs to improve cardiovascular health outcomes, as identified throughout this NOFO.

• 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 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.

Applicants must describe the following:

• How they will use Geographic Information System (GIS) mapping technology to identify priority populations at the highest risk of stroke that will be the focus of the LC or coalition.

• State crude stroke mortality rate of at least 55.9 per 100,000, using 2018-2021 CDC WONDER data for adults aged 18 years or older, with mortality identified via the ICD- 10 codes for cerebrovascular disease (stroke) i.e., I60-I69. Additionally, applicants must propose activities in communities disproportionately burdened by stroke as evidenced by crude stroke prevalence at the census tract level that is at least 1.5 times greater than crude stroke prevalence for the corresponding county. Emphasis should be on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies in this NOFO.

• Propose a process to support the collection and analysis of in-hospital stroke data for those who have had a stroke, ensuring post-discharge follow-up in rehabilitation or other community-supportive recovery services.

• How the applicant working with an LC or stroke coalition will address the strategies and activities outlined in this NOFO to achieve sustainable change and improvement towards the specified outcomes.

• The LC’s or stroke coalition’s history of achieving the goals outlined in the NOFO.

These interdisciplinary partnerships must demonstrate that they have successfully and effectively served 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.

• How their heart disease and stroke LCs or stroke coalitions will 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.

• How members of the LC or stroke coalition will 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.

Required LC, or stroke coalition activities include:

• Reporting on the effects of efforts to address the impact of social injustices on cardiovascular health outcomes, including high blood pressure, high cholesterol, and stroke specifically.

• Achieving impact and reach among those at the highest risk of stroke across geographic locations where the approved populations of focus can benefit from the strategies included in this NOFO.

• Designing and implementing strategies using EHR and HIT to detect and mitigate health care disparities, prioritizing hypertension, and utilize quality improvement techniques to achieve optimal health outcomes among those at the highest risk of stroke.

During the Period of Performance, recipients are also charged with ensuring the LC, or stroke coalition, 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.

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

• Ensuring newly established or existing LCs or stroke coalitions 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 building relationships at the designated levels to decrease health care disparities in hypertension and stroke and advance health equity.

1. Collaborations

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

Applicants should establish collaborative, strategic partnerships with other CDC funded programs within and outside the state health departments, tribes and tribal organizations to allow for more efficient use of existing resources. This also allows for 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, The National Cardiovascular Health Program , The Innovative Cardiovascular Health Program, Good Health and Wellness in Indian Country, Community Health Workers for COVID Response and Resilient Communities, the Million Heart® Initiative, and other CDC-funded chronic disease prevention and management programs. Applicants should also link to strategies and collaborations described in the State Chronic Disease Plan, as appropriate. Applicants should describe how they will collaborate with CDC-funded programs and health equity subject-matter experts.

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:

The applicant should describe its history of establishing or partnering with multi-sectoral learning collaboratives, or stroke coalitions, 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.

Applicants are required to collaborate with partners and agencies that serve the priority population of interest or work with the identified communities of interest. Applicants are 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, Emergency Medical Services (EMS) units, 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, faith-based organizations, health information technology experts, public and private payers, mental and behavioral health professionals, https://www.cdc.gov/dhdsp/funding-opps/national-dp-23-0003.htm https://www.cdc.gov/dhdsp/funding-opps/national-dp-23-0004.htm https://www.cdc.gov/dhdsp/funding-opps/national-dp-23-0004.htm https://www.cdc.gov/dhdsp/funding-opps/national-dp-23-0005.htm https://www.cdc.gov/healthytribes/ghwic.htm https://www.cdc.gov/healthytribes/ghwic.htm https://www.cdc.gov/covid-community-health-workers/index.html https://www.cdc.gov/covid-community-health-workers/index.html https://millionhearts.hhs.gov/index.html 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, Electronic Health Records/Health Information Technology-focused entities.

It is critical to 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, 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.

2. Population(s) of Focus This NOFO recommends the use of CDC data sources, i.e., CDC WONDER and CDC PLACES.

CDC WONDER 2018-2021 data helped identify states with a crude stroke mortality rate of at least 55.9 per 100,000, for adults aged 18 years or older, with mortality identified via the ICD-10 codes for cerebrovascular disease (stroke), i.e., I60-I69. CDC PLACES can help identify stroke prevalence at the census tract level. Applicants must propose activities in communities most burdened by stroke as evidenced by crude stroke prevalence at the census tract level that is at least 1.5 times greater than crude stroke prevalence for the corresponding county.

Applicants must align with or establish learning collaboratives, or stroke coalitions, to facilitate communication, exchange ideas, and share best practices for addressing the needs of those at the highest risk of stroke.

Emphasis should be on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies in this NOFO. Applicants must also propose a process to support the collection and analysis of in-hospital stroke data for those who have had a stroke, ensuring post-discharge follow-up in rehabilitation or other community-supportive recovery services.

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 experienced by populations at the highest risk of CVD.

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. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO. 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.

Applicants 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 $500,000 to $750,000, with an average award of $650,000.

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

Process (Implementation) Evaluation:

• To what extent have recipients increased the reach of the program strategies for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension?

• To what extent has program strategy implementation led to improved health outcomes among those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension?

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

• What factors or components were associated with effective implementation of program strategies and learning collaboratives, or stroke coalitions?

• What factors were associated with identifying and addressing social services and support needs and social determinants of health for those who have experienced a stroke and those at the highest risk of stroke due to undiagnosed or uncontrolled hypertension?

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

Outcome Evaluation:

• To what extent have the implemented program strategies contributed to a measurable change in health outcomes and health equity across the stroke continuum of care in partner, health care and community settings? To what extent have the program strategies contributed to reduced health care disparities and improved health outcomes within populations at the highest risk of cardiovascular disease?

• To what extent have the implemented strategies and learning collaboratives, or stroke coalitions, contributed to a measurable change in health outcomes within approved populations of focus?

• To what extent have implemented program strategies reduced strokes within partner, health care and community settings, for those who have experienced a stroke and those at the highest risk of stroke?

• To what extent have implemented program strategies reduced disparities in strokes within partner, health care and community settings, for those at the highest risk of stroke?

• To what extent have implemented program strategies increased utilization of social and support services within partner, health care and community settings for those who have experienced a stroke and those at the highest risk of stroke?

CDC will use an evaluation approach that consists of (1) ongoing monitoring and evaluation through the collection and reporting of performance measures, (2) a CDC-led national 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 annually to CDC, and CDC will manage and analyze the data to assess recipient program progress, respond to broader technical assistance needs, and report to partners. CDC will analyze performance measure data annually and develop aggregate performance measure reports to be disseminated to recipients and other key partners, including federal partners, other funded and non-funded partners, and policy makers, 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 national 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 will 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 state-level program improvement and for the overall evaluation of the program. For all components of the evaluation, CDC and recipients will only collect data that will be analyzed and used.

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

The data collected by CDC for performance measurement and evaluation are directly related to the implementation of the strategies and 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. Recipients will report their performance measure data annually and will only have access to their data. Over the five-year period of performance, data will be secured with limited access to authorized CDC program and evaluation staff to the extent allowed under applicable Federal law. CDC will aggregate data across all recipients to publish annual and summative reports. Applicants should submit a Data Management Plan (DMP). A 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…