Foa_Content_of_CDC-RFA-DP22-2210.pdf

Centers for Disease Control and Prevention

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH

PROMOTION

Closing the Gap with Social Determinants of Health Accelerator Plans

CDC-RFA-DP22-2210

07/08/2022

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- DP22-2210. 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:

Closing the Gap with Social Determinants of Health Accelerator Plans C. Announcement Type: New - Type 1:

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

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP22-2210

E. Assistance Listings Number:

93.945 F. Dates:

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

06/08/2022

2. Due Date for Applications:

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

07/08/2022 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call:

Date: June 09, 2022 Time: 3:00p.m - 4:30p.m Eastern Standard Time Topic: Closing the Gap: Social Determinants of Health-DP22-2210

Register in advance for this webinar:

https://cdc.zoomgov.com/webinar/register/WN_WdEyIDGHQbWSZcsfQWhH-A

Or an H.323/SIP room system:

H.323: 161.199.138.10 (US West) or 161.199.136.10 (US East) Meeting ID: 160 559 8999 Passcode: 42885676 SIP: 1605598999@sip.zoomgov.com Passcode: 42885676

After registering, you will receive a confirmation email containing information about joining the webinar.

G. Executive Summary:

1. Summary Paragraph The Centers for Disease Control and Prevention (CDC) announces the availability of funds to develop multisector action plans to address the social determinants of health (SDOH). The purpose of the NOFO is to accelerate action in state, local, territorial, and tribal jurisdictions that lead to improved chronic disease outcomes among persons experiencing health disparities and inequities.

Collaborative planning among public health, government, business, non-profit organization, and healthcare partners is essential for addressing SDOH. Through community health assessment and long-range planning, policy, system, environmental, and programmatic changes can improve SDOH in communities with the poorest health outcomes.

a. Eligible Applicants:

Open Competition

b. Funding Instrument Type:

G (Grant)

c. Approximate Number of Awards

d. Total Period of Performance Funding:

$5,000,000

e. Average One Year Award Amount:

$125,000

f. Total Period of Performance Length:

https://www.grants.gov/ https://cdc.zoomgov.com/webinar/register/WN_WdEyIDGHQbWSZcsfQWhH-A mailto:1605598999@sip.zoomgov.com

g. Estimated Award Date:

September 29, 2022

h. Cost Sharing and / or Matching Requirements:

No Cost sharing or matching funds are not required for this program. 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 Health equity is achieved when every person has the chance to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances” (WHO). Achieving health equity can be realized by addressing the social determinants of health (SDOH) such as systemic racism, poverty, poor access to quality healthcare, transportation, housing insecurity, nutrition insecurity, commercial tobacco-free policies, safe spaces for physical activity, and social connectedness.

SDOH are conditions in the places where people are born, live, learn, work, play, and worship which influence the availability of fair and just opportunities and resources needed to live healthy lives and to improve a wide range of social, mental, and physical health outcomes.

Through community health needs assessment, multi-sector partnerships, and improvement planning, federal, state, local, tribal, and territorial governments can invest in long-range strategies to address and improve SDOH in communities with the poorest health outcomes.

Chronic diseases such as heart disease and stroke, cancer, diabetes, and obesity are the leading causes of death and disabilities. Inequities in SDOH contribute to stark and persistent chronic disease disparities among population groups based on race, ethnicity, socioeconomic status, and other characteristics, systematically limiting opportunities and resources needed to live healthy lives.

To maximize public health impact, policy, systems, environmental, and programmatic strategies that address SDOH have the potential to narrow disparities in many chronic diseases by removing systemic and unfair barriers to practicing healthy behaviors. Sustaining positive health outcomes requires a focus not just on individual behaviors and patient care, but on root causes of disparities and community-wide approaches aimed at improving population health. Healthy People 2030 categorizes SDOH into five domains: 1) Economic Stability; 2) Education Access and Quality; 3) Health Care Access and Quality; 4) Neighborhood and Built Environment; and 5) Social and Community Context.

Based on the five domains of Healthy People 2030, CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) developed an integrated framework to address SDOH (https://www.cdc.gov/chronicdisease/programs-impact/sdoh.htm) with a specific focus on five determinants that impact chronic disease risk factors and health outcomes:

https://www.cdc.gov/chronicdisease/programs-impact/sdoh.htm

1) Built Environment

2) Community-Clinical Linkages

3) Food and Nutrition Security

4) Social Connectedness

5) Tobacco-Free Policy

Leadership from public health officials, multi-sector partners, and community representatives is essential to developing an action plan and implementing strategies that address SDOH in diverse sectors such as housing, healthcare, transportation, and human services. Planning and collaboration across multiple areas within and outside these sectors is required, including governments, private businesses, non-profit and community organizations and residents, hospitals, and clinical delivery systems. Creating sustainable partnerships with public health, healthcare, human services, and the community are critical to ensure individuals have equitable access to chronic disease prevention services, treatment, and care.

b. Statutory Authorities This program is authorized under Section 301(a) of the Public Health Service Act, 42 U.S.C.

241(a).

c. Healthy People 2030 This funding opportunity supports Healthy People 2030 objectives in the topic area of Social Determinants of Health. For specific objectives, please visit Browse Objectives - Healthy People 2030 | health.gov.

d. Other National Public Health Priorities and Strategies The Guide to Community Preventive Services The National Partnership for Action to End Health Disparities: Toolkit for Community Action Thriving Together: A Springboard for Equitable Recovery and Resilience in Communities Across America - Community Commons COVID-19 Health Equity Strategy National Stakeholder Strategy for Achieving Health Equity Active People, Healthy Nation Surgeon General Priority: Community Health and Economic Prosperity Agency for Healthcare Research and Quality Social Determinants of Health and Practice Improvement Centers for Medicare & Medicaid Services Innovation Center Strategic Objectives

e. Relevant Work This NOFO builds on and supports the following funding opportunities.

Closing the Gap with Social Determinants of Health Accelerator Plans (CDC-FRA-DP21-2111) National Breast and Cervical Cancer Early Detection Program (CDC-RFA-DP17-1701) State Physical Activity and Nutrition Program (CDC-RFA-DP18-1807) High Obesity Program (CDC-RFA-DP18-1809) State Actions to Improve Oral Health Outcomes (CDC-RFA-DP18-1810) Racial and Ethnic Approaches to Community Health (CDC-RFA-DP18-1813) Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke (CDC-RFA-DP18-1815) Well-Integrated Screening and Evaluation for Women Across the Nation (CDC-RFA-DP18-https://health.gov/healthypeople/objectives-and-data/browse-objectives https://health.gov/healthypeople/objectives-and-data/browse-objectives https://www.thecommunityguide.org/ https://lucascountyhealth.com/wp-content/uploads/2016/07/NPA_Toolkit-for-Community-Action.pdf https://www.communitycommons.org/entities/fb33981e-616a-43aa-a0d7-28c14566ebbd#:~:text=Well%20Being%20Trust-,Thriving%20Together%3A%20A%20Springboard%20for%20Equitable%20Recovery%20and%20Resilience%20in,tangled%20threats%20to%20our%20nation.

https://www.communitycommons.org/entities/fb33981e-616a-43aa-a0d7-28c14566ebbd#:~:text=Well%20Being%20Trust-,Thriving%20Together%3A%20A%20Springboard%20for%20Equitable%20Recovery%20and%20Resilience%20in,tangled%20threats%20to%20our%20nation.

https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/cdc-strategy.html https://www.phdmc.org/program-documents/healthy-lifestyles/dche/64-achieving-health-equity/file https://www.cdc.gov/physicalactivity/activepeoplehealthynation/index.html https://www.hhs.gov/surgeongeneral/priorities/community-health-economic-prosperity/index.html https://www.ahrq.gov/sdoh/practice-improvement.html https://www.ahrq.gov/sdoh/practice-improvement.html https://innovation.cms.gov/strategic-direction https://www.grants.gov/web/grants/search-grants.html?keywords=CDC-RFA-DP21-2111 https://www.cdc.gov/cancer/nbccedp/index.htm https://www.cdc.gov/nccdphp/dnpao/state-local-programs/span-1807/index.html https://www.cdc.gov/nccdphp/dnpao/state-local-programs/hop-1809/high-obesity-program-1809.html https://www.cdc.gov/oralhealth/funded_programs/cooperative_agreements/index.htm https://www.cdc.gov/nccdphp/dnpao/state-local-programs/reach/current_programs/index.html https://www.cdc.gov/chronicdisease/about/foa/1815/index.htm https://www.cdc.gov/chronicdisease/about/foa/1815/index.htm https://www.cdc.gov/wisewoman/about.htm

1816) Good Health and Wellness in Indian Country (CDC-RFA-DP19-1903) Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees (CDC-RFA-

DP19-1908)

National and State Tobacco Control Program (CDC-RFA-DP20-2001) Networking2Save (CDC-RFA-DP18-1808) State-based Perinatal Quality Collaboratives (CDC-RFA-DP17-1702)

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

CDC-RFA-DP22-2210 Logic Model: Closing the Gap with Social Determinants of Health (SDOH) Accelerator Plans Bold indicates period of performance outcome

Strategies and Activities

Short-term Outcomes

Intermediate Outcomes

Long-term Outcomes

Convene and coordinate a Leadership Team consisting of multisectoral partners

Develop an implementation ready SDOH Accelerator Plan

Increased collaboration and engagement across multisectoral partners

Completed implementation ready SDOH Accelerator Plan, including all required components

Implementation of the SDOH Accelerator Plan among multisectoral partners

Establishment of infrastructure and funding to support SDOH Accelerator Plan implementation

Improved health and social outcomes for people experiencing health disparities and inequities

Reduced health disparities and increased health equity

i. Purpose Approximately 40 applicants will be funded to collaborate with multisectoral partners to develop implementation ready SDOH Accelerator Plans to reduce disparities in health outcomes related to chronic disease within a state, local, territorial, and tribal jurisdiction, community,* or catchment area.**

*A community within the state could be defined as a city, county, parish, or jurisdiction/sub-jurisdiction.

**Catchment areas are defined in this NOFO as a county, metropolitan statistical area(s) or a group of contiguous counties.

ii. Outcomes The recipient is expected to complete activities that will impact the bolded short-term outcomes:

Increased collaboration and engagement across multisectoral partners Completed implementation ready SDOH Accelerator Plan, including all required components https://www.cdc.gov/healthytribes/ghwic.htm https://www.cdc.gov/reproductivehealth/global/preventing-maternal-deaths.htm https://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/index.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Ftobacco%2Fstateandcommunity%2Ftobacco_control_programs%2Fntcp%2Findex.htm https://www.cdc.gov/tobacco/about/foa/national-networks-nofo/coop-agreement/index.html https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pqc.htm

iii. Strategies and Activities Strategy 1: Convene and Coordinate a Leadership Team Consisting of Multisectoral Partners Prior to convening and coordinating the Leadership Team and developing the SDOH Accelerator Plan, applicants are required to describe the community, population(s), and priority SDOH selected.

1. Identify and describe the tribe, community, or catchment area Applicants are required to identify and describe the location disproportionately affected by disparities in chronic disease outcomes (e.g., name, affiliation, location, size, geopolitical and historical context, etc.)

NOTE: Applicants are expected to identify and define their community as appropriate to their needs and priorities of the jurisdiction; defining at the tribal, territorial, and sub-jurisdictional levels are consistent with the expectations of this grant.

2. Identify the population(s) disproportionately affected by chronic disease and related risk factors Applicants are required to identify and describe the population(s) affected by poverty, lack economic resources, including communities with high rates of income inequity or low employment opportunities. Population description should include:

Results from a community health needs assessment (CHA) and/or state health needs assessment (SHA). The assessments should have been completed within the last five (5) years. Using the CHA and/or SHA and other data sources, the applicant should include:

o Demographic characteristics o Health status o Community profile o Chronic disease burden o Available health care systems

Evidence of disproportionate vulnerability to adverse health outcomes by poverty rate and CDC Social Vulnerability Index (SVI) score How the SDOH Accelerator Plan will improve disparate chronic disease health outcomes related to the social determinant and contribute to enhancing resiliency of the tribe, community, or catchment area.

Other data sources to define and describe the population(s). Examples of cited data sources include:

o County Health Rankings o City Health Dashboard o PLACES o Census o American Community Survey o Community Commons https://www.atsdr.cdc.gov/placeandhealth/svi/index.html https://www.countyhealthrankings.org/ https://www.cityhealthdashboard.com/ https://www.cdc.gov/places/index.html https://data.census.gov/ https://www.census.gov/programs-surveys/acs https://www.communitycommons.org/ o CARES HQ – Center for Applied Research and Engagement Systems o Behavioral Risk Factor Surveillance Systems (BRFSS) o Youth Risk Behavior Surveillance System (YRBSS) o Nutrition, Physical Activity, and Obesity: Data, Trends and Maps o Pregnancy Risk Assessment Monitoring System o Centers for Medicare & Medicaid Services Medicare Current Beneficiary Survey

(MCBS)

o Centers for Medicare and Medicaid Services Innovation Center Data & Reports o Substance Abuse and Mental Health Services Administration (SAMHSA):

Racial/Ethnic Differences in Mental Health Service Use Among Adults

3. Identify Leadership Team Applicants will provide evidence of an existing or newly established Leadership Team that will advise on the development of the SDOH Accelerator Plan. In developing the plan, the Leadership Team should employ a community based participatory approach that includes shared decision making and builds upon the collective assets of the community. The Leadership Team should have diverse and inclusive membership consisting of the following:

At least two (2) members of the community that understand the distinct characteristics and culture of the selected population(s) and are recognized by their peers as trusted voices for the community.

A minimum of five (5) additional representatives from different sectors (e.g., healthcare, human services, housing, transportation, food systems, etc.) with the expertise and authority to accomplish the development of the implementation ready SDOH Accelerator Plan in the selected SDOH priority areas.

Examples of potential members to recruit for the multisector Leadership Team include:

Accountable care organizations (ACOs) Health care systems Health care providers and related professionals (e.g., physicians, nurses, community health workers, pharmacists) o Health care related organizations, (e.g., pharmacies, testing centers; urgent care clinics) o Healthcare facilities (e.g., Critical Access Hospitals (CAHs), children’s hospitals, urgent care clinics) o Social services providers and organizations, including those that address social determinants of health (e.g., community transportation; anti-discrimination organizations legal services; service providers for persons with disabilities) o Asian American, Native Hawaiian, and Pacific Islander Serving Institutions (AAPI) o Tribes, Tribal organizations and health systems, Urban Indian organizations o Community and economic development organizations and programs o State and locally funded recipients of Federal Programs including:

Administration for Children and Families (ACF) (e.g., Social Services and Childcare)

Administration for Community Living (ACL) (e.g., Area Agencies on Aging, Meals on Wheels) https://careshq.org/ https://www.cdc.gov/brfss/ https://www.cdc.gov/healthyyouth/data/yrbs/ http://www.cdc.gov/nccdphp/dnpao/data-trends-maps/index.html https://www.cdc.gov/prams/index.htm https://www.cms.gov/research-statistics-data-and-systems/research/mcbs https://www.cms.gov/research-statistics-data-and-systems/research/mcbs https://innovation.cms.gov/data-and-reports https://www.samhsa.gov/data/sites/default/files/MHServicesUseAmongAdults/MHServicesUseAmongAdults.pdf https://www.samhsa.gov/data/sites/default/files/MHServicesUseAmongAdults/MHServicesUseAmongAdults.pdf

Health Resources and Services Administration (HRSA) (e.g., Health Service Centers, FQHCs, State Offices of Rural Health (SORH), State Rural Health Associations (SRHAs)

Centers for Medicare and Medicaid Services (CMS) Centers for Disease Control and Prevention (CDC) (e.g., CDC-RFA-DP21-2109 -

Community Health Workers for COVID Response and Resilient Communities; CDC-RFA-OT21-2103 - National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities; CDC-RFA- TP22-2201 - Public Health Crisis Response Cooperative Agreement)

Governmental organizations focused on non-health services (e.g., Coordinating Council on Access and Mobility – Department of Transportation, Supportive housing for the elderly – Housing and Urban Development; Community Development Financial Institutions Fund-Department of the Treasury)

Local governmental agencies and community leaders (e.g., libraries, pools, parks) Local businesses and business community networks and organizations, (e.g., employers, local chambers of commerce, small business community groups or associations)

Labor Unions and other employee organizations Community-based and civic organizations (e.g., community gardens, literacy organizations) Academic institutions, and universities (e.g., Historically Black Colleges and

Universities (HBCUs), Hispanic Association of Colleges and Universities (HACUs), American Indian Higher Education Consortium (AIHEC), Tribal Colleges and Universities (TCUs)

Faith-based organizations Public and private non-governmental organizations (e.g., Boys and Girls Club) Correctional facilities and institutions

The recipient should strive to integrate innovative or best practices for establishing, expanding, and coordinating, diverse and inclusive multisectoral and community partnerships.

Applicants are required to collaborate with state and local healthcare providers, hospitals, and related health systems as appropriate to ensure that activities and plans are coordinated and synergistic.

The applicant is required to submit a letter of support that describes how they will collaborate with relevant the health care providers, i.e. Federal Qualified Health Centers, hospitals, insurance plans, Medicaid, Medicare). The letter (s) must be signed by the applicant and the related partner's organizational leader. Applicants must name the file “Healthcare Sector_Letter_of_Support” and upload it to www.grants.gov.

The applicant is required to submit at least four letters of support from Leadership Team members detailing their commitment to the development of the SDOH Accelerator Plan.

The applicant will name the file "Leadership_Team_Letters_of_Support" and upload it to www.grants.gov.

If the applicant is NOT a health department, the applicant is required to submit a letter of participation from the community’s jurisdictional health authority outlining their specific http://www.grants.gov/ role in the development of the SDOH accelerator plan and their relationship to the “Community Health Needs Assessment (CHA)”. The applicant will name the file “Health_Authority_Letter_of_Participation” and upload it to www.grants.gov.

The recipient will be responsible for managing and facilitating Leadership Team activities, including convening the Leadership Team in person or virtually.

The recipient and the Leadership Team are required to attend three virtual CDC technical assistance convenings: 1) Kickoff meeting, 2) Mid-year progress meeting, and 3) Closeout meeting to share lessons learned and discuss Accelerator Plan Implementation and sustainability strategies. In addition, recipients may be required to participate in other technical assistance calls and or meetings to support their planning throughout the period of performance

4. Select SDOH priority areas

The applicant is required to select a minimum of two (2) SDOH priority areas that reduce health disparities and inequities and improve health outcomes related to chronic disease.

Listed below are the SDOH priority areas. The applicant will plan strategies and activities for the selected SDOH priority areas.

SDOH Priority Areas Impact

Strategy and Activity Examples to Include in the SDOH Accelerator Plan

Built Environment

A healthy built environment facilitates access to transportation and physical resources that enhance quality of life, minimizes exposures to environmental contaminants, and supports physical activity, safe and accessible recreation, and other protective factor that improve chronic disease outcomes.

Collaborate with key partners and allies to create and promote activity-friendly, safe routes to everyday destinations (e.g., from home, schools, or work to parks, public spaces, and transit stops).

Develop systems to provide reliable and affordable transportation for essential worker and disadvantaged populations.

Community- Clinical Linkages

Effective community-clinical linkages improve chronic disease outcomes by increasing access to and utilization of preventive services in local communities.

Provide assistance with disease management (e.g., medication access and education, referrals, keeping people in care, information on when to go to the emergency department, home blood http://www.grants.gov pressure monitoring for pregnant and postpartum persons, Community Health Worker (CHW) programs).

Strengthen access to preventive services such as cancer, diabetes, hypertension screening, obesity screening, and screening related to SDOH; access to oral health services; access to behavioral health and substance use services.

Promote clinical Fruit & Vegetable and Physical Activity Rx programs

Strengthen community-clinical collaborations for achieving healthy weight.

Implement clinical linkages to nutrition assistance programs (e.g., Supplemental Nutrition Assistance Program [SNAP]; Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]; and Child and Adult Care Food Program [CACFP]), affordable housing, free tax assistance, and safe transportation programs.

Food and Nutrition Security

Enhancing durable access to and routine consumption of adequate, nutritious food supports overall health, reduces morbidity and mortality associated with chronic disease, and decreases health care utilization.

Work with community coalitions, food policy councils, and community sites to equitably increase durable access to quality fruits and vegetables (e.g., through retail outlets, farmers markets, food banks, health care systems, traditional foods distribution networks).

Increase acceptance of food assistance and nutrition incentive vouchers in communities that lack equitable access to healthy food.

Implement healthy food service guidelines at institutions such as worksites, early care and education centers, hospitals, and faith-based organizations.

Implement nutrition guidelines and environmental supports for food banks and pantries that account for the cultural preferences of people in the community.

Social Connectedness

Social connectedness is a significant determinant of mental, emotional, and physical health and serves as a key factor in protecting, improving, and maintaining individual and community well-being. A high degree of social connectedness can increase the likelihood of individuals engaging in positive health behaviors, ultimately improving chronic disease outcomes by moderating the negative health effects of psychological adversities such as stress, trauma, adversity, anxiety, and depression.

Collaborate with key partners and allies to identify community led social activities and support services that encourage personal interaction, connectedness to community, and a sense of identity and belonging.

Implement new or improved community strategies that emphasize and integrate social support services and activities for older adults and other populations (e.g., individuals with disabilities) at higher risk for social isolation, loneliness, anxiety, and depression (e.g., congregate and homebound meal programs, home health visits, mental health outreach, or other programs).

Promote participation in low cost or free volunteer programs, walking groups, book clubs, and other community activities that support safe and healthy social activity.

Tobacco-Free Policies*

Commercial tobacco-free policies reduce tobacco initiation and use, promote commercial tobacco cessation, and protect people from exposure to commercial tobacco products and secondhand smoke, protecting all populations.

Implement commercial tobacco-free policies within worksites and multi-unit housing.

Implement health care system screening for commercial tobacco use, quit advice, and providing comprehensive resources for counseling and medications.

Implement community-based culturally appropriate messages that focus on: harmful effects of tobacco use; exposure to secondhand smoke;

encouraging individuals who use commercial tobacco to quit; promoting the Quitline.

Decrease exposure to commercial tobacco marketing and access to commercial tobacco products, including e-cigarettes and other emerging commercial tobacco products.

*When CDC references tobacco, the reference is for commercial tobacco and not the sacred and traditional use of tobacco by some American Indian communities

Strategy 2: Develop an Implementation-Ready SDOH Accelerator Plan In collaboration with the Leadership Team, the recipient will develop an implementation ready SDOH Accelerator Plan. The recipient is encouraged to collaborate with subject matter experts to assist with the development of the SDOH Accelerator Plan; template will be provided by CDC. The SDOH Accelerator Plan is due 30 days prior to the end of the Period of Performance.

1. Create the SDOH Accelerator Plan The recipient is required to include the following components in the SDOH Accelerator Plan.

Background o Community Background

Describe and define the tribe, community, or catchment area that the SDOH Accelerator Plan will address. Include any relevant background or historical information that contributes to current health and social community context.

o Community Health Issues Identify primary health issues in the community and describe how the recipient used data to determine primary health issues in the community including information about the Community Health Needs Assessment (CHA) if relevant.

o Selected population(s) Describe the population(s) selected and the process by which this population was identified. Include description of data used to identify selected population(s) (e.g., demographic, geographic, political boundaries, size of population).

Partnerships o Leadership Team

Describe the Leadership Team, including the organizational affiliation of each team member, the community and/or population that each member represents, and the role they will serve in developing and reviewing the SDOH Accelerator Plan.

o Multisectoral Partners Describe multisectoral partner roles, responsibilities, and goals.

Identify potential missing partners that may contribute to improving

SDOH.

Describe method used to engage diverse and inclusive new and existing partners in program planning and implementation efforts.

Describe new partner linkages and how duplication of services across partners was minimized or avoided.

o Shared Mission and Goal Statement The Leadership Team will articulate a shared mission statement that represents the purpose of the SDOH Accelerator Plan, with mutually agreed upon goals.

Programs and Resources for SDOH o Existing Resources and Programs

Describe the existing resources and programs available for the selected population(s). If multisectoral intake and referral systems exist, include a description of how the various programs currently work together.

Approach o SDOH Priority areas Describe the selected SDOH priority areas (a minimum of two (2)) and provide justification for selecting the priority areas.

o Outcomes Describe the short-, intermediate, and long-term outcomes that will result from the planned SDOH strategies and activities.

o Activities Describe the process for identifying and tailoring approaches to the selected tribe, community, or catchment area.

Describe the activities required to improve SDOH for the selected population(s).

Describe the number and types of evidence-based practices identified and tailored to improve SDOH for the selected population(s).

Describe the types of community and systemic barriers encountered and addressed during the plan development process.

Describe how policy, systems, environmental, programmatic and infrastructure activities build on each other to sustain health improvements and the achievement of selected outcomes.

o Anticipated reach of the activities Describe the potential reach of the activities for the selected population(s).

o Anticipated policy, systems, environmental, programmatic and infrastructure outcomes Describe sustainable outcomes that will result from implementation of the SDOH

Accelerator Plan strategies and activities.

Evaluation of the SDOH Accelerator Plan Strategies o Describe how the SDOH Accelerator Plan strategies and outcomes will be measured, with particular focus on the social and public health impact on the selected population(s).

o Describe the evaluation purpose, goals, evaluation questions, data collection and methods.

o Data Integration o Describe existing data sources across partners.

o Describe process for monitoring and integrating data elements to create a comprehensive system for tracking selected population(s) resource utilization.

o Responsible Party o Describe how each partner will participate in the planning, implementation, and reporting process.

o Implementation Plan o Provide a budget for implementing the strategies and activities.

o Provide a work plan with a timeline to complete proposed strategies and activities.

o Sustainability/Funding Strategy o Describe strategies to expand, diversify, and sustain implementation efforts, including funding.

2. Success Story

Complete a success story at the end of the planning process on establishing, expanding, and coordinating multisector partners. The success story is required to include the following components.

o Title.

o Problem/Issue.

o Approach.

o Achievements and Impact.

o Challenges.

o Lessons Learned.

o Future Direction.

Recipients can use CDC’s National Center for Chronic Disease Prevention and Health Promotion’s (NCCDPHP) Success Stories application to create the success story. This free tool provides step-by-step instructions to create a professionally designed 1-page success story

1. Collaborations

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

To ensure that applicants proposed SDOH Accelerator Planning activities are not duplicative of current ongoing CDC programs; in the event CDC funded state and/or local programs exist, applicants are required to submit at least one letter of support that describes how they will collaborate with CDC-funded chronic disease prevention program(s) as appropriate. The letter(s) must be signed by the applicant and the program director of the CDC-funded program.

Applicants must name the file "CDC_Letter_of_Support" and upload to www.grants.gov.

https://www.cdc.gov/chronicdisease/programs-impact/success-stories/index.htm

CDC-funded chronic disease and health promotion programs include the following.

Arthritis Cancer Prevention and Control Diabetes Good Health and Wellness in Indian Country Heart Disease and Stroke Prevention Nutrition, Physical Activity, and Obesity Oral Health Racial and Ethnic Approaches to Community Health (REACH) Reproductive Health School Health.

National Tobacco Control Program.

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b. With organizations not funded by CDC:

Recipients are required to strengthen existing partnerships, identify, and develop new partnerships, and collaborate with key partners who have existing community or social service delivery programs for population groups experiencing health disparities and inequities. Key partners may include:

Community health centers (e.g., federally qualified health centers, (FQHCs), Rural Health Clinics (RHCs))

Community-based and civic organizations (e.g., community gardens, literacy organizations)

Tribes, tribal or native serving organizations and health systems, urban Indian organizations

Academic institutions, and universities (e.g., Historically Black Colleges and Universities (HBCUs), Hispanic Association of Colleges and Universities (HACUs), American Indian Higher Education Consortium (AIHEC), Tribal Colleges and Universities (TCUs)

Asian American, Native Hawaiian, and Pacific Islander Serving Institutions (AAPI) Faith-based organizations Public and private non-governmental organizations (e.g., Area Agencies on Aging, Boys and Girls Club) Correctional facilities and institutions Local governmental agencies and community leaders (e.g., libraries, pools, parks) Local businesses and business community networks and organizations, (e.g., employers, local chambers of commerce, small business community groups or associations) Labor Unions and other employee organizations Social services providers and organizations, including those that address social determinants of health (e.g., community transportation; anti-discrimination organizations legal services; service providers for persons with disabilities)

Health care providers and related professionals (e.g., physicians, nurses, community health workers, pharmacists) https://www.cdc.gov/arthritis/ https://www.cdc.gov/cancer/index.htm https://www.cdc.gov/diabetes/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdiabetes%2Fhome%2Findex.html https://www.cdc.gov/healthytribes/ghwic.htm https://www.cdc.gov/dhdsp/ https://www.cdc.gov/nccdphp/dnpao/ https://www.cdc.gov/oralhealthdata/ https://www.cdc.gov/nccdphp/dnpao/state-local-programs/reach/index.htm https://www.cdc.gov/reproductivehealth/index.html https://www.cdc.gov/healthyschools/ https://www.cdc.gov/tobacco/ https://www.cdc.gov/tobacco/about/foa/national-networks-nofo/coop-agreement/index.html

Health-related organizations, (e.g., pharmacies, testing centers) State Offices of Rural Health (SORH) or equivalent, State Rural Health Associations

(SRHAs) Healthcare facilities (e.g., Critical Access Hospitals (CAHs), children’s hospitals, urgent care clinics) Governmental organizations focused on non-health services (e.g., Coordinating Council on Access and Mobility – Department of Transportation, Supportive housing for the elderly – Housing and Urban Development; Community Development Financial Institutions Fund - Department of the Treasury)

Community and Economic Development organizations Through this collaborative approach, recipients will be better able to maximize the impact of current sources of federal funding, strengthen any future implementation of strategies and activities outlined in the SDOH Accelerator Plan, align resources, and strengthen their capacity to improve chronic disease health outcomes among populations who are at higher risk and are underserved. The applicant is required to describe how strategic partnerships will contribute to the development of the SDOH Accelerator Plan.

2. Target Populations This NOFO addresses the public health needs of populations that are affected by disparities related to chronic disease and related risk factors which, depending on the needs and priorities of the applicant, may include Black/African American, Hispanic/Latino, and American Indian and Alaska Native people, Asian and Asian-Americans and Native Hawaiian and Pacific Islanders, and other people of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people; people with disabilities; people who live in rural communities;

people over the age of 65, and people otherwise adversely affected by persistent poverty or inequality.

Applicants should clearly describe the identified community, population(s), and social determinant(s) of health to be addressed in the SDOH Accelerator Plan. Describe the health disparities and inequities of the identified population and how the strategies and activities proposed in the plan can benefit the identified population(s) within that community.

a. Health Disparities CDC recognizes that social and economic opportunities, health behavior, and the physical environment in which people live greatly impact health outcomes. Health disparities represent preventable differences in the burden of disease, disability, injury or violence, or in opportunities to achieve optimal health. Applicants must describe the population(s) selected, including relevant health disparities, and how the SDOH Accelerator Plan will improve health and reduce or eliminate one or more identified chronic disease health disparities. This is an opportunity to demonstrate how increased awareness of available community services, navigation assistance to access services, and partner alignment to ensure that available services support tribal, community, or catchment area needs can positively impact chronic disease health outcomes.

iv. Funding Strategy N/A

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy

Evaluation and performance measurement help demonstrate program accomplishments and strengthen the evidence for strategy implementation. CDC will collaborate with recipients individually and collectively to monitor implementation of recipient strategies and activities and assess progress in achieving NOFO outcomes during the period of performance. CDC will seek to answer the following evaluation questions:

To what extent was the recipient successful in convening and coordinating the Leadership Team?

To what extent was the recipient successful submitting an implementation ready SDOH Accelerator Plan?

What obstacles and/or challenges did recipients encounter in building and collaborating with their leadership team and in developing their Accelerator Plan?

Performance measures developed for this NOFO correspond to the high-level broad strategy categories and outcomes described in the logic model.

CDC will monitor performance and respond to broader technical assistance needs and report to partners and allies.

Outcome Required Performance Measures

Increased collaboration and engagement across multisectoral partners

Number of partner organizations Range of partner organization types Number of meetings and partner attendance Completed success story on establishing, expanding, and coordinating multisector partners

Completed implementation ready SDOH Accelerator Plan including all required components

Number of activities and outcomes included in SDOH Accelerator Plans

Completed SDOH Accelerator Plan, including all required components

This NOFO does not involve the generation or collection of public health data, therefore a Data Management Plan is NOT required.

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

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

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

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

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

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

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

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

Describe key evaluation questions to be addressed by these evaluations.

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

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

Due to the nature of this grant, applicants are NOT required to provide an overall Evaluation and Performance Measurement Plan or a Data Management Plan with their application and should disregard the standard template language noted under section ii. Applicant Evaluation and Performance Measurement Plan (above).

Applicants are required to include evaluation plans for the Accelerator plan strategies that will be included in their final Accelerator Plan deliverable, as described in the strategies and activities section of this NOFO.

In their project narrative and work plan, applicants will need to describe an approach to ensure:

Strategies and activities are implemented as planned.

Strategy and activity progress is occurring.

Performance measures data are collected.

Recipients will be strongly encouraged to use evaluation and performance measurement data to monitor, evaluate, and continuously improve program performance. Recipients will be required to report CDC defined performance measures data at the end of the period of performance.

c. Organizational Capacity of Recipients to Implement the Approach Applicants need to demonstrate the capacity to complete all activities proposed. Organizational capacity demonstrates the applicant's ability to successfully execute the funding opportunity https://www.cdc.gov/grants/additional-requirements/ar-25.html strategies and meet project outcomes. Applicant should provide a staffing plan, including an organizational chart, CVs/resumes, position descriptions and project management structure that will be sufficient to meet the goals of the proposed project. Applicants must name the files "Organizational_Chart," "Resumes," "Position_Descriptions," and "Project_Management_Structure" and upload them to www.grants.gov.

To ensure that recipients have the capacity to execute CDC program requirements and meet period of performance outcomes, applicants must describe the following:

Experience engaging communities in public health planning and implementation processes addressing SDOH that improve outcomes for chronic disease, including current activities.

Readiness and ability to convene leadership team and develop SDOH Accelerator Plan at the time of award.

Experience developing and maintaining multisectoral partnerships.

Experience using data to identify populations and tribes, communities, or catchment areas most affected by chronic diseases and SDOH.

Experience implementing strategies and activities in collaboration with multisectoral partners to reduce health disparities and improve health equity.

Experience with budget management and administration capacity to establish financial procedures and track, monitor, and report expenditures.

Ability to virtually attend CDC-sponsored trainings, meetings and events and other training opportunities recommended by CDC.

Applicants are required to include the following collaboration documentation:

The applicant is required to submit a letter of support that describes how they will collaborate with relevant the health care providers i.e. Federal Qualified Health Centers, hospitals, insurance plans, Medicaid, Medicare). The letter (s) must be signed by the applicant and the related partners organizational leader. Applicants must name the file “Healthcare Sector_Letter_of_Support” and upload it to www.grants.gov

The applicant is required to submit at least four letters of support from Leadership Team members detailing their commitment to the development of the SDOH Accelerator Plan.

The applicant will name the file "Leadership_Team_Letters_of_Support" and upload it to www.grants.gov.

If the applicant is NOT a health department, the applicant is required to submit a letter of participation from the community’s jurisdictional health authority outlining their specific role in the development of the SDOH accelerator plan. The applicant will name the file “Health_Authority_Letter_of_Participation” and upload it to www.grants.gov.

Applicants are required to submit at least one letter of support that describes how they will collaborate with CDC-funded state and/or local chronic disease prevention program(s) as appropriate. The letter(s) must be signed by the applicant and the program director of the CDC-funded program. Applicants must name the file "CDC_Letter_of_Support" and upload it to www.grants.gov.

d. Work Plan http://www.grants.gov http://www.grants.gov http://www.grants.gov/

Applicants must provide a detailed work plan for one year. Applicants must name the file “Work_Plan” and upload to www.grants.gov. A work plan example is provided below.

The work plan should include the following components:

Period of Performance Outcome Strategies and Activities Performance Measure Responsible Party Completion Date

Period of Performance Outcome:

[from Outcomes section and/or logic model]

Outcome Measure:

[from Evaluation and Performance Measurement section]

Strategies and Activities

Process Measure [from Evaluation and Performance Measurement section]

Responsible Position / Party

Completion Date

1.

2.

3.

4.

5.

e. CDC Monitoring and Accountability Approach Monitoring activities include routine and ongoing communication between CDC and recipients, site visits, and recipient reporting (including work plans, performance, and financial reporting).

Consistent with applicable grants regulations and policies, CDC expects the following to be included in post-award monitoring for grants and cooperative agreements:

Tracking recipient progress in achieving the desired outcomes.

Ensuring the adequacy of recipient systems that underlie and generate data reports.

Creating an environment that fosters integrity in program performance and results.

Monitoring may also include the following activities deemed necessary to monitor the…