Foa_Content_of_CDC-RFA-EH-24-0016.pdf

Agency for Toxic Substances and Disease Registry (ATSDR)

Notice of Funding Opportunity

Application due April 19, 2024

Advancing Health Equity in Asthma Control through EXHALE Strategies Opportunity number: CDC-RFA-EH-24-0016

Contents Before you begin 3

Step 1: Review the Opportunity 4

Basic information 5

Eligibility 8

Program description 10

Step 2: Get Ready to Apply 38

Get registered 39

Step 3: Prepare Your Application 41

Application contents and format 42

Step 4: Learn About Review and Award 50

Application review 51

Award notices 57

Step 5: Submit Your Application 58

Application submission and deadlines 59

Application checklist 61

Step 6: Learn What Happens After Award 62

Post-award requirements and administration 63

Contacts and Support 69

Endnotes 72

Contents 2

Before you begin If you believe you are a good candidate for this funding opportunity, secure your SAM.gov and Grants.gov registrations now. If you are already registered, make sure your registration is active and up-to-date.

SAM.gov registration (this can take several weeks) You must have an active account with SAM.gov. This includes having a Unique Entity Identifier (UEI).

See Step 2: Get Ready to Apply

Grants.gov registration (this can take several days) You must have an active Grants.gov registration. Doing so requires a Login.gov registration as well.

See Step 2: Get Ready to Apply

Apply by April 19, 2024 Applications are due by 11:59 p.m. Eastern Time on April 19, 2024.

Before you begin 3 https://sam.gov/ https://grants.gov/

Jump to a step

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1:

Review the Opportunity

In this step

Basic information 5

Eligibility 8

Program description 10

Basic information Centers for Disease Control and Prevention (CDC)

National Center for Environmental Health (NCEH)

Agency for Toxic Substances and Disease Registry (ATSDR)

Improve health outcomes for people with asthma through increased community partnerships and multi-component approaches to care.

Have questions?

See Contacts and support.

Key facts

Opportunity name:

Advancing Health Equity in Asthma Control through EXHALE Strategies

Opportunity number:

CDC-RFA-EH-24-0016

Federal Assistance Listing:

93.070: Environmental Public Health and Emergency Response

Key dates

Application deadline:

April 19, 2024, at 11:59 p.m. ET

Optional letter of intent deadline:

March 19, 2024

Informational call:

March 8, 2024, 2:00 p.m. ET

Expected award date:

August 1, 2024

Expected start date:

September 1, 2024

Summary Our purpose is to improve the health and quality of life for people living with asthma. Given evidence that a multi-component approach to controlling asthma is more effective than individual strategies applied in isolation[1], this funding opportunity is based on a technical package known as EXHALE.

EXHALE represents six evidence-based strategies selected for their potential of having the greatest collective impact on controlling asthma:

• Education on asthma self-management

• “X-tinguishing,” smoking and exposure to secondhand smoke

• Home visits for trigger reduction and asthma self-management education

• Achievement of guidelines-based medical management

• Linkages and coordination of care

• Environmental policies or best practices to reduce indoor and outdoor asthma triggers

We aim to address systems-level, environmental, and social drivers of disparities through strengthening strategic partnerships to help implement EXHALE strategies.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 5 https://www.cdc.gov/asthma/pdfs/exhale_technical_package-508.pdf

If you receive funding, we will expect you to:

• Strengthen existing organizational infrastructure in areas such as leadership, program management, strategic partnerships, surveillance, communication, and evaluation.

• Collaborate with diverse partners like coalitions, community and faith-based organizations, racial, ethnic, and minority organizations, tribal communities, schools, transportation systems, housing, healthcare systems, and nongovernmental organizations.

• Implement EXHALE strategies, working with community members to expand the reach and sustainability of asthma control services.

Funding details Type: Cooperative agreement

We plan to award projects for four 12-month budget periods for a 4-year period of performance.

Expected total program funding over the 4-year performance period:

$64,000,000

Expected total program funding per budget period: $16,000,000

Expected awards: 28

Funding range per applicant per budget period: $400,000 to $725,000

Expected average award amount per budget period: $500,000

CDC will approve no more than one award within each state, territory, or Tribal nation.

The number of awards is subject to available funds and program priorities.

Step 1: Review the Opportunity 6

Funding strategy

Population Funding level

100,000 to 299,999 $400,000

300,000 to 599,999 $450,000

600,000 to 999,999 $475,000

1,000,000 to 2,999,999 $500,000

3,000,000 to 4,999,999 $550,000

5,000,000 to 6,999,999 $600,000

7,000,000 to 8,999,999 $625,000

9,000,000 to 11,999,999 $650,000

12,000,000 to 14,999,999 $675,000

15,000,000 to 19,999,999 $700,000

20,000,000 and over $725,000

To help you find what you need, this NOFO uses internal links. In Adobe Reader, you can go back to where you were by pressing Alt + Left Arrow on your keyboard.

Step 1: Review the Opportunity 7

Eligibility Who can apply Open competition.

Eligible applicants Only these types or organizations may apply:

• State governments

• County governments

• City or township governments

• Special district governments

• Independent school districts

• Public and state-controlled institutions of higher education

• Native American tribal governments (Federally recognized)

• Public housing authorities and Indian housing authorities

• Native American tribal organizations, other than federally recognized tribal governments

• Nonprofits having a 501(c)(3) status, other than institutions of higher education

• Nonprofits without 501(c)(3) status, other than institutions of higher education

• Private institutions of higher education

Other required qualifying factors To be eligible, you should:

• Serve a population of at least 100,000 people.

• Regularly analyze asthma data sets for your jurisdiction, including the following data sets: Behavioral Risk Factor Surveillance System (BRFSS) Core, BRFSS Random Child Selection and Childhood Asthma Prevalence modules, state-specific children’s health survey, or National Survey of Children’s Health, Vital Statistics, Hospitalization and Emergency Department Visits.

Step 1: Review the Opportunity 8

• Work with partners for asthma control, as specified in your letters of collaboration.

You must provide documentation to support this eligibility criteria. See Attachments.

Cost sharing and matching funds This program has no cost-sharing requirement or matching funds requirement. If you choose to include cost-sharing funds as a contribution to the award, we won’t consider it during review of your application.

Step 1: Review the Opportunity 9

Program description Background Overview Asthma is a complex, highly prevalent chronic disease. It is consistently one of the top five most costly health conditions. According to 2021 asthma prevalence estimates, almost 25 million Americans have asthma, including about 4.7 million children and 20.3 million adults.

The facts

• 986,453 emergency department visits in 2020

• 94,560 hospitalizations in 2020

• 13.8 million missed school days in 2013

• 14.2 million missed workdays in 2018[2]

• In 2013, the estimated cost to the U.S. economy was $81.9 billion in medical expenses, missed school and workdays, and deaths.

• Despite available drugs and approaches to treat and control asthma, in the United States on average 10 people die of asthma each day.[3]

Health disparities There are significant disparities in asthma outcomes by race, ethnicity, and income level. In the U.S., the burden of asthma falls disproportionately on non-Hispanic African American, Hispanic, and American Indian and Alaska Native populations. Disparities persist in asthma prevalence and outcomes in the United States.[4]

• Non-Hispanic African American people are nearly three times as likely to die from asthma than white individuals.

• People from Puerto Rico have higher asthma prevalence compared to other people in the United States.[5]

The strategies in EXHALE:

• Are based on the best available evidence.

• Can improve asthma control and reduce healthcare costs.

• Help to inform decision-making in communities, organizations, and states.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 10 https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf

Related work

• This opportunity builds upon work of state, local, and territorial public health departments and non-governmental partners supported with previous CDC funding from CDC-RFA-EH19-1902 and CDC-RFA-

EH20-2002.

• CDC National Asthma Control Program (NACP) has funded state, local and territorial public health departments to encourage a comprehensive public health approach to asthma control. The program also funds non-governmental organizations, including efforts to encourage adherence to National Asthma Education and Prevention Program (NAEPP), Expert Panel Report-3 (EPR-3) guidelines.

• CDC’s Office on Smoking and Health (OSH) funds the National and State Tobacco Control Program to encourage coordinated, national efforts to reduce tobacco-related diseases and deaths.

• This work is framed around the four CDC CORE pillars: cultivating health equity science, optimizing interventions, reinforcing and expanding robust partnerships, and enhancing capacity and workforce engagement.

Health equity is the state in which everyone has 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.

Purpose This funding supports progress toward:

• reducing asthma-related emergency department visits, hospitalizations, mortality, and disparities

• implementing EXHALE strategies for populations with high asthma prevalence

• improving organizational infrastructure to advance health equity and sustainability

You are expected to implement a subset of EXHALE strategies in home, schools, healthcare, or community settings and in a coordinated manner to reach focus populations.

This funding opportunity advances health equity by prioritizing environmental justice and social determinants of health in the planning, implementation, evaluation, and expansion of the EXHALE technical package among communities with high prevalence of asthma.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 11 https://www.cdc.gov/asthma/nacp.htm https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma https://www.cdc.gov/tobacco/stateandcommunity/tobacco-control/index.htm https://www.cdc.gov/tobacco/stateandcommunity/tobacco-control/index.htm https://www.cdc.gov/healthequity/core/index.html https://www.cdc.gov/healthequity/index.html https://www.cdc.gov/healthequity/index.html

You will collaborate with diverse partners, such as coalitions, government agencies and departments, schools, healthcare systems, housing organizations, transportation organizations, community and faith-based organizations, racial, ethnic, and minority organizations, and tribal communities to coordinate the implementation of selected interventions under EXHALE. The approach will address health equity by prioritizing the identified drivers of inequity within the setting or settings you have chosen (homes, schools, healthcare, or community).

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.

Approach Overview The following logic model includes the strategies and activities allowed under this NOFO. It also includes the program’s expected outcomes. The asterisked outcomes are what we expect you to achieve during the four-year period of performance.

Outcomes are the results that you intend to achieve and usually show the intended direction of change, such as increase or decrease. Not all outcomes apply to all strategies. The table shows how they apply. You will use these outcomes as a guide for developing performance measures (PMs) as described later in this document.

Program logic model The logic model shows the strategies and activities of the program along with the outcomes we expect over time. We will require you to report on the asterisked (*) outcomes as follows.

Step 1: Review the Opportunity 12

Strategies and Activities Short-term Outcomes

Intermediate Outcomes

Long-Term Outcomes

Strategy 1. Implement EXHALE strategies for populations with high asthma burden.

• Implement four EXHALE strategies in collaboration with multisectoral partners.

• Focus your EXHALE implementation in at least one of four settings–schools, healthcare, homes, or communities.

Strategy 2. Improve organizational infrastructure to advance health equity and sustainability.

• Update strategic plan for asthma control to include approaches to address health equity and sustainability.

• Advance health equity partnerships with community organizations, community health workers, and multi-sector agencies.

• Leverage evaluation findings to support health equity and sustainability.

• Maintain and enhance asthma surveillance system to enable monitoring and use of data to guide strategic action.

• Increased implementation of selected

EXHALE

strategies in identified settings.* (Strategy 1)

• Increased linkages to community resources to address drivers of health inequity.* (Strategies 1 and 2)

• Increased use of surveillance and evaluation data to drive program improvement.* (Strategy 2)

• Enhanced partnerships, including demonstrated expansion of at least one new strategic partnership representing a focus population.* (Strategy 2)

• Increased access to

EXHALE

interventions for people with uncontrolled asthma.* (Strategy 1 and 2)

• Reduced impact on the identified driver of health inequity for asthma control among populations with highest risk.* (Strategy 1 and 2)

• Increased coordination of care across settings. (Strategy 1)

• Reduced exposure to environmental asthma triggers.

(Strategy 1)

• Improved sustainability of results-based health equity partnerships.

(Strategy 2)

• Increased policies and plans enacted and evaluated to address drivers of asthma control.

• Reduced asthma-related emergency department visits and hospitalizations.

• Reduced asthma-related mortality and disparities.

*Indicates outcomes you are required to report on.

Step 1: Review the Opportunity 13

Strategies and activities This section elaborates on the strategies and activities described in the logic model and provides details on our expectations of you to implement the

NOFO.

During the period of performance, you will conduct activities under two main strategies for asthma control:

• Strategy 1: Implement EXHALE strategies for populations with high asthma burden.

• Strategy 2: Improve organizational infrastructure to advance greater health equity and sustainability.

Under each strategy, tailor the proposed interventions to the populations at highest risk, as defined by your jurisdiction’s surveillance data. When possible, these approaches should:

• Meet people where they are: where they live, learn, work, play, worship, and receive services

• Have materials that are clear, easy to understand, and culturally appropriate, including language and messaging that can reach and resonate with the focus population

When possible, include partners that have experience with the focus populations and have an established record of trust and collaboration. These partners should be included as you develop and finalize messaging and interventions. Consider health equity in all areas of your proposal.

Strategy 1: Implement EXHALE strategies for populations with high asthma burden.

Activity 1.1: Work on at least four EXHALE strategies

We require the following two:

• Linkages and coordination of care across settings

• Environmental policies or best practices to reduce asthma triggers from indoor, outdoor, and occupational sources

Then, choose two or more from:

• Education on asthma self-management

• X-tinguishing smoking and secondhand smoke

• Home visits for trigger reduction and asthma self-management education

• Achievement of guidelines-based medical management

Step 1: Review the Opportunity 14

See the technical guidance related to these EXHALE strategies.

You may implement activities in one or more of four settings: schools, healthcare, homes, and communities. See a short description of each in focus populations.

Use required and additional data sets to identify and describe your population of focus for the setting. See Activity 2.4 for more information.

We expect you to propose and define a set of activities under your required and selected EXHALE strategies in one or more settings.

In your project narrative strategies and activities section, explain:

• Which EXHALE strategies you plan to use.

• The setting or settings in which you will implement the EXHALE strategies.

• Your approach to implementing them.

Activity 1.2: Describe partner engagement and audiences

You will put these strategies into action with the help of partners. These partners must represent communities with disproportionate asthma burdens.

In your project narrative strategies and activities section, address the following:

• List your partners and describe each of their roles and responsibilities in supporting the proposed activities.

• Briefly describe audience and communications approaches. Describe who else might benefit from these activities.

You can include more information about communications in your project narrative’s organizational capacity section. See program description, organizational capacity for guidance.

Strategy 2: Improve organizational infrastructure to advance health equity and sustainability.

Activity 2.1: Develop or update your strategic plan

Within the first six months after your award, you must update your strategic plan for asthma control to include components for health equity and sustainability.

If you do not currently have a strategic plan for asthma control, you will develop a draft plan within the first six months of the performance period.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 15

You will complete your full plan, including elements for health equity and sustainability, within 12 months. Your plan should include:

• A description of problem across the entire geographic area

• A list of groups experiencing the highest asthma burden, a description of their unique needs, and methods for addressing these needs

• An assessment of the current availability of asthma control services

• A list of goals, objectives, or strategies to be accomplished and expected outcomes

• A list of activities to be implemented collaboratively between you and your partners

• A description of the roles of the recipient and lead partners

• A timeline for completion

In years two through four, you will provide progress updates related to your health equity and sustainability efforts for asthma control.

In your project narrative strategies and activities section, address the following:

• Health equity: Briefly describe your focus population, and address how your program’s EXHALE activities will increase the focus population’s inclusion in the process of refining and implementing the interventions.

You will provide more detail about your focus population in that section of your project narrative.

• Sustainability: Describe how you plan to increase the asthma program’s sustainability. You might consider topics such as:

◦ Organizational capacity

◦ Planning

◦ Communications

◦ Evaluation

◦ Partnerships

◦ Funding

These areas appear across several common tools that provide guidance on how to approach sustainability efforts, including the CDC Sustainability Planning Guide for Healthy Communities, the HHS Office of Population Affairs (OPA) Framework for Program Sustainability, the HUD Healthy Homes Program Guidance Manual (HHPGM), and the Program Sustainability Assessment Tool (PSAT).

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 16 https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/pdf/sustainability_guide.pdf https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/pdf/sustainability_guide.pdf https://opa.hhs.gov/sites/default/files/2021-02/framework-for-program-sustainability.pdf https://opa.hhs.gov/sites/default/files/2021-02/framework-for-program-sustainability.pdf https://www.hud.gov/program_offices/healthy_homes/HHPGM https://www.hud.gov/program_offices/healthy_homes/HHPGM https://www.sustaintool.org/psat/ https://www.sustaintool.org/psat/

You can reference these tools to learn more information about sustainability and determine which approaches may work within your jurisdiction.

Activity 2.2. Advance health equity partnerships with community organizations, community health workers, and multi-sector agencies.

We expect you to establish at least one strategic partnership for your focus population by the end of the performance period. This partner should have demonstrated success working with the focus population for at least two years.

In your project narrative strategies and activities section, describe the processes you and the partner will use to plan, implement, evaluate, and sustain strategies to expand the reach of asthma control services, particularly among the focus population.

Review health equity resources at:

• Health Equity Guiding Principles for Inclusive Communication | Gateway to Health Communication | CDC

• Health Equity: Resources | CDC Foundation

• Advancing Health Equity and Preventing Chronic Disease | DNPAO | CDC

Activity 2.3. Leverage evaluation findings to support health equity and sustainability.

Use data from evaluation results to drive improvements in program implementation, with a particular focus on health equity and sustainability. As examples, you might:

• Collaborate with stakeholders to conduct systematic, high-quality evaluations for effectiveness and efficiency of your EXHALE services and expansion of strategies. Include both process and outcome evaluations.

• Build evaluation capacity to plan, conduct, and use evidence to improve asthma programs, using strategies such as those noted in Learning and Growing through Evaluation: State Asthma Program Evaluation Guide.

Where possible, we encourage you to develop business cases based on information from economic evaluations of expanding EXHALE and supporting coverage of asthma services and medications.

In your project narrative, strategies and activities section, describe your general approach to this activity.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 17 https://www.cdc.gov/healthcommunication/Health_Equity.html https://www.cdc.gov/healthcommunication/Health_Equity.html https://www.cdcfoundation.org/HealthEquity/resources https://www.cdc.gov/nccdphp/dnpao/health-equity/health-equity-guide/index.htm https://www.cdc.gov/asthma/program_eval/guide.htm

Where you take on specific evaluation studies, in your project narrative, evaluation and performance management plan, you should:

• Describe the type of evaluations—process, outcome, or both

• Describe key evaluation questions you will address in these evaluations

• Describe other information, such as measures and data sources

• Describe the intended use for and users of the information generated

You can find more information in the Evaluation and Performance Measurement section.

Activity 2.4. Maintain and enhance your asthma surveillance system to enable monitoring and use of data to guide strategic action

In your project narrative, strategies and activities section, describe your approach to meeting the following expectations.

We expect you to:

Maintain and enhance your asthma surveillance data:

• Obtain, analyze, interpret, and report required core data sets and related measures annually for both children (under age 18 years) and adults (18 years and older).

◦ Core data sets: BRFSS Core, BRFSS Random Child Selection and Childhood Asthma Prevalence modules, State-specific children’s health survey/ National Survey of Children’s Health, Vital Statistics, Hospitalization and Emergency Department Visits.

◦ Core measures: Adult Lifetime Prevalence, Child Lifetime Prevalence, Adult Current Prevalence, Child Current Prevalence, Mortality Rates (underlying cause), Hospital Discharge Rates (1st-listed diagnosis) and Emergency Department Visits Rates (first-listed diagnosis)

• Describe asthma prevalence (lifetime and current), hospitalizations, Emergency Department visits, mortality, and trends in the entire population over time.

◦ Monitor and report these measures annually to CDC.

◦ Obtain, analyze, and interpret additional datasets and measures needed to support effective planning, implementation, and evaluation of asthma control programs conducted by you and your partners.

Step 1: Review the Opportunity 18

▪ Additional data sets: These data sets may include but are not limited to: Youth Tobacco Survey, Youth Risk Behavior Survey, Medicaid or Other Payer data, Workers’ Compensation Data, School Health (nurse reports / absenteeism), and Prescription Data.

▪ The source of these datasets and measures may be public health departments, community clinics, federally qualified health centers, state Medicaid offices, hospitals, schools, pharmacies, housing authorities, health plans, and related sources.

• Describe the burden of asthma in your entire state, territory, or tribe using population-based surveillance data.

• Identify specific sub-populations that are disproportionately affected by asthma compared with the general population. When determining these sub-populations, consider factors such as age, race, ethnicity, gender, economic status, education, disability status, and geographic area.

Monitor and use data to guide strategic action:

• Use surveillance data to identify sub-populations with a high asthma burden and guide program activities.

• Create maps, tables, or other tools that demonstrate the alignment of program activities and the asthma burden as indicated by surveillance data.

• Publish (using electronic or paper formats) and disseminate asthma-specific reports, fact sheets, maps, web tables, briefs, newsletters, or other materials that promote and support program activities. Report each required core measure in one of these published materials.

Outcomes The program logic model includes asterisked outcomes that we expect you to report progress on and achieve within the period of performance. Combined, we expect these outcomes to contribute to overarching intentions to help prevent asthma-related emergency department visits and hospitalizations among focus populations (such as children) over time.

Focus populations Focus populations experience a disproportionate burden for asthma. These populations include but are not limited to:

Step 1: Review the Opportunity 19

• People who are African American, Hispanic/Latino (particularly Puerto Ricans), American Indian/Alaska Native, and those who identify as two or more races

• People experiencing low-income as defined by Federal Poverty Guidelines

• Children aged birth to 17

Describe your focus population, including the settings for your activities, in your project narrative’s focus populations section. See the following settings.

Settings In your project narrative, strategies and activities section, you must define the settings for your activities. In your focus population section, describe how the following settings serve your focus populations. For more information when considering settings, please visit the NACP website.

School settings

Activities in school settings must reach school-aged populations in geographic areas disproportionately burdened by asthma. Prioritize activities for school-aged children with uncontrolled asthma.

School settings can include activities both within the school settings and during out-of-school time. You should consider social determinants of health (SDOH) when determining how to implement activities. Asthma control services in schools might include helping schools:

• Provide (or make available) asthma self-management education (AS-ME).

• Assist students in using asthma medications and devices correctly

• Refer students to medical care or emergency care when needed

• Reduce exposures in the school environment that can trigger asthma symptoms.

Health equity-related activities and approaches in schools might include all of these examples here, provided that the efforts are focused on populations at higher risk:

• Expanding the adoption of AS-ME programs for populations at higher risk, including sustaining and scaling up programs.

• Increasing access to stock quick-relief asthma medicine, including identifying and training of appropriate staff to administer medicines.

• Reviewing inhaler technique at every care touchpoint for school-aged children.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 20 https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines https://www.cdc.gov/asthma/nacp.htm

Home settings

Evidence shows that the home environment is connected to many factors leading to the development and exacerbation of asthma, particularly in children[6]. Attempts to decrease asthma-related emergency department visits and hospitalizations ideally would include an assessment of the home environment, and a multi-component intervention to decrease possible exacerbations.

Home visits are one activity that can help persons with asthma reduce asthma triggers and expand their knowledge about asthma self-management education. These visits can help improve medication adherence and reduce asthma-related emergency department visits and hospitalizations.

Home visits should be flexible regarding potential barriers due to age range, language, home ownership status, and education level of the participants.

Multi-unit housing approaches should consider how to work collaboratively with tenants and landlords or management companies, particularly for when repairs may be needed.

Health equity-related activities and approaches in home settings might include:

• Scaling up home visit programs for populations of focus within the jurisdiction

• Referring persons enrolled in home visit programs to resources like cleaning services, mold removal, pest management, and legal or housing assistance

• Expanding collaborations between the private sector and landlords for home repairs to address asthma-related triggers in the home

• Increasing the adoption of smoke-free policies for multi-unit housing

Healthcare settings

Healthcare professionals can guide people with asthma and their communities to follow best practices and help improve asthma control by using relevant EXHALE strategies. Interventions and partnerships should have a direct connection to a population of focus that is experiencing a disproportionate burden of asthma. Consider how SDOH may impact how the population of focus interacts with the local or regional healthcare system for asthma care as you tailor your interventions.

Step 1: Review the Opportunity 21

You should partner with organizations that can advance quality of care for populations of focus. Example partners include federally qualified health centers (FQHCs), community health centers, Medicaid and managed care organizations (MCOs). For more information, please see the Collaborations section.

Health equity-related activities and approaches in healthcare settings might include activities for focus populations such as:

• Promote shared decision-making (SDM) among patients and their providers

• Promote opportunities related to smoking cessation

• Address reasons for why patients might not adhere to care recommendations

• Increase services and treatments that are consistent with National Asthma Education and Prevention Program (NAEPP), Expert Panel Report-3 (EPR-3) guidelines for diagnosis and management, including recognizing poorly controlled asthma.

• Promote linkages and coordination of care across settings

Community settings

This setting is defined as multi-sectoral interventions focused on a particular community. Compounding factors may affect asthma control. For example, a community may have aging housing stock, older schools and community facilities, or proximity to multiple environmental exposures. The community may also be underserved by healthcare organizations, public transportation, and other services.

Focus on communities that face the highest burden of asthma, as indicated by data from the required and additional data sets mentioned in this funding opportunity announcement, or other data sources available to you.

Health equity-related activities and approaches in community settings might involve:

• Including community voices, support, and participation throughout the intervention

• Developing provider-community relationships to support people with asthma and their families and care providers

• Include linkages to tobacco quit lines and policies for smokefree workplaces and community spaces

• Supporting and expanding programs for community health workers, nurses, social workers, and certified asthma educators, community

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 22 https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma paramedics, and others to conduct AS-ME training programs, home-based assessments, and other interventions

• Linking people with uncontrolled asthma to services and resources

• Increasing linkages between schools, healthcare organizations, private and public partnerships, and other community organizations and services

Equal opportunities 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.

Health disparities The goal of health equity is for everyone to have a fair and just opportunity to attain their highest level of health. Health disparities are often caused by social determinants that influence which populations are most disproportionately affected by health conditions.

A health disparity is a difference in health burdens between groups of people with differing social determinants of health.

Social determinants of health are conditions in the environments where people are born, live, learn, work, play, worship, and age. These determinants affect a wide range of health, functioning, and quality-of-life outcomes and risks.

Each setting under Strategy 1 has considerations for health equity when proposing activities.

Organizational capacity You must demonstrate capacity to meet the purpose of this opportunity by your organizational capacity in the following four categories (1.1, 1.2, 1.3, and 1.4) further described in the summary table.

Address all of the following in your project narrative, organizational capacity section.

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 23 https://www.cdc.gov/about/sdoh/index.html

1.1a: Leadership and management Describe the commitment of senior managers to ensure support for proper staffing (including supervision), guidance, contracting mechanisms and other resources specifically for the asthma program.

Document that you currently have a staff of highly qualified public health professionals with appropriate experience in asthma and expertise in leadership, supervision, program management, epidemiology, surveillance, evaluation, training, cultural competencies, and communications that is sufficient for implementing and expanding the proposed strategies and activities in this NOFO.

Clearly define the duties of each staff member.

In your attachments, include position descriptions and resumes indicating that each person has the qualifications, knowledge, training, and experience to perform assigned duties. Include organizational charts showing the location of the asthma program within the agency organizational structure.

You will submit resumes for filled positions or position descriptions for unfilled positions. See Attachments.

1.1b: Budget management and administration Describe the existing financial management system in place that allows proper funds management and segregation of funds by program and meets the requirements stated in the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards.

The financial system should permit the preparation of reports required by the general and program-specific terms and conditions and the tracing of funds to a level of expenditure adequate to establish that such funds have been used according to the federal statutes, regulations, and terms and conditions of the federal award.

Describe the current capacity to write, award, and manage contracts in accordance with applicable grants regulations.

1.1c: Communications Describe your organizational capacity for communications, including describing the audiences for your interventions, their needs for information, and communication channels. If funded, you are expected to develop a more

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 24 https://www.ecfr.gov/current/title-45/part-75 https://www.ecfr.gov/current/title-45/part-75 detailed communication plan within the first 6 months of the award, in collaboration with CDC. The plan will include elements such as:

• Identify and describe the audiences, with an emphasis on health equity.

• Describe their needs for information.

• Identify communications channels for them.

1.1d: Surveillance

• Maintain a robust, comprehensive asthma surveillance system with capacity for future expansion.

• Obtain, analyze, interpret, and report population-based emergency department and hospital discharge data for the entire state, territory, or tribe as well as local levels.

• Obtain datasets and analyze, interpret, and report hospital discharge rates, emergency department visits rates, mortality rates, adult lifetime and current prevalence, child lifetime and current prevalence.

• Obtain, analyze, interpret, and report data from the Behavioral Risk Factor Surveillance System (BRFSS) Core, BRFSS Random Child Selection and Childhood Asthma Prevalence modules, State-specific children’s health survey/ National Survey of Children’s Health, Vital Statistics, Hospitalization and Emergency Department Visits, Vital Statistics, and other data such as medical or pharmacy claims, school district reports, use of healthcare services, or costs of care.

• Use data to develop, produce, and disseminate communication and education materials in multiple media formats and languages.

• Provide certification that you have the responsibility to collect, analyze, and report on asthma control data for their jurisdiction.

1.1e: Epidemiology

• Obtain, analyze, interpret, and report aggregate data on participants in

EXHALE-related asthma interventions and their asthma-related outcomes.

• Develop, produce, and disseminate summary materials.

1.1f: Program evaluation

• Describe your commitment to promoting a culture of evaluation within your organization.

Step 1: Review the Opportunity 25

• Describe current capacity to collaborate and coordinate with partners to plan, develop, and implement evaluation plans, including economic evaluations.

• Describe current capacity to collect performance measures and use evaluation to improve effectiveness and efficiency of strategies and enhance overall programming.

• Describe current capacity and ability to build evaluation capacity among partners.

• Describe current capacity and willingness to collaborate with other recipients of this NOFO in planning and sharing lessons learned from evaluations.

1.2: Relevant experience

• Describe prior experience in implementing asthma control activities for the jurisdiction.

• Describe program capacity to implement evidence-based strategies.

1.3: Health equity and partnerships

• Describe the current capacity to address health equity and health disparities related to asthma control.

• Describe existing partners that currently have a significant role in implementing strategies.

• Specify how partners have been engaged and supported the applicant’s efforts.

1.4: Letters of collaboration

• In your attachments, provide at least three collaboration letters from partners who plan to participate in proposed activities. Specific examples of successful collaborations should be mentioned in two letters.

• A third letter can be from a new partner organization that explains how they intend to collaborate with you.

See Attachments.

Collaborations We expect you to identify and leverage opportunities with other public health programs with common interests and objectives related to asthma.

Step 1: Review the Opportunity 26

In your project narrative, collaborations section, explain the programs and organizations you plan to collaborate with, including their roles.

With other CDC programs and CDC-funded organizations We encourage you, where applicable and appropriate, to collaborate with CDC programs that are implementing evidence-based and practice-based prevention strategies that align within the Strategies and Activities section and note this in your application.

• Recipients of funding from the CDC National Asthma Control Program (NACP) are encouraged to collaborate with the non-governmental organizations funded by NACP to encourage provider adherence to national guidelines and encourage entities to provide home-based, multi-trigger, multi-component interventions for people whose asthma is poorly controlled. These organizations currently include the American Lung Association, the Allergy and Asthma Network, the Asthma and Allergy Foundation of America, and the National Environmental Education Foundation. If you are funded through CDC-RFA-EH-24-0016 you are also encouraged to collaborate with recipients of any future cooperative agreements awarded by the NACP.

• Recipients of funding from CDC’s National Center for Environmental Health, such as Environmental Public Health Tracking, Climate and Health, and the Childhood Lead Poisoning Prevention Program for the purposes of sharing data such as syndromic surveillance data, emergency department and hospital visits, or other data. Additional purposes may include establishing consistent definitions and measures, creating maps, tables, or other tools, and developing policies related to environmental exposures and health effects on people with asthma.

• Recipients of funding from CDC’s National Center for Chronic Disease Prevention and Health Promotion, including but not limited to, the Division of Adolescent and School Health; Office on Smoking and Health;

Division of Nutrition, Physical Activity and Obesity; Division of Heart Disease and Stroke Prevention; and the Division of Diabetes Translation, for the purposes of conducting and analyzing the Behavioral Risk Factor Surveillance Survey and asthma-related modules; school health programs using the Whole School, Whole Community, Whole Child (WSCC) framework and health services; smoking cessation activities, including elimination of secondhand smoke exposure; coordinated school health programs and health services; community needs assessments; self-management education; chronic disease quality improvement projects; community health worker training;

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 27 https://www.lung.org/ https://www.lung.org/ https://allergyasthmanetwork.org/ https://aafa.org/ https://aafa.org/ https://www.neefusa.org/ https://www.neefusa.org/ https://www.cdc.gov/healthyschools/wscc/index.htm https://www.cdc.gov/healthyschools/wscc/index.htm communication campaigns; or any other activities related to asthma control.

• Recipients of funding from CDC’s National Center for Immunization and Respiratory Diseases (NCIRD), including but not limited to the Influenza Division, the Immunization Services Division (ISD), the Division of Bacterial Diseases (DBD), and the Division of Viral Diseases (DVD) for the purposes of coordinating messaging around vaccinations, influenza, respiratory diseases, and asthma control.

With organizations not funded by CDC You are strongly encouraged to collaborate with organizations that are not funded by CDC that are essential to the effective implementation of strategies described in this NOFO, such as:

• State administrators managing applicable programs such as Medicaid, Children’s Health Insurance Program (CHIP), and other offices, senior public health officials, state environmental health directors, public health chronic disease directors, state medical societies, and others.

• Subject matter experts with expertise in public health tools, strategies, and resources, including advanced knowledge of the public health systems at the national, state, tribal and local levels.

• Regional offices of the U.S. Environmental Protection Agency, U.S.

Department of Housing and Urban Development, and U.S. Department of Health and Human Services.

• Primary care practice representatives, healthcare organization representatives, and health systems representatives.

• State and local housing authorities.

• State department of education and local school districts.

• Local community-based organization representatives.

• Local public health departments.

• Representatives of programs addressing social determinants of health (SDOH). Further topics can be found at: CDC SDOH.

• Organizations representing focus populations.

Partners to support interventions within selected setting You must engage partnerships, such as public health, health care, education, social services, non-governmental, coalitions, community and faith-based organizations, racial, ethnic, and minority serving organizations, and tribal communities to coordinate the implementation of selected interventions under EXHALE. The approach will address health equity by prioritizing the

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 28 https://www.cdc.gov/about/sdoh/index.html identified drivers of inequity within the setting you select. Partner examples for the following settings could include:

• Schools: Public and private schools, which can include K-12, Pre-K, or early childhood education centers.

• Healthcare: Children’s hospitals, FQHCs, MCOs, primary care clinics, healthcare systems.

• Homes: Professionals and organizations who can assist in delivery of AS- ME or Home Visit interventions, such as community health workers, emergency medical technicians, community paramedics, certified asthma education specialists, or other professionals; landlord associations;

tenants associations; property management companies.

• Community settings: Community-based organizations, faith-based organizations, childcare organizations, neighborhood or civic associations, transportation agencies or services, establishments who provide services such as grocery stores, pharmacies, clinics, and other services and community establishments frequented by focus populations.

Data, monitoring, and evaluation CDC strategy Evaluation and performance measurement help demonstrate achievement of project outcomes, build a stronger evidence base for specific interventions, clarify applicability of the evidence base to different populations, settings, and contexts, and drive continuous improvement. Evaluation and performance measurement can also determine if strategies and activities are sustainable, scalable, and effective at increasing health equity. The evaluation strategy is grounded in the CDC Evaluation Framework for Public Health, MMWR, September 18, 1999, Vol. 48 / No. RR-11, as well as in the utilization-focused and participatory approach described in Learning and Growing Through Evaluation: State Asthma Program Evaluation Guide.

Throughout the period of performance, you will:

• Use established evaluation frameworks to evaluate services and expansion strategies for efficiency and effectiveness

• Build sufficient evaluation capacity within the asthma program and among partners to support high-quality evaluation

• Apply evidence of program efficiency and effectiveness to support the development of business cases

1. Review 2. Get ready 3. Prepare 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 29 https://www.cdc.gov/mmwr/PDF/RR/RR4811.pdf

• Use a strategic evaluation plan and individual evaluation plans to guide evaluations

• Use evaluation findings to improve and enhance programming throughout period of performance and create action plans to document use

• Share evidence of effectiveness with others in the field

The specific number of evaluations to be planned and conducted will vary based on the scope of evaluations proposed, but it is expected that major program components will be evaluated during the period of performance.

CDC will work individually and…