oppCDC-RFA-DP18-1815PPHF18-cfda93.426-cidCDC-RFA-DP18-1815PPHF18-instructions.pdf

Centers for Disease Control

National Center for Chronic Disease Prevention and Health Promotion

Improving the Health of Americans Through Prevention and Management of Diabetes and

Heart Disease and Stroke-Financed in part by 2018 Prevention and Public Health Funds (PPHF)

CDC-RFA-DP18-1815PPHF18

Application Due Date: 06/11/2018

Improving the Health of Americans Through Prevention and Management of Diabetes and

Heart Disease and Stroke-Financed in part by 2018 Prevention and Public Health Funds (PPHF)

CDC-RFA-DP18-1815PPHF18

TABLE OF CONTENTS

Part I. Overview Information A. Federal Agency Name B. Funding Opportunity Title C. Announcement Type D. Agency Funding Opportunity Number E. Catalog of Federal Domestic Assistance (CFDA) Number F. Dates G. Executive Summary

Part II. Full Text A. Funding Opportunity Description B. Award Information C. Eligibility Information D. Required Registrations E. Review and Selection Process F. Award Administration Information G. Agency Contacts H. Other Information I. Glossary

Part I. Overview Information Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Send Me Change Notifications Emails" link to ensure they receive notifications of any changes to CDC-RFA-DP18-1815PPHF18. 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) B. Notice of Funding Opportunity (NOFO) Title:

Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke-Financed in part by 2018 Prevention and Public Health Funds (PPHF) 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)).

Cooperative Agreement

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP18-1815PPHF18

E. Catalog of Federal Domestic Assistance (CFDA) Number:

93.426 F. Dates:

1. Due Date for Letter of Intent (LOI): N/A Is a LOI: Not Applicable N/A

2. Due Date for Applications: 06/11/2018, 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Date for Informational Conference Call: 04/23/2018 Scheduled for 3:00 - 4:00 pm, Eastern Standard Time.

URL: https://adobeconnect.cdc.gov/r798tz97pl0/

Conference Number(s):

Conference I.D.: 3461523#

Conference Number: 18885667703

Questions may be submitted to 1815COMMS@cdc.gov as soon as the NOFO is released.

G. Executive Summary:

1. Summary Paragraph:

This NOFO is non-competitive, and will support state investments in implementing and evaluating evidence-based strategies to prevent and manage cardiovascular disease (CVD) and 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.grants.gov https://adobeconnect.cdc.gov/r798tz97pl0/ diabetes in high-burden populations/communities within each state and the District of Columbia, contributing to improved health outcomes. High burden populations are those affected disproportionately by high blood pressure, high blood cholesterol, diabetes, or prediabetes due to socioeconomic or other characteristics, including inadequate access to care, poor quality of care, or low income. Category A strategies focus on diabetes management and type 2 diabetes prevention. Category B strategies focus on CVD prevention and management. In both categories, applicants will select from a menu of strategies, and should focus in areas where they have capacity, subject matter expertise, and potential to achieve greatest reach and impact. Where appropriate, applicants will apply their selected Category A and B strategies in the same targeted communities/settings, so that work on these strategies may be mutually reinforcing. Complementary strategies should be addressed in a way that benefits both people with prediabetes or diabetes and people with high blood pressure and with or at risk for high blood cholesterol. Funding, resources, and level of effort should be divided equally between Category A and B strategies.

a. Eligible Applicants: Limited

b. NOFO Type: Cooperative Agreement

c. Approximate Number of Awards: 51

d. Total Period of Performance Funding: $530,000,000

e. Average One Year Award Amount: $1,765,000 Refer to the Funding Table for specific funding amounts for each recipient.

f. Number of Years of Award: 4.75

g. Estimated Award Date: 09/30/2018

h. Cost Sharing and / or Matching Requirements: N Cost sharing or matching funds are not required for this program. Although no statutory matching requirement for the NOFO exists, applicants are encouraged to leverage other resources and related ongoing efforts to promote sustainability.

Part II. Full Text Executive Summary This NOFO is non-competitive, and will support state investments in implementing and evaluating evidence-based strategies to prevent and manage cardiovascular disease (CVD) and diabetes in high-burden populations/communities within each state and the District of Columbia, contributing to improved health outcomes. High burden populations are those affected disproportionately by high blood pressure, high blood cholesterol, diabetes, or prediabetes due to socioeconomic or other characteristics, including inadequate access to care, poor quality of care, or low income. Category A strategies focus on diabetes management and type 2 diabetes prevention. Category B strategies focus on CVD prevention and management. In both categories, applicants will select from a menu of strategies, and should focus in areas where they have capacity, subject matter expertise, and potential to achieve greatest reach and impact. Where appropriate, applicants will apply their selected Category A and B strategies in the same targeted communities/settings, so that work on these strategies may be mutually reinforcing. Complementary strategies should be addressed in a way that benefits both people with prediabetes or diabetes and people with high blood pressure and with or at risk for high blood cholesterol. Funding, resources, and level of effort should be divided equally between Category A and B strategies.

A. Funding Opportunity Description

1. Background

a. Overview

Diabetes is the 7th leading cause of death in the U.S.; the number one cause of kidney failure, lower-limb amputations, and adult-onset blindness; and a leading cause of heart disease and stroke. A large body of evidence supports the effectiveness of diabetes self-management education and support (DSMES) in improving health outcomes (A1c, systolic blood pressure), lowering medication use, and decreasing hospitalizations and other health care costs for people with diabetes. However, DSMES utilization rates are low.

Approximately 84 million Americans, or 1 in 3 adults, have prediabetes, a health condition characterized by blood glucose levels that are higher than normal but not high enough to be diagnosed as diabetes. People with prediabetes have an increased risk of developing type 2 diabetes, heart disease, and stroke. Prediabetes is treatable, but only about 10 percent of people who have it are aware that they do. The CDC-led National Diabetes Prevention Program (National DPP) is a partnership of public and private organizations working collectively to build the infrastructure for nationwide delivery of an evidence-based lifestyle change program for adults with prediabetes to prevent or delay onset of type 2 diabetes. The lifestyle change program is founded on the science of the Diabetes Prevention Program research study, and several translation studies that followed, which showed that making modest behavior changes helped participants with prediabetes lose 5% to 7% of their body weight and reduce their risk of developing type 2 diabetes by 58%. The program has been shown to be cost effective and can be cost saving.

Heart disease is the leading cause of death, and stroke is the 5th leading cause of death, in the U.S. Cardiovascular Disease (CVD) , including heart disease, stroke, and other vascular diseases, accounts for >800 000, or about 1 in 3, deaths/year, and around 1 in 5 who die from CVD are younger than 65 years. CVD is costly, with an estimated 1 in 7 health care dollars spent on CVD (about 15%). Hypertension is a primary risk factor for CVD. While control of hypertension, reflective of individual and system-level improvements, has been increasing, less than half of those with hypertension are controlled. Interventions to support patient engagement, prevention, and health system improvements need to be maximized to improve hypertension management. High blood cholesterol is another primary risk factor for CVD. Several modifiable health behaviors can lower cholesterol, including eating a healthy diet, losing weight, and being physically active. Behavior modification improvements and health systems advances are needed to reduce the need for treatment and close the gap in treatment across the population. Health system interventions may include use of team-based care and community health workers, electronic health record alignment with national guidelines, improved medication adherence, and interventions supporting better continuity of care across health care settings.

This NOFO represents a collaboration between CDC's Division of Diabetes Translation and Division for Heart Disease and Stroke Prevention. It will build on the accomplishments and outcomes achieved in the healthcare systems and community-clinical linkage domains of CDC- RFA-DP13-1305 (1305) and CDC-RFA-DP14-1422 (1422). The purpose of this NOFO is to implement and evaluate evidence-based strategies contributing to the prevention and management of CVD and diabetes in high-burden populations.

b. Statutory Authorities Section 30l(a) of the Public Health Service Act [42] U.S.C. Section 241(a) 93.426 Title IV Section 4002 of the Affordable Care Act, Prevention and Public Health Fund

c. Healthy People 2020

CVD:

HDS-2: Reduce coronary heart disease deaths.

HDS-3: Reduce stroke deaths.

HDS-7: Reduce the proportion of adults with high total blood cholesterol levels.

HDS-8: Reduce the mean total blood cholesterol levels among adults.

HDS-12: Increase the proportion of adults with hypertension whose blood pressure is under control.

https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke Diabetes:

D-14: Increase the proportion of persons with diagnosed diabetes who receive formal diabetes education.

Increase the proportion of persons at high risk for diabetes with prediabetes who report increasing their levels of physical activity (D-16.1), trying to lose weight (D-16.2), and reducing the amount of fat or calories in their diet (D-16.2).

https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes

d. Other National Public Health Priorities and Strategies Hypertension prevention, detection, and control Million Hearts® 2022 https://millionhearts.hhs.gov/ National Diabetes Prevention Program (type 2 diabetes prevention): https://www.cdc.gov/diabe tes/prevention/index.html Diabetes care and self-management Diabetes and cardiovascular disease management: https://www.thecommunityguide.org/

e. Relevant Work https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes https://millionhearts.hhs.gov/ https://www.cdc.gov/diabetes/prevention/index.html https://www.cdc.gov/diabetes/prevention/index.html https://www.thecommunityguide.org/

This NOFO builds on the accomplishments and outcomes achieved in the healthcare systems and community-clinical linkage domains of CDC-RFA-DP13-1305 (https://www.cdc.gov/chron icdisease/about/state-public-health-actions.htm) and CDC-RFA-DP14-1422 (https://www.cdc .gov/chronicdisease/about/foa/2014foa/public-health-action.htm).

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

i. Purpose This NOFO will support the implementation and evaluation of a set of evidence-based strategies to prevent and control diabetes and cardiovascular disease (CVD) in high-burden populations.

Category A includes diabetes management and type 2 diabetes prevention strategies. Category B includes CVD prevention and management strategies. Applicants are encouraged to https://www.cdc.gov/chronicdisease/about/state-public-health-actions.htm https://www.cdc.gov/chronicdisease/about/state-public-health-actions.htm https://www.cdc.gov/chronicdisease/about/foa/2014foa/public-health-action.htm https://www.cdc.gov/chronicdisease/about/foa/2014foa/public-health-action.htm implement Category A and B strategies in the same high burden areas/communities, so that work on these strategies is mutually reinforcing and implemented in a coordinated fashion to accelerate progress toward goals.

ii. Outcomes Applicants will focus only on those outcomes that align with the strategies they select.

Applicants are required to select a minimum of 5 strategies from Category A (minimum of 2 diabetes management strategies and 3 type 2 diabetes prevention strategies) and a minimum of 5 strategies from Category B. Refer to the Strategy Table in Section 2.b.i. CDC Evaluation and Performance Measurement Strategy for more information.

CATEGORY A: Diabetes Management and Type 2 Diabetes Prevention Diabetes Management Short-term outcomes:

--Increased access to and coverage for ADA-recognized/AADE-accredited diabetes self-management education and support (DSMES) programs for people with diabetes (Note: These programs meet national quality standards and are more likely to be sustained long-term due to reimbursement by Medicare, many private insurance plans, and some State Medicaid Agencies.)

--Increased use of pharmacist patient care processes that promote medication management for people with diabetes Intermediate outcomes:

--Increased participation in ADA-recognized/AADE-accredited DSMES programs by people with diabetes Long-term outcomes:

--Decreased proportion of people with diabetes with an A1C > 9 Type 2 Diabetes Prevention Short-term outcomes:

--Increased access to and coverage for the National DPP lifestyle change program for people with prediabetes --Increased community clinical links that facilitate referrals and provide support to enroll and retain participants in the National DPP lifestyle change program Intermediate outcomes:

--Increased enrollment and retention in CDC-recognized organizations delivering the National DPP lifestyle change program Long-term outcomes:

--Increased number of people with prediabetes enrolled in a CDC-recognized lifestyle change program who have achieved 5-7% weight loss

CATEGORY B: Cardiovascular Disease Prevention and Management Short-term outcomes:

--Increased reporting, monitoring, and tracking of clinical data for improved identification, management, and treatment of patients with high blood pressure and high blood cholesterol --Increased use of and adherence to evidence-based guidelines and policies related to team-based care for patients with high blood pressure and high blood cholesterol --Increased community clinical links that support systematic referrals, self-management, and lifestyle change for patients with high blood pressure and high blood cholesterol Intermediate outcomes:

--Increased medication adherence among patients with high blood pressure and high blood cholesterol --Increased engagement in self-management among patients with high blood pressure and high blood cholesterol --Increased participation in evidence-based lifestyle interventions among patients with high blood pressure and high blood cholesterol Long-term outcomes:

--Increased control among adults with known high blood pressure and high blood cholesterol

iii. Strategies and Activities Category A (Diabetes Management and Type 2 Diabetes Prevention) and Category B (Cardiovascular Disease Prevention and Management) strategies are listed below. Applicants are encouraged to implement Category A and B strategies in the same high burden areas/communities, so that work on these strategies is mutually reinforcing. Complementary strategies should be addressed in a way that benefits both people with prediabetes or diabetes and people with high blood pressure and with or at risk for high blood cholesterol. Applicants will select a minimum of 5 strategies from Category A (minimum of 2 diabetes management strategies and 3 type 2 diabetes prevention strategies) and a minimum of 5 strategies from Category B.

Category A: Diabetes Management and Type 2 Diabetes Prevention Strategies (Applicants will select a minimum of 5 strategies from the list below. Selected strategies must include a minimum of 2 diabetes management and 3 type 2 diabetes prevention strategies) Diabetes Management: Improve care and management of people with diabetes.

A.1. Improve access to and participation in ADA-recognized/ AADE-accredited DSMES programs in underserved areas (Note: These programs meet national quality standards and are more likely to be sustained long-term due to reimbursement by Medicare, many private insurance plans, and some State Medicaid Agencies.)

OPTIONAL: Applicants selecting strategy #1 may also choose to engage in efforts to increase participation in other DSMES programs that are not recognized/accredited or in chronic disease self-management programs (CDSMP). These programs/curricula must have evidence documenting their impact on people with diabetes. If selected, this work should be secondary to improving access to and participation in ADA-recognized/AADE-accredited DSMES programs that meet national quality standards.

A.2. Expand or strengthen DSMES coverage policy among public or private insurers or employers, with emphasis on one or more of the following: Medicaid and employers A.3. Increase engagement of pharmacists in the provision of medication management or DSMES for people with diabetes Type 2 Diabetes Prevention: Improve access to, participation in, and coverage for the National Diabetes Prevention Program (National DPP) lifestyle change program for people with prediabetes, particularly in underserved areas A.4. Assist health care organizations in implementing systems to identify people with prediabetes and refer them to CDC-recognized lifestyle change programs for type 2 diabetes prevention A.5. Collaborate with payers and relevant public and private sector organizations within the state to expand availability of the National DPP as a covered benefit for one or more of the following groups: Medicaid beneficiaries; state/public employees; employees of private sector organizations A.6. Implement strategies to increase enrollment in CDC-recognized lifestyle change programs Diabetes Management and/or Type 2 Diabetes Prevention A.7. Develop a statewide infrastructure to promote long-term sustainability/reimbursement for Community Health Workers (CHWs) as a means to establish or expand their use in a) CDC-recognized lifestyle change programs for type 2 diabetes prevention and/or b) ADA-recognized/AADE-accredited DSMES programs for diabetes management

Category B: Cardiovascular Disease Prevention and Management Strategies Recipients will select a minimum of 5 strategies.

Track and Monitor Clinical Measures shown to improve healthcare quality and identify patients with hypertension B.1. Promote the adoption and use of electronic health records (EHR) and health information technology (HIT) to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed hypertension and management of adults with hypertension.

B.2. Promote the adoption of evidence-based quality measurement at the provider level (e.g., use dashboard measures to monitor healthcare disparities and implement activities to eliminate healthcare disparities) Implement Team-Based Care for patients with high blood pressure and high blood cholesterol B.3. Support engagement of non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management in clinical settings B.4. Promote the adoption of MTM between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification Link Community Resources and Clinical Services that support systematic referrals, self-management, and lifestyle change for patients with high blood pressure and high blood cholesterol B.5. Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol B.6. Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support among adults with hypertension B.7 Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources

1. Collaborations

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

Applicants are encouraged to collaborate with other related CDC-funded programs that have a role in achieving the NOFO outcomes for the strategies selected. Collaborations may center on shared data; partner organizations; coalitions; intervention settings/locations; marketing approaches/messages; EHRs or other electronic clinical decision support systems; and/or targeted high burden populations. Related CDC-funded programs include but are not limited to WISEWOMAN; national organizations funded under CDC-DP17-1705 (Scaling the National Diabetes Prevention Program in Underserved Areas); tribes or tribal organizations funded under CDC-DP14-1421 (Good Health and Wellness in Indian Country); and other CDC-funded chronic disease prevention and management programs (for example, State Disability and Health Programs, see https://www.cdc.gov/ncbddd/disabilityandhealth/index.html). Applicants should also link to strategies and collaborations described in the State Chronic Disease Plan, as appropriate. Letters of support and MOAs/MOUs are not required but should be considered where appropriate and helpful in supporting collaborative efforts.

b. With organizations not funded by CDC:

Collaborations with a variety of public and private organizations are encouraged to leverage resources and maximize reach and impact for the strategies selected. These organizations include employers; commercial health plans; hospitals; FQHCs/RHCs/community health centers; non-profit agencies; other federal, state, or local government agencies (e.g., State Medicaid Agency, State Employee Benefit Agency, etc.); tribes or tribal organizations;

professional associations (state medical society, other medical specialty associations, etc.);

quality improvement organizations; ADA-recognized and AADE-accredited diabetes self-management education and support programs; local/regional ADA or AADE chapters; CDC-recognized organizations delivering the National DPP lifestyle change program; and others that have a stake in supporting the evidence-based strategies described in this NOFO. Letters of support and MOAs/MOUs are not required but should be considered where appropriate and helpful in supporting collaborative efforts.

2. Target Populations Applicants must identify criteria for selecting their priority populations based on disease and risk factor burden data and combined potential to impact large numbers of adults across the state. Priority populations should include those affected disproportionately by high blood pressure, high blood cholesterol, diabetes, or prediabetes due to socioeconomic or other characteristics, including inadequate access to care, poor quality of care, or low income. Emphasis should be placed on achieving maximum reach and impact across these populations.

a. Health Disparities Eliminating health disparities is one of the four Healthy People 2020 Foundational Health Measures. This NOFO will address the challenges and health inequities in chronic disease risk factors and conditions that high-burden populations experience. These efforts will help determine the public health impact of programs intended to improve specific risks, conditions, and/or barriers experienced by populations living with high levels of disease burden for high blood pressure, high blood cholesterol, diabetes, or prediabetes. Additionally, the program will include populations who can benefit from the strategies included in this NOFO (e.g., people with disabilities; non-English speaking populations; lesbian, gay, bisexual, and transgender (LGBT) populations; people with limited health literacy); or other targeted populations.

iv. Funding Strategy (for multi-component NOFOs only) Summary of Anticipated Funding The table below provides guidance related to the maximum amount of funding available by state for this non-competitive program. This funding is based on a funding formula that includes factors for base funding, population, and poverty. The funding amounts listed below are for the "Year 1" budget period, which is only 9 months. As such, the ceiling for each recipient is lower than the anticipated amount for subsequent 12-month budget periods.

State Dollar Amount State Dollar Amount

Alabama $ 1,864,604 Montana $ 1,610,090

Alaska $ 1,465,310 Nebraska $ 1,552,328

Arizona $ 1,891,018 Nevada $ 1,690,222

Arkansas $ 1,812,378 New Hampshire $ 1,392,190

California $ 2,713,246 New Jersey $ 1,713,264

Colorado $ 1,641,838 New Mexico $ 1,861,156

Connecticut $ 1,544,264 New York $ 2,185,574

Delaware $ 1,545,214 North Carolina $ 1,941,614

District of Columbia $ 1,798,784 North Dakota $ 1,489,144

Florida $ 2,209,728 Ohio $ 1,947,414

Georgia $ 1,973,450 Oklahoma $ 1,795,560

Hawaii $ 1,468,850 Oregon $ 1,695,066

Idaho $ 1,643,522 Pennsylvania $ 1,917,642

Illinois $ 1,922,022 Rhode Island $ 1,606,580

Indiana $ 1,789,184 South Carolina $ 1,793,280

Iowa $ 1,602,110 South Dakota $ 1,585,672

Kansas $ 1,615,262 Tennessee $ 1,859,840

Kentucky $ 1,891,702 Texas $ 2,442,842

Louisiana $ 1,972,564 Utah $ 1,541,326

Maine $ 1,575,268 Vermont $ 1,516,606

Maryland $ 1,604,430 Virginia $ 1,721,810

Massachusetts $ 1,657,760 Washington $ 1,702,200

Michigan $ 1,916,042 West Virginia $ 1,807,428

Minnesota $ 1,598,396 Wisconsin $ 1,679,650

Mississippi $ 1,960,486 Wyoming $ 1,499,930

Missouri $ 1,774,142

Total: $ 90,000,000

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. They can also assist in determining whether the identified strategies and associated activities can be implemented at various levels

(i.e., state, sub-population, etc.) within a state.

Throughout the five-year period, CDC will work individually and collectively with recipients to track the implementation of recipient strategies and activities and assess progress on achieving the 5-year NOFO outcomes. Both the process and outcome evaluation will seek to answer the following overarching evaluation questions in five areas:

1. Approach: To what extent has the recipient's implementation approach resulted in achieving the desired outcomes?

2. Effectiveness:

1. To what extent has the recipient increased the reach of Category A and B strategies to prevent and control diabetes and cardiovascular disease?

2. To what extent has implementation of Category A and B strategies led to improved health outcomes among the identified priority population(s)?

3. What factors were associated with effective implementation of Category A and B strategies?

3. Efficiency: To what extent has the NOFO affected efficiencies with regard to infrastructure, management, partners, and financial resources?

4. Sustainability: To what extent can the strategies implemented be sustained after the

NOFO ends?

5. Impact: To what extent have the strategies implemented contributed to a measurable change in health, behavior, or environment in a defined community, population, organization, or system?

CDC will use an evaluation approach that consists of (1) ongoing monitoring and evaluation through the collection and reporting of performance measures, (2) a CDC-led national evaluation, and (3) state-led evaluations.

Performance measures developed for this program correspond to the strategies and outcomes described in the logic model. Performance measures recipients will be responsible for collecting and reporting on are noted in the table in this section in the table below. Tier 1 measures are measures that will be reported by all recipients regardless of the strategies selected, and will focus on long term outcomes. Tier 2 measures are measures that will be reported by recipients based on the specific strategies selected, and will focus on short term outcomes. CDC will work with recipients on operationalizing and further defining each performance measure, and guidance will be provided prior to the first year of reporting. Performance measures will be reported annually to CDC, and CDC will manage and analyze the data to assess recipient program improvements, respond to broader technical assistance needs, and report to stakeholders. CDC will analyze performance measure data annually and develop aggregate performance measure reports to be disseminated to recipients and other key stakeholders, including federal partners, other funded and non-funded partners, and policy makers, as appropriate. These aggregate findings may also be presented during site visits and recipient meetings. In addition to performance measures reported by recipients, CDC will track specific intermediate outcome measures and other short and long-term measures (as indicated in the table below) that are relevant to the program through national datasets or national evaluation activities.

For the national evaluation activities, CDC will lead the design, data collection, analysis, and reporting. Recipients will be asked to participate in national evaluation activities such as surveys, interviews, case studies, and other data collection efforts. An appropriate level of guidance and support will be provided to the recipients to ensure their effective participation in the national evaluation. CDC will use findings from these evaluation efforts to refine its technical assistance and, in turn, maximize and sustain program outcomes.

For state-led evaluations, CDC will assist recipients in developing and implementing evaluation plans that are useful for state-level program improvement and for the overall evaluation of the program. For all components of the evaluation, CDC and recipients will only collect data that will be analyzed and used.

CDC will provide recipients with performance measure reporting templates, and potentially, with evaluation plan reporting templates. CDC will provide evaluation technical assistance and ongoing evaluation guidance on recipient-level evaluation and performance measures.

Evaluation technical assistance will be provided using a tiered approach to ensure that the tools and services provided best meet the needs of the recipients. All information will be stored using a secure system. All evaluation findings produced by CDC and recipients, where appropriate, will contribute to: (1) continuous improvement of quality and effectiveness of program strategies; (2) the evidence base; (3) documentation and sharing of lessons learned to support replication and scaling of these program strategies; and/or (4) future funding opportunities supported by CDC.

The data collected by CDC for performance measurement and evaluation are directly related to the implementation of the strategies and/or the desired outcomes indicated in the logic model.

The data collected for this NOFO for performance measurement and national evaluation do not include any personally identifiable information. Data being collected are strictly related to the implementation of the NOFO strategies, and shall be used for assessing and reporting progress and for other pertinent program improvement actions. All performance measure data will be stored using a secure data system. Recipients will report their performance measure data annually and will only have access to their data. Over the 5-year performance period, data will be secured with limited access to authorized CDC program and evaluation staff to the extent allowed under applicable Federal law. CDC will aggregate data across all recipients to publish annual and summative reports.

Short-term measures for each strategy (reported based on the strategies selected) and long-term measures reported by all recipients are described in the table below. The table aligns with the logic model and shows the alignment between the overarching focus areas, specific strategies, outcomes, and performance measures.

Category A (Diabetes Management and Type 2 Diabetes Prevention) and Category B (Cardiovascular Disease Prevention and Management) strategies are listed below. Applicants are encouraged to implement Category A and B strategies in the same high burden areas/communities, so that work on these strategies is mutually reinforcing. Complementary strategies should be addressed in a way that benefits both people with prediabetes or diabetes and people with high blood pressure and with or at risk for high blood cholesterol. Applicants will select a minimum of 5 strategies from Category A (minimum of 2 diabetes management strategies and 3 type 2 diabetes prevention strategies) and a minimum of 5 strategies from Category B.

Category A: Diabetes Management and Type 2 Diabetes Prevention Strategies

Strategies (Applicants will select a minimum of 5 strategies from the list below.

Selected strategies must include a minimum of 2 diabetes management and 3 type 2 diabetes prevention strategies)

Short term outcomes and measures (Recipients will report the short term measure for each strategy selected) All measures are Tier 2 measures

Intermediate outcomes and measures All measures are Tier 1 measures

Long term outcomes and measures All measures are Tier 1 measures

Diabetes Management: Improve care and management of people with diabetes.

Outcomes:

Increased access to and coverage for

ADA-

recognized/AADE-accredited diabetes self-management education and support (DSMES) programs for people with diabetes

Increased use of pharmacist patient care processes that promote medication management for people with diabetes

Outcome:

Increased participation in

ADA-

recognized/AADE

- accredited DSMES programs by people with diabetes

Outcome:

Decreased proportion of people with diabetes with an A1C > 9

A.1. Improve access to and participation in ADA-recognized/ AADE-accredited DSMES programs in underserved areas (Note: These programs meet national quality standards and are more likely to be sustained long-term due to reimbursement by Medicare, many private insurance plans, and some State Medicaid

Measure: A.1. # and proportion of new recognized/accredited DSMES programs

Measure: A.8. # of people with diabetes with at least one encounter at an

ADA-

recognized/AADE -accredited DSMES program

Measure: A.10.

Proportion of people with diabetes with an

Agencies.)

OPTIONAL: Applicants selecting strategy #1 may also choose to engage in efforts to increase participation in other DSMES programs that are not recognized/accredited or in chronic disease self-management programs (CDSMP). These programs/curricula must have evidence documenting their impact on people with diabetes. If selected, this work should be secondary to improving access to and participation in ADA-recognized/AADE-accredited DSMES programs that meet national quality standards.

A.2. Expand or strengthen DSMES coverage policy among public or private insurers or employers, with emphasis on one or more of the following: Medicaid and employers

Measure: A.2. # of employees/Medicaid beneficiaries who have DSMES as a covered benefit

A.3. Increase engagement of pharmacists in the provision of medication management or DSMES for people with diabetes

Measure: A.3. # of pharmacy locations/ pharmacists using patient care processes that promote medication management or DSMES for people with diabetes

Measure: A.3. No Intermediate term measures

Type 2 Diabetes Prevention:

Improve access to, participation in, and coverage for the National Diabetes Prevention Program (National DPP) lifestyle change program for people with prediabetes, particularly in underserved areas

Outcomes:

Increased access to and coverage for the National DPP lifestyle change program for people with prediabetes Increased community clinical links that

Outcome:

Increased enrollment and retention in CDC-recognized organizations delivering the National DPP lifestyle change program

Outcome:

Increased number of people with prediabetes enrolled in a CDC-recognized lifestyle change program who have achieved 5-facilitate referrals and provide support to enroll and retain participants in the National DPP lifestyle change program

7% weight loss

A.4. Assist health care organizations in implementing systems to identify people with prediabetes and refer them to CDC-recognized lifestyle change programs for type 2 diabetes prevention

Measure: A.4. # of patients served within healthcare organizations with systems to identify people with prediabetes and refer them to CDC-recognized lifestyle change programs

A.5. Collaborate with payers and relevant public and private sector organizations within the state to expand availability of the National DPP as a covered benefit for one or more of the following groups:

Medicaid beneficiaries; state/public employees; employees of private sector organizations

Measure: A.5. # of employees; Medicaid beneficiaries;

state/public employees; and/or employees of private sector organizations who have the National DPP lifestyle change program as a covered benefit

A.6. Implement strategies to increase enrollment in CDC-recognized lifestyle change programs

Measure: A.6. No Short term measures

Measure: A.9. # of participants enrolled in CDC-recognized lifestyle change programs

Measure: A.11.

# of people with prediabetes participating in CDC-recognized lifestyle change programs who have achieved 5- 7% weight loss

Diabetes Management and/or Type 2 Diabetes Prevention

A.7. Develop a statewide infrastructure to promote long-term sustainability/reimbursement for Community Health Workers (CHWs) as a means to establish or expand their use in a) CDC-recognized lifestyle change

Measure: A.7. # of CHWs covered under state efforts to expand CHW curricula and training delivery vehicles, CHW certification systems, Measure: A.7. No intermediate performance measure

Measure: A.10.

a) Proportion of people with diabetes with an

A.11. b) # of programs for type 2 diabetes prevention and/or b) ADA-recognized/AADE-accredited DSMES programs for diabetes management and/or CHW payment mechanisms people with prediabetes participating in CDC-recognized lifestyle change programs who have achieved 5- 7% weight loss

Category B: Cardiovascular Disease Prevention and Management Strategies

Strategies (recipients will select a minimum of 5 strategies)

Short term outcomes and measures (recipients will report the short term measure for each strategy selected) All measures are Tier 2 measures

Intermediate outcomes and measures (all intermediate measures will be tracked/evaluated by CDC)

Long term outcomes and measures (all recipients will report long term measures as Tier 1 measures)

Track and Monitor Clinical Measures shown to improve healthcare quality and identify patients with hypertension

Outcome:

Increased reporting, monitoring, and tracking of clinical data for improved identification, management, and treatment of patients with high blood pressure and high blood cholesterol

Outcome: Increased medication adherence among patients with high blood pressure and high blood cholesterol

Outcome:

Increased control among adults with known high blood pressure and high blood

B.1. Promote the adoption and use of electronic health records (EHR) and health information technology (HIT) to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed

Measure: B.1. # and % of patients within health care systems with systems to report standardized clinical quality measures for the management and

Measure:

B.7.

Proportion of adults with known high blood pressure who hypertension and management of adults with hypertension.

treatment of patients with high blood pressure (e.g., NQF0018)

B.2. Promote the adoption of evidence-based quality measurement at the provider level (e.g., use dashboard measures to monitor healthcare disparities and implement activities to eliminate healthcare disparities)

Measure: B.2. # and % of clinics or providers that use standardized quality measures to track differences in BP control and cholesterol management in priority populations compared to overall populations

Implement Team-Based Care for patients with high blood pressure and high blood cholesterol

Outcome:

Increased use of and adherence to evidence-based guidelines and policies related to team-based care for patients with high blood pressure and high blood cholesterol

Outcome: Increased medication adherence among patients with high blood pressure and high blood cholesterol

Increased engagement in self-management among patients with high blood pressure and high blood cholesterol

B.3. Support engagement of non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management in clinical settings

Measure: B.3. # and % of patients that are in health care systems that have policies or systems to encourage a multi-disciplinary team approach to blood pressure control and have achieved blood pressure control

Measure:

B.8.

Proportion of patients with total cholesterol at goal (LDL and HDL).

management

B.4. Promote the adoption of MTM between pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification

Measure: B.4. # and % of pharmacists engaged in the practice of MTM to promote medication self -management and lifestyle modification for high blood pressure and high blood cholesterol

Link Community Resources and Clinical Services that support systematic referrals, self-management, and lifestyle change for patients with high blood pressure and high blood cholesterol

Outcome:

Increased community clinical links that support systematic referrals, self-management, and lifestyle change for patients with high blood pressure and high blood cholesterol

Outcomes:

Increased medication adherence among patients with high blood pressure and high blood cholesterol

Increased engagement in self-management among patients with high blood pressure and high blood cholesterol

Increased participation in evidence-based lifestyle interventions among patients with high blood pressure and high blood cholesterol

B.5. Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol

Measure B.5. # of CHWs covered under state efforts to expand CHW curricula and training delivery vehicles, CHW certification systems, and/or CHW payment mechanisms

B.6. Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support among adults with hypertension

Measure B.6. # and % of patients within health care systems with policies or systems to encourage self-monitoring of high blood pressure tied to clinical support

B.7 Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources

Measure B.7. # and % of patients in health care systems with high blood pressure and high blood cholesterol referred to an evidence-based lifestyle program

In Category A (Diabetes Management and Type 2 Diabetes Prevention), the following performance measures are not required for recipients to report but will be tracked and/or evaluated by CDC (through national datasets, data from the American Diabetes Association's Education Recognition Program and the American Association of Diabetes Educators' Diabetes Education Accreditation Program, and the CDC Diabetes Prevention Recognition Program):

· # of people with diabetes with at least one encounter at an ADA-recognized/AADE-accredited DSMES program

· # of participants enrolled in CDC-recognized lifestyle change programs

· Proportion of people with diabetes with an A1C > 9

· # of people with prediabetes participating in CDC-recognized lifestyle change programs who have achieved 5-7% weight loss In Category B (Cardiovascular Disease Prevention and Management), the following performance measures are not required for recipients to report but will be tracked and/or evaluated by CDC (through national datasets, Million Hearts® data, national evaluation of the program, evaluations conducted by innovation states, case studies, etc.):

· # and % of providers with a protocol for identifying patients with undiagnosed hypertension

· % of patients with high blood pressure in adherence to medication regimens

· # and % of patients considered at high risk of cardiovascular events who were prescribed or were on statin therapy

· # and % of patients with high blood pressure that have a self-management plan

· # and % of health care systems with an implemented community referral system (tracking bi-directional referrals) for evidence-based lifestyle change programs for people with high blood pressure and high blood cholesterol

· # and % of patients referred to an evidence based lifestyle intervention who attend at least one session

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

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

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), if applicable, for accuracy throughout the lifecycle of the project. 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/additionalrequirements/ar-25.html.

Where the applicant chooses to, or is expected to, take on specific evaluation studies, they 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, within the first 6 months of award, as described in the Reporting Section of this NOFO.

In addition, evaluation plans should:

Describe data collection approaches, measures, and data sources.

Align each evaluation question with the approach, instruments/data sources, and https://www.cdc.gov/grants/additionalrequirements/ar-25.html timeline.

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

Describe the amount of the award allocated to evaluation.

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

Applicants are encouraged to work with professional evaluators (either internal or external) to meet the evaluation and performance reporting requirements of this NOFO. Therefore, CDC encourages allocating at least 10% of the total funding award to evaluation and performance monitoring and to consider both development and implementation costs. For information on developing an evaluation plan, please refer to the CDC Framework for Program Evaluation in Public Health (Centers for Disease Control and Prevention. Framework for Program Evaluation in Public Health. MMWR 1999; 48, No. RR-11) https://www.cdc.gov/mmwr/preview/mmwrh tml/rr4811a1.htm.

With support from CDC, recipients will be required to submit a more detailed Evaluation and Performance Measurement Plan, including a Data Management Plan (DMP), within the first 6 months of receiving the award, as described in the Reporting Section of this NOFO. CDC will review and approve the recipient's monitoring and evaluation plan to ensure that it is appropriate for the activities to be undertaken as part of the agreement and for compliance with the monitoring and evaluation guidance established by CDC or other guidance otherwise applicable to this cooperative agreement.

Applicants are required to submit a plan for Performance Measurement Data Collection and Use. A detailed plan for Performance Measurement Data Collection and Use will be due within 6 months of receiving the award.