PKG00249507-instructions.pdf

Centers for Disease Control

National Center for Environmental Health

A Comprehensive Public Health Approach to Asthma Control Through Evidence-Based

Interventions

CDC-RFA-EH19-1902

Application Due Date: 05/31/2019

A Comprehensive Public Health Approach to Asthma Control Through Evidence-Based

Interventions

CDC-RFA-EH19-1902

TABLE OF CONTENTS

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

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

Part I. Overview 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-EH19-1902. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) / Agency for Toxic Substances and Disease Registry (ATSDR) B. Notice of Funding Opportunity (NOFO) Title:

A Comprehensive Public Health Approach to Asthma Control Through Evidence-Based Interventions C. Announcement Type: New - Type 1 This announcement is only for non-research activities supported by CDC. If research is proposed, the application will not be considered. For this purpose, research is defined at https ://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf.

Guidance on how CDC interprets the definition of research in the context of public health can be found at https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html (See section 45 CFR 46.102(d)).

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-EH19-1902

E. Assistance Listings (CFDA) Number:

93.070 F. Dates:

1. Due Date for Letter of Intent (LOI): 05/01/2019

2. Due Date for Applications: 05/31/2019, 11:59 p.m. U.S. Eastern

Standard Time, at www.grants.gov.

A Letter of Intent is requested, but is not required.

3. Date for Informational Conference Call:

N/A

G. Executive Summary:

1. Summary Paragraph:

The Centers for Disease Control and Prevention announces availability of Fiscal Year (FY) 2019 funds for CDC-RFA-EH19-1902, A Comprehensive Public Health Approach to Asthma Control through Evidence-Based Interventions. The purpose of the award is to improve the reach, quality, effectiveness, and sustainability of asthma control services and to reduce asthma morbidity, mortality and disparities by implementing evidence-based strategies across multiple sectors. Activities align with the CDC initiative, Controlling Childhood Asthma Reducing Emergencies (CCARE), which focuses on key levers to improve childhood asthma outcomes.

Recipients will strengthen existing organizational infrastructure to expand the reach of services through six EXHALE strategies: Education on asthma self-management; eXtinguishing smoking and exposure to second-hand smoke; Home visits for trigger reduction and asthma 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://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf self-management education (AS-ME); Achievement of guidelines-based medical management;

Linkages and coordination of care; and Environmental policies or best practices to reduce indoor and outdoor asthma triggers. Key outcomes are increased capacity to deliver AS-ME, expanded services for those with the highest burden, improved asthma control, increased insurance coverage, coordinated care and reduced health disparities.[1] Long-term outcomes will contribute to the CCARE goal of preventing 500,000 hospitalizations and emergency department visits among children with asthma within five years.

a. Eligible Applicants: Open Competition

b. NOFO Type: Cooperative Agreement

c. Approximate Number of Awards: 25

d. Total Period of Performance Funding: $70,000,000

e. Average One Year Award Amount: $500,000

f. Total Period of Performance Length: 5

g. Estimated Award Date: 09/01/2019

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 this NOFO exists, leveraging other resources and related ongoing efforts to encourage sustainability is suggested.

Part II. Full Text A. Funding Opportunity Description

Part II. Full Text

1. Background

a. Overview Asthma in the United States is both common and costly. According to recent estimates, more than

26.5 million Americans have asthma, including 6.1 million children and 20.4 million adults.[2] In addition, asthma accounts for 1.7 million emergency department visits, 11 million physician office visits and 439,000 hospitalizations.[3] Asthma is responsible for 13.8 million missed school days and 14.2 million missed workdays annually.[4] In spite of available drugs to treat and control asthma, 10 people die of asthma each day.[5] Asthma places a significant economic burden on the United States. Estimates from 2008-2013 Medical Expenditure Panel Survey household data showed that the cost of treating asthma was $50.3 billion annually, while the total cost of asthma, including costs incurred by absenteeism and mortality, amounted to $81.9 billion.[6] Asthma also affects certain groups disproportionately, rendering significant disparities. For example, asthma is more common and more severe among children, women, low-income, inner-city residents, and African American and Puerto Rican communities, who have higher rates of emergency department visits, hospitalizations and deaths.[7] American Indian/Alaska Native children are 60 percent more likely to have asthma as https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/most_recent_data.htm https://www.cdc.gov/asthma/most_recent_data.htm https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.aafa.org/asthma-facts https://www.atsjournals.org/doi/10.1513/AnnalsATS.201703-259OC https://www.nhlbi.nih.gov/health-pro/resources/lung/naci/discover/disparities.htm non-Hispanic White children.[8]. The reasons for these disparities are complex, but cannot be attributed to genetic differences alone. Economic, social, and cultural factors, ranging from lack of access to quality health care to differences in health beliefs between patients and their doctors, add to the greater asthma burden among these groups. Individuals may also face housing and work conditions that place them at greater risk for frequent and prolonged exposure to environmental allergens and irritants that worsen asthma.[9] This NOFO builds upon work of state and territorial public health departments and their partners supported by CDC through funding opportunity announcements CDC-RFA-EH14-1404 and CDC-RFA-EH16-1606 as well as other entities. Given evidence that a multi-component approach to controlling asthma is more effective than individual strategies applied in isolation, this NOFO is based on a technical package known as EXHALE, which is comprised of six evidence-based strategies selected for their potential of having the greatest collective impact on controlling asthma.[10] To reduce the burden of asthma and help advance the CDC CCARE (Controlling Childhood Asthma Reducing Emergencies) aspirational goal of preventing 500,000 hospitalizations and emergency department visits among children, this NOFO requires strong leadership and enhanced program infrastructure. EXHALE strategies include: Education on self-management, eXtinguishing smoking and second-hand smoke, Home visits for trigger reduction and asthma self-management education, Achievement of guidelines-based medical management, Linkages and coordination of care across settings, and Environmental policies or best practices to reduce asthma triggers from indoor and outdoor sources. Recipients will implement these strategies as a package, ensuring that all six strategies are conducted in the same, high-burden geographic location or population so that strategies complement and reinforce each other.

b. Statutory Authorities Section 317 (k)(2) and 317I of the Public Health Service Act, [42 U.S.C. Sections 247b and 247b-10], as amended.

c. Healthy People 2020 The NOFO addresses Healthy People 2020 and 2030 (proposed) objectives in the focus area of Respiratory Diseases. The four core (proposed) objectives for Healthy People 2030 are: Reduce asthma deaths among the U.S. population, reduce emergency department visits for children with asthma under 5 years, reduce emergency department visits for persons with asthma aged >5 years and reduce asthma attacks among persons with current asthma. Three developmental objectives are: Reduce hospitalizations for asthma among children under age 5 years, reduce hospitalizations for asthma among children and adults aged 5 to 64 years, and reduce hospitalizations for asthma among adults aged 65 years and older.

d. Other National Public Health Priorities and Strategies This NOFO supports the Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 3 (EPR-3) from the National Asthma Education and Prevention Program (NAEPP), Coord inated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities, the Guide to Commu nity Preventive Services and the Institute of Medicine report on Primary Care and Public Health.

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=30 https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=30%20 https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.healthypeople.gov/2020/topics-objectives/topic/respiratory-diseases https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf https://www.nhlbi.nih.gov/science/national-asthma-education-and-prevention-program-naepp https://www.epa.gov/asthma/coordinated-federal-action-plan-reduce-racial-and-ethnic-asthma-disparities https://www.epa.gov/asthma/coordinated-federal-action-plan-reduce-racial-and-ethnic-asthma-disparities https://www.thecommunityguide.org/ https://www.thecommunityguide.org/ http://www.nationalacademies.org/hmd/Reports/2012/Primary-Care-and-Public-Health.aspx

e. Relevant Work Since its inception, the CDC National Asthma Control Program (NACP) has funded state and territorial public health departments to better understand the impact of asthma and to encourage a comprehensive public health approach to asthma control.[11] NACP also funds non-governmental organizations, expanding its efforts to encourage adherence to National Asthma Education and Prevention Program (NAEPP), Expert Panel Report-3 (EPR-3) guidelines and encourage home-based, multi-trigger, multi-component interventions for people whose asthma is poorly controlled.[12] NACP involvement in the 6|18 initiative has aligned evidence-based practices with emerging value-based payment and delivery models.[13] NACP recently started the CCARE initiative to improve asthma outcomes in children.

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

The logic model shown below describes the relationships between the program activities and its intended outcomes.

i. Purpose This NOFO supports progress toward expanding the reach, quality, effectiveness, and sustainability of asthma control services by strengthening leadership and other essential infrastructure components and expanding the six EXHALE strategies. Applicants are encouraged to implement EXHALE strategies in a coordinated manner and in the same high burden areas or https://www.cdc.gov/asthma/ https://www.cdc.gov/asthma/nacp.htm https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf https://www.thecommunityguide.org/topic/asthma https://www.cdc.gov/sixeighteen/index.html https://www.cdc.gov/sixeighteen/asthma/index.htm populations to accelerate progress toward their goals, including the CCARE goal. This NOFO contributes to coordinated care, lower health care costs, and reduced morbidity and mortality due to asthma.

ii. Outcomes Short-term outcomes (1-3 years)

Expanded capacity to deliver or refer people with asthma to asthma self-management education (AS-ME). Education may occur in a variety of settings (e.g., clinics, schools, pharmacies, communities) by a variety of providers (e.g., nurses, respiratory therapists, certified asthma educators, community health workers).

Expanded access, referral to and delivery of coordinated services in high burden areas.

Coordination of services should involve multiple sectors (e.g., social services, housing, schools, employers, non-governmental organizations (NGOs)).

Improved systems that encourage team-based asthma care.

Use of data (surveillance and evaluation) for program improvement. Surveillance data should be used for monitoring population trends in asthma morbidity, mortality, health care utilization and strategic decision making. Evaluation information should be used to improve the efficiency, effectiveness and sustainability of the asthma control program.

For example, data can be used for expanding services to areas of high need; optimizing referrals and coordination of services; developing business cases using economic evaluation data to encourage enhanced coverage of health care.

Intermediate outcomes (4-5 years)

More people with asthma receive appropriate medical assessments, essential medications and devices.

Established linkages and coordination across public health and health care systems.

Long-term outcomes (5+ years)

More people have well-controlled asthma, fewer asthma attacks, and fewer missed school or work days.

Fewer asthma-related emergency department visits, hospitalizations, and deaths.

Combined, these outcomes are expected to contribute to the CCARE goal of preventing a half million asthma-related emergency department visits and hospitalizations among children over time.

iii. Strategies and Activities During the period of performance, recipients will conduct strategies and activities in two major categories, Category A: Enhance Program Infrastructure and Category B: Leverage Partnerships to Expand EXHALE. In Category A, recipients will strengthen their agency leadership and program management, mobilize strategic partners in multiple sectors to coordinate the delivery of asthma control services to priority populations, enhance their asthma surveillance system, conduct appropriate communication activities and use findings from program evaluations to guide continuous program improvement. These efforts will create a strong foundation needed to implement strategies described later in Category B. For purposes of this cooperative agreement, recipients may address people with asthma in all age groups, however, an emphasis on children and adolescents (ages 0-17) is required to advance the work of the CDC CCARE initiative to reduce hospitalizations and emergency department visits among children.

CATEGORY A: ENHANCE PROGRAM INFRASTRUCTURE

Strategy A1: Leadership and Program Management Activities:

a. Provide leadership to encourage planning, coordination and expansion of asthma services and the adoption of evidence-based practices.

Position asthma control as a high priority within the recipient organization. For example, specify asthma as a priority topic within a state health improvement plan, chronic disease prevention and control strategy or other state, territorial or tribal strategic plan.

Assess and monitor the quality of asthma care in the recipient state, territory or tribe and participate in the selection of asthma quality measures (if this process is already underway).

b. Within the first 18 months, develop a strategic plan for asthma control which addresses the recipient's entire geographic area. Write the plan collaboratively with partners and seek input from leaders of the recipient's health agency. The plan should include the following:

Description of problem across the entire geographic area Groups experiencing the highest asthma burden, a description of their unique needs and methods for addressing these needs Assessment of the current availability of asthma control services A listing of goals and objectives (or strategies) to be accomplished and expected outcomes A listing of activities to be implemented collaboratively by the recipient and its partners A description of the roles of the recipient and lead partners A time line for completion

c. Monitor the progress of activities implemented and provide annual updates for partners.

d. Provide technical assistance, training and other resources to partners.

Guide, train, and provide shared learning opportunities to assist partners in implementing effective programs, policies or other activities.

Share best practices and lessons learned.

Share business case analyses with providers and payers to support coverage and reimbursement of asthma services, medications and devices.

Maintain a website where educational, surveillance and evaluation information will be easily accessible to defined audiences.

Strategy A2: Strategic Partnerships:

Activities:

a. Mobilize partners to plan, implement, evaluate and sustain strategies designed to expand the reach of asthma control services, particularly among target audiences with significant disparities in asthma health outcomes as compared with the general population with asthma.

b. Identify priority populations and goals that are common among partners representing multiple sectors (e.g. housing, transportation, maternal and child health). Work to share information and resources for collective impact, expansion of services and reduction of the duplication of effort.

Strategy A3: Surveillance Activities:

a. Maintain and enhance the recipient asthma surveillance system. Monitor and use data to guide strategic action.

Obtain data from the following core data sets: Hospitalization, Emergency Department Visits, Behavioral Risk Factor Surveillance System (BRFSS) Core, BRFSS Random Child Selection Module, BRFSS Child Prevalence Module, BRFSS Asthma Call-Back Survey (adult), BRFSS Asthma Call-Back Survey (child) and Vital Statistics.

Obtain data from additional data sets such as the Youth Tobacco Survey, Youth Risk Behavior Survey, payers (such as Medicaid), worker's compensation, school health (nurse reports/attendance records) or prescription medications. The source of these data sets may be public health departments, community clinics, federally qualified health centers, state Medicaid offices, hospitals, schools, pharmacies, housing authorities, health plans, or other agencies. A list of the core and additional data sets is found in the Glossary of this NOFO.

Analyze, interpret and report measures from the core and additional data sets above for both children and adults. These measures are needed to support effective planning, implementation, and evaluation of asthma control programs conducted by the recipients and their partners. Required core measures include: Hospital Discharge Rates (asthma is first-listed discharge diagnosis), Emergency Department Visit Rates (asthma is first-listed diagnosis), Lifetime Prevalence Rates, Current Prevalence Rates, Asthma Control, Asthma Attacks (in the past 30 days and past 12 months), Activity Limitations, Number of Missed School and Work Days Due to Asthma, Asthma Self-Management Education Activities and Behaviors, and Mortality Rates (where asthma is the underlying cause). Monitor trends in the entire population over time and report annually to CDC.

b. Describe the burden of asthma in the recipient's entire state, territory, or tribe using population-based surveillance data.

Identify specific key audiences that are disproportionately affected by asthma compared with the general population. When determining these key audiences, consider relevant socioeconomic factors as well as geographic area. Use this information to guide program planning 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 either electronic, online or paper formats) and disseminate asthma-specific reports, fact sheets, maps, web tables, briefs, newsletters, or other materials that support program activities.

Strategy A4: Communication Activities:

a. Conduct health communication activities to support people with asthma and their caregivers.

b. Tailor activities to address specific needs of identified audiences, paying attention to culture, literacy, education and other factors of these groups.

c. Define key audiences and develop behavioral communication products and messaging based on NAEPP, EPR-3 guidelines.

Strategy A5: Evaluation Activities:

a. Collaborate with stakeholders to conduct systematic, high quality evaluations of EXHAL E services and expansion of strategies for effectiveness and efficiency. Include both process and outcome evaluations.

b. Build evaluation capacity.

Using strategies such as those noted in Learning and Growing through Evaluation:

State Asthma Program Evaluation Guide, build evaluation capacity to plan, conduct, and use evidence to improve asthma programs. Tailor capacity building efforts to support evaluation efforts, including integrating performance measurement, as noted in section b, Evaluation and Performance Measurement.

c. Use evidence to support business cases.

Develop business cases based on information generated from economic evaluations for expanding EXHALE and supporting coverage of asthma services and medications.

For a description of additional evaluation activities to be implemented in this NOFO, see section iv.b., Evaluation and Performance Measurement.

Category B: Leverage Partnerships to Expand EXHALE In Category B, recipients will implement at least one activity in each of the six EXHALE strategies by the end of the second year of the period of performance. By year five, they will implement and expand all the EXHALE strategies and activities as outlined below, taking into consideration the critical social and cultural context of individuals with asthma and their communities. The EXHALE package outlines opportunities for many different sectors to participate in implement EXHALE strategies and activities on pages 31-33. Opportunities for public health agencies include collecting and disseminating surveillance data, coordinating https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/program_eval/guide.htm https://www.cdc.gov/asthma/program_eval/guide.htm https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf partners who implement the strategies and activities, promoting information sharing across sectors, evaluating activities, and tracking progress toward goals. Therefore, public health has an important role in the Linkages and Coordination of Care across Settings (L in EXHALE) activities. Recipients should prioritize establishing and institutionalizing linkages between partners and across settings, while promoting guidelines-based medical management and expanding asthma self-management education. Although the order of implementation of the strategies will be determined by the recipients and its partners, recipients should also expand access to home visits for asthma trigger reduction and asthma self-management education, support environmental policies and best practices, and make referrals to reduce exposure to indoor and outdoor asthma triggers in order to achieve the greatest public health impact. By the end of the five years, recipients should implement all of the EXHALE strategies in new communities to be determined in consultation with CDC.

Strategy B1: Education on asthma self-management (E in EXHALE) Activities:

a. Expand access to and delivery of asthma self-management education (AS-ME) to people with asthma and their caregivers.

Raise public awareness and increase the use of existing AS-ME programs (e.g., through communication campaigns, educating providers and health plans, or through partners such as schools and day care centers.)

Develop or strengthen partnerships with health care organizations and health plans to expand access to and reimbursement for AS-ME.

Explore proven models and potential pathways for sustaining delivery of AS-ME.

See http://www.cdc.gov/sixeighteen/asthma

b. Develop a cadre of diverse skilled instructors to deliver AS-ME and tailor curricula.

Assess the capacity and training needs of organizations that will deliver asthma self-management education programs. Share evidence-based training materials and work with partners to address those needs prior to implementation.

Define key audiences, develop or adapt, and implement asthma education and communication interventions that are evidence-based and tailored to the needs of individuals with asthma and caregivers of children with asthma, along with intermediary audiences (e.g. clinicians, school personnel, etc.)

c. Educate people with asthma and caregivers in AS-ME skills.

Facilitate partner delivery of AS-ME in multiple settings (e.g., homes, clinics, schools, day care centers, workplaces, pharmacies, etc.) for people with asthma and their caregivers and by a variety of providers (e.g., nurses, respiratory therapists, certified asthma educators, community health workers, etc.)

d. Report data on implementation and outcomes of AS-ME programs. CDC will provide standard data definitions, formats and other instructions.

Strategy B2: Extinguish smoking and exposure to second-hand smoke (X in EXHALE) Activities:

a. Work with partners to make referrals to available smoking cessation programs.

Encourage relevant health care, governmental and non-governmental partner http://www.cdc.gov/sixeighteen/asthma organizations to refer people with asthma who smoke (or their caregivers) to appropriate cessation interventions, counseling and cessation medications approved by the Food and Drug Administration (FDA). Note that recipients may not use more than $2,500 of cooperative agreement funds annually to support activities related to state tobacco control quit lines. For additional information on state and community tobacco control programs funded by CDC, go to https://www .cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/index.htm

Encourage partners to track initiation and completion rates of people participating in these cessation interventions.

b. Report information on smoking status, exposure to second-hand smoke, and referrals to smoking cessation programs in performance measures C and F. See the table of performance measures in the CDC Evaluation and Performance Measure Strategy section of this NOFO.

Strategy B3: Home visits for trigger reduction and AS-ME (H in EXHALE) Activities:

a. Expand access to and delivery of home visits for asthma triggers.

Encourage payers and health plans to offer home visits to improve asthma control among high risk individuals whose asthma is not well-controlled despite guidelines-based medical management and asthma self-management education outside the home.

Offer training and encourage reimbursement for a variety of providers who can effectively deliver home visits for asthma, including nurses, respiratory therapists, certified asthma educators, and trained community health workers.

Encourage the implementation of evidence-based programs and use of environmental assessment tools to reduce asthma triggers in the home. See checklist at https://www.epa.gov/sites/production/files/2018-05/documents/asthm a_home_environment_checklist.pdf

Ensure that programs are evidence-based, cost-effective, sustainable, culturally appropriate, and tailored to the needs of program participants.

Identify existing and new organizations (e.g., community organizations, local health departments, health care organizations or visiting nurse programs) that can expand the reach of asthma home visiting programs; provide those organizations with technical assistance as needed.

Increase awareness of existing home visit delivery programs in the area and encourage providers, health plans, and schools to referrals people to these services. (Other proven models and potential pathways for sustaining the delivery of home visit programs for asthma can be found at http://www.cdc.gov/sixeighteen /asthma.)

b. Report implementation and outcomes data related to home visits for asthma trigger reduction and AS-ME in the performance measures. See the table of performance measures in the CDC Evaluation and Performance Measure Strategy section of this

NOFO.

https://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/index.htm https://www.cdc.gov/tobacco/stateandcommunity/tobacco_control_programs/index.htm https://www.epa.gov/sites/production/files/2018-05/documents/asthma_home_environment_checklist.pdf https://www.epa.gov/sites/production/files/2018-05/documents/asthma_home_environment_checklist.pdf

Strategy B4: Achievement of guidelines-based medical management (A in EXHALE) Activities:

a. Strengthen systems, including quality improvement initiatives, to support guidelines-based medical care.

Encourage Medicaid managed care organizations, other health plans, health care organizations, school-based health centers and group practices to choose asthma as a topic for quality improvement activities.

Use effective, evidence-based processes for quality improvement activities (e.g., audit and feedback, decision support tools, emergency department protocols, care coordination, etc.).

Facilitate focused training of health care providers including physicians, nurses, community health workers and pharmacists to provide team-based care for asthma.

Encourage health plans and providers to use administrative and clinical data to identify patients with poor asthma control and to develop mechanisms for delivering necessary services.

b. Improve access and adherence to medications and devices.

Work with health plans and payers to eliminate barriers (e.g. co-payments, prior authorization, or refill limits) to obtaining and using asthma medications and devices.

Encourage shared treatment decision-making, in which patients with asthma and their health care providers decide on treatment based on patient goals, preferences, and concerns.

c. Provide information on quality improvement initiatives focused on access to care and adherence issues. Report outcome data in the performance measures. See the table of performance measures in the CDC Evaluation and Performance Measure Strategy section of this NOFO.

Strategy B5: Linkages and coordination of care across settings (L in EXHALE) Activities:

a. Encourage coordinated care (including team-based care) across settings.

Encourage health care provider organizations, health insurance plans, schools, community organizations and others to emphasize coordinated care through patient-centered medical homes, disease management, case management, and school- or community-based programs.

Encourage linkages within and across the health care system and community services to address patient needs (e.g., medical or social) and improve health.

Develop systems and mechanisms that are consistent with privacy regulations for bi-directional sharing of information between schools, health care providers and community-based organizations for the purpose of coordinating care for people with asthma.

b. Ensure linkages to community resources.

Develop new or strengthen existing partnerships between asthma service providers and local, state or regional organizations that address relevant social determinants of health (e.g., transportation to medical appointments, integrated pest management, home weatherization assistance programs, tenant advocacy, etc.).

c. Report information on the implementation of coordinated care activities and linkages to community resources in the performance measures. See the table of performance measures in the CDC Evaluation and Performance Measure Strategy section of this

NOFO.

Strategy B6: Adopt environmental policies or best practices to reduce indoor and outdoor asthma triggers (last E in EXHALE) Activities:

a. Encourage the adoption of environmental policies and best practices.

Collaborate with partners that encourage home energy efficiency, including home weatherization assistance programs for low-income families. Structural improvements made by these programs may complement home visiting programs for asthma.

Partner with tobacco control programs to develop and implement smoke-free policies that reduce tobacco smoking and reduce exposure of non-smokers to second-hand smoke (such as smoke-free workplaces, restaurants, and bars) and policies that encourage voluntary or mandatory smoke-free policies for residences such as multi-family homes or apartments.

Encourage the adoption of clean diesel technology (such as retrofitting or modifying school buses with older diesel engines) so they run more cleanly.

Encourage the use of novel air technologies to measure indoor or outdoor air quality.

b. Report information on entities that adopt new policies and best practices in the annual performance report. CDC will provide format and other instructions in post-award guidance.

1. Collaborations

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

Recipients are encouraged, but not required, to collaborate with other CDC-funded programs when interests and activities align. These may include:

Recipients of funding from the CDC National Asthma Control Program (NACP) that funds non-governmental organizations to encourage provider adherence to national guidelines; and encourages entities to provide home-based, multi-trigger, multi-component interventions for people whose asthma is poorly controlled. These are the American Lung Association, Asthma and Allergy Foundation of America, Allergy and Asthma Network, and the National Environmental Education Foundation as well as recipients of any future cooperative agreements awarded by the NACP.

Recipients of funding from the National Center for Environmental Health such as Environmental Public Health Tracking, Climate and Health, and Childhood Lead Poisoning Prevention Programs for the purposes of sharing data, 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 National Center for Chronic Disease Prevention and Health Promotion, including but not limited to, the Division of Population 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; smoking cessation activities; coordinated school health programs and health services; community needs assessments; self-management education; chronic disease quality improvement projects; community health worker training; communication campaigns; or any other activities related to asthma.

CDC Office of the Associate Director for Policy, for the purpose of participating in the 6 |18 Initiative whereas CDC partners are targeting six common and costly health conditions with 18 proven interventions.

CDC Disability and Health Programs, for the purpose of fully engaging people with disabilities into activities regarding asthma management and control.

b. With organizations not funded by CDC:

Recipients should also collaborate with organizations that are not funded by CDC, but are essential to the effective implementation of strategies described in this NOFO. These include, but are not limited to State Medicaid and Children's Health Insurance Program (CHIP) offices;

hospitals; federally qualified health centers and other health care organizations; primary care associations; state medical societies; 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; public health agencies; state departments of education; state and local housing authorities; relevant professional organizations; insurers; quality improvement organizations; social services; or other groups that serve populations experiencing a disproportionate burden of asthma.

2. Target Populations Recipients will be expected to focus on key audiences in their state, territory or tribe that are disproportionately affected by asthma or are at high risk for poor health outcomes, based on analysis of population-based surveillance data. Recipients may address people with asthma in all age groups, however an emphasis on children and adolescents (ages 0-17) is required to advance the work of the CDC CCARE initiative.

a. Health Disparities Strategies and activities described in this NOFO are designed to reduce health disparities and improve social determinants of health among key audiences with the greatest needs. Recipients will first use surveillance data to identify these groups, then implement strategies and activities to deliver or refer people to appropriate asthma control services. Emphasis will be on those most vulnerable. Recipients will engage partners to foster the coordination of care across the health system, including appropriate members of the asthma care team, to ensure delivery of care that is culturally appropriate, and that connections are made to other community resources such as housing or social services.

iv. Funding Strategy The table below provides a list of funding levels available to applicants, based on population size

Population Funding Level 100,000 - 399,999 $300,000 400,000 - 699,999 $350,000 700,000 - 999,999 $450,000 1,000,000 - 1,999,999 $500,000 2,000,000 - 2,999,999 $525,000 3,000,000 - 3,999,999 $550,000 4 ,000,000 - 4,999,999 $575,000 5,000,000 - 5,999,999 $600,000 6,000,000 - 8,999,999 $625,000 9,000,000 - 11,999,999 $650,000 12,000,000 - 14,999,999 $675,000 15,000,000 - 17,999,999 $700,000 18,000,000 - 19,999,999 $750,000 20,000,000 - 24,999,999 $775,000 25,000,000 and over $800,000

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement 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 scalable and effective at reaching target populations. The evaluation strategy is grounded in the CDC Evalu ation 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 Throu gh Evaluation: State Asthma Program Evaluation Guide.

Throughout the five-year period of performance, recipients will 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; and use evaluation findings to improve and enhance programming throughout period of performance. The specific number of evaluations to be 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.

http://www.cdc.gov/mmwr/PDF/RR/RR4811.pdf http://www.cdc.gov/mmwr/PDF/RR/RR4811.pdf http://www.cdc.gov/asthma/program_eval/guide.htm http://www.cdc.gov/asthma/program_eval/guide.htm

CDC will work individually and collectively with recipients to: (1) increase the efficiency and effectiveness of the asthma program; (2) build and share the practice base regarding strategies that reduce the burden of asthma; and (3) contribute toward the goal of the CDC Controlling Childhood Asthma, Reducing Emergencies (CCARE) initiative, preventing a half million hospitalizations and emergency department visits among children with asthma in five years.

Four overarching evaluation questions map to the program logic model. They are:

1. To what extent has the recipient strengthened and expanded programmatic infrastructure to support optimizing services and health systems?

2. To what extent has the recipient leveraged partnerships and policies to expand the EXHALE strategies to ensure availability, efficiency, effectiveness, and health equity?

3. To what extent has the recipient successfully engaged with health plans or health care practices in efforts to improve quality of care?

4. To what extent has the recipient made progress toward achieving the long-term outcomes associated with asthma control, including the reduction of asthma disparities?

To answer these questions, CDC will use an evaluation approach with both qualitative and quantitative methods. Recipients will be required to: (1) report on CDC-developed process and outcome performance measures specified in the table below; (2) plan, develop, implement, and report on results from evaluations prioritized by the recipients and which contribute to overarching evaluation questions in this NOFO; (3) use evaluation evidence to develop business cases in support of sustainable services; and (4) participate in collaborative evaluation efforts with other recipients of this NOFO.

The following performance measures should be collected at the specified intervals using the format described in post-award guidance. CDC will work with recipients in the first year of the cooperative agreement to establish state-specific targets for each measure, specify data formats, and identify key audiences to be tracked over time. Recipients may develop additional measures.

CDC will also work with recipients to define additional qualitative and quantitative measures of progress toward long-term outcomes that are based on the recipients context and baseline situation. CDC will develop specific reporting processes and templates and provide guidance on their function to facilitate and standardize data collection.

Associated Strategies and Activities

Outcomes Performance Measures (PMs

A1.

Leadership/program management

Provide leadership to encourage planning, coordination and expansion of asthma services

Intermediate:

Established linkages and coordination across public health and health care systems

PM B: Linking Activities and Outcomes Documented activities and outcomes to lead and coordinate the establishment and expansion of linkages between components of the EXHALE technical package at the organizational level (e.g., linkages that encourage reimbursement or referrals;

and the adoption of evidence-based practices

Provide technical assistance & training systems developed to share information across providers;

health plans that link with home-based based services or schools

A2. Strategic Partnerships Engage partners to develop, evaluate and sustain strategies, expand comprehensive services.

Intermediate:

Established linkages and coordination across public health and health care systems

PM B: Linking Activities and Outcomes Documented activities and outcomes to lead and coordinate the establishment and expansion of linkages between components of the EXHALE technical package at the organizational level (e.g., linkages that encourage reimbursement or referrals;

systems developed to share information across providers;

health plans that link with home-based based services or schools

A3. Surveillance system/data

Maintain and enhance a state-wide surveillance system

Monitor and use data to guide strategic action

Short-term:

Use of data (surveillance and evaluation) for program improvement

PM A: Analysis and Use of Core Data Sets and Measures Number and percentage of core measures updated, analyzed and reported to CDC during each budget period.

Core measures are listed in the Glossary of the NOFO.

A5. Evaluation

Evaluate services and expansion strategies for

Short-term:

Use of data (surveillance and evaluation) for program

PM E: Use of Evaluation Findings Actions taken or decisions made during the reporting effectiveness and efficiency

Build evaluation capacity

Use evidence to support business cases improvement period to improve program activities and increase program effectiveness as a result of evaluation findings

B1-B6. Leverage Partnerships to Expand

EXHALE

Short-term:

Expanded access, referral to, and delivery of coordinated community-based services in high burden areas

PM C: Comprehensive Services Expansion in High Burden Areas Number and description of existing, new, and discontinued services supported by the recipient and their partners, by geographic area and intervention type;

and alignment of services with high burden geographic areas.

Asthma self-management education (AS-ME) outside of a home visit

Home visits for trigger reductions and/or

ASME

Interventions to improve asthma medical management

Interventions to sustain linkages across interventions (including care coordination)

Smoke-free home policies in multi-unit housing

Smoke-free school campus policies

Other school-based interventions (i.e., not policy, AS-ME, improved medical management or care coordination)

B1. Education on asthma self-management

Expand access to and delivery of asthma self-management education

Develop a cadre of diverse, skilled instructors and tailor curricula

Educate people with asthma and their caregivers in AS-ME skills

Short-Term:

Expanded capacity to deliver or refer to AS-ME Long-Term:

More people have well-controlled asthma, fewer asthma attacks, missed school/work days

PM F: AS-ME Completion Rates Number and demographics of people with asthma who initiated and attended at least 60 percent of sessions of guidelines-based, asthma self-management education (AS- ME); and description of the setting and curriculum of AS- ME courses PM G: Improvement in Asthma Control among AS- ME Completers The number of participants with poorly-controlled asthma on enrollment (a subset of the previous measure) who report that their asthma is well-controlled one month or more after attending at least 60 percent of asthma self-management education sessions

B4. Achievement of guidelines-based medical management

Strengthen systems (including quality improvement initiatives) to support guidelines-based medical care

Improve access and adherence to

Short-Term:

Improved systems to encourage guidelines-based medical management Intermediate:

More people with asthma receiving appropriate medical assessments, essential

PM D: Quality of Guidelines-Based Care Documented improvements in the quality of care or health outcomes (e.g., asthma control, emergency department visits, hospitalizations, AS-ME) as a result of quality improvement initiatives medications and devices medications and devices

CDC will work with recipients to refine and provide further specifications for these measures as needed. Recipients may also choose to develop additional process and outcome indicators to guide and monitor progress toward the outcomes in the logic model. CDC will work with recipients to operationalize the performance measures and identify feasible data sources for the measures. CDC will develop specific reporting processes and templates and provide guidance on their function to facilitate and standardize data collection. CDC will periodically review the use of performance measures and discontinue those that are not informative.

Recipients of this NOFO will be required to submit a Data Management Plan within the first 6 months of award. Measures for all EXHALE strategies will be reported as part of the Performance Measures or the Annual Performance Report. CDC will manage, analyze, and disseminate reports on state-specific and aggregated performance measure information to recipients and appropriate audiences, including federal partners, non-funded partners, the public, and policy makers, as appropriate. The analysis of performance measures and evaluation findings across recipients will guide the CDC technical assistance approach and support a community of practice through which recipients will share program successes and challenges, using the resources provided by CDC (e.g., listservs, online forums and dashboards, calls, and meetings).

CDC will also use aggregated information from the performance measures and evaluation findings to assess recipient progress toward the goals of this NOFO, including CCARE, and establish high-level recommendations for recipients and key stakeholders on program impact, sustainability, and continued program improvement upon completion of the award. CDC will develop and maintain a Data Re-release Plan detailing the planned dissemination and use of surveillance data and performance measures information submitted by recipients.

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…