PKG00251019-instructions.pdf

Centers for Disease Control

National Center for Chronic Disease Prevention and Health Promotion

Mississippi Delta Health Collaborative (MDHC)

CDC-RFA-DP19-1907

Application Due Date: 07/16/2019

Mississippi Delta Health Collaborative (MDHC)

CDC-RFA-DP19-1907

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-DP19-1907. 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:

Mississippi Delta Health Collaborative (MDHC) 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-DP19-1907

E. Assistance Listings (CFDA) Number:

93.816 F. Dates:

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

2. Due Date for Applications: 07/16/2019, 11:59 p.m. U.S. Eastern

Standard Time, at www.grants.gov.

3. Date for Informational Conference Call:

N/A

G. Executive Summary:

1. Summary Paragraph:

The purpose of this NOFO is to implement population-wide and priority population approaches to prevent and control high blood pressure, and reduce health disparities associated with high blood pressure, among adults in the 18-county Mississippi (MS) Delta Region, which is a high burden, underserved, rural area. This will be achieved by the applicant implementing strategies related to health systems interventions and community-clinical linkages across the 18-county MS Delta Region. This NOFO is non-competitive.

a. Eligible Applicants: Single

b. NOFO Type: Cooperative Agreement

c. Approximate Number of Awards: 1 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

d. Total Period of Performance Funding: $15,750,000

e. Average One Year Award Amount: $3,150,000

f. Total Period of Performance Length: 5

g. Estimated Award Date: 09/29/2019

h. Cost Sharing and / or Matching Requirements: N

Part II. Full Text A. Funding Opportunity Description

Part II. Full Text

1. Background

a. Overview In recent decades, efforts in chronic disease prevention and management have achieved numerous successes alongside other areas of stagnation and new challenges. Where successes have occurred, such as in the reduction of cardiovascular disease mortality, these have generally resulted from long-term, multi-tiered interventions to improve the organization and provision of preventive care within health systems. This has also been achieved through the establishment of community-clinical linkages to connect individuals at risk to evidence-based programs and services available in communities and worksites. Despite such successes, there are significant barriers and variations in core chronic disease risk factors and conditions by location and across populations in the US. Numerous challenges exist to improving the health of high-burden populations, including access to preventive services and care, poor quality of care, limited development of effective community-clinical linkages, and the competing demands of other health and social conditions.

Cardiovascular disease (CVD) is the leading cause of deaths in the United States (>800 000, or about 1 in 3 overall deaths/year), and around 1 in 5 who die from CVD are younger than 65 years. CVD is costly, with an estimated 1 in every 7 health care dollars is spent on CVD (about 15%). Considerable improvements in CVD mortality has been recognized in the preceding decades, with advancements in the treatment of CVD and in public health interventions significantly contributing to the gains.

Hypertension is a primary risk factor for CVD. The burden and deleterious effects of hypertension are significant, affecting an estimated 75M adults in the US (about 1 in 3). While control of hypertension, reflective of individual and system-level improvements, has been increasing, only about half of those with hypertension are controlled. Hypertension is also a frequent contributing factor to major CVD outcomes. For example, 69% of people who have a first heart attack, 77% of people who have a first stroke, and 75% of people with chronic heart failure have hypertension. Interventions to further support patient engagement, prevention, and health system improvements are available and need to be maximized to improve hypertension management.

Residents of the 18-county MS Delta Region experience age-adjusted rates of death due to heart disease, stroke, and major CVDs that are considerably higher than the state of MS and national rates. Marked racial health disparities exist, with African American men having the highest rates of heart disease and stroke. Medical care costs for people with chronic diseases account for more than 75% of the nation's $2.6 trillion medical care costs. In 2010, the total costs of cardiovascular diseases in the United States were estimated to be $444 billion and treatment costs for heart diseases accounts for about $1 of every $6 spent on health care.

b. Statutory Authorities Section 317(k)(2) of the PHS Act, 42 U.S.C. 247b(k)(2).

c. Healthy People 2020 Healthy People 2020 Topic Area(s): https://www.healthypeople.gov/2020/topics-objectives aligned to this NOFO include the following:

Cardiovascular Disease-related HP 2020 objectives: https://www.healthypeople.gov/2020/topics -objectives/topic/heart-disease-and-stroke.

HDS-2: Reduce coronary heart disease deaths.

HDS-3: Reduce stroke deaths.

HDS-5.1: Reduce the proportion of adults with hypertension.

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.

d. Other National Public Health Priorities and Strategies This NOFO supports work in the following areas: improving quality of care in healthcare systems and building community-clinical linkages. These have been identified as priority areas of focus by the National Center for Chronic Disease Prevention and Health Promotion.

Additionally, this NOFO supports work in the following priority areas identified by the Division for Heart Disease and Stroke Prevention:

Hypertension prevention, detection, and control Additional recommended strategies for Cardiovascular Disease Prevention and Control may be found at: https://www.thecommunityguide.org/content/task-force-findings-cardiovascular-disease

Million Hearts® 2022: https://millionhearts.hhs.gov/

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

CDC's work in the MS Delta Region has been implemented over several phases.

Initially, in 2006 (Phase One), CDC collaborated with the Mississippi Department of Health to establish the groundwork for the Mississippi Delta Health Collaborative (MDHC) through a 2-year planning phase which included the development of a strategic plan.

During the 2-year project period for CDC-RFA-DP08-820 (Phase Two), and the 6-year project period for CDC-RFA-DP10-1013 (Phase Three), MDHC, the Mississippi Department of Health, and partners implemented environmental strategies and community-clinical linkage strategies that were tailored to meet the unique local needs of the 18-county MS Delta Region to achieve greatest community-wide impact related to the prevention and control of heart disease and stroke.

The most recent project period for CDC-RFA-DP16-1612 supported implementation of population-wide and priority population approaches to prevent and control high blood pressure among adults in the 18-county Mississippi (MS) Delta Region through the implementation of two components: Component 1 implemented and strengthened environmental strategies to increase environments that promote, support, or reinforce physical activity and healthy foods and beverages, particularly those with low or no sodium, and to increase environments that are tobacco- and smoke-free. Component 2 implemented and strengthened health systems and community-clinical linkage strategies. These were implemented simultaneously and synergistically to address the prevention and control of high blood pressure among MS Delta Region's general and priority populations. Priority populations are those adult population subgroups in the MS Delta Region with uncontrolled high blood pressure who experience racial/ethnic and socioeconomic disparities, including inadequate access to care and poor quality of care.

This NOFO will advance the agency priorities of hypertension prevention, detection, and control associated with Million Hearts® 2022. This NOFO will support innovation, allowing the state to explore, evaluate, and document novel approaches to addressing critical gaps in programmatic knowledge in the MS Delta region. This NOFO will also build on the accomplishments and outcomes achieved in the health care systems and community-clinical linkages arenas in CDC-RFA-DP13-1305 (https://www.cdc.gov/chronicdisease/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 innovation, allowing the applicant to explore, evaluate, and document novel approaches to addressing critical gaps in programmatic knowledge in the MS Delta region. This NOFO will also build on the accomplishments and outcomes achieved in the health care systems and community-clinical linkages arenas in CDC-RFA-DP13-1305 and CDC-RFA-

DP16-1612.

ii. Outcomes 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 bi-directional referrals, self-management, and lifestyle change for patients with high blood pressure, high blood cholesterol, and/or who have had a cardiac event

Long-term outcomes:

--Increased control among adults with known high blood pressure

--Increased cholesterol management among patients at high risk of cardiovascular events

iii. Strategies and Activities Applicant must address all activities in alignment with the primary strategies Track and Monitor Clinical Measures shown to improve healthcare quality and identify patients with high blood pressure and high blood cholesterol 1.) Increase identification of patients with undiagnosed hypertension using EHRs/HIT 2.) Explore and test innovative ways to promote the adoption of evidence-based quality measurement at the provider level (e.g., use dashboard measures to monitor health outcomes among high burden subpopulations and implement related activities) Implement Team-Based Care for patients with high blood pressure and high blood cholesterol 3.) Explore and test innovative ways to engage non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management in clinical settings 4.) Promote the adoption of MTM between community 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 bi-directional referrals, self-management, and lifestyle change for patients with high blood pressure, high blood cholesterol and/or who have had a cardiac event 5.) Facilitate engagement of patient navigators/community health workers in high blood pressure and high cholesterol management in clinical and community settings 6.) Implement systems to facilitate bi-directional referral between community programs/resources and healthcare systems (e.g. using EHRs, 800 numbers, 211 referral systems, etc.)

7.) Explore and test innovative ways to expand use of telehealth including mobile health technology (e.g., smart apps, text messages) to promote management of hypertension and high blood cholesterol 8.) Explore and test innovative ways to enhance referral, participation, and adherence in cardiac rehabilitation programs in traditional and community settings, including home-based settings

1. Collaborations

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

Applicant is 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 CDC-RFA- DP18-1816: WISEWOMAN; national organizations funded under CDC-DP17-

1705 (Scaling the National Diabetes Prevention Program in Underserved Areas); tribes or tribal organizations funded under CDC-RFA-DP14-1421 (Good Health and Wellness in Indian Country, which ends in FY 2019); CDC-RFA-DP18-1815: Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke; and other CDC-funded chronic disease prevention and management programs, where appropriate.

Applicant should also link to strategies and collaborations described in the jurisdiction's Chronic Disease Plan, as applicable.

Letters of support and MOAs/MOUs are not required but should be considered where appropriate and helpful in supporting collaborative efforts. If used, they should be named "MOUs/MOAs.jurisdiction name" and uploaded as a PDF file at www.grants.gov.

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. Applicant should describe collaborations proposed with organizations relevant to strategies selected and activities proposed in the NOFO. These organizations may include employers; commercial health plans; hospitals; FQHCs/RHCs/community health centers; non-profit agencies; other federal, state, or local government agencies; tribes or tribal organizations; professional associations (state medical society, other medical specialty associations, etc.); quality improvement organizations; and others.

Letters of support and MOAs/MOUs are not required but should be considered where appropriate and helpful in supporting collaborative efforts. If used, they should be named "MOUs/MOAs.jurisdiction name" and uploaded as a PDF file at www.grants.gov.

2. Target Populations All recipient activities supported through this NOFO must reflect an approach that targets the entire population of the 18-county MS Delta Region, as well as specific, selected priority populations of the 18-county MS Delta Region. Priority populations are those who are at high risk or experience a disproportionate burden of cardiovascular disease, including high blood pressure and high blood cholesterol due to racial/ethnic, socioeconomic or other characteristics, including inadequate access to care, and poor quality of care. 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 cardiovascular disease, particularly high blood pressure and high blood cholesterol.

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 Applicant is strongly encouraged to sub-award 50% of award funds to local- and regional-level entities to contribute to the work, must provide leadership and technical assistance to selected MS Delta Region communities, and must ensure overall coordination.

Applicant is encouraged to allocate at least 10% of its total funding award to evaluation and performance monitoring.

In order to maximize the reach of federal funding, applicant must ensure that efforts are complementary and not duplicative of other efforts in the 18-county MS Delta Region, such as CDC-RFA-DP18-1815: Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke; and other CDC-funded chronic disease prevention and management programs.

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 determine whether the identified strategies and associated activities can be implemented at various levels (i.e., state, cities, counties, priority populations, etc.) within a state.

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

1. Approach: To what extent have recipients' implementation approaches been innovative in achieving the desired outcomes?

2. Effectiveness:

To what extent has the NOFO increased the reach of strategies to prevent and control cardiovascular disease and related risk factors?

To what extent has implementation of selected strategies led to improved health outcomes in the identified priority populations?

What factors or components were associated with effective implementation of selected strategies?

What innovative strategies implemented by recipients can be replicated and/or scaled?

3. Sustainability: To what extent can the strategies implemented be sustained after the NOFO ends?

4. 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? The recipient will also participate in relevant CDC-led evaluation activities.

CDC will use an evaluation approach that consists of ongoing monitoring and evaluation through the collection and reporting of performance measures and recipient -led evaluations.

CDC will work with applicant to operationalize the required outcome performance measures and assist with the identification of sound data collection approaches and/or the availability of existing data collection instruments.

For the CDC-led evaluation activities, CDC will lead the design, data collection, analysis, and reporting. Recipient will be asked to participate in evaluation activities such as surveys, interviews, case studies, and other data collection efforts. CDC will use findings from these evaluation efforts to refine its technical assistance and, in turn, maximize and sustain program outcomes.

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 customized approach to ensure that tools and services provided meet the needs of the recipient. All information will be reported via a secure system. All evaluation findings produced by CDC and recipient will contribute to: (1) continuous program and quality improvement of program efforts; (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 recipient-led 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. Recipient will report performance measure data annually and will only have access to their data. Over the five-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 may aggregate data to publish annual and summative reports.

Short-term measures and long term measures reported by recipient are detailed below.

Short Term Outcomes Measures

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

B.1. # and % of providers with a protocol for identifying patients with undiagnosed hypertension B.2. % improvement blood pressure control and cholesterol management among priority populations based on innovative activities at the provider level

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

B.3. % improvement in blood pressure control and cholesterol management among patients based on innovative activities B.4. # and % of community pharmacists engaged in the practice of MTM to promote medication self -management for high blood pressure and high blood cholesterol

Increased community clinical links that support bi-directional referrals, self-management, and lifestyle change for patients with high blood pressure, high blood cholesterol, and/or who have had a cardiac event

B.5a. # of patients within health care systems that engage Community Health Workers (CHWs) or community navigators to link patients to community resources that promote self-management of high blood pressure

B.5b. # of patients within clinical and/or community settings that engage with CHWs or community navigators who link patients to community resources that promote cholesterol management B.6a. # of adult patients within 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

B.6b. # of adult patients within health care systems with an implemented community referral system tracking bi-directional referrals for evidence-based lifestyle change programs for people with high blood cholesterol B.7a: # and % of patients in the selected clinical or community settings with hypertension who use telehealth technologies to manage their blood pressure

B.7b: # and % of patients in the selected clinical or community settings with high blood cholesterol who use telehealth technologies to manage their cholesterol B.8a. # and % of patients in selected clinical and/or community settings who have had a qualifying event or diagnosis within the previous 12 months, who receive a new referral to a Cardiac Rehabilitation program B.8b. # and % of patients in selected clinical and/or community settings who have had a qualifying event or diagnosis, who attend at least 1 session in a Cardiac Rehabilitation program B.8c. # and % of patients in selected clinical and/or community settings who have had a qualifying event or diagnosis, who have enrolled in a Cardiac Rehabilitation program and have participated in 25 or more sessions Long-Term Outcomes Increased control among adults with known

Long Term Outcomes Measures

Increased control among adults with known high blood pressure

B.9. Proportion of adults with known high blood pressure who have achieved blood pressure control

Increased cholesterol management among patients at high risk of cardiovascular events

B.10. Proportion of patients considered at high risk of cardiovascular events who have their cholesterol managed with statin therapy Alternate Performance Measure: Proportion of patients with a diagnosis of dyslipidemia who have been prescribed statin therapy

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, if applicable, within the first 6 months of award, as described in the Reporting Section of this NOFO.

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 strongly encourages recipient to allocate a minimum of 10% of the total funding award to evaluation and performance monitoring, and 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/mmwrhtml/rr4811a1.htm).

With support from CDC, recipient 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. CDC will work closely with recipients to develop the detailed plan to ensure that it is appropriate for the activities undertaken, for compliance with the monitoring and evaluation guidance established by CDC, or other guidance otherwise applicable to this cooperative agreement.

c. Organizational Capacity of Recipients to Implement the Approach The applicant must describe its organizational capacity to carry out the strategies included in the NOFO. CDC expects applicant to demonstrate sufficient capacity and readiness to address and implement the required strategies and demonstrate impact on the performance measures over the 5-year period of performance.

When applicants are describing organizational capacity, emphasis should be given to prior experience regarding:

Addressing health equity within the jurisdiction (state, city, county, or group of cities/counties).

https://www.cdc.gov/grants/additionalrequirements/ar-25.html

Minimizing duplication of effort, and particularly, building on complementary efforts being funded by CDC.

Coordinating efforts with other federally and privately funded programs within the jurisdiction in an effort to leverage resources and maximize impact.

Demonstrated readiness to implement the evidence-based strategies in this NOFO includes the ability to describe the following:

Established partnerships with groups/organizations relevant to the strategies selected.

Prior experience working and providing technical assistance on the strategies selected.

Proven ability to conduct program evaluation and monitor performance, including the ability to collect data at a population level and use data to demonstrate impact on priority populations.

Experience with planning and implementing programs at a jurisdiction-wide or systems level

Sufficient leadership within the applicant's organization for program planning and development including the identification, hiring, or reassignment and supervision of staff, contractors, and/or consultants sufficient in number and subject matter expertise to plan and implement strategies selected.

d. Work Plan

Complete a work plan template that describes relevant activities aligned with all primary strategies.

Track and Monitor Clinical Measures shown to improve healthcare quality and identify patients with high blood pressure and high blood cholesterol

Strategy Description

Activity Description Lead Personnel

Contributin g Partners

Key Contracts and Consultants

Start Quarter End Quarter

Activity 1

Activity 2

Activity 3

Activity 4

Activity 5

Short Term Outcomes

Short Term and Intermediate Performance Measures

(Outcome Description) (For each measure, include the Measure Description, Baseline Value, Year 1 Target Value, and Data source)

Measure:

· Baseline:

· Year 1 Target:

· Data Source:

Measure:

· Baseline:

· Data Source:

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

Contributin g Partners

Key Contracts and Consultants

Start Quarter End

(Outcome Description) (For each measure, include the Measure Description, Baseline Value, Year 1 Target Value, and Data source)

Measure:

· Baseline:

· Year 1 Target:

· Data Source:

Measure:

· Baseline:

· Data Source:

Link Community Resources and Clinical Services that support bi-directional referrals, self-management, and lifestyle change for patients with high blood pressure, high blood cholesterol and/or who have had a cardiac event

Contributin g Partners

Key Contracts and Consultants

Start Quarter End

(Outcome Description) (For each measure, include the Measure Description, Baseline Value, Year 1 Target Value, and Data source)

Measure:

· Baseline:

· Year 1 Target:

· Data Source:

Measure:

· Baseline:

· Year 1 Target:

· Data Source:

Provide a general summary of work plan activities proposed for Years 2-5 (maximum of one page narrative).

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

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

Tracking recipient progress in achieving the desired outcomes.

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

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

Monitoring may also include the following activities deemed necessary to monitor the award:

Ensuring that work plans are feasible based on the budget and consistent with the intent of the award.

Ensuring that recipients are performing at a sufficient level to achieve outcomes within stated timeframes.

Working with recipients on adjusting the work plan based on achievement of outcomes, evaluation results and changing budgets.

Monitoring performance measures (both programmatic and financial) to assure satisfactory performance levels.

Monitoring and reporting activities that assist grants management staff (e.g., grants management officers and specialists, and project officers) in the identification, notification, and management of high-risk recipients.

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

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

Tracking recipient progress in achieving the desired outcomes.

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

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

Monitoring may also include the following activities deemed necessary to monitor the award:

Ensuring that work plans are feasible based on the budget and consistent with the intent of the award

Ensuring that recipients are performing at a sufficient level to achieve outcomes within stated timeframes

Working with recipients on adjusting the work plan based on achievement of outcomes, evaluation results and changing budgets.

Monitoring performance measures (both programmatic and financial) to assure satisfactory performance levels.

Monitoring and reporting activities that assist grants management staff (e.g., grants management officers and specialists, and project officers) in the identification, notification, and management of high-risk recipients.

The proposed work plan and performance measures will be reviewed annually by the project officer and evaluation staff, and may need to be altered to better reflect program activities as outlined in the NOFO. Monitoring will occur routinely through ongoing communication between CDC and recipients via monthly calls, reporting mechanisms (i.e., work plans, performance measures, and financial reporting), and site visits. Post-award cooperative agreement monitoring and provision of technical assistance and training will include:

Ensuring that work plans are feasible, fiscally responsible, consistent with the intent of the NOFO, and have acceptable milestones and timelines.

Ensuring that the activities outlined in the NOFO are being completed Assisting recipients in adjusting work plan activities based on achievement of objectives and/or budget changes.

Communicating as needed, or at minimum monthly, with the project coordinator and other program staff on conference calls/webinars.

Sponsoring webinars and other meetings/trainings associated with the NOFO.

Providing tools/resources aligned with program activities and NOFO outcomes, assessment, and implementation support.

CDC will analyze performance measurement data to review progress and identify technical assistance needs for NOFO strategies on an annual basis. The performance measure data will be triangulated with the other internal and external sources of appropriate data to arrive at a rational assessment of progress. The findings from the annual analysis of performance measure data will be used to identify areas of program improvement, broader technical assistance needs, and to report to stakeholders. CDC will develop periodic, performance measure reports to be disseminated to recipient and other key stakeholders, including federal partners, non-funded partners, and policy makers as appropriate. These findings may also be presented during the site visits and recipient meetings. In addition to performance measures reported by recipient, CDC will track all outcome measures (not listed in required recipient table for reporting) that are relevant to the program through national datasets or other evaluation activities that span across division programmatic work, where appropriate.

The evaluation will be used to answer questions in the domains of approach, efficiency, effectiveness, sustainability, impact, and innovation for the strategies being implemented by recipients. The specific questions in each domain will be updated annually, based on findings from the performance measure data, as well as other lessons learned throughout the year. All evaluation findings produced by CDC and recipient, 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 up of these program strategies; and/or (4) future funding opportunities at CDC.

f. CDC Program Support to Recipients (THIS SECTION APPLIES ONLY TO

COOPERATIVE AGREEMENTS)

The CDC programs supporting this NOFO will be substantially involved beyond site visits and regular performance and financial monitoring during the period of performance. Substantial involvement means that the recipient can expect federal programmatic partnership in carrying out efforts under the award. CDC will work in partnership with the recipient to ensure the success of the cooperative agreement by:

Supporting recipient in implementing cooperative agreement requirements and meeting program outcomes;

Providing technical assistance to revise annual work plans;

Assisting recipient in advancing program activities to achieve project outcomes;

Providing scientific subject matter expertise and resources in support of the selected strategies;

Collaborating with recipient to develop and implement evaluation plans that align with

CDC evaluation activities;

Providing technical assistance on recipient evaluation and performance measurement plans;

Providing technical assistance to define and operationalize performance measures;

Using webinars and other social media for recipient and CDC to communicate and share tools and resources;

Establishing learning communities to facilitate the sharing of information among recipient and sub-recipients, where applicable;

Providing professional development and training opportunities either in person or through virtual, web-based training formats for the purpose of sharing the latest science, best practices, success stories, and program models;

Participating in relevant meetings, committees, conference calls, and working groups related to the cooperative agreement requirements to achieve outcomes;

Coordinating communication and program linkages with other CDC programs and Federal agencies, such as the Health Resources and Services Administration (HRSA), Centers for Medicare & Medicaid Services (CMS), Indian Health Service (IHS), and the National Institutes of Health (NIH);

Providing surveillance technical assistance and state-specific data collected by CDC;

Providing technical expertise to other CDC programs and Federal agencies on how to interface with recipient;

Translating and disseminating lessons learned through publications, meetings, and other means on promising and best practices to expand the evidence base; and Hosting a meeting/training during the first 18 months of the period of performance and later in the period of performance (for a total of 2 meetings/trainings for recipient)

Additionally, CDC will:

Ensure that recipient has access to expertise found throughout the National Center for Chronic Disease Prevention and Health Promotion.

Collaborate with recipient to explore appropriate flexibilities needed to meet public health outcomes and goals. Flexibility in cooperative agreements includes recipient ability to propose alternative methods to achieve the outcomes and goals of the cooperative agreement that align with recipient opportunities for success, infrastructure, partner and stakeholder buy-in, demographics, and burden. This includes bringing together resources from multiple cooperative agreements to jointly advance the goals of each, and expanding the dialogue to bring in other CDC and recipient staff to reach a win/win solution.

Create greater efficiencies and consistency across NCCDPHP programs. For example:

1.) Jointly developed resources and tools that focus on cross-cutting functions, settings, domains, risk factors, conditions and diseases to ensure consistent messages and to meet technical assistance needs and 2.) Joint training and technical assistance opportunities that help state health departments produce policies and programs that are more holistic.

Continue and expand support for recipient to leverage National Center for Chronic Disease Prevention and Health Promotion resources to address cross-cutting functions, domains, settings, risk factors, and diseases.

B. Award Information

1. Funding Instrument Type: Cooperative Agreement CDC's substantial involvement in this program appears in the CDC Program Support to Recipients Section.

2. Award Mechanism: U58

3. Fiscal Year: 2019

4. Approximate Total Fiscal Year Funding: $3,150,000

5. Approximate Period of Performance Funding: $15,750,000

This amount is subject to the availability of funds.

Estimated Total Funding: $15,750,000

6. Approximate Period of Performance Length: 5 year(s)

7. Expected Number of Awards: 1

8. Approximate Average Award: $3,150,000 Per Budget Period

9. Award Ceiling: $3,150,000 Per Budget Period

This amount is subject to the availability of funds.

10. Award Floor: $2,150,000 Per Budget Period

11. Estimated Award Date: 09/29/2019

12. Budget Period Length: 12 month(s)

Throughout the project period, CDC will continue the award based on the availability of funds, the evidence of satisfactory progress by the recipient (as documented in required reports), and the determination that continued funding is in the best interest of the federal government. The total number of years for which federal support has been approved (project period) will be shown in the “Notice of Award.” This information does not constitute a commitment by the federal government to fund the entire period. The total period of performance comprises the initial competitive segment and any subsequent non-competitive continuation award(s).

13. Direct Assistance Direct Assistance (DA) is not available through this NOFO.

C. Eligibility Information

1. Eligible Applicants Eligibility Category: Others (see text field entitled "Additional

Information on Eligibility" for clarification)

Additional Eligibility Category:

2. Additional Information on Eligibility Financial assistance from this Notice of Funding Opportunity will be provided only to the Mississippi Department of Health /Mississippi Delta Health Collaborative (MDHC). No other applications will be solicited or reviewed.

3. Justification for Less than Maximum Competition FY 2016 and FY 2019 Congressional language called for CDC to continue working with MDHC and relevant stakeholders (e.g., local pharmacy schools, community health networks) to reach populations at high risk in the MS Delta through interventions such as team-based approaches designed to link communities with clinical care, medication therapy management, and community-based health initiatives.

The Mississippi Department of Health’s mission is to promote and protect the health of the citizens of Mississippi. In addition, the Mississippi Department of Health is designated as the sole and official agency to administer and supervise all health planning responsibilities for the state, as established by Section 41-7-171 et seq., of the Mississippi Code 1972. Therefore, it is uniquely qualified to identify those areas of greatest need in the state; develop strategies to reduce barriers and deficiencies in the state’s public health care system; and establish policies to encourage the provision of appropriate and quality care in the public and private health care system. Through its program, MDHC, reach of the Mississippi Department of Health is further extended to address rural health issues of the state. The 18-county MS Delta Region, identified as a rural health area with high need, bears a disproportionate burden of heart disease and stroke, and related conditions as compared to the rest of Mississippi and to the nation.

CDC’s work in the MS Delta Region has been implemented over several phases. Initially, in 2006 (Phase One), CDC collaborated with the Mississippi Department of Health to establish the groundwork for MDHC through a 2-year planning phase which included the development of a strategic plan. During the 2-year project period for CDC-RFA-DP08-820 (Phase Two), and the 6-year project period for CDC-RFA-DP10-1013 (Phase Three), MDHC, the Mississippi Department of Health, and partners implemented environmental strategies and community-clinical linkage strategies that were tailored to meet the unique local needs of the 18-county MS Delta Region to achieve greatest community-wide impact related to the prevention and control of heart disease and stroke.

The most recent project period for CDC-RFA-DP16-1612 supported implementation of population-wide and priority population approaches to prevent and control high blood pressure among adults in the 18-county Mississippi (MS) Delta Region through the implementation of two components across the MS Delta Region:

Component 1 implemented and strengthened environmental strategies to increase environments that promote, support, or reinforce physical activity and healthy foods and beverages, particularly those with low or no sodium, and to increase environments that are tobacco- and smoke-free.Component 2 implemented and strengthened health systems and community-clinical linkage strategies. These were implemented simultaneously and synergistically to address the prevention and control of high blood pressure among MS Delta Region's general and priority populations. Priority populations are those adult population subgroups in the MS Delta Region with uncontrolled high blood pressure who experience racial/ethnic and socioeconomic disparities, including inadequate access to care and poor quality of care.

4. Cost Sharing or Matching Cost Sharing / Matching Requirement: No

5. Maintenance of Effort Maintenance of effort is not required for this program.

D. Application and Submission Information

1. Required Registrations An organization must be registered at the three following locations before it can submit an application for funding at www.grants.gov.

a. Data Universal Numbering System:

All applicant organizations must obtain a Data Universal Numbering System (DUNS) number.

A DUNS number is a unique nine-digit identification number provided by Dun & Bradstreet (D&B). It will be used as the Universal Identifier when applying for federal awards or cooperative agreements.

The applicant organization may request a DUNS number by telephone at 1-866-705-5711 (toll free) or internet at http:// fedgov.dnb. com/ webform/ displayHomePage.do. The DUNS https://www.grants.gov/ http://fedgov.dnb.com/webform/displayHomePage.do number will be provided at no charge.

If funds are awarded to an applicant organization that includes sub-recipients, those sub-recipients must provide their DUNS numbers before accepting any funds.

b. System for Award Management (SAM):

The SAM is the primary registrant database for the federal government and the repository into which an entity must submit information required to conduct business as a recipient. All applicant organizations must register with SAM, and will be assigned a SAM number. All information relevant to the SAM number must be current at all times during which the applicant has an application under consideration for funding by CDC. If an award is made, the SAM information must be maintained until a final financial report is submitted or the final payment is received, whichever is later. The SAM registration process can require 10 or more business days, and registration must be renewed annually. Additional information about registration procedures may be found at www.SAM.gov.

c. Grants.gov:

The first step in submitting an application online is registering your organization at www.grants.gov, the official HHS E-grant Web site. Registration information is located at the "Applicant Registration" option at www.grants.gov.

All applicant organizations must register at www.grants.gov. The one-time registration process usually takes not more than five days to complete. Applicants should start the registration process as early as possible.

Step System Requirements Duration Follow Up 1 Data