CDC-RFA-DP-23-0005: The Innovative Cardiovascular Health Program

Notice of Funding Opportunity: The Innovative Cardiovascular Health Program

DP-23-0005 Notice of Funding Opportunity Announcement

The Innovative Cardiovascular Health Program is a 5-year cooperative agreement which will focus on comprehensive efforts to identify and respond to health care disparities in CVD and improve related outcomes, specifically for those with hypertension and high cholesterol.

Proposed interventions must assess and address the disparities and inequities in communities at highest risk, where there is a particular need for equity-focused health system interventions to prevent, detect, control, and manage hypertension and high cholesterol.

Populations of focus for this award are adults aged 18 and older with a hypertension crude prevalence of 53% or higher, as shown by data specifically at the census tract level. Emphasis should be placed on achieving impact and reach across geographic locations where disparate populations can benefit from the strategies included in this NOFO. Applicants must provide details in the Target Population section of the Project Narrative that clearly demonstrate the methodology and data sources used for identifying the population of focus at the census tract level. CDC will work with successful applicants post award to offer confirmation and approval of identified populations through technical assistance with revising workplan, evaluation plan, and budget.

Eligibility

This NOFO is open competition.

Strategies

Successful applicants will be expected to implement activities designed to achieve the short, intermediate, and long term outcomes specified in this NOFO that are in alignment with the following broad strategy categories:

1. Track and Monitor Clinical Measures Shown to Improve Health and Wellness, and Health Care Quality Within Approved Populations of Focus with Hypertension and High Cholesterol.
2. Implement Team-Based Care to Prevent, Detect, Control, and Manage Hypertension and High Cholesterol Within Approved Populations of Focus.
3. Link Community Resources and Clinical Services that Support Comprehensive Bidirectional Referral and Follow-Up Systems Aimed at Mitigating Social Services and Support Barriers for Optimal Health Outcomes Within Approved Populations of Focus.

Outcomes

Recipients are expected to achieve the following outcomes by the end of the period of performance:

Short-term outcomes by strategy 

Strategy 1:

• Increased use of EHRs and HIT to report, monitor, and track clinical data and social services and support needs to improve detection of health care disparities and the identification, management, and treatment within approved populations of focus.
• Increased use of standardized processes or tools, such as GIS or other Geo-mapping tools, to identify, assess, track, and address the social services and support needs within approved populations of focus.

Strategy 2:

• Increased use of health information systems to support communication and coordination among care team members to monitor and address hypertension and high cholesterol within approved populations of focus.
• Increased use of multidisciplinary care teams adhering to evidence-based guidelines to address social services and support needs within approved populations of focus.
• Increased multidisciplinary partnerships that address identified barriers and social services and support needs within approved populations of focus.

Strategy 3:

• Increased community clinical links to identify and respond to social services and support needs within approved populations of focus.
• Increased engagement of CHWs (or their equivalents) to provide a continuum of care by extending clinical interventions and addressing social services and support needs within approved populations of focus.
• Increased use of SMBP with clinical support within approved populations of focus.

Intermediate outcomes

• Improved blood pressure control among populations within partner health care and community settings.
• Reduced disparities in blood pressure control among populations within partner health care and community settings.
• Increased utilization of social support services among approved populations of focus.