About the State, Local, and Tribal Programs

CDC supports all 50 states and the District of Columbia in their efforts to address the serious national health problems of diabetes, heart disease, and stroke.  CDC supports state efforts to:

• Prevent or delay development of type 2 diabetes in people at high risk and improve the health of people living with diabetes.
• Prevent and manage cardiovascular disease.

In September 2018, State Health Departments were awarded funds under a new 5-year cooperative agreement. With CDC support, State Health Departments will work to:

• Increase reporting, monitoring, and tracking of clinical data for improved identification, management, and treatment of patients with high blood pressure and high blood cholesterol.
• Increase 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.
• Increase community-clinical links that support systematic referrals, self-management, and lifestyle change for patients with high blood pressure and high blood cholesterol.
• Increase medication adherence among patients with high blood pressure and high blood cholesterol.
• Increase engagement in self-management among patients with high blood pressure and high blood cholesterol.
• Increase participation in evidence-based lifestyle interventions among patients with high blood pressure and high blood cholesterol.

Learn more about the other programs for the prevention and management of diabetes.

In September 2018, CDC awarded funds to State and Local Health Departments to design, test, and evaluate innovative approaches to address the significant national health problems of diabetes and heart disease and stroke.

29 awardees were funded by this new 5-year cooperative agreement, which include:

• 22 State Health Departments.
• 5 Large City/County Health Departments.
• 2 Consortia of City/County Health Departments.

Of the 29 total awardees funded,

• 17 received both diabetes and heart disease and stroke awards.
• 8 additional recipients received heart disease and stroke awards.
• 4 additional recipients received diabetes awards.

With CDC support, these health departments will develop new approaches to increase the reach and effectiveness of evidence-based public health strategies in populations and communities with a high burden of diabetes, or heart disease and stroke.  Recipients will conduct rigorous evaluations so that CDC and others can learn from this work.

These new approaches aim to:

• Prevent or delay development of type 2 diabetes in people at risk and improve the health of people living with diabetes.
• Prevent and manage cardiovascular disease.

Recipients will develop and evaluate innovative approaches in areas such as:

• Track and monitor clinical measures shown to improve healthcare quality and identify patients with high blood pressure and high blood cholesterol.
• Implement team-based care for patients with high blood pressure and high blood cholesterol, including testing innovative ways to engage non-physician team members.
• 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 through:
  • Engagement of patient navigators/community health workers.
  • Bi-directional referral between community programs/resources and healthcare systems.
  • Expanded use of telehealth including mobile health technology.
  • Innovative ways to enhance referral, participation, and adherence in cardiac rehabilitation programs in traditional and community settings, including home-based settings.

Learn more about the innovative approaches for the prevention and management of diabetes.

DHDSP funds Good Health and Wellness in Indian Country, a cooperative agreement for American Indians and Alaska Natives that allows grantees to develop and work on strategies to improve the health of tribal communities. This cooperative agreement supports the following activities:

• 12 tribes work on effective community-chosen and culturally adapted strategies.
• 11 tribal organizations provide leadership, technical assistance, training, and resources to tribes and villages in their Indian Health Service Administrative Areas.
• 12 Tribal Epidemiology Centers perform a variety of functions in consultation with, and at the request of, tribes, tribal organizations, and urban Indian organizations.

Learn more about Good Health and Wellness in Indian Country (1421).

The WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) program serves low-income, uninsured, and underinsured women aged 40 to 64 years. CDC provides funding to WISEWOMAN programs in 21 states and 3 tribal organizations to enable qualifying women to receive free screenings and counseling about their risk for heart disease and stroke. Organizations in 7 states also received Innovation funding in 2019. The program operates in states and tribal organizations that participate in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which helps ensure women participating in the NBCCEDP receive a full range of health services. Women participate in evidence-based lifestyle programs, receive individual health coaching, or are referred to other community resources. The services provided by each WISEWOMAN program vary, but all are designed to promote lifelong heart-healthy lifestyle changes.

Learn more about WISEWOMAN.

With support from CDC’s Division for Heart Disease and Stroke Prevention, the YMCA of the USA (Y-USA) has developed an evidence-based Blood Pressure Self-Monitoring program that empowers adults with high blood pressure to take control of their hypertension through regular blood pressure self-monitoring and other heart healthy activities. The Y-USA’s Blood Pressure Self-Monitoring program focuses on regulated home self-monitoring of one’s blood pressure using proper measuring techniques, individualized support, and nutrition education for better blood pressure management. With support from a trained Healthy Heart Ambassador, participants measure and record their blood pressure at least two times per month, attend two personalized consultations per month, and attend monthly Nutrition Education Seminars.

Learn more about Y-USA’s Blood Pressure Self-Monitoring program.

Through the Mississippi Delta Health Collaborative (MDHC), the Mississippi State Department of Health leads a coordinated effort to improve heart disease and stroke care within the 18-county Delta region. In alignment with CDC and the Agency for Healthcare Research and Quality, MDHC strives to:

• Enhance collaboration and partnerships at all levels.
• Implement evidence- and population-based interventions in clinical and community settings.
• Increase awareness of high blood pressure, disease management, early recognition, and response to acute events.
• Impact policies to support healthy behaviors in community, faith, and clinical settings.

Four major evidence-based interventions implemented are:

• Clinical Community Health Worker Initiative.
• Medication Therapy Management.
• Policy, Systems, and Environmental Change through Mayoral Health Councils.
• Hypertension Risk Reduction Screening and Provider Referral in Partnership with Congregational Health Nurses, Community Health Workers, and Barbers.

With support from CDC’s Division for Heart Disease and Stroke Prevention, the Association of State and Territorial Health Officials (ASTHO), and participating state teams created and refined a new systems change model for public health. The Collaborative engaged minds across state and local communities— including public health agencies, health care, quality improvement organizations, health information technology experts, payers, and community-based organizations—to develop, expand, and sustain efforts to improve hypertension prevention, detection, and control.

Using this interrelated model, and building on lessons learned from CDC-funded efforts nationwide to prevent heart disease and stroke, states made extraordinary progress toward improved hypertension prevention, detection, and control. This integrated approach sparked a system-wide effort and set the bar for how state public health can help prevent and control hypertension, as well as other chronic disease areas.

ASTHO brought state teams together to share insights and tools to help strengthen and transform blood pressure control across the nation. In each year, the collaborative evolved to expand its reach and impact.

ASTHO currently includes 22 states (Alabama, Arkansas, Colorado, Connecticut, Georgia, Illinois, Indiana, Kansas, Maryland, Michigan, Minnesota, New Hampshire, New York, North Dakota, Ohio, Oklahoma, South Carolina, Texas, Utah, Vermont, Virginia, and Wisconsin), the District of Columbia, the Eastern Aleutian Tribes of Alaska, the US Virgin Islands, the Republic of Palau, Guam, and the Commonwealth of the Northern Mariana Islands (CNMI).

Learn more about the ASTHO State Learning Collaborativeexternal icon.