A Strategic Approach to Advancing Health Equity for Priority Populations with or at Risk for Diabetes—Subject Matter Expertise, Training, and Technical Assistance

The purpose of this NOFO is to support the goals and objectives of the proposed companion NOFO, CDC-RFA-DP23-2320: A Strategic Approach to Advancing Health Equity for Priority Populations with or at Risk for Diabetes, which seeks to prevent or delay onset of type 2 diabetes among adults with prediabetes, improve self-care practices, quality of care, and early detection of complications among people with diabetes, and support implementation of evidence-based, family-centered childhood obesity interventions as a type 2 diabetes risk reduction strategy. All work supported under the companion NOFO will focus on reducing health disparities and achieving health equity for priority populations*, defined as those who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. This NOFO aims to increase capacity among the companion NOFO recipients to improve equitable access to and delivery of diabetes management and type 2 diabetes prevention and risk reduction interventions for priority populations*. Successful applicants will ensure companion NOFO recipients have relevant knowledge and skills by 1) obtaining and providing subject matter expertise through a network of sustainable partnerships, 2) providing training and technical assistance (TA), and 3) developing guidance documents and resources that inform their work. Applicants will be required to describe the approach they will take to address the three strategies contained within this NOFO: Strategy 1: Obtain and provide subject matter expertise through a network of partners and subject matter experts to ensure companion NOFO recipients have relevant knowledge and skills to implement evidence-based approaches to diabetes management and type 2 diabetes prevention and risk reduction in priority populations*. At a minimum, this subject matter expertise includes the following: Diabetes Self-Management Education and Support (DSMES): Strengthening self-care practices through engagement, enrollment, and retention of priority populations* in DSMES and complementary support programs and services; achieving and supporting the uptake of Medicaid and employer health benefit coverage for DSMES; achieving/maintaining American Diabetes Association recognition or Association of Diabetes Care and Education Specialists' accreditation for DSMES services; sustaining program services through billing National Diabetes Prevention Program (National DPP): Enrolling and retaining priority populations* in the National DPP lifestyle intervention; achieving and supporting the uptake of Medicaid and employer health benefit coverage for the National DPP lifestyle intervention; sustaining program services through billing and umbrella hub arrangements; Lifestyle Coach development Type 2 Diabetes Risk Reduction in Youth: Supporting implementation of 4 specific evidence-based family-centered childhood obesity interventions [1. Mind, Exercise, Nutrition...Do It! (MEND)], 2. Family Based Behavioral Therapy, 3. Bright Bodies, 4. Healthy Weight and Your Child] in clinical and community settings Improving Quality of Care for People with Diabetes: Working with health care organizations/systems to promote team-based care; adopt and use clinical quality measures; and maximize the use of clinical decision support, electronic health records, telehealth technology, and other resources to improve care for people with diabetes and support early detection of diabetes complications, with emphasis on chronic kidney disease and diabetic retinopathy Pharmacy: Working with pharmacy networks [e.g., Community Pharmacy Enhanced Services Networks (CPESN), state pharmacy associations] and chain pharmacies to increase and sustain pharmacy-based DSMES and National DPP delivery sites through involvement in umbrella hub arrangements, enhancement of billing systems and processes, and implementation of electronic systems that enable two-way exchange of information between pharmacies and primary care [bidirectional e-referral systems] Bidirectional e-Referral: Supporting the development and use of electronic referral systems to facilitate two-way exchange of information between health care and community-based programs and services to increase participation in the National DPP lifestyle intervention and DSMES services Innovative Service Delivery and Payment Models: Developing/testing innovative delivery and payment models that bundle the National DPP lifestyle intervention and/or DSMES with other programs and services that address social determinants of health-related barriers and needs of priority populations* Community Health Worker (CHW) Infrastructure: Building the infrastructure necessary to promote long-term sustainability and sustainable financing for CHWs to expand their involvement in evidence-based diabetes prevention and management programs and services Social Determinants of Health: Working to reduce barriers to access and participation in diabetes prevention and management programs and services among populations disproportionately impacted by disease burden/risk; tailoring programs and services to better engage and support those populations or work with groups [e.g., historically black colleges and universities, CBOs, faith-based organizations, etc.] with this specialized experience Multisectoral Partnerships: Supporting partners from across sectors (e.g., payers, CBOs, or other groups with demonstrated experience reaching and engaging priority populations*, CDC-recognized program delivery organizations, health care organizations, and others as needed) in leading a synchronized effort to achieve a common goal Technical writing and editing: Working with partners to obtain an in-depth understanding of their work and promising approaches; producing well-written and technically accurate documents and resources appropriate for the intended CDC-RFA-DP23-2320 recipient audience and CDC Applicants will be responsible for securing and providing subject matter expertise to support recipient work across all strategies listed in the companion CDC-RFA-DP23-2320 NOFO. Applicants will be required to describe the expertise, experience, and organizational capacity of their organization and each proposed subject matter expert or partner organization to successfully provide the support requested. Strategy 2: Provide training and technical assistance to ensure relevant knowledge and skills of the companion NOFO recipients to implement evidence-based approaches to diabetes management and type 2 diabetes prevention and risk reduction in priority populations*. In consultation with CDC, applicants will be responsible for: 1) conducting a rapid assessment of companion NOFO recipients to identify training and TA needs; 2) developing a training and TA plan that includes peer learning; 3) establishing communities of practice and/or learning collaboratives to facilitate information sharing and peer learning; 4) developing, promoting, delivering, and facilitating training and TA; and 5) evaluating the delivery of training, TA, and peer learning activities. Strategy 3: Develop guidance documents and resources for the companion NOFO recipients to ensure relevant knowledge and skills to implement evidence-based approaches to diabetes management and type 2 diabetes prevention and risk reduction in priority populations*. In consultation with CDC, applicants will be responsible for developing: 1) well-written and technically accurate guidance documents to support recipients' understanding and implementation of the companion NOFO strategies; 2) a standard interactive orientation package for new recipient staff; 3) resources to demonstrate the value of program activities and showcase recipients' progress, success, capacity, and outcomes (e.g., success stories, summation of lessons learned, impact briefs, reports, newsletters, websites, etc.); and 4) materials to support the evaluation of program activities and identify and document promising practices (e.g., case studies, emerging practice examples, etc.). *Priority populations are defined as those who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.