Cardiovascular disease (CVD), which includes heart disease, stroke, and other vascular diseases, is the leading cause of death in the United States and related mortality rates are increasing.1 In 2021, 934 509 people died from CVD, representing a 0.6% increase from 2020 (928 713).1 In addition to increasing mortality rates, CVD is costly, with an estimated 1 in 8 health care dollars spent on CVD.2 Hypertension and high blood cholesterol are primary risk factors for CVD. While hypertension can be treated or controlled to mitigate the risk of CVD, it is inequitably distributed across the American population.3,4 Only one quarter of those with a diagnosis of hypertension have their condition under control.3 Additionally, from 2017 to 2020, 111.1 million US adults (44.7%) aged 20 years or older had suboptimal total cholesterol levels.2 To improve hypertension and cholesterol management and, consequently, improve CVD outcomes, interventions to support patient engagement, prevention, and health system improvements need to be maximized.5 Several modifiable health behaviors can improve CVD and associated risk factors, such as eating a healthy diet, losing weight, and being physically active. The prevalence of US adults engaging in modifiable health behaviors is low,2 which necessitate health system interventions that support behavior modification and improve diagnosis and clinical treatment of hypertension and high blood cholesterol.5 To act on CVD outcomes in the United States, in 2018, the Centers for Disease Control and Prevention's (CDC's) Division for Heart Disease and Stroke Prevention (DHDSP) established three five-year cooperative agreement programs, representing $84 million, to fund 111 state and local health departments and tribal organizations. The cooperative agreements were Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke (DP18-1815), Innovative State and Local Public Health Strategies to Prevent and Manage Diabetes, Heart Disease, and Stroke (DP18-1817), and Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN). The three cooperative agreements had a shared long-term goal of increasing hypertension control among adults with known high blood pressure and managing high blood cholesterol among adults at high risk of CVD. Recipients worked with health care systems and community partners to (1) enhance the effective use of health information technology and clinical quality measures to improve diagnosis and tracking of patients with high blood pressure and high blood cholesterol; (2) institutionalize the use of team-based care approaches to better manage these diagnosed patients; and (3) strengthen community-clinical linkages to connect patients with the resources they need to manage their health. The three overarching program focus areas for the cooperative agreements are as follows: track and monitor clinical measures, implement team-based care, and link community resources and clinical services, which can be found in Table 1 along with their strategies. TABLE 1 - Program Focus Areas and Strategies by Cooperative Agreementa Program Focus Areas 1815 Strategies 1817 Strategies WISEWOMAN Strategies Track and monitor clinical measures Promote the adoption and use of EHRs and health information technology to improve provider outcomes and patient health outcomes related to identification of individuals with undiagnosed hypertension and management of adults with hypertension. Increase identification of patients with undiagnosed hypertension using EHRs/HIT Provide reports to monitor and track clinical data to improve identification, management, treatment, and outcomes of women with high blood pressure Promote the adoption of evidence-based quality measurement at the provider level (eg, use dashboard measures) to monitor health care disparities and implement activities to eliminate health care disparities Explore and test innovative ways to promote the adoption of evidence-based quality measurement at the provider level (eg, use dashboard measures to monitor health outcomes among high-burden subpopulations and implemented related activities) Provide cardiovascular risk screening to under- or uninsured women in the priority age range of 40-64 years during the clinic office visit Develop metrics to evaluate the effectiveness of interventions using collected data and deploy improvement strategies as needed Implement team-based care Support engagement of nonphysician team members in hypertension and cholesterol management in clinical settings Explore and test innovative ways to engage nonphysician team members in hypertension and cholesterol management in clinical settings Engage health professionals and community health workers, social workers, patient navigators, pharmacists, and others to expand follow-up and support expanded health team members engaged in community settings outside of health care facilities Promote the adoption of MTM between pharmacists and physicians for managing hypertension, high blood cholesterol, and lifestyle modification Promote the adoption of MTM between community pharmacists and physicians for managing high-blood pressure, high-blood cholesterol, and lifestyle modification Communicate and coordinate care among team members (including coordination of community resource referrals and HBSS and clinical services) Support provider assessment, planning, training, implementation, and sustainability of care teams to support CVD improvements Link community resources and clinical services Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol Facilitate engagement of patient navigators/community health workers in hypertension and cholesterol management in clinical and community settings Facilitate the use of self-measured blood pressure with clinical support among adults with hypertension Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources Partner or contract with community groups that provide evidence-informed HBSS.Use EBS/EIS to ensure participants are engaged in HBSS Implement systems to facilitate bidirectional referral between community programs/resources and health care systems (eg, using EHRs, 800 numbers, and 211 referral systems) Identify, enhance, or build systems that facilitate provider and community bidirectional referrals to support medical follow-up, HBSS, tracking of the nature, type, and scope of referrals, and other critical support services Explore and test innovative ways to expand the use of telehealth including mobile health technology (eg, smart apps and text messages) to promote the management of hypertension and high blood cholesterol Explore and test innovative ways to enhance referral, participation, and adherence in cardiac rehabilitation programs in traditional and community settings, including home-based settings Abbreviations: CHWs, community health workers; CVD, cardiovascular disease; EBS/EIS, evidence-based and evidence-informed strategies; EHR, electronic health record; HBSS, healthy behavior support services; HIT, health information technology; MTM, Medication Therapy Management.aThe rows in the table indicate where strategies overlap across cooperative agreements. Although the cooperative agreements had a common, long-term goal, each one was nuanced in its approach to achieving the goal. For DP18-1815, DHDSP and the Division of Diabetes Translation established cooperative agreements with 50 state health departments and Washington, DC, to support the prevention and management of CVD and diabetes and improve health outcomes. This cooperative agreement was structured into two disease areas (ie, heart disease and diabetes) that aligned with each division's priorities. These priorities included reaching populations disproportionately affected by high blood pressure, high blood cholesterol, diabetes, or prediabetes due to socioeconomic or other characteristics, including inadequate access to care or poor quality of care. To complement the work under DP18-1815 and strengthen the prevention and management of CVD and diabetes through evidence-based strategies (EBSs), DHDSP provided funding through the DP18-1817 cooperative agreement. Under this cooperative agreement, DHDSP funded 25 state, county, and city health departments to design, test, and evaluate novel approaches to use EBSs to reduce risks, complications, and socioeconomic barriers to prevent and control CVD among disproportionately affected populations. Recipients' innovative approaches to address CVD among disproportionately affected populations were expected to reduce health disparities and improve social determinants of health among populations at the highest risk for CVD. Lastly, DHDSP funded 30 state health departments and tribal organizations under the WISEWOMAN program. WISEWOMAN focused on helping low-income, under- or uninsured women aged 40 to 64 who participated in the CDC-funded National Breast and Cervical Cancer Early Detection Program understand and reduce their risk for CVD by providing risk factor screenings and access to healthy behavior support services. It was important to evaluate the funded programs to ensure accountability, facilitate program improvement at the recipient and CDC levels, and expand practice-based evidence through sharing successful strategies. DHDSP utilized a general structure to support evaluations of the three cooperative agreements similar to one previously reported in Vaughan et al.6 The evaluation structure included four primary components: (1) a CDC-led evaluation; (2) recipient-led evaluations; (3) performance measurement; and (4) evaluation technical assistance. Each component is aligned with a series of evaluation activities. This supplement focuses on the progress and outcomes identified through recipient-led evaluations. For the recipient-led evaluation, each recipient was required to select 2 to 3 strategies to evaluate. Each year recipients built upon the previous year's evaluation work by focusing on a different evaluation core area (approach, efficiency, effectiveness, sustainability, and impact). This approach guided recipients through the evaluation process sequentially allowing them to highlight key aspects of their work throughout the five years of funding. The evaluation core areas and a set of overarching evaluation questions (Supplemental Digital Content 1, available at https://links.lww.com/JPHMP/B364, which lists evaluation core areas and overarching evaluation questions by cooperative agreement) created a structure for recipients to capture important information about the program activities and outcomes as the program was implemented. Recipients' evaluation findings provided examples of how public health practitioners were implementing cardiovascular health interventions in the field across the cooperative agreements and demonstrated the impact of the three interrelated program focus areas. These cooperative agreements were complex, large-scale, public health programs that required intensive technical assistance from CDC to enhance success. DHDSP's program and evaluation branches collaborated with a coordinated and responsive technical assistance approach to ensure that recipients were supported in their program evaluations throughout the duration of the cooperative agreement. Each recipient was assigned a program project officer and an evaluator to help them meet program milestones and submit required annual deliverables. The program project officer and evaluator regularly met with recipients, reviewed deliverables, shared expert feedback, and developed relevant and timely action plans to address recipient challenges. This technical assistance approach enhanced recipients' capacity to meet their program needs and achieve the health outcomes they were funded to attain. Echoing the Knowledge to Action framework,7 this collaboration helped recipients gather practice-based evidence from their recipient-led evaluations, recognize the value of their work, and disseminate their findings as demonstrated in this supplement.
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