0920-24FI In-Depth Assessment – Exploratory Assessment Recipient I

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

In-Depth Assessment – Exploratory Assessment Recipient Interview Guide –

Team-Based Care – The National Cardiovascular Health Program & The Innovative Cardiovascular Health Program

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Exploratory Assessment

Recipient Interview Guide

Date of Interview
Interviewer
Notetaker
Organization Name
Organization Type
State
Organization City		Zip Code
Cooperative Agreement	☐ The National CVH Program ☐ The Innovative CVH Program
Strategy	Strategy 2: Implement Team Based Care
Interviewee Name(s)
Interviewee Role(s) or Title(s)

Introduction

Thank you for taking the time to participate in this interview. My name is <Insert name> and I am with the Deloitte evaluation team. Our team is working with the CDC Division for Heart Disease and Stroke Prevention to evaluate the <Insert Cooperative Agreement>. As part of the larger evaluation, we are seeking to learn more about the effectiveness of Strategy 2: Implement Team-Based Care at the site level and gain insights on sustainability and program replicability. The information you share will provide valuable insights on approaches for promoting team-based care for improved patient management and help us understand which approaches seem to work well in specific contexts.

This interview is expected to take no longer than 90 minutes. Your participation in this interview is completely voluntary. You may choose not to respond to questions at any time and it will not in any way impact the funding or technical assistance to your organizations receive from CDC. All information will be kept secure and any personally identifiable information will be removed when results are aggregated for analysis.

During this interview we will be referencing back to information gathered during the Evaluability Assessment interviews to further understand how things may have changed or remained the same since <September 2024 through September 2025>. If you did not participate in the Evaluability Assessment or were not yet with <recipient organization> we understand that you may not be able to speak to everything that is referenced. We still value your input and are interested in learning about what is currently happening at your organization.

If at any time during the interview you are not clear about what we are asking, be sure to let me know. Please answer questions based on your own knowledge and experience. We appreciate your candid answers and hope that today’s interview can be a conversation among participants. Please let us know when things your colleagues are saying resonate with your experience or when your experience has been different.

Do you consent to this interview?

☐ Yes

☐ No

With your permission, we would like to record this interview for transcription purposes.

Do we have your permission to record?

☐ Yes

☐ No

Do you have any questions or concerns before we start the interview?

Background

Thank you again for agreeing to participate in this interview. For reference, for today’s interview we will be talking about Strategy 2, which is defined as

Implement team-based care to prevent and reduce CVD risk with a focus on hypertension and high cholesterol prevention, detection, control, and management through the mitigation of social support barriers to improve outcomes. (The National CVH Program)

Implement team-based care to prevent, detect, control, and manage hypertension and high cholesterol within approved populations of focus. (The Innovative CVH Program)

We will discuss the following sub-strategies under Strategy 2:

[Interviewer Note: Only describe the relevant sub-strategies for which the recipient organization has self-nominated]

2A: Advance the use of health information systems that support team-based care to monitor population health with a focus on health disparities, hypertension, and high cholesterol [within approved populations of focus (The Innovative CVH Program)]

2B: Assemble or create multidisciplinary teams (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers, and community-based workers) to identify patients' social services and support needs

• and to improve the management and treatment of hypertension and high cholesterol (The National CVH Program)

• within approved populations of focus (The Innovative CVH Program)

2C: Build and manage a coordinated network of multidisciplinary partnerships that address identified barriers

• to social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing) within populations at highest risk of CVD (The National CVH Program)

  • and needs within approved populations of focus, related to their social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing) (The Innovative CVH Program)

I’d like to start with some questions to understand the work <name of recipient organization> is doing to support patients at risk of or with high blood pressure or high cholesterol, and also understand your role within the organization.

1. During the Evaluability Assessment it was shared that you <personal role in relation to supporting strategy approaches>. Is this still true or has this changed since we last spoke?

Probes:

• How long have you been working with <organization name>?

• How long have you been in this role?

• Can you tell me about your role in relation to supporting the implementation of TBC approaches?

• How many years have you been working on TBC-related work within your organization?

Support for TBC Strategies

We’d like to learn more about how recipients are supporting TBC strategies. We are particularly interested in learning how things have changed since our last round of discussions in <insert time e.g., Fall 2025> during the Evaluability Assessment. We will summarize what we heard about implementation during the key informant interviews and ask you to confirm if the activities are the same or have changed.

2. In the Evaluability Assessment interview, <you, key personnel from your organization> shared that <recipient organization> supports the implementation of <TBC activities> by <actions described in the last interview>. Is this still true or has it changed since we last spoke?

Probes:

• What has changed in the past two years? Why did you make these changes? 

  • How has your role and the support you provide changed?

  • How have you expanded <activities>? What progress has been made? Tell us more about key achievements and major milestones.

  • Are there any unique or novel approaches that you would like to highlight?

• [If no longer implementing the program activity] Why are you no longer implementing? What are you doing in place of the <activity>?  

For the next topic of discussion, we would like to explore the partnerships between <recipient organization>, learning collaboratives (LCs), and partner organizations. Please think about the process of working together to implement <activities related to TBC strategies>.

3. Does your organization still have a partnership with <names of partners reported in the Evaluability Assessment>?

Probes:

• Have there been any changes (i.e., added or removed partnerships) to your organization’s partnerships since we last spoke?

  • [If partner added] Why was this partner added?

    • Is this partner organization part of the LC?

    • Was this partnership planned?

    • Was there an unexpected gap identified?

  • [If partner removed] Why was this partner removed?

    • Was this removal planned?

    • Were there challenges that existed with this partnership?

4. During the key informant interviews for the Evaluability Assessment, we learned that <how the LC support implementation and its influence on partnership networking >. How has the support of the LC evolved since we last spoke?

Probes:

• What has changed in the past two years?

  • How has the LC support for <activities related to TBC strategy implementation> changed?

5. How has the LC affected the exchange of ideas and strategies?

Probes:

• How has the LC influenced partnership networking?

• How has the LC impacted program reach?

6. Can you describe any key actions or characteristics you feel mattered most in facilitating an effective and beneficial partnership with your partner organizations?

7. Is there anything you would want to change in your collaboration to improve your partnerships?

Probes:

• What are the gaps in your current partnerships?

• What are the gaps in your LC?

  • [If there are gaps] How does your organization plan to overcome these gaps?

Next, we’d like to discuss any new or ongoing challenges that <Recipient Organization> is encountering when implementing or supporting the implementation of <activities related to TBC> and ways that the organization has overcome these challenges or any additional support the organization may need to overcome them.

[Interviewer Note: Reference challenges and barriers mentioned in the Evaluability Assessment key informant interviews by participants, probe for new or ongoing challenges.]

8. During the key informant interviews for the Evaluability Assessment, we heard that <challenges and barriers referenced> were some of the challenges for implementing or supporting the implementation of TBC strategies. Have these challenges persisted?

[Interviewer Note: For the next question, only describe relevant sub-strategies for which the recipient organization has self-nominated.]

Probes:

• Have challenges persisted with:

  • 2A: advancing the use of health information systems to support TBC?

  • 2B: integrating non-physician team members within patient care teams?

  • 2C: managing a coordinated network of multidisciplinary partnerships?

• How did your organization resolve these challenges?

9. Have any new challenges emerged?

Probes:

• How is your organization addressing these challenges?

• What support, TA, or resources does your organization need to overcome these challenges?

10. What factors have helped to support <activities related to implementing TBC>?

Probe:

• How did these factors provide support for <TBC activities>?

We are interested in learning about changes since we last spoke related to the external or contextual factors that may support or hinder <TBC activities> such as state or organizational policies or guidelines, other initiatives or cooperative agreements.

11. During the Evaluability Assessment it was shared that <contextual factors that support or hinder activities related to strengthening TBC>. Have there been any changes in these contextual factors?

Probe:

• Have there been any recent policy level or other external changes within your jurisdiction that impact your <TBC efforts>? What about changes within your organization?

[Interviewer Note: Only ask the next set of questions if the recipient organization participates in more than one NOFO. Otherwise, move on to the Effectiveness of TBC Practices section.]

In addition to receiving funding from <insert cooperative agreement being interviewed for> you also receive funding from <The National CVH Program, The Innovative CVH Program, WISEWOMAN program>. [If applicable to recipient: We are also aware that <recipient in same state or jurisdiction> received funding from <name of cooperative agreement> and are interested in how your organization is coordinating with <other recipient organizations>. These next questions will focus on any changes since we last spoke related to participating in and coordinating with multiple cooperative agreements.

12. During the Evaluability Assessment we learned that your organization was <coordination across NOFO name(s) findings>. Is this still an accurate reflection of how your organization is coordinating across <NOFO name(s)>? Have there been any changes since we last spoke?

Probes:

• How is your organization coordinating across <NOFO name(s)> to maximize resources and avoid duplication of effort?

  • How does your organization leverage funding across NOFOs?

  • How does your organization leverage partnerships across NOFOs?

  • How has your organization coordinated resources for shared impact across NOFOs?

  • [If implementing both the National and Innovative CVH Programs] How are you coordinating learning collaboratives for The National and Innovative CVH Programs?

13. During the Evaluability Assessment we heard that <advantages of participating in or coordinating with multiple NOFOs findings>, have these advantages persisted?

Probes:

• Have any new advantages of participating in and/or coordinating with multiple NOFOs emerged?

• How has participating in and/or coordinating with multiple NOFOs helped to maximize the impact of hypertension control and other CVD outcomes?

14. In the previous interview <you/your colleague> referenced that challenges to participating in more than one NOFO or coordinating with other NOFOs included <challenges referenced in previous interview>. Have these challenges persisted?

Probes:

• Have any new challenges emerged with participating in and/or coordinating with more than one NOFO?

• How has your organization addressed these challenges?

Effectiveness of TBC Practices

The following questions are going to ask you about effective practices for implementing program strategies. We are interested in learning more about the resources and support provided to partner organizations for implementing <TBC activities>.

[Interviewer Note: Only ask questions related to the sub-strategies for which the recipient organization has self-nominated]

[Interviewer Note: For Questions 15 through 17, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

15. [2A] How has the advancement of EHR/HIT affected monitoring population health with a focus on health disparities, hypertension, and high cholesterol?

Probes:

• What types of resources or support were most helpful to partner health systems/clinics?

• What was the role of the LC in supporting <strategy 2A implementation>?

• What activities were most helpful for monitoring:

  • Health disparities?

  • Patient’s high blood pressure?

  • Patient’s high cholesterol?

• What activities were most successful at increasing the use of EHR/HIT to support TBC?

• What activities were most helpful to strengthen or create new processes or workflows to use health information systems to support communication and coordination among care team members?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

16. [2B] How has engagement of non-physician care team members in patient care by your partner health systems/clinics affected the identification of social services and support needs, and management and treatment of high blood pressure and high cholesterol among patients?

Probes:

• What types of resources or support were most helpful to partner health systems/clinics?

• What was the role of the LC in supporting <strategy 2B implementation>?

• What activities were most helpful for:

  • Identifying patients’ social services and support needs?

  • Managing and treating high blood pressure?

  • Managing and treating high cholesterol?

• What intervention activities were most successful at engaging non-physician care team members in patient care?

• What are best practices to improve communication among care team members?

• What activities were most helpful to strengthen or create new processes or workflows to use multidisciplinary care teams to identify patients’ social services and support needs?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

17. [2C] How has the use of coordinated networks of multidisciplinary partnerships improved patient care coordination and follow-up?

Probes:

• What types of resources or support were most helpful to partners?

• What was the role of the LC in supporting <strategy 2C implementation>?

• What activities were most helpful for addressing identified barriers to social services and support needs?

• What activities were most helpful to strengthen or create new processes or workflows to use multidisciplinary partnerships to address barriers to social services and support needs?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

Now we will ask you questions about reaching your population of focus and health outcomes. We’re interested in outcomes related to advancing health equity particularly through identifying and addressing social determinants of health (SDOH) and reducing CVD disparities.

18. As indicated from <Evaluability Assessment, document review, etc.>, the population of focus for your organization are <population of focus identified>. How effective is your organization in reaching your population of focus?

Probes:

• How are <TBC activities> designed to address the specific needs of the <population of focus>?

• How does your organization ensure that <TBC activities> are adaptable to meet the needs of <population of focus>?

• What are examples of how program feedback (e.g., from quality improvement efforts, program data, evaluation data) has been incorporated to improve program reach?

• How does your organization define reach?

  • What metrics did your organization use to measure reach?

  • What are the findings?

• How has reach amongst <population of focus> changed?

• What are barriers that your organization encountered in reaching the population of focus?

  • What has helped your organization reach your population?

[Interviewer Note: For Question 19, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

19. How do <TBC activities being implemented by the Recipient and partner organizations> contribute to patient level health outcomes?

Probes:   

• What changes in health outcomes has your organization observed or measured?

• How do <TBC activities being implemented by the Recipient and partner organizations> support patients to control their blood pressure or cholesterol levels?  

• How has the LC contributed to patient level health outcomes?

• What factors support or hinder your organization’s ability to meet patient needs?

20. How have the <TBC activities implemented by the Recipient and partner organizations> contributed to addressing drivers of health inequities?

Probes:

• What health inequity drivers have been addressed (e.g., health system and organizational level practices and policies)?

• How do <TBC activities being implemented by the Recipient and partner organizations> affect social services and support needs of patients?

• Did the Learning Collaborative provide support for QI and other multidisciplinary partnership efforts to address identified disparities in the diagnosis, care, or health outcomes for your population of focus?

  • [If yes]- in what ways did the LC provide support?

• In what ways has the reduction in SDOH barriers influenced CVD-related outcomes?

[Interviewer Note: For Question 21, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

21. Have there been any measured reductions in health disparities as a result of <TBC activities being implemented by the Recipient and partner organizations>?

Probes:

• If yes:

  • What are examples of how health disparities were reduced through implementation of <TBC strategies>?

  • How does <Recipient and partner activities related to TBC strategy implementation> address gaps in care for your population of focus?

  • Has the LC impacted capacity to address SDOH and systematic barriers to care?

    • [If yes]- in what ways?

• If no:

  • Are there any barriers that affect your ability to mitigate health disparities? Please describe.

  • Are there barriers to measuring changes in health disparities?

• What additional resources are needed to address patient’s unmet SDOH needs?

22. What other outcomes, intended or unintended, have come out because of these implemented strategies?

Probe:

• [If recipient reports an unintended outcome] Can you elaborate on the unintended outcome and why this may have resulted?

23. Can you tell us about any processes or outcomes that your organization has achieved as a result of these implemented strategies that you are especially proud of?

Sustainability [The National CVH Program]

For the following questions, we are interested in learning more about your plans and preparation for sustaining the activities related to TBC after the completion of the cooperative agreement.

24. [2A] What steps has your organization taken to ensure that partner health systems and clinics can sustain the use of health information systems to support TBC?

Probe:

• Can you share any challenges with supporting partner health systems and clinics to sustain the use of health information systems and how they were addressed?

25. [2B] What steps has your organization taken to sustain the use of multidisciplinary teams in patient care to mitigate social support barriers?

Probe:

• Can you share any challenges with supporting partner health systems and clinics to sustain multidisciplinary teams in patient care and how they were addressed?

26. [2C] What steps has your organization taken to sustain multidisciplinary partnerships for TBC?

Probe:

• Can you share any challenges with supporting partners in sustaining multidisciplinary partnerships for TBC?

26. Are any modifications needed to ensure sustainability? If so, what modifications are needed?

Probe:

• What additional support, TA, or resources are needed to improve sustainability?

[Interviewer Note: Only ask the questions that align with the sub-strategy for which the recipient organization self-nominated]

27. [2A] How do you plan to proceed with activities related to supporting the use of health information systems that support TBC to monitor population health after completing the cooperative agreement?

28. [2B] How do you plan to proceed with activities related to supporting the use of multidisciplinary teams to identify social services and support needs of patients, and improve patient management and treatment of high blood pressure and high cholesterol after completing the cooperative agreement?

29. [2C] How do you plan to proceed with activities related to supporting the management of a coordinated network of multidisciplinary partnerships to address identified social barriers after completing the cooperative agreement?

30. Once the cooperative agreement ends, are there any aspects of the <TBC related activities> you will not continue? Are there aspects that you would like to continue but do not feel like you could sustain?

31. Aside from funding, is there any resource, tool, or any type of additional support that would be beneficial to continuing <TBC activities being implemented by the Recipient and partner organizations> after the cooperative agreement?

Scalability and Replicability [The Innovative CVH Program]

Now we’d like to learn more about the potential for scalability and replicability of program strategies.

32. Can you describe the team-based care activities that have been successful in your organization and partner organizations, and for <activities implemented by partners> and could potentially be scalable or replicable?

Probe:

• What factors contribute to their scalability?

33. What intervention components would be difficult to replicate or scale up? Please describe why.

34. What program modifications are needed to support replication and scale-up?

Probe:

• What changes would you have to make in order to expand your program?

35. What resources are needed to support replication and scale-up?

36. Is there anything else you would like to add about implementation, scalability, or replicability of TBC strategies?

Special Topics

[Interviewer Note: Only ask these questions if the recipient organization is working on cardiac rehabilitation, hypertension in women, and/or hypertension in pregnant or postpartum people. If not, then skip to end and close out the interview]

[Interviewer Note: Ask questions 37-41 if recipient share that they implement cardiac rehab during the Evaluability Assessments]

37. In the Evaluability Assessment interview, <you, key personnel from your organization> shared that <recipient organization> implements cardiac rehabilitation. Is this still true or has it changed since we last spoke?

Probes:

• What has changed in the past two years? Why did you make these changes? 

  • How have you expanded <activities>? What progress has been made?

  • Tell us more about key achievements and major milestones.

  • Are there any unique or novel approaches that you would like to highlight?

• [If no longer implementing the program activity] Why are you no longer implementing?

38. What factors have helped to support <cardiac rehabilitation activities>?

39. What challenges have you experienced with < cardiac rehabilitation activities >?

Probes:

• How are these challenges addressed? What solutions helped to minimize barriers?

• What support, resources, or TA do you need to overcome these barriers?

40. Have there been any measurable improvements in patient level outcomes as a result of <cardiac rehabilitation activities >?

Probes:   

• What changes in health outcomes has your organization observed or measured?

41. How do < cardiac rehabilitation activities > contribute to reducing health disparities?

[Interviewer Note: Ask questions 42-46 if recipient stated that they implement activities related to hypertension in women during the Evaluability Assessments]

42. In the Evaluability Assessment interview, <you, key personnel from your organization> shared that <recipient organization> focuses on hypertension control in women. Is this still true or has it changed since we last spoke?

Probes:

• What has changed in the past two years? Why did you make these changes? 

  • How have you expanded <activities>? What progress has been made?

  • Tell us more about key achievements and major milestones.

  • Are there any unique or novel approaches that you would like to highlight?

• [If no longer implementing the program activity] Why are you no longer implementing?

43. What factors have helped to support <activities related to hypertension in women>?

44. What challenges have you experienced with < activities related to hypertension in women >?

Probes:

• How are these challenges addressed? What solutions helped to minimize barriers?

• What support, resources, or TA do you need to overcome these barriers?

45. Have there been any measurable improvements in patient level outcomes as a result of < activities related to hypertension in women >?

Probes:   

• What changes in health outcomes has your organization observed or measured?

46. How do < activities related to hypertension in women > contribute to reducing health disparities?

[Interviewer Note: Ask questions 47-51 if recipient stated that they implement activities related to pregnant or postpartum people during the Evaluability Assessments]

47. In the Evaluability Assessment interview, <you, key personnel from your organization> shared that <recipient organization> focuses on hypertension control in pregnancy and postpartum. Is this still true or has it changed since we last spoke?

Probes:

• What has changed in the past two years? Why did you make these changes? 

  • How have you expanded <activities>? What progress has been made?

  • Tell us more about key achievements and major milestones.

  • Are there any unique or novel approaches that you would like to highlight?

• [If no longer implementing the program activity] Why are you no longer implementing?

48. What factors have helped to support < activities related to hypertension control in pregnancy or postpartum>?

49. What challenges have you experienced with < activities related to hypertension control in pregnancy or postpartum >?

Probes:

• How are these challenges addressed? What solutions helped to minimize barriers?

• What support, resources, or TA do you need to overcome these barriers?

50. Have there been any measurable improvements in patient level outcomes as a result of < activities related to hypertension control in pregnancy or postpartum >?

Probes:   

• What changes in health outcomes has your organization observed or measured?

51. How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?

Close

Lastly, what questions do you have for me? Is there anything else you’d like to share?

Thank you for your time. This concludes our interview about the implementing team-based care strategy for the <Insert cooperative agreement>. If you have any additional questions, please feel free to contact the Comprehensive Evaluation Team, [email protected].