Form 0920-24FI In-Depth Assessment – Exploratory Assessment Partner Int

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

In-Depth Assessment – Exploratory Assessment Partner Interview Guide – Community Clinical Links – WISEWOMAN

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Exploratory Assessment

Partner Interview Guide

Date of Interview
Interviewer
Notetaker
Organization Name
Organization Type
State
Organization City		Zip Code
Cooperative Agreement	☐ WISEWOMAN
Strategy	Strategy 3: Link Community Resources and Clinical Service
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 3: Link Community Resources and Clinical Service at the site level and gain insights on sustainability and program replicability. The information you share will provide valuable insights on supporting collaboration with community groups, promoting use of evidence-based and informed healthy behavior support services, and strengthening participant referrals to community lifestyle programs to support the CVD prevention and management and help us

understand which approaches seems 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 <partner 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 3, which is defined as

Link community resources and clinical services that support comprehensive bidirectional referral and follow-up systems aimed at mitigating social support barriers and supporting participation in and completion of lifestyle change programs for participants at risk of and with CVD.

We will discuss the following sub-strategies under Strategy 3:

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

3A: Identify, enhance, or build systems that facilitate provider and community bidirectional referrals to support medical follow-up, healthy behavior support services (HBSS), and social services and support.

3B: Collaborate with community groups who represent and serve the priority population, provide evidence-informed HBSS, and refer participants to those HBSS.

3C: Use evidence-based and evidence-informed strategies to ensure participants are actively engaged in HBSS.

3D: Refer participants to appropriate social services and support; track and monitor use.

I’d like to start with some questions to understand the work <name of partner organization> is doing to support program participants at risk of or cardiovascular disease (CVD), and also understand your roles 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 developing, modifying, enhancing, or otherwise supporting community clinical link (CCL) efforts within your organization?

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

Implementation of CCL Strategies

We’d like to learn more about how partner organizations are implementing these sub-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. For each participant, 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. We last spoke about your activities related to <support for and implementation of community clinical links> during the key informant interviews for the Evaluability Assessment. 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.

  • Can you please share any unique or novel activities that your organization has implemented that you are particularly proud of or 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 your organization and <recipient organization>, and other partner organizations. Please think about the process of working together to implement <activities related to CCL strategies>.

3. How did the <recipient organization> support your organization in linking community resources and clinical services to support bidirectional referral and follow-up systems?

Probes:

• What types of support have been most helpful to <partner organization> to develop or strengthen these <CCL activities>?

• How is the <recipient organization> helping you with respect to developing workflows/systems to create/enhance <CCL activities>?

  • Are there other partner organizations that are also helping your organization with this work?

4. Is there anything you would want to change in your collaboration to improve your partnerships with <recipient organization>? What about with other partner organizations?

Probes:

• What are the gaps in your current partnerships?

  • [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 <partner organization> is encountering when implementing <activities related to CCL strategy> and ways that your organization has overcome these challenges or any additional support the organization may need to overcome them.

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

5. 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 CCL 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:

  • 3A: identifying/enhancing/developing systems that facilitate bidirectional referrals?

  • 3B: collaborating with community groups who refer to and provide HBSS?

  • 3C: using evidence-based and evidence-informed strategies to ensure active engagement in HBSS?

  • 3D: referring participants to social support services?

• How did your organization resolve these challenges?

6. Have any new challenges emerged?

Probes:

• How is your organization addressing these challenges?

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

7. What factors have helped to implement <activities related to linking community resources and clinical services>?

Probe:

• How did these factors provide help with implementing <CCL activities>?

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

8. During the Evaluability Assessment it was shared that <contextual factors that support or hinder activities related to linking community resources and clinical services>. 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 <CCL efforts>? What about changes within your organization?

Effectiveness of CCL

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 <CCL strategies>.

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

[Interviewer Note: For Questions 9 through 12, 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.]

9. [3A] How have systems that facilitate provider and community bidirectional referrals affected medical follow-up, healthy behavior support services, and social services and support?

Probes:

• What types of resources or support were most helpful to your organization to strengthen or develop CCL processes?

• What activities were most helpful for facilitating provider and community bidirectional referrals?

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

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

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

10. [3B] How has the collaboration with community groups affected referrals to evidence-based and evidence-informed HBSS?

Probes:

• What types of resources or support were most helpful to your organization to strengthen or develop CCL processes?

• What activities were most helpful for:

  • Providing evidence-informed HBSS?

  • Referring participants to HBSS?

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

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

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

11. [3C] How has the use of evidence-based and evidence-informed strategies affected engagement in HBSS?

Probes:

• What types of resources or support were most helpful to your organization to strengthen or develop CCL processes?

• What activities were most helpful for:

  • Participant engagement in HBSS?

  • Participant completion of HBSS?

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

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

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

12. [3D] How have <CCL activities> affected referrals of participants to appropriate social services and support?

Probes:

• What types of resources or support were most helpful to your organization to strengthen or develop CCL processes?

• What activities were most helpful for:

  • Referring participants to social services and support?

  • Tracking and monitoring participant use of social services and support?

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

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

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

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

13. We would like to learn more about how your organization is reaching the population of focus. The population of focus, as defined by <recipient organization>, are <population of focus identified>. How effective is your organization in reaching your population of focus?

Probes:

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

• How does your organization ensure that <CCL activities> are adapted to meet the needs <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 implementation?

• How does your organization define reach?

  • What metrics did your organization use to measure reach?

  • What are the findings?

• How has reach amongst the <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 14, 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.]

14. How do <partner’s CCL activities> contribute to participant level outcomes?

Probes:

• How do <your CCL activities> support participants to reduce CVD risk?

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

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

15. How have the <partner’s CCL activities> 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 <partner activities related to CCL strategy implementation> affect social services and support needs of participants within your organizations?

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

[Interviewer Note: For Question 16, 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.]

16. Have there been any measurable reductions in health disparities as a result of <partner’s activities related to CCL strategy implementation>?

Probes:

• If yes:

  • What are specific examples of how health disparities were reduced through the implementation of <CCL strategy>?

  • How do <partner activities related to CCL strategy implementation> address gaps in care for your population of focus?

• If no:

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

  • Are there any barriers to measuring changes in health disparities?

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

17. What other outcomes, intended or unintended, have occurred as a result of the sub-strategies?

Probe:

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

18. 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

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

19. [3A] What steps has your organization taken to help sustain systems that facilitate bidirectional referrals?

Probe:

• Can you share any challenges faced in building or strengthening systems and how they were addressed?

20. [3B] What steps has your organization taken to help sustain collaborations with community groups?

Probe:

• Can you share any challenges faced in collaborating with community groups and how they were addressed?

21. [3C] What steps has your organization taken to help sustain use of evidence-based and evidence-informed strategies?

Probe:

• Can you share any challenges faced in using evidence-based and evidence-informed strategies and how they were addressed?

22. [3D] What steps has your organization taken to help sustain referrals to appropriate social services and support?

Probe:

• Can you share any challenges faced in referring participants to social services and support and how they were addressed?

23. 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]

24. [3A] How do you plan to proceed with <partner activities related to systems that facilitate bidirectional referrals> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

25. [3B] How do you plan to proceed with <partner activities related to collaborating with community groups> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

26. [3C] How do you plan to proceed with <partner activities related to using evidence-based and evidence-informed strategies> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

27. [3D] How do you plan to proceed with <partner activities related to referring participants to appropriate social services and support> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

28. After <September 2028 or date the partner is no longer engaged with NOFO>, are there any aspects of <CCL activities that the partner is implementing> you will not continue? Are there aspects of the program that you would like to continue but do not feel like you could sustain?

29. Aside from funding, is there any resource, tool, or any type of additional support that would be beneficial to continuing <partner activities related to CCL> after the cooperative agreement? Please explain the impact of this.

Scalability and Replicability

30. What insights can other organizations gain from your organization’s successes or challenges with <strategy implementation>?

Probes:

• Can you share any lessons learned that could be beneficial for similar programs?

• How can successful activities be replicated elsewhere? How could other organizations implement similar activities?

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 clinical-community link strategy for the <Insert cooperative agreement>. If you have any additional questions, please feel free to contact the Comprehensive Evaluation Team, [email protected].