Non-Substantive Change Request Memo [EO]_30APR2025

Non-substantive Change Request

OMB Control Number 0920-1453

The Comprehensive Evaluations for the Well-Integrated Screening and Evaluation for Women Across the Nation Program (WISEWOMAN), The National Cardiovascular Health Program (The National CVH Program), and The Innovative Cardiovascular Health Program (The Innovative CVH Program)

Date Submitted: 3/5/2025

Summary of request: CDC/NCCDPHP is requesting a change request to revise questions to align with recent executive orders, including EO 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government and EO 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing.

Description of Changes Requested: This request updates questions used in the The Comprehensive Evaluations for the Well-Integrated Screening and Evaluation for Women Across the Nation Program (WISEWOMAN), The National Cardiovascular Health Program (The National CVH Program), and The Innovative Cardiovascular Health Program (The Innovative CVH Program) to be in accordance with EO 14168 and EO 14151.

Please check the boxes below if your request includes:

☒ Revision of an existing question(s)

☒Deletion of an existing question(s)

Table A: Description of Changes	Type of Change	Question/Item	Requested Change
3.a Evaluability Assessment Nomination Form_NCHP_ICHP	Question Revision	Do you implement activities related to hypertension among pregnant or postpartum people? Yes No	Do you implement activities related to hypertension among pregnant or postpartum women? Yes No
3.a Evaluability Assessment Nomination Form_NCHP_ICHP	Question Deletion	Please identify the population(s) of focus for your work in [insert selected strategy from Q5]. Please select all that apply Black of African American Asian Hispanic or Latino American Indian or Alaska Native Women Pregnant or postpartum people People with disabilities People living in rural communities People who are migrant workers People living near, at, or below the poverty level People who are uninsured or under-insured People within census tracts with a hypertension crude prevalence of 53% or higher Other, please specify Not applicable-this program does not implement any targeted activities
3.a Evaluability Assessment Nomination Form_NCHP_ICHP	Question Deletion	Who is the staff person focused on health equity?
3.a Evaluability Assessment Nomination Form_NCHP_ICHP	Question Deletion	What percentage of the LC collaborators and partners represent the populations of focus?
3.b Evaluability Assessment Nomination Form_WW	Question Revision	Do you implement activities related to hypertension among pregnant or postpartum people? Yes No	Do you implement activities related to hypertension among pregnant or postpartum women? Yes No
3.b Evaluability Assessment Nomination Form_WW	Question Deletion	Please identify the population(s) of focus for your work in [insert selected strategy from Q5]. Please select all that apply Black of African American Asian Hispanic or Latino American Indian or Alaska Native Women Pregnant or postpartum people People with disabilities People living in rural communities People who are migrant workers People living near, at, or below the poverty level People who are uninsured or under-insured People within census tracts with a hypertension crude prevalence of 53% or higher Other, please specify Not applicable-this program does not implement any targeted activities
3.c Eval Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	Can you tell me about your organization and the populations that it serves, specifically for cardiovascular related diseases? Probes: What types of services/programs does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services/implementing these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, genders, geography, etc.) that your organization typically serves?	Can you tell me about your organization and the populations that it serves, specifically for cardiovascular related diseases? Probes: What types of services/programs does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services/implementing these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, sex, geography, etc.) that your organization typically serves?
3.c Eval Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	Thinking about <name of strategy> in the <name of cooperative agreement>, can you describe: Strategy 1: How does the learning collaborative increase the use of EHRs and HIT to detect and mitigate health care disparities? Strategy 1: What is the learning collaborative’s role in promoting quality improvement? Strategy 2: How does the learning collaborative work to expand care teams to include non-physician team members to identify patient’s social services and support needs? Examples: Community health workers, social workers, patient navigators, pharmacists, and other members of the care team in community settings outside of health care facilities Strategy 3: How does the learning collaborative create and enhance community-clinical links to respond to social services and support needs?	Thinking about <name of strategy> in the <name of cooperative agreement>, can you describe: Strategy 1: How does the learning collaborative increase the use of EHRs and HIT to detect and mitigate differences in health outcomes? Strategy 1: What is the learning collaborative’s role in promoting quality improvement? Strategy 2: How does the learning collaborative work to expand care teams to include non-physician team members to identify patient’s social services and support needs? Examples: Community health workers, social workers, patient navigators, pharmacists, and other members of the care team in community settings outside of health care facilities Strategy 3: How does the learning collaborative create and enhance community-clinical links to respond to social services and support needs?
3.c Eval Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	How will LC activities lead to system or community-level reductions in health disparities?	How will LC activities address differences in health outcomes?
3.c Eval Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder learning collaborative operations? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder learning collaborative operations? Probes Describe external factors Describe internal factors
3.c Eval Assessment_LC_Interview Guide_NCHP_ICHP	Question Deletion	What type of data related to health equity are collected and tracked? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.c Eval Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC?
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Revision	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to < adoption of EHRs/HIT, implementation of clinical measures, use of quality improvement tools >, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been <offering these services, implementing these programs, providing this support>? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, genders, geography, <census tracts for Innovative CHV Program>) that your organization typically serves or focuses on related to CQM?	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to < adoption of EHRs/HIT, implementation of clinical measures, use of quality improvement tools >, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been <offering these services, implementing these programs, providing this support>? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, sex, geography, <census tracts for Innovative CHV Program>) that your organization typically serves or focuses on related to CQM?
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Revision	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum people.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum people. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum people? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum women.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum women. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum women? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How do you define populations at highest risk of CVD? (The National CVH Program) How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the health disparities in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How do you define populations at highest risk of CVD? (The National CVH Program) How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD?
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Revision	How do your <EHRs/HIT activities> address health disparities related to hypertension? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? How are EHR/HIT data used to advance health equity?	How do your <EHRs/HIT activities> address differences in health outcomes related to hypertension? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population?
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder <activities related to tracking and monitoring clinical measures>? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder <activities related to tracking and monitoring clinical measures>? Probes Describe external factors Describe internal factors
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Deletion	How is health equity incorporated into your evaluation plan? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.d Eval Assessment_CQM_Recipient Interview Guide_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the <name of cooperative agreement>?
3.e Eval Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum people.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum people. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum people? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum women.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum women. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum women? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?
3.e Eval Assessment_CQM_Recipient Interview Guide_WW	Question Revision	What is the <program’s> population of focus? Probes: How do you define the population of focus? What demographics, patient characteristics, or geographies are you prioritizing? How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the health disparities in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk?	What is the <program’s> population of focus? Probes: How do you define the population of focus? What demographics, patient characteristics, or geographies are you prioritizing? How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD?
3.e Eval Assessment_CQM_Recipient Interview Guide_WW	Question Revision	How do your <EHRs/HIT activities> address health disparities related to hypertension? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? 1A: How does SDOH affect the patient uptake of CVD risk assessments? How does this affect your program approach? 1.E: How are data extracted from EHR/HIT used to advance health equity and improve health outcomes	How do your <EHRs/HIT activities> address differences in health outcomes related to hypertension? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? 1.E: How are data extracted from EHR/HIT used to improve health outcomes
3.e Eval Assessment_CQM_Recipient Interview Guide_WW	Question Revision	Can you tell us about the contextual factors that support or hinder <activities related to tracking and monitoring clinical measures>? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder <activities related to tracking and monitoring clinical measures>? Probes Describe external factors Describe internal factors
3.e Eval Assessment_CQM_Recipient Interview Guide_WW	Question Deletion	How is health equity incorporated in your evaluation plan? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.e Eval Assessment_CQM_Recipient Interview Guide_WW	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the <name of cooperative agreement>?
3.f Eval Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to < implementing EHRs/HITs, tracking and monitoring clinical measures, using quality improvement tools >, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services/implementing these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, genders, geography, <census tracts for Innovative CHV Program>) that your organization typically serves?	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to < implementing EHRs/HITs, tracking and monitoring clinical measures, using quality improvement tools >, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services/implementing these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, sex, geography, <census tracts for Innovative CHV Program>) that your organization typically serves?
3.f Eval Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers do the population(s) of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers do the population(s) of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.f Eval Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	How do your <EHRs/HIT activities> address health disparities related to hypertension and high cholesterol? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? How are EHR/HIT activities tailored to the needs of your population?	How do your <EHRs/HIT activities> address differences in health outcomes related to hypertension and high cholesterol? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? How are EHR/HIT activities tailored to the needs of your population?
3.f Eval Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to <tracking and monitoring clinical measures>? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder activities related to <tracking and monitoring clinical measures>? Probes Describe external factors Describe internal factors
3.f Eval Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Deletion	What type of data related to health equity are collected and tracked? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.f Eval Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the <name of cooperative agreement>?
3.g Eval Assessment_CQM_Partner Interview_WW	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers do the population of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers do the population of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.g Eval Assessment_CQM_Partner Interview_WW	Question Revision	How do your <EHRs/HIT activities> address health disparities related to hypertension? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? 1A: How do SDOH affect the patient uptake of CVD risk assessments? How does this affect your program approach? 1E: How are data extracted from EHR/HIT used to advance health equity and improve health outcomes?	How do your <EHRs/HIT activities> address differences in health outcomes related to hypertension? Probes: How are quality improvement efforts tailored to the needs of your population of focus? How do EHR/HIT activities address the needs of your population? 1E: How are data extracted from EHR/HIT used to improve health outcomes?
3.g Eval Assessment_CQM_Partner Interview_WW	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to <tracking and monitoring clinical measures>? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder activities related to <tracking and monitoring clinical measures>? Probes Describe external factors Describe internal factors
3.g Eval Assessment_CQM_Partner Interview_WW	Question Deletion	What type of data related to health equity are collected and tracked? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.g Eval Assessment_CQM_Partner Interview_WW	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the WISEWOMAN program?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CQM> for the WISEWOMAN program?
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Revision	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to implementing team-based care does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been <offering these services, implementing these programs, providing this support>? What are the overall goals of these programs? What is your organization hoping to achieve through these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, genders, geography, <census tracts for Innovative CHV Program>) that your organization typically serves?	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to implementing team-based care does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been <offering these services, implementing these programs, providing this support>? What are the overall goals of these programs? What is your organization hoping to achieve through these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, sex, geography, <census tracts for Innovative CHV Program>) that your organization typically serves?
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Revision	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum people.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum people. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum people? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum women.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum women. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum women? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How do you define populations at highest risk of CVD? (The National CVH Program) How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the health disparities in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How do you define populations at highest risk of CVD? (The National CVH Program) How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD?
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Revision	How does your <program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: How do SDOH affect patient engagement with TBC? How does this inform your program approach? What challenges has your program experienced with engaging patients in TBC? What strategies have worked best for engaging the population(s) of focus in TBC? What innovations are implemented to address SDOH? (The Innovative CVH Program)	How does your <program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: What challenges has your program experienced with engaging patients in TBC? What strategies have worked best for engaging the population(s) of focus in TBC?
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to strengthening TBC? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder activities related to strengthening TBC? Probes Describe external factors Describe internal factors
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Deletion	How is health equity incorporated in your evaluation plan? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.h Eval Assessment_TBC_Recipient Interiew_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from CDC? What have been some lessons learned from your experience with data collection and evaluation related to TBC for the <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from CDC? What have been some lessons learned from your experience with data collection and evaluation related to TBC for the <name of cooperative agreement>?
3.i Eval Assessment_TBC_Recipient Interiew_WW	Question Revision	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum people.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum people. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum people? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum women.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum women. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum women? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?
3.i Eval Assessment_TBC_Recipient Interiew_WW	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the health disparities in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus? What barriers do the population(s) of focus face in terms of management and treatment of CVD?
3.i Eval Assessment_TBC_Recipient Interiew_WW	Question Revision	How does your program focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: How do SDOH affect how patients engage with CVD management and care, and how does this inform your TBC approach? What challenges has your program experienced with engaging patients in TBC? What strategies have worked best for engaging the population(s) of focus in TBC?	How does your program focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: What challenges has your program experienced with engaging patients in TBC? What strategies have worked best for engaging the population(s) of focus in TBC?
3.i Eval Assessment_TBC_Recipient Interiew_WW	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to strengthening TBC? Probes Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture	Can you tell us about the contextual factors that support or hinder activities related to strengthening TBC? Probes Describe external factors Describe internal factors
3.i Eval Assessment_TBC_Recipient Interiew_WW	Question Deletion	How is health equity incorporated in your evaluation plan? Probes What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.i Eval Assessment_TBC_Recipient Interiew_WW	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to TBC for <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcomes or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from [name of recipient organization]? What about from the CDC? What have been some lessons learned from your experience with data collection and evaluation related to TBC for <name of cooperative agreement>?
3.j Eval Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to <team-based care>, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services/implementing these programs? Can you describe to me the different populations (i.e. race, ethnicity, socioeconomic status, age, genders, geography, <census tracts for Innovative CVH Program>) that your organization typically serves?	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to <team-based care>, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services/implementing these programs? Can you describe to me the different populations (i.e. race, ethnicity, socioeconomic status, age, sex, geography, <census tracts for Innovative CVH Program>) that your organization typically serves?
3.j Eval Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers do the population(s) of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers do the population(s) of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.j Eval Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	How does your <program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: How do SDOH affect how patients engage with CVD management and care, and how does this inform your TBC approach? What innovations will be implemented to address SDOH? (The Innovative CVH Program) What challenges has your program experienced with engaging patients in TBC? What strategies have worked best for engaging the population(s) of focus in TBC?	How does your <program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: What challenges has your program experienced with engaging patients in TBC? What strategies have worked best for engaging the population(s) of focus in TBC?
3.j Eval Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to strengthening TBC? Probes: Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate. Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture.	Can you tell us about the contextual factors that support or hinder activities related to strengthening TBC? Probes: Describe external factors. Describe internal factors.
3.j Eval Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Deletion	What type of data related to health equity are collected and tracked? Probes: What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.j Eval Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and reporting related to <TBC> for <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and reporting related to <TBC> for <name of cooperative agreement>?
3.k Eval Assessment_TBC_Partner Interview_WW	Question Revision	What is the program’s population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barrier does the population of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the program’s population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barrier does the population of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.k Eval Assessment_TBC_Partner Interview_WW	Question Revision	How does your <program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: How do SDOH affect how patients engage with CVD care, and how does this inform your TBC approach? What challenges has your <program> experienced with engaging patients in TBC? What approaches have worked best for engaging the population(s) of focus in TBC?	How does your <program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: What challenges has your <program> experienced with engaging patients in TBC? What approaches have worked best for engaging the population(s) of focus in TBC?
3.k Eval Assessment_TBC_Partner Interview_WW	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to TBC? Probes: Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate. Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture.	Can you tell us about the contextual factors that support or hinder activities related to TBC? Probes: Describe external factors. Describe internal factors.
3.k Eval Assessment_TBC_Partner Interview_WW	Question Deletion	What type of data related to health equity are collected and tracked? Probes: What SDOH data are collected? How will health disparities be measured and defined? What sort of methods or tools are used to measure health equity outcomes?
3.k Eval Assessment_TBC_Partner Interview_WW	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and reporting related to <TBC> for the WISEWOMAN program?	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from the CDC? What have been some lessons learned from your experience with data collection and reporting related to <TBC> for the WISEWOMAN program?
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Revision	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to <the implementation of community and clinical linkages, community health worker programs, and self-monitored blood pressure monitoring programs>, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been <offering these services, implementing these programs, providing this support>? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, genders, geography, <census tracts for Innovative CHV Program>) that your organization typically serves?	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to <the implementation of community and clinical linkages, community health worker programs, and self-monitored blood pressure monitoring programs>, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been <offering these services, implementing these programs, providing this support>? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, sex, geography, <census tracts for Innovative CHV Program>) that your organization typically serves?
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Revision	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum people.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum people. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum people? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum women.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum women. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum women? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How do you define populations at highest risk of CVD? (The National CVH Program) How do you identify your population of focus? What data and methods do you use? What barrier does the population of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How do you define populations at highest risk of CVD? (The National CVH Program) How do you identify your population of focus? What data and methods do you use? What barrier does the population of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Revision	How does your <program> focus on <name of population of focus>? Please describe how <program activities> are tailored to the needs of your population. Probes: How do SDOH affect patient engagement with SMBP and program referrals? How does this inform your program approach? What challenges has your program experienced with referrals to social and support programs/services and SMBP? What approaches have worked best for identification recruitment, enrollment, and retention? What innovations are implemented to address SDOH through <CCL, CHW, and SMBP>? (The Innovative CVH Program)	How does your <program> focus on <name of population of focus>? Please describe how <program activities> are tailored to the needs of your population. Probes: What challenges has your program experienced with referrals to social and support programs/services and SMBP? What approaches have worked best for identification recruitment, enrollment, and retention?
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to <linking community resources and clinical services>? Probes: Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate. Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture.	Can you tell us about the contextual factors that support or hinder activities related to <linking community resources and clinical services>? Probes: Describe external factors. Describe internal factors.
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Deletion	How is health equity incorporated into your evaluation plan? Probes: What SDOH data do you collect? How will health disparities be measured and defined? What sorts of methods or tools are used or will be used to measure health equity outcomes?
3.l Eval Assessment_CCL_Recipient Interiew_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CCL> for <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CCL> for <name of cooperative agreement>?
3.m Eval Assessment_CCL_Recipient_Interview Guide_WW	Question Revision	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum people.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum people. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum people? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?	[Interviewer Note: Ask the following questions if the recipient stated in the nomination form that they are working on cardiac rehab, or hypertension among women, or hypertension among pregnant or postpartum women.] According to the < nomination form>, we learned that you are implementing <cardiac rehab and/or activities related to hypertension in women and/or activities related to hypertension in pregnant or postpartum women. > Can you tell us more about these activities? Probes: [If applicable based on recipient response in the nomination form] Tell me more about your cardiac rehab programming. What types of activities are implemented? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on pregnant or postpartum women? How do you tailor your activities for pregnancy and postpartum period? [If applicable based on recipient response in the nomination form] What types of intervention activities prioritize or focus on women? How do you tailor your activities for women?
3.m Eval Assessment_CCL_Recipient_Interview Guide_WW	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the health disparities in your population of focus? What barriers do the population of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: How did you identify your population of focus? What data and methods do you use? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus? What barriers do the population of focus face in terms of management and treatment of CVD?
3.m Eval Assessment_CCL_Recipient_Interview Guide_WW	Question Revision	How does your program focus on <name of priority population>? Please describe how program activities are tailored to the needs of your population. Probes: How do SDOH affect patient engagement with HBSS and social support services? How does this inform your program approach? What challenges has your program experienced with referrals to social and support services among <name of population of focus>? How do you and your partners plan to address these barriers? What approaches have worked best for recruitment, enrollment, and retention in HBSS for <name of population of focus>?	How does your program focus on <name of priority population>? Please describe how program activities are tailored to the needs of your population. Probes: What challenges has your program experienced with referrals to social and support services among <name of population of focus>? How do you and your partners plan to address these barriers? What approaches have worked best for recruitment, enrollment, and retention in HBSS for <name of population of focus>?
3.m Eval Assessment_CCL_Recipient_Interview Guide_WW	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to <linking community resources and clinical services>? Probes: Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate. Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture.	Can you tell us about the contextual factors that support or hinder activities related to <linking community resources and clinical services>? Probes: Describe external factors. Describe internal factors.
3.m Eval Assessment_CCL_Recipient_Interview Guide_WW	Question Deletion	How is health equity incorporated into your evaluation plan? Probes: What SDOH data do you collect? How will health disparities be measured and defined? What sorts of methods or tools are used or will be used to measure health equity outcomes?
3.m Eval Assessment_CCL_Recipient_Interview Guide_WW	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CCL> implementation for WISEWOMAN>?	What, if any, barriers have you encountered with data collection or monitoring and evaluation activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from CDC? What have been some lessons learned from your experience with data collection and evaluation related to <CCL> implementation for WISEWOMAN?
3.n Eval Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to <implementation of community and clinical linkages, community health worker programs, and self-monitored blood pressure monitoring program>, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services or implementing these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, genders, geography, <census tracts for Innovative CVH Program>) that your organization typically serves?	From the <nomination form, APR, work plan, EPMP, etc.>, we learned that your organization offers <programs and services> for <population >. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs, related to <implementation of community and clinical linkages, community health worker programs, and self-monitored blood pressure monitoring program>, does your organization offer to support individuals who have or at high risk for high blood pressure or high cholesterol? How long has your organization been offering these services or implementing these programs? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, sex, geography, <census tracts for Innovative CVH Program>) that your organization typically serves?
3.n Eval Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers does the population of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barriers does the population of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.n Eval Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	How does <your program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: How do SDOH affect patient engagement with SMBP and program referrals? How does this inform your program approach? What challenges has your program experienced with referrals to social and support programs/services and SMBP? What approaches have worked best for identification, recruitment, enrollment, and retention? What innovations will be implemented to address SDOH through <CCL, CHW, and SMBP>? (The Innovative CVH Program)	How does <your program> focus on <name of population of focus>? Please describe how program activities are tailored to the needs of your population. Probes: What challenges has your program experienced with referrals to social and support programs/services and SMBP? What approaches have worked best for identification, recruitment, enrollment, and retention?
3.n Eval Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to <CCL, CHW, and SMBP>? Probes: Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate. Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture.	Can you tell us about the contextual factors that support or hinder activities related to <CCL, CHW, and SMBP>? Probes: Describe external factors. Describe internal factors.
3.n Eval Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Deletion	What type of data related to health equity are collected and tracked? Probes: What SDOH data do you collect? How will health disparities be measured and defined? What sorts of methods or tools are used or will be used to measure health equity outcomes?
3.n Eval Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from CDC? What have been some lessons learned from your experience with data collection and reporting related to <CCL> for <name of cooperative agreement>?	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from CDC? What have been some lessons learned from your experience with data collection and reporting related to <CCL> for <name of cooperative agreement>?
3.o Eval Assessment_CCL_Partner_Interview Guide_WW	Question Revision	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barrier does the population of focus face in terms of management and treatment of CVD? How do SDOH factors affect their CVD risk? What tools and resources have you used to understand or identify the health disparities in your population of focus?	What is the <program’s> population of focus? What demographics, patient characteristics, or geographies are you prioritizing? Probes: What barrier does the population of focus face in terms of management and treatment of CVD? What tools and resources have you used to understand or identify the differences in health outcomes in your population of focus?
3.o Eval Assessment_CCL_Partner_Interview Guide_WW	Question Revision	How does your <program> focus on <name of population of focus>? Please describe how <program activities> are tailored to the needs of your population. Probes: How do SDOH affect patient engagement with HBSS and social support services? How does this inform your program approach? What challenges has your program experienced with referrals to social and support services and HBSS? How do you and your partners plan to address these barriers? What approaches have worked best for recruitment, enrollment, and retention in HBSS?	How does your <program> focus on <name of population of focus>? Please describe how <program activities> are tailored to the needs of your population. Probes: What challenges has your program experienced with referrals to social and support services and HBSS? How do you and your partners plan to address these barriers? What approaches have worked best for recruitment, enrollment, and retention in HBSS?
3.o Eval Assessment_CCL_Partner_Interview Guide_WW	Question Revision	Can you tell us about the contextual factors that support or hinder activities related to <linking community resources and clinical services>? Probes: Describe external factors such as complementing or competing initiatives, additional funding sources, partnerships and collaborations, state policies, political/economic climate. Describe internal factors such as organizational policies, leadership buy-in, internal capacity, organizational culture.	Can you tell us about the contextual factors that support or hinder activities related to <linking community resources and clinical services>? Probes: Describe external factors. Describe internal factors.
3.o Eval Assessment_CCL_Partner_Interview Guide_WW	Question Deletion	What type of data related to health equity are collected and tracked? Probes: What SDOH data do you collect? How will health disparities be measured and defined? What sorts of methods or tools are used or will be used to measure health equity outcomes?
3.o Eval Assessment_CCL_Partner_Interview Guide_WW	Question Revision	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What challenges, if any, are there with collecting SDOH data? What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from CDC? What have been some lessons learned from your experience with data collection and reporting related to <CCL> for the WISEWOMAN program?	What, if any, barriers have you encountered with data collection or monitoring and reporting activities? Probes: What barriers, if any, do you anticipate in data collection or reporting related to outcome or impact? What specific strategies have been used or will be used to overcome these barriers? What additional support or TA do you need from <name of recipient organization>? What about from CDC? What have been some lessons learned from your experience with data collection and reporting related to <CCL> for the WISEWOMAN program?
4.a Ex Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	We learned in the Evaluability Assessment that <LC activities> hoped to achieve <system or community-level reductions in health disparities>. [If no interviewee participated in the Evaluability Assessment interview] Are you able to speak to these activities? [IF some/all interviewees participated in the Evaluability Assessment interview or If no interviewee participated but can speak to the plans] Can you talk about your progress related to <system or community-level reductions in health disparities>? Probes: If yes What are specific examples of how system or community-level health disparities were reduced? If no Are there any barriers that affect your ability to mitigate health disparities? Please describe.	We learned in the Evaluability Assessment that <LC activities> hoped to address <system or community-level differences in health outcomes>. [If no interviewee participated in the Evaluability Assessment interview] Are you able to speak to these activities? [IF some/all interviewees participated in the Evaluability Assessment interview or If no interviewee participated but can speak to the plans] Can you talk about your progress related to addressing <system or community-level differences in health outcomes>? Probes: If yes What are specific examples of how system or community-level differences in health outcomes were addressed? If no Are there any barriers that affect your ability to address differences in health outcomes? Please describe.
4.a Ex Assessment_LC_Interview Guide_NCHP_ICHP	Question Revision	Have the <health disparities being measured and tracked as indicated in the Evaluability Assessment> changed since we last talked in <September 2024 through September 2025>?	Have the <differences in health outcomes being measured and tracked as indicated in the Evaluability Assessment> changed since we last talked in <September 2024 through September 2025>?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[1A] How has the advancement of EHR/HIT affected identifying, tracking, and monitoring clinical measures and social services and support needs? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 1A implementation>? What activities were most helpful for monitoring: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use EHR/HIT to identify patients in need of clinical and social support services? 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?	[1A] How has the advancement of EHR/HIT affected identifying, tracking, and monitoring clinical measures and social services and support needs? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 1A implementation>? What activities were most helpful for monitoring: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use EHR/HIT to identify patients in need of clinical and social support services? 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 differences in health outcomes?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[1B] How has the use of new processes or tools affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 1B implementation>? What activities were most helpful for: Identifying social services and support needs of patients at highest risk of CVD? Monitoring and assessing patient referrals to services? Monitoring and assessing utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use new processes or tools to identify patients in need of clinical and social support services? What specific changes have you observed that have resulted from <above activities>? How has the use of processes or tools contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials >? How has it contributed to achieving <intermediate outcomes>? How has the use of processes or tools contributed to addressing health disparities?	[1B] How has the use of new processes or tools affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 1B implementation>? What activities were most helpful for: Identifying social services and support needs of patients at highest risk of CVD? Monitoring and assessing patient referrals to services? Monitoring and assessing utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use new processes or tools to identify patients in need of clinical and social support services? What specific changes have you observed that have resulted from <above activities>? How has the use of processes or tools contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials >? How has it contributed to achieving <intermediate outcomes>? How has the use of processes or tools contributed to addressing differences in health outcomes?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Deletion	How have the <CQM 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 <CQM 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 or other EHR/HIT 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?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Revision	Have there been any measurable reductions in health disparities as a result of <CQM activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are specific examples of how health disparities were reduced through the implementation of <CQM strategy>? How does <Recipient and partner activities related to CQM strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address health disparities? [If yes]- in what ways? 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 patient’s unmet SDOH needs?	Have there been any measurable differences in health outcomes as a result of <CQM activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are specific examples of how differences in health outcomes were addressed through the implementation of <CQM strategy>? How does <Recipient and partner activities related to CQM strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address differences in health outcomes? [If yes]- in what ways? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring changes in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < cardiac rehabilitation activities > contribute to reducing health disparities?	How do < cardiac rehabilitation activities > contribute to addressing differences in health outcomes?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < activities related to hypertension in women > contribute to reducing health disparities?	How do < activities related to hypertension in women > contribute to addressing differences in health outcomes?
4.b Ex Assessment_CQM_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?	How do < activities related to hypertension control in pregnancy or postpartum > contribute to addressing differences in health outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	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 CQM 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: 1A: providing CVD risk assessments? 1B: integrating/aligning EHRs and HIT within provider workflows? 1C: using standardized procedures? 1D: using metrics from program data to guide quality improvement activities? 1E: identifying health care disparities through the use of EHR, HIT, or program data? How did your organization resolve these challenges?	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 CQM 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: 1A: providing CVD risk assessments? 1B: integrating/aligning EHRs and HIT within provider workflows? 1C: using standardized procedures? 1D: using metrics from program data to guide quality improvement activities? 1E: identifying differences in health outcomes through the use of EHR, HIT, or program data? How did your organization resolve these challenges?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1A] How has the use of CVD risk assessments among the population of focus (i.e., under- and uninsured participants between the ages of 35-64 years) affected the identification of patients at risk or with CVD? Probes: What types of resources or support were most helpful to partners? What activities were most helpful for supporting partners in providing CVD risk assessments? What activities were most helpful to strengthen or create new processes or workflows to provide CVD risk assessments? 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?	[1A] How has the use of CVD risk assessments among the population of focus (i.e., under- and uninsured participants between the ages of 35-64 years) affected the identification of patients at risk or with CVD? Probes: What types of resources or support were most helpful to partners? What activities were most helpful for supporting partners in providing CVD risk assessments? What activities were most helpful to strengthen or create new processes or workflows to provide CVD risk assessments? 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 differences in health outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1B] How has the use of EHR/HIT affected identification, monitoring, and tracking of clinical and social services and support needs? Probes: What types of resources or support were most helpful to partners? What activities were most helpful for: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use EHR/HIT to identify patients in need of clinical and social support services? 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?	[1B] How has the use of EHR/HIT affected identification, monitoring, and tracking of clinical and social services and support needs? Probes: What types of resources or support were most helpful to partners? What activities were most helpful for: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use EHR/HIT to identify patients in need of clinical and social support services? 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 differences in health outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1C] How has the use of new processes or tools affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to partners? What activities were helpful for: Identifying social services and support needs? Monitoring and assessing referrals? Monitoring and assessing utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use standardized procedures to identify patients in need of clinical and social support services? 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?	[1C] How has the use of new processes or tools affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to partners? What activities were helpful for: Identifying social services and support needs? Monitoring and assessing referrals? Monitoring and assessing utilization of services? What activities were most helpful to strengthen or create new processes or workflows to use standardized procedures to identify patients in need of clinical and social support services? 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 differences in health outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1D] How has the use of metrics from program data affected quality improvement activities? Probes: What types of resources or support were most helpful to partners? What activities were helpful for increasing: Program enrollment? Patient retention? Referrals to additional services? What activities were most helpful to strengthen or create new processes or workflows to use program metric data to guide quality improvement activities? 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?	[1D] How has the use of metrics from program data affected quality improvement activities? Probes: What types of resources or support were most helpful to partners? What activities were helpful for increasing: Program enrollment? Patient retention? Referrals to additional services? What activities were most helpful to strengthen or create new processes or workflows to use program metric data to guide quality improvement activities? 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 differences in health outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1E] How has the use of EHR, HIT, or program data affected the identification of health care disparities? Probes: What types of resources or support were most helpful to partners? What activities were helpful for: Identifying health care disparities? Addressing health outcomes? What activities were most helpful to strengthen or create new processes or workflows to use EHR/HIT to identify health care disparities? 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>?	[1E] How has the use of EHR, HIT, or program data affected the identification of differences in health outcomes? Probes: What types of resources or support were most helpful to partners? What activities were helpful for: Identifying differences in health outcomes? Addressing health outcomes? What activities were most helpful to strengthen or create new processes or workflows to use EHR/HIT to identify differences in health outcomes? 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>?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Deletion	How have the <CQM 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 <CQM activities being implemented by the Recipient and partner organizations> affect social services and support needs of patients? In what ways has the reduction in SDOH barriers influenced CVD-related outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	Have there been any measurable reductions in health disparities as a result of <CQM activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are specific examples of how health disparities were reduced through the implementation of <CQM strategy>? How does <Recipient and partner activities related to CQM 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 patient’s unmet SDOH needs?	Have there been any measurable changes in differences in health outcomes as a result of <CQM activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are specific examples of how differences in health outcomes were addressed through the implementation of <CQM strategy>? How does <Recipient and partner activities related to CQM strategy implementation> address gaps in care for your population of focus? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1E] What steps has your organization taken to ensure that partners can sustain use of EHR, HIT, and program data to identify health care disparities and address health outcomes? Probe: Can you share any challenges faced in supporting partners in using EHR, HIT, or program data and how they were addressed?	[1E] What steps has your organization taken to ensure that partners can sustain use of EHR, HIT, and program data to identify and address differences in health outcomes? Probe: Can you share any challenges faced in supporting partners in using EHR, HIT, or program data and how they were addressed?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	[1E] How do you plan to proceed with activities related to supporting the use of EHRs, HIT, and program data to identify health care disparities after completing the cooperative agreement?	[1E] How do you plan to proceed with activities related to supporting the use of EHRs, HIT, and program data to identify differences in health outcomes after completing the cooperative agreement?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	How do < cardiac rehabilitation activities > contribute to reducing health disparities?	How do < cardiac rehabilitation activities > contribute to addressing differences in health outcomes?
4.c Ex Assessment_CQM_Recipient Interview Guide_WW	Question Revision	How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?	How do < activities related to hypertension control in pregnancy or postpartum > contribute to addressing differences in health outcomes?
4.d Ex Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	[1A] How has the advancement of EHR/HIT affected identifying, tracking, and monitoring clinical measures and social services and support needs? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What was the role of the LC in supporting <strategy 1A implementation> What activities were most helpful for: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? 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?	[1A] How has the advancement of EHR/HIT affected identifying, tracking, and monitoring clinical measures and social services and support needs? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What was the role of the LC in supporting <strategy 1A implementation> What activities were most helpful for: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? 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 differences in health outcomes?
4.d Ex Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	[1B] How have the use of new processes or tools implemented affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What was the role of the LC in supporting <strategy 1B implementation>? What activities were most helpful for: Identifying social services and support needs of patients at highest risk of CVD? Monitoring and assessing patient referrals to services? Monitoring and assessing utilization of services? 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>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing health disparities?	[1B] How have the use of new processes or tools implemented affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What was the role of the LC in supporting <strategy 1B implementation>? What activities were most helpful for: Identifying social services and support needs of patients at highest risk of CVD? Monitoring and assessing patient referrals to services? Monitoring and assessing utilization of services? 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>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing differences in health outcomes?
4.d Ex Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Deletion	How have the <partner’s CQM 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 CQM strategy implementation> affect social services and support needs of patients within your organizations? Did the Learning Collaborative provide support for QI or other EHR/HIT 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?
4.d Ex Assessment_CQM_Partner_Interview Guide_NCHP_ICHP	Question Revision	Have there been any measurable reductions in health disparities as a result of <partner’s activities related to CQM strategy implementation>? Probes: If yes: What are specific examples of how health disparities were reduced through the implementation of <CQM strategy>? How do <partner activities related to CQM strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address health disparities? [If yes]- in what ways? 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 patient’s unmet SDOH needs?	Have there been any measurable changes in differences in health outcomes as a result of <partner’s activities related to CQM strategy implementation>? Probes: If yes: What are specific examples of how differences in health outcomes were reduced through the implementation of <CQM strategy>? How do <partner activities related to CQM strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address differences in health outcomes? [If yes]- in what ways? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	How did the <recipient organization> support your organization in the development or enhancement of <CQM processes> to support the identification, tracking, and monitoring of patients’ clinical and social support services? Probes: How did the <recipient organization> provide support for the development or enhancement of EHRs to support identification of health care disparities? What types of support have been most helpful to <partner organization> to develop or strengthen these <CQM activities>? How is the <recipient organization> helping you with respect to developing workflows/systems to create/enhance <CQM activities>? Are there other partner organizations that are also helping your organization with this work?	How did the <recipient organization> support your organization in the development or enhancement of <CQM processes> to support the identification, tracking, and monitoring of patients’ clinical and social support services? Probes: How did the <recipient organization> provide support for the development or enhancement of EHRs to support identification of differences in health outcomes? What types of support have been most helpful to <partner organization> to develop or strengthen these <CQM activities>? How is the <recipient organization> helping you with respect to developing workflows/systems to create/enhance <CQM activities>? Are there other partner organizations that are also helping your organization with this work?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	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 CQM 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: 1A: providing CVD risk assessments? 1B: integrating/aligning EHRs and HIT within provider workflows? 1C: using standardized procedures? 1D: using metrics from program data to guide quality improvement activities? 1E: identifying health care disparities through the use of EHR, HIT, or program data? How did your organization resolve these challenges?	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 CQM 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: 1A: providing CVD risk assessments? 1B: integrating/aligning EHRs and HIT within provider workflows? 1C: using standardized procedures? 1D: using metrics from program data to guide quality improvement activities? 1E: identifying differences in health outcomes through the use of EHR, HIT, or program data? How did your organization resolve these challenges?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	[1A] How has the use of CVD risk assessments among the population of focus (i.e., under- and uninsured participants between the ages of 35-64 years) affected the identification of patients at risk or with CVD? Probes: What types of support or resources were most helpful to your organization to ensure CVD risk assessments were being performed at all recommended office visits (i.e., baseline, follow-up, reassessment)? What activities were most helpful for providing CVD risk assessments during baseline, follow-up, and reassessment? What specific changes have you observed that have resulted from <above activities>? How has providing CVD risk assessments to the population of focus contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to achieving <intermediate outcomes>? How has the use of CVD risk assessments contributed to addressing health disparities?	[1A] How has the use of CVD risk assessments among the population of focus (i.e., under- and uninsured participants between the ages of 35-64 years) affected the identification of patients at risk or with CVD? Probes: What types of support or resources were most helpful to your organization to ensure CVD risk assessments were being performed at all recommended office visits (i.e., baseline, follow-up, reassessment)? What activities were most helpful for providing CVD risk assessments during baseline, follow-up, and reassessment? What specific changes have you observed that have resulted from <above activities>? How has providing CVD risk assessments to the population of focus contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to achieving <intermediate outcomes>? How has the use of CVD risk assessments contributed to addressing differences in health outcomes?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	[1B] How has the use of EHR/HIT affected identification, monitoring, and tracking of clinical and social services and support needs? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were most helpful for: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? 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?	[1B] How has the use of EHR/HIT affected identification, monitoring, and tracking of clinical and social services and support needs? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were most helpful for: Identifying patient’s needs? Assessing and tracking patient’s needs? Tracking referrals and utilization of services? 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 differences in health outcomes?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	[1C] How have the use of new processes or tools implemented affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were helpful for: Identifying social services and support needs? Monitoring and assessing referrals? Monitoring and assessing utilization of services? 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?	[1C] How have the use of new processes or tools implemented affected the identification of social services and support needs of patients at highest risk of CVD? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were helpful for: Identifying social services and support needs? Monitoring and assessing referrals? Monitoring and assessing utilization of services? 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 differences in health outcomes?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	[1D] How has the use of metrics from program data affected quality improvement activities? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were helpful for increasing: Program enrollment? Patient retention? Referrals to additional services? 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?	[1D] How has the use of metrics from program data affected quality improvement activities? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were helpful for increasing: Program enrollment? Patient retention? Referrals to additional services? 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 differences in health outcomes?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	[1E] What types of resources or support were most helpful for using EHR, HIT, and program data to identify health care disparities? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were helpful for: Identifying health care disparities? Addressing health outcomes? 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?	[1E] What types of resources or support were most helpful for using EHR, HIT, and program data to identify differences in health outcomes? Probes: What types of resources or support were most helpful to your organization to develop or strengthen CQM processes? What activities were helpful for: Identifying differences in health outcomes? Addressing health outcomes? 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 differences in health outcomes?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Deletion	How have <partner’s CQM 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 CQM strategy implementation> affect social services and support needs of patients within your organizations? In what ways has the reduction in SDOH barriers influenced CVD-related outcomes?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	Have there been any measurable reductions in health disparities as a result of <partner’s activities related to CQM strategy implementation>? Probes: If yes: What are specific examples of how health disparities were reduced through the implementation of <CQM strategy>? How do <partner activities related to CQM 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 patient’s unmet SDOH needs?	Have there been any measurable changes in differences in health outcomes as a result of <partner’s activities related to CQM strategy implementation>? Probes: If yes: What are specific examples of how differences in health outcomes were reduced through the implementation of <CQM strategy>? How do <partner activities related to CQM strategy implementation> address gaps in care for your population of focus? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.e Ex Assessment_CQM_Partner_Interview Guide_WW	Question Revision	[1E] What steps has your organization taken to help sustain use of EHR, HIT, and program data to identify health care disparities and address health outcomes? Probe: Can you share any challenges faced in using EHR, HIT, or program data and how they were addressed?	[1E] What steps has your organization taken to help sustain use of EHR, HIT, and program data to identify and address differences in health outcomes? Probe: Can you share any challenges faced in using EHR, HIT, or program data and how they were addressed?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[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?	[2A] How has the advancement of EHR/HIT affected monitoring population health with a focus on 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: Differences in health outcomes? 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 differences in health outcomes?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[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?	[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 differences in health outcomes?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[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?	[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 differences in health outcomes?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Deletion	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?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	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?	Have there been any measured changes in health outcomes as a result of <TBC activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are examples of how differences in health outcomes were addressed 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 barriers to care? [If yes]- in what ways? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < cardiac rehabilitation activities > contribute to reducing health disparities?	How do < cardiac rehabilitation activities > contribute to addressing differences in health outcomes?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < activities related to hypertension in women > contribute to reducing health disparities?	How do < activities related to hypertension in women > contribute to addressing differences in health outcomes?
4.f Ex Assessment_TBC_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?	How do < activities related to hypertension control in pregnancy or postpartum > contribute to addressing differences in health outcomes?
4.g Ex Assessment_TBC_Recipient Interview Guide_WW	Question Revision	[2A] How has engaging program participants and health professionals affected participant follow-up and communication and coordination among the care team? Probes: What types of resources or support were most helpful to partners? What activities were helpful for enhancing: participant follow-up? communication and coordination among the care team? What activities were most helpful to strengthen or create new processes or workflows to engage program participants and health professionals? 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?	[2A] How has engaging program participants and health professionals affected participant follow-up and communication and coordination among the care team? Probes: What types of resources or support were most helpful to partners? What activities were helpful for enhancing: participant follow-up? communication and coordination among the care team? What activities were most helpful to strengthen or create new processes or workflows to engage program participants and health professionals? 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 differences in health outcomes?
4.g Ex Assessment_TBC_Recipient Interview Guide_WW	Question Revision	[2B] How has the development and maintenance of networks of state, regional, and local social services and support affected the mitigation of social support barriers? Probes: What types of resources or support were most helpful to partners? What activities were helpful for building and maintaining networks of state, regional, and local social services and support? What activities were most helpful to strengthen or create new processes or workflows to establish and maintain multidisciplinary partnerships? 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?	[2B] How has the development and maintenance of networks of state, regional, and local social services and support affected the mitigation of social support barriers? Probes: What types of resources or support were most helpful to partners? What activities were helpful for building and maintaining networks of state, regional, and local social services and support? What activities were most helpful to strengthen or create new processes or workflows to establish and maintain multidisciplinary partnerships? 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 differences in health outcomes?
4.g Ex Assessment_TBC_Recipient Interview Guide_WW	Question Deletion	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 participants? In what ways has the reduction in SDOH barriers influenced CVD-related outcomes?
4.g Ex Assessment_TBC_Recipient Interview Guide_WW	Question Revision	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? 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?	Have there been any measured changes in health outcomes as a result of <TBC activities being implemented by the Recipient and partner organizations >? Probes: If yes: What are examples of how differences in health outcomes were addressed 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? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address participant’s unmet needs?
4.g Ex Assessment_TBC_Recipient Interview Guide_WW	Question Revision	How do < cardiac rehabilitation activities > contribute to reducing health disparities?	How do < cardiac rehabilitation activities > contribute to addressing differences in health outcomes?
4.g Ex Assessment_TBC_Recipient Interview Guide_WW	Question Revision	How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?	How do < activities related to hypertension control in pregnancy or postpartum > contribute to addressing differences in health outcomes?
4.h Ex Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	[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 your organization to develop or strengthen TBC processes? 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 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?	[2A] How has the advancement of EHR/HIT affected monitoring population health with a focus on hypertension and high cholesterol? Probes: What types of resources or support were most helpful to your organization to develop or strengthen TBC processes? What was the role of the LC in supporting <strategy 2A implementation>? What activities were most helpful for monitoring: Differences in health outcomes? 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 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 differences in health outcomes?
4.h Ex Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	[2B] How has engagement of non-physician care team members in patient care 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 your organization to develop or strengthen TBC processes? 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 improving communication among care team members? What specific changes have you observed that have resulted from <above activities>? How has engaging non-physician care team members in patient care contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to <intermediate outcomes>? How has engaging non-physician care team members in physician care contributed to addressing health disparities?	[2B] How has engagement of non-physician care team members in patient care 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 your organization to develop or strengthen TBC processes? 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 improving communication among care team members? What specific changes have you observed that have resulted from <above activities>? How has engaging non-physician care team members in patient care contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to <intermediate outcomes>? How has engaging non-physician care team members in physician care contributed to addressing differences in health outcomes?
4.h Ex Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	[2C] How has the use of coordinated networks of multidisciplinary partnerships affected patient care coordination and follow-up? Probes: What types of resources or support were most helpful to your organization to develop or strengthen TBC processes? 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 specific changes have you observed that have resulted from <above activities>? How has engaging non-physician care team members in patient care contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to <intermediate outcomes>? How has engaging non-physician care team members in physician care contributed to addressing health disparities?	[2C] How has the use of coordinated networks of multidisciplinary partnerships affected patient care coordination and follow-up? Probes: What types of resources or support were most helpful to your organization to develop or strengthen TBC processes? 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 specific changes have you observed that have resulted from <above activities>? How has engaging non-physician care team members in patient care contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to <intermediate outcomes>? How has engaging non-physician care team members in physician care contributed to addressing differences in health outcomes?
4.h Ex Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Deletion	How have the <partner’s TBC 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 TBC strategy implementation> affect social services and support needs of patients within your organizations? 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?
4.h Ex Assessment_TBC_Partner_Interview Guide_NCHP_ICHP	Question Revision	Have there been any measurable reductions in health disparities as a result of <partner’s activities related to TBC strategy implementation>? Probes: If yes: What are specific examples of how health disparities were reduced through implementation of <TBC strategy>? How do <partner activities related to TBC strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address health disparities? [If yes]- in what ways? 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 patient’s unmet SDOH needs?	Have there been any measurable changes in health outcomes as a result of <partner’s activities related to TBC strategy implementation>? Probes: If yes: What are specific examples of how differences in health outcomes were addressed through implementation of <TBC strategy>? How do <partner activities related to TBC strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address differences in health outcomes? [If yes]- in what ways? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.i Ex Assessment_TBC_Partner_Interview Guide_WW	Question Revision	[2A] How has engaging program participants and health professionals affected participant follow-up and communication and coordination among the care team? Probes: What types of resources or support were most helpful to your organization to strengthen or develop TBC processes? What activities were helpful for enhancing: participant follow-up? communication and coordination among the care team? 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?	[2A] How has engaging program participants and health professionals affected participant follow-up and communication and coordination among the care team? Probes: What types of resources or support were most helpful to your organization to strengthen or develop TBC processes? What activities were helpful for enhancing: participant follow-up? communication and coordination among the care team? 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 differences in health outcomes?
4.i Ex Assessment_TBC_Partner_Interview Guide_WW	Question Revision	[2B] How has the development and maintenance of networks of state, regional, and local social services and support affected the mitigation of social support barriers? Probes: What types of resources or support were most helpful to your organization to strengthen or develop TBC processes? What activities were helpful for building and maintaining networks of state, regional, and local 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 <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?	[2B] How has the development and maintenance of networks of state, regional, and local social services and support affected the mitigation of social support barriers? Probes: What types of resources or support were most helpful to your organization to strengthen or develop TBC processes? What activities were helpful for building and maintaining networks of state, regional, and local 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 <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 differences in health outcomes?
4.i Ex Assessment_TBC_Partner_Interview Guide_WW	Question Deletion	How have the <partner’s TBC 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 TBC 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?
4.i Ex Assessment_TBC_Partner_Interview Guide_WW	Question Revision	Have there been any measurable reductions in health disparities as a result of <partner’s activities related to TBC strategy implementation>? Probes: If yes: What are specific examples of how health disparities were reduced through implementation of <TBC strategy> How do <partner activities related to TBC 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?	Have there been any measurable changes in health outcomes as a result of <partner’s activities related to TBC strategy implementation>? Probes: If yes: What are specific examples of how differences in health outcomes were addressed through implementation of <TBC strategy> How do <partner activities related to TBC strategy implementation> address gaps in care for your population of focus? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address participant’s unmet needs?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[3A] How have community-clinical links affected the identification of SDOH and responses to social services and support needs? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 3A implementation>? What activities were most helpful for: Identifying SDOH? Responding to social services and support needs? What activities have been most successful for increasing CCL to address social support service needs? 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 has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing health disparities?	[3A] How have community-clinical links affected the identification of and responses to social services and support needs? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 3A implementation>? What activities were most helpful for: Responding to social services and support needs? What activities have been most successful for increasing CCL to address social support service needs? 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 has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing differences in health outcomes?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	[3B] How has the identification and engagement of CHWs by your partners affected continuum of care and services provided? Probes: What types of resources or support were most helpful to you partner health systems/clinics? What was the role of the LC in supporting <strategy 3B implementation>? What activities were most helpful for: Providing a continuum of care? Addressing social services and support needs? What are best practices for establishing or strengthening new processes or workflows to engage CHWs to provide a continuum of care? 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 details>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing health disparities?	[3B] How has the identification and engagement of CHWs by your partners affected continuum of care and services provided? Probes: What types of resources or support were most helpful to you partner health systems/clinics? What was the role of the LC in supporting <strategy 3B implementation>? What activities were most helpful for: Providing a continuum of care? Addressing social services and support needs? What are best practices for establishing or strengthening new processes or workflows to engage CHWs to provide a continuum of care? 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 details>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing differences in health outcomes?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How has the use of self-measured blood pressure monitoring (SMBP) with clinical support by partner health systems/clinics address SDOH? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 3C implementation>? What activities were most helpful for promoting the use of SMBP? What are best practices to enhance or strengthen processes or workflows related to the use of SMBP? 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 has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing health disparities?	What activities were most helpful for promoting the use of SMBP? Probes: What types of resources or support were most helpful to partners? What was the role of the LC in supporting <strategy 3C implementation>? What are best practices to enhance or strengthen processes or workflows related to the use of SMBP? 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 has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing differences in health outcomes?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Deletion	How have the <CCL 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 <CCL 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?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	Have there been any measured reductions in health disparities as a result of <CCL activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are examples of how health disparities were reduced through implementation of <CCL strategies>? How does <Recipient and partner activities related to CCL 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 any barriers to measuring changes in health disparities? What additional resources are needed to address patient’s unmet SDOH needs?	Have there been any measured changes in health outcomes as a result of <CCL activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are examples of how differences in health outcomes were addressed through implementation of <CCL strategies>? How does <Recipient and partner activities related to CCL strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address barriers to care? [If yes]- in what ways? If no: Are there any barriers that affect your ability to address differences in health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < cardiac rehabilitation activities > contribute to reducing health disparities?	How do < cardiac rehabilitation activities > contribute to reducing addressing differences in health outcomes?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < activities related to hypertension in women > contribute to reducing health disparities?	How do < activities related to hypertension in women > contribute to addressing differences in health outcomes?
4.j Ex Assessment_CCL_Recipient_Interview Guide_NCHP_ICHP	Question Revision	How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?	How do < activities related to hypertension control in pregnancy or postpartum > contribute to addressing differences in health outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	[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 partners? What activities were most helpful for facilitating provider and community bidirectional referrals? What activities were most helpful for creating or strengthening systems that facilitate bidirectional referrals? What specific changes have you observed that have resulted from the <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?	[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 partners? What activities were most helpful for facilitating provider and community bidirectional referrals? What activities were most helpful for creating or strengthening systems that facilitate bidirectional referrals? What specific changes have you observed that have resulted from the <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 differences in health outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	[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 partners? What activities were most helpful for: Providing evidence-informed HBSS? Referring participants to HBSS? What activities were most helpful for establishing or strengthening new processes or workflows for collaborating with community groups? 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 details>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing health disparities?	[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 partners? What activities were most helpful for: Providing evidence-informed HBSS? Referring participants to HBSS? What activities were most helpful for establishing or strengthening new processes or workflows for collaborating with community groups? 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 details>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing differences in health outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	[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 partners? What activities were most helpful for: Participant engagement in HBSS? Participant completion of HBSS? What activities were most helpful to enhance or strengthen new processes or workflows to use evidence-based and evidence-informed strategies to increase participation in 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 details>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing health disparities?	[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 partners? What activities were most helpful for: Participant engagement in HBSS? Participant completion of HBSS? What activities were most helpful to enhance or strengthen new processes or workflows to use evidence-based and evidence-informed strategies to increase participation in 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 details>? How has it contributed to achieving <intermediate outcomes>? How has the use of <above activities> contributed to addressing differences in health outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	[3D] How are <CCL activities> affecting referrals of participants to appropriate social services and support? Probes: What types of resources or support were most helpful to partners? What activities were most helpful for: Referring participants to social services and support? Tracking and monitoring participant use of social services and support? What activities were most helpful to establish or strengthen new processes or workflows to refer participants to social services and supports? 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?	[3D] How are <CCL activities> affecting referrals of participants to appropriate social services and support? Probes: What types of resources or support were most helpful to partners? What activities were most helpful for: Referring participants to social services and support? Tracking and monitoring participant use of social services and support? What activities were most helpful to establish or strengthen new processes or workflows to refer participants to social services and supports? 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 differences in health outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Deletion	How have the <CCL 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 <CCL activities being implemented by the Recipient and partner organizations> affect social services and support needs of participants? In what ways has the reduction in SDOH barriers influenced CVD-related outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	Have there been any measured reductions in health disparities as a result of <CCL activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are examples of how health disparities were reduced through implementation of <CCL strategies>? How does <Recipient and 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?	Have there been any measured changes in health outcomes as a result of <CCL activities being implemented by the Recipient and partner organizations>? Probes: If yes: What are examples of how differences in health outcomes were addressed through implementation of <CCL strategies>? How does <Recipient and 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 address health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address participant’s unmet needs?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	How do < cardiac rehabilitation activities > contribute to reducing health disparities?	How do < cardiac rehabilitation activities > contribute to addressing differences in health outcomes?
4.k Ex Assessment_CCL_Recipient Interview Guide_WW	Question Revision	How do < activities related to hypertension control in pregnancy or postpartum > contribute to reducing health disparities?	How do < activities related to hypertension control in pregnancy or postpartum > contribute to addressing differences in health outcomes?
4.l Ex Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	How did the <recipient organization> support your organization in linking community resources and clinical services to support addressing social determinants? 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?	How did the <recipient organization> support your organization in linking community resources and clinical services to support addressing factors that impact CVD? 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.l Ex Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	[3A] How has the use of community-clinical links affected the identification of SDOH and responses to social services and support needs? Probes: What types of resources or support were most helpful to your organization to strengthen or develop CCL processes? What was the role of the LC in supporting <strategy 3A implementation>? What activities were most helpful for: Identifying SDOH? Responding to social services and support needs? What activities have been most successful for increasing CCL to address social support service needs? 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?	[3A] How has the use of community-clinical links affected the identification and responses to social services and support needs? Probes: What types of resources or support were most helpful to your organization to strengthen or develop CCL processes? What was the role of the LC in supporting <strategy 3A implementation>? What activities were most helpful for: Responding to social services and support needs? What activities have been most successful for increasing CCL to address social support service needs? 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 differences in health outcomes?
4.l Ex Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	[3B] How has the identification and engagement of CHWs affected continuum of care and services provided? Probes: What types of resources or support were most helpful to your organization to strengthen or develop CCL processes? What was the role of the LC in supporting <strategy 3B implementation>? What activities were most helpful for: Providing a continuum of care? Addressing 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 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?	[3B] How has the identification and engagement of CHWs affected continuum of care and services provided? Probes: What types of resources or support were most helpful to your organization to strengthen or develop CCL processes? What was the role of the LC in supporting <strategy 3B implementation>? What activities were most helpful for: Providing a continuum of care? Addressing 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 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 differences in health outcomes?
4.l Ex Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	[3C] How has the use of self-measured blood pressure monitoring (SMBP) with clinical support addressed SDOH? Probes: What types of resources or support were most helpful to your organization to strengthen or develop CCL processes? What was the role of the LC in supporting <strategy 3C implementation>? What activities were most helpful for promoting the use of SMBP? 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?	[3C] What activities were most helpful for promoting the use of SMBP? Probes: What types of resources or support were most helpful to your organization to strengthen or develop CCL processes? What was the role of the LC in supporting <strategy 3C implementation>? 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 differences in health outcomes?
4.l Ex Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Deletion	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 patients within your organizations? Did the Learning Collaborative provide support for QI or other CCL 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?
4.l Ex Assessment_CCL_Partner_Interview Guide_NCHP_ICHP	Question Revision	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? Has the LC impacted capacity to address health disparities? [If yes]- in what ways? 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 patient’s unmet SDOH needs?	Have there been any measurable changes in health outcomes as a result of <partner’s activities related to CCL strategy implementation>? Probes: If yes: What are specific examples of how differences in health outcomes were addressed through the implementation of <CCL strategy>? How do <partner activities related to CCL strategy implementation> address gaps in care for your population of focus? Has the LC impacted capacity to address differences in health outcomes? [If yes]- in what ways? If no: Are there any barriers that affect your ability to address health outcomes? Please describe. Are there any barriers to measuring differences in health outcomes? What additional resources are needed to address patient’s unmet needs?
4.m Ex Assessment_CCL_Partner_Interview Guide_WW	Question Revision	[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?	[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 differences in health outcomes?
4.m Ex Assessment_CCL_Partner_Interview Guide_WW	Question Revision	[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?	[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 differences in health outcomes?
4.m Ex Assessment_CCL_Partner_Interview Guide_WW	Question Revision	[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?	[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 differences in health outcomes?
4.m Ex Assessment_CCL_Partner_Interview Guide_WW	Question Revision	[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?	[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 differences in health outcomes?
4.m Ex Assessment_CCL_Partner_Interview Guide_WW	Question Deletion	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?
4.m Ex Assessment_CCL_Partner_Interview Guide_WW	Question Revision	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?	Have there been any measurable changes in health outcomes as a result of <partner’s activities related to CCL strategy implementation>? Probes: If yes: What are specific examples of how differences in health outcomes were addressed 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 address differences in health outcomes? Please describe. Are there any barriers to measuring changes in differences in health outcomes? What additional resources are needed to address participant’s unmet needs?
5.d Cost Study_Interview Guide_Partners	Question Revision	From the <recipient documents (i.e., recipient cost tool, budget markup, FFR, APR, work plan, EPMP, etc.)>, we learned that your organization offers <partner programs and services> for <populations of focus>. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs does your organization offer to support individuals who have or are at high risk for high blood pressure? How long has your organization been <offering these services, implementing these programs, providing this support>? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, geography, <census tracts for Innovative CVH Program>, <gender for National CVH Program and Innovative CVH Program>) that your organization typically serves or focuses on?	From the <recipient documents (i.e., recipient cost tool, budget markup, FFR, APR, work plan, EPMP, etc.)>, we learned that your organization offers <partner programs and services> for <populations of focus>. Is this correct? Is there anything else you would like to add or clarify? Probes: What types of services/programs does your organization offer to support individuals who have or are at high risk for high blood pressure? How long has your organization been <offering these services, implementing these programs, providing this support>? Can you describe to me the different populations (i.e., race, ethnicity, socioeconomic status, age, geography, <census tracts for Innovative CVH Program>, <sex for National CVH Program and Innovative CVH Program>) that your organization typically serves or focuses on?

Description of Changes to Burden:

There is no change in Burden Hours associated with the modifications made to comply with EO 14168 and EO 14151.

Other Considerations (optional section):

N/A

ATTACH THE DATA COLLECTION FORM WITH THE MODIFIED QUESTIONS.