[Federal Register Volume 69, Number 77 (Wednesday, April 21, 2004)]
[Notices]
[Pages 21536-21548]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-9080]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Secretary


Community-Focused Initiative To Reduce the Burden of Stroke

AGENCY: Department of Health and Human Services, Office of the 
Secretary, Office of Public Health and Science, Office of Minority 
Health.
    Funding Opportunity Title: Community-Focused Initiative to Reduce 
the Burden of Stroke.
    Announcement Type: Initial announcement of availability of funds.

    Catalog of Federal Domestic Assistance Number: 93.004.

    Key Dates: Application Availability Date: Monday, April 19, 2004; 
Technical Assistance Conference Call for Potential Applicants: Tuesday, 
April 27, 2004; Letter of Intent: Wednesday, May 12, 2004; Application 
Deadline: Thursday, June 17, 2004.

SUPPLEMENTARY INFORMATION:

I. Funding Opportunity Description

    Authority: This program is authorized under section 1707 of the 
Public Health Service Act (PHS), as amended, 42 U.S.C. 300u-6.

    Purpose: This announcement is made by the United States Department 
of Health and Human Services (HHS or The Department), acting through 
the Office of Minority Health (OMH) located within the Office of Public 
Health and Science (OPHS), and working in a ``One-Department'' approach 
collaboratively with participating HHS agencies and programs 
(entities). As part of a new Secretary of HHS initiative, the 
Department announces availability of FY 2004 (future funding periods on 
an as-funds-are-available basis) funding for a cooperative agreement 
program for implementation of a core framework entitled, ``The Stroke 
Belt Elimination Initiative (SBEI).'' (See Section VIII. A. Rationale, 
for description of the core components of SBEI.)
    Project Requirements: Activities designed to achieve SBEI core 
goals and objectives, implement the core framework that includes an 
Enabling ring of collaborative activities and a core collaboration 
process, and use core

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measures are required. Other activities may be added by the Stroke Belt 
Community Action Team (SBCAT) upon approval under terms of the 
cooperative agreement with HHS. The community recipient will be 
responsible for activities listed in section 1 and HHS for activities 
listed in section 2.

1. Required Community Recipient Activities

A. Fiduciary Responsibilities
    i. Specify the Lead (Fiduciary) Agency within the SBCAT. The lead 
agency must have valid Internal Revenue Service (IRS) 501(c)(3) tax-
exempt status or other IRS status indicating a bona fide not-for-profit 
organization or a public entity.
    ii. Allocate Funds. Allocate and disperse funds to implement at 
least core activities within the community. Include adequate funds to 
participate fully in the orientation meeting and support a SBCAT 
Coordinator.
    iii. Oversight of SBCAT-linked Services. This includes 
responsibility for overseeing fiscal and programmatic services linked 
to the SBCAT, and that are deemed necessary to accomplish the goals and 
objectives of this program announcement.
    iv. Link Budget to Performance. Provide timely integrated progress 
and financial reports that link performance to expenditures by the 
SBCAT and its key partners.
B. Leadership, Coordination, and Management
    i. Establish or Designate the SBCAT and Implement Activities that 
include an Enabling ring. Identify existing key partners and coalitions 
that focus on chronic disease, especially stroke and high blood 
pressure, that have existing capacity and strong track records. 
Strengthen partnerships and coalitions committed to participating 
actively in the planning, implementation, and evaluation of the SBEI. 
Key partners should demonstrate a high-level commitment to the 
initiative by their willingness to invest expertise, leadership, 
personnel, and other resources in the success of this initiative.
    Partners must include, but are not limited to, local and State 
health departments; community-based health centers and other health 
care offices, clinics, systems or providers identified to provide care 
to medically insured, under insured and uninsured people identified 
with high blood pressure through activities of this or other 
initiatives; key community, health care, voluntary, and professional 
organizations; business, community, and faith-based leaders; and at 
least one lay representative of the population to be served. Other 
partners may include, but are not limited to, existing community 
coalitions or entities (especially those already focusing on stroke and 
high blood pressure), local education agencies; worksite wellness 
programs, health care purchasers, health plans, unions, health care 
providers for farm and migrant workers and their families, primary care 
associations, social service providers, health maintenance 
organizations, private providers, hospitals, universities, schools of 
public health, academic health centers, State Medicaid officials, 
community service organizations, aging services organizations, senior 
centers, community action groups, consumer groups, and the media.
    Partnerships will operate in accordance to the core collaboration 
process and Enabling ring framework described above.
    ii. Establish or Designate, and Coordinate a Leadership Team. This 
team will consist of a subset of SBCAT members who function as a 
steering or executive committee. The Leadership team will be 
responsible for overseeing project activities, establishing and 
maintaining an organizational structure and governance for the SBCAT 
(including decisionmaking procedures), determining the project budget 
and subcontracts, and participating in project-related local and 
national meetings. The leadership team should include, but is not 
limited to, the local health department, key community leaders, and 
others who have experience working in community health promotion and 
addressing stroke, high blood pressure, and high-risk populations.
    iii. Establish or Designate and Support a SBCAT Coordinator or 
other Project Staff as Required. Project staff must include a full-time 
SBCAT Coordinator with a strong background in community-based projects, 
communications and health data evaluation, and experience in 
coordination of community-wide initiatives. The Coordinator will 
function as the program manager, coordinate community activities, help 
to facilitate the SBCAT, and effectively collaborate with the Stroke 
Belt Regional Action Team (SBRAT) Coordinator and the HHS Action Team. 
Other part-time, full-time, or in-kind staff, contractors, and 
consultants must be sufficient in number and expertise to ensure 
project success and have demonstrated skills and experience in 
coalition and partnership development, community mobilization, health 
care systems, public health, program evaluation, epidemiology, data 
management, health promotion, policy and environmental interventions, 
health care quality improvement, communications, resource development, 
and the prevention and control of stroke and high blood pressure.
    iv. Rapidly Develop a Stroke Belt Community Action Plan and 
Implement Community-Based Interventions. Identify and implement high 
priority, intervention strategies proven to prevent and control 
hypertension and stroke. Communities must examine their stroke and 
hypertension burdens, higher-risk populations, current services and 
resources, and partnership capabilities to develop a comprehensive 
community action plan that effectively addresses required activities 
including coordination among SBCAT members, its leadership team, 
coordinator, community, State or sub-regional, regional, and national 
resources and activities via application of an Enabling ring model.
    v. Project Management. The SBCAT Coordinator, in collaboration with 
other project staff and the leadership team, should:
    a. Encourage active participation of SBCAT in project activities 
and decisions, through regular meetings and other proactive methods of 
communication.
    b. Actively oversee all project activities during their planning, 
development, implementation, and evaluation phases.
    c. Track performance in relationship to the achievement of short-
term and intermediate goals and objectives as well as budgetary 
expenditures.
    d. Collaborate with the SBRAT Coordinator to seek technical 
assistance from the State, region, HHS and other Federal agencies, 
other recipients, national voluntary organizations, universities, or 
other sources (see Core Collaboration Process section).
    e. Collaborate with the SBRAT Coordinator to keep the Project 
Officer informed and seek Project Officer input and assistance.
    f. When necessary, take corrective action promptly to ensure 
project success.
    g. Participate in program evaluation and use evaluation data for 
program improvement.
C. Core Objectives
    Core Objective 1--Increase community awareness and knowledge of 
hypertension and stroke.
    Communities are required to implement coordinated interventions

[[Page 21538]]

designed to educate the community about stroke and high blood pressure. 
Such interventions might include:
    i. Conducting community-wide campaigns about the signs and symptoms 
of stroke and recommended action steps; facilitating and coordinating 
prevention messages including collaborating with existing educational 
campaigns such as those occurring in May related to National Stroke 
Awareness Month, National High Blood Pressure Education Month, and 
National Physical Fitness and Sports Month.
    ii. Coordinating with organizations and specific community settings 
via a community Enabling ring and a core collaboration process to 
increase the knowledge of people about prevention and control of stroke 
and high blood pressure. These include but are not limited to 
worksites, schools, health care settings, media outlets, and other 
community organizations such as faith-based organizations and senior 
centers.
    Core Objective 2--Enhance early detection of high blood pressure 
and stroke with early referral to care.
    Such interventions might include:
    i. Working with community-based health centers, health care 
providers, health systems and plans, and employer/purchasers to 
increase the use of evidence-based preventive care practices for 
enhancing prevention and control of stroke and hypertension.
    ii. Providing access to training for health care professionals on 
implementation of effective guideline-based care plans, including 
guidance on effective self-management for patients, employees, and 
other individuals with hypertension or stroke.
    iii. Ensuring that mechanisms are in place in the community for 
networked notification about the when and where of free blood pressure 
checks and referrals to care. This might be done through increased 
collaborations with community-based health centers, clinics, medical 
offices, systems, plans, worksites, faith-based sites, volunteer health 
professionals, and others.
    iv. Enhancing access to and utilization of quality health care 
services for prevention and control of stroke and hypertension.
    Core Objective 3--Increase the community's adoption and use of 
lifestyle behaviors known to promote prevention and control of 
hypertension and stroke.
    Promote lifestyle behaviors aimed at preventing or reducing risk of 
high blood pressure and stroke at the individual/patient, health 
professional/provider, health system or plan, and other organizational 
levels as well as in other community sectors.
    Such interventions might include:
    i. Improving community environmental/ecological policies and 
systems to manage strokes during the acute phase and decrease deaths 
and disability related to stroke. For example, enhancing 911 coverage, 
EMS and other first responder stroke training and protocols, and 
hospital stroke protocols.
    ii. Working with health professionals and health professional 
organizations to more effectively counsel individuals regarding 
adoption and continued use of stroke- and hypertension-prevention and 
control health behaviors.
    iii. Working with commercial, Medicaid, and Medicare health plans 
to more effectively counsel patients to use stroke- and hypertension-
prevention and control health behaviors.
    iv. Working with health systems to develop and implement policy-
level incentives for providers and staff to more effectively counsel 
patients as regards use of stroke- and hypertension-prevention and 
control health behaviors.
    v. Working with other community sectors to encourage students, 
employees, members, clients, local media, and others to use stroke- and 
hypertension-prevention and control health behaviors.
    Core Objective 4--Enhance blood pressure control rates among 
community persons who are known to have hypertension and who are 
members of a health plan or otherwise visit health systems, clinics, or 
medical offices.
    It is expected that activities will be undertaken to facilitate 
incorporation of clinical practice guideline-based approaches into 
organizational programmatic and system-wide policies and procedures 
that will improve high blood pressure control rates in health plans, 
health systems, and medical practice.
    Such interventions might include:
    i. Working with health care providers and in other settings to 
ensure effectiveness of systems designed to support appropriate and 
timely monitoring and care of persons with hypertension and sharing 
verbal and written BP readings and BP goals with them. For example, 
identification and effective management of patients with hypertension, 
including referrals to care, follow-up on visits, and use of patient as 
well as provider reminder systems.
    ii. Working with community, state, and national partners to enhance 
hypertension and stroke training and continuing education for health 
professionals.
    iii. Working with health professionals and health professional 
organizations to increase the percentage of community residents with 
hypertension whose blood pressure is controlled to guideline-
recommended levels.
    iv. Working with commercial, Medicaid, and Medicare health plans to 
meet or exceed the national average for controlling high blood pressure 
reported annually by the National Committee for Quality Assurance 
(NCQA).
    v. Collaborating with health systems to develop and implement 
effective policy-level incentives for providers and staff to meet or 
exceed the national average for controlling high blood pressure 
reported annually by the NCQA.
    vi. Partnering with pharmacists, pharmaceutical companies, and 
others to enhance access to basic anti-hypertensive medications for 
persons with hypertension who lack sufficient drug coverage.
    vii. Increasing medical self-management skills of persons with 
hypertension or stroke, including better adherence to medication and 
other health regimens.

2. HHS Activities

A. Leadership and Coordination
    i. HHS Stroke Belt Action Team. An HHS-level Stroke Belt Action 
Team (HHSAT) has been established to coordinate and organize the Stroke 
Belt Elimination Initiative at the national level. The HHSAT is 
comprised of high-level representatives of participating HHS entities. 
The team will provide SBEI policy oversight and direction. In addition, 
the HHSAT will develop agreements with HHS entities as well as national 
partners specifying how each will assist the SBRAT and SBCAT and 
coordinate technical assistance in support of achievement of the goals 
and objectives described in this program announcement.
    ii. Regional Stroke Belt Action Team. An SBRAT will be formally 
established and an SBRAT Coordinator hired to facilitate and coordinate 
activities among the funding communities. The action team will work 
with representatives from funded communities; States; and sub-regional, 
regional, and national partners to ensure effective use of an enabling 
ring-based collaboration process by SBCATs, funded under this program 
announcement, and their key partners. This action team should: 1) 
anticipate priority needs of recipients and help to meet such needs 
collaboratively and on

[[Page 21539]]

a timely basis so that the SBEI is implemented efficiently and 
effectively; and 2) assist in organizing and facilitating approaches to 
sharing experiences, lessons-learned, results, outcomes, and resources 
among recipients and existing community and state chronic disease 
programs.
B. Technical Assistance
    HHS will provide technical assistance training and support to 
funded communities in the areas of surveillance and epidemiology, 
community assessment and planning, evidence-based interventions, 
community mobilization and partnership development, monitoring of 
program performance outcomes, baseline data acquisition and data 
management, program sustainability, and other areas as deemed necessary 
by SBCATs and approved by HHS.
C. Baseline Mean Community Blood Pressure and Follow-up
    Because of the importance of external baseline determination of 
average community blood pressure using representative cross-sampling 
methodologies, HHS will provide this critical element.
D. Evaluation Oversight and Coordination
    HHS will separately fund and direct an independent, external 
evaluation of the SBEI. However, recipients are expected to budget for 
their full participation in the data collection associated with this 
external review. Additionally, HHS will work with recipients to 
finalize the evaluation plan based upon the initial plan included with 
the recipient's application.

II. Award Information

    Estimated Funds Available for Competition: $2,000,000.
    Anticipated Number of Awards: 3 to 4.
    Range of Awards: $500,000 to $650,000 per year.
    Anticipated Start Date: Friday, July 30, 2004.
    Budget Period Length: 12 months.
    Period of Performance: 4 Years.
    Continuation awards and level of funding within an approved project 
period will be based on the availability of funds and satisfactory 
progress in achieving performance measures as evidenced by required 
progress reports. It is expected that projects will begin to implement 
interventions within Year One of funding. It is also expected that 
assessment and evaluation will require special emphasis during the 
first two years of funding. It is anticipated that additional FY 2004 
resources may enable HHS to fund additional prevention initiatives 
based on this announcement or a separate announcement.
    Pending availability of funds, beginning in FY 2004 and each of the 
remaining years of this program announcement, there may be an open 
season for new competitive applications. Specific guidance will be 
provided with application due dates and funding levels each year.
    Type of Award: Cooperative Agreement.
    Type of Application Accepted: New.
    Applicants funded for the first time will be required to submit a 
revised work plan and budget to address issues identified in the 
objective review of applications in order to receive their first year 
of funding. For subsequent years of funding, the applicants may be 
required to submit a revised work plan and budget to address issues 
identified in the technical review of their continuation applications.

III. Eligibility Information

1. Eligible Applicants

    This announcement only requests qualified applicants from 
communities in each of the contiguous Seven Core Stroke Belt States 
(Alabama, Arkansas, Georgia, Mississippi, North Carolina, South 
Carolina, and Tennessee). These States are part of the original 11 
Stroke Belt States and either have a long history of ranking high in 
terms of stroke death rates or rank first in the 2001 analysis (see 
Attachment B). That these states are also contiguous provides 
opportunity to truly regionalize this initiative, assuring enhanced 
ability to form an Enabling ring around the priority condition (stroke) 
and priority risk factor (hypertension) in a contiguous region of 
significant need.
    Applicants must meet the following additional criteria:
    A. Must be a public or non-profit organization, including faith-
based organizations;
    B. Have been in the community for at least five years to enhance 
likelihood of familiarity with and recognition by other community 
entities and individuals; and
    C. Have an agreement (e.g., Memorandum of Understanding, contract, 
written agreement) or document that an agreement is being developed 
with one or more community health centers and/or other health 
providers, systems or plans to offer care to uninsured people 
identified as having high blood pressure through the activities of this 
initiative to assure availability of followup care of hypertension.
    For this announcement, the term ``community'' is defined as any 
contiguous geographic area (including counties). Applicants can specify 
an intervention area that is smaller than the entire city or county, or 
includes multiple counties, but the intervention area must be 
geographically contiguous. The area must include a population of at 
least 100,000 residents for an urban community and 60,000 residents for 
a rural community. Although multiple applications may be submitted from 
an eligible community, only one award will be made to a community that 
is selected as part of this SBEI.
    Communities with substantial expertise and infrastructure for the 
design, delivery, and evaluation of chronic disease prevention and 
control interventions and are able to begin intervention activities 
under the program announcement in year one of funding are encouraged to 
apply under this announcement.

2. Cost Sharing or Matching

    Matching funds, that is, a specific percentage of program costs 
that must be contributed by a recipient in order to be eligible for 
this announcement, are not required. Applicants are encouraged, 
however, to identify financial and in-kind contributions from their own 
organization and their partners to support and sustain the activities 
of this program announcement. Applicants are encouraged to seek 
partnerships and in-kind support from a variety of partners including 
(1) private partners (e.g., health care providers or systems, 
businesses), (2) regional and State partners (e.g., regional stroke 
networks, the State Health Department Heart Disease and Stroke 
Prevention Program), and (3) federally funded partners (e.g., Federally 
Funded Health Centers).

3. Other

    Organizations must submit documentation of nonprofit status with 
their applications. If documentation is not provided, the application 
will be considered non-responsive and will not be entered into the 
review process. The organization will be notified that the application 
did not meet the submission requirements.
    Any of following serves as acceptable proof of nonprofit status:
     A reference to the applicant organization's 
listing in the Internal Revenue Service's (IRS) most recent list of 
tax-exempt organizations described in section 501(c)(3) of the IRS 
Code.

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     A copy of a currently valid IRS tax exemption 
certificate.
     A statement from a State taxing body, State 
Attorney General, or other appropriate State official certifying that 
the applicant organization has a nonprofit status and that none of the 
net earnings accrue to any private shareholders or individuals.
     A certified copy of the organization's 
certificate of incorporation or similar document that clearly 
establishes nonprofit status.
     Any of the above proof for a State or national 
organization and a statement signed by the parent organization that the 
applicant organization is a local nonprofit affiliate.
    If funding is requested in an amount greater than the ceiling of 
the award range, the application will be considered non-responsive and 
will not be entered into the review process. The application will be 
returned with notification that it did not meet the submission 
requirements.
    Applications that are not complete or that do not conform to or 
address the criteria of this announcement will be considered non-
responsive and will not be entered into the review process. The 
application will be returned with notification that it did not meet the 
submission requirements.
    An organization may submit no more than one proposal for the Stroke 
Belt Elimination Initiative. Organizations submitting more than one 
proposal for the same grant program will be deemed ineligible. The 
proposals will be returned without comment.
    Organizations are not eligible to receive funding from more than 
one OMH grant program to carry out the same project and/or activities.

IV. Application and Submission Information

1. Address To Request Application Package

    To obtain an application kit, write to: Ms. Karen Campbell, 
Director, OPHS Office of Grants Management, Office of Public Health and 
Science, Department of Health and Human Services, 1101 Wootton Parkway, 
Suite 550, Rockville, MD 20852, or telephone (301) 594-0758, e-mail 
[email protected].

2. Content and Form of Application

A. Letter of Intent
    A Letter of Intent (LOI) is required from all potential applicants 
for the purpose of planning the competitive review process. The 
narrative should be no more than two pages, double-spaced, printed on 
one side, with one-inch margins, and unreduced 12-point font. LOIs 
should include the following information: (1) The program announcement 
title and number; (2) whether the application will be from an urban or 
rural community; (3) the exact boundaries and total population size of 
the contiguous geographic area with population that qualifies the 
applicant as eligible for this program announcement; and (4) the name 
of the applicant agency or organization, the official contact person 
and that person's telephone number, fax number, and mailing and e-mail 
addresses. If an applicant does not submit an LOI prior to submitting 
an application, the application will not be entered into the review 
process.
    Submit the LOI to: Ms. Karen Campbell, Director, OPHS Office of 
Grants Management, 1101 Wootton Parkway, Suite 550, Rockville, MD 
20852. Letters of intent must be received by the OPHS Office of Grants 
Management by 5 p.m. e.d.t. on Wednesday, May 12, 2004.
B. Application
    Applications must be prepared using Form PHS 5161-1 (revised July 
2000 and approved by OMB under Control Number 0348-0043). This form is 
available in Adobe Acrobat format at the following Web site: http://www.cdc.gov/od/pgo/forminfo/htm.
    The narrative (excluding attachments) should be no more than 50 
pages, double-spaced, printed on one side, with one-inch margins, and 
unreduced 12-point font. In addition to the application forms, the 
application must contain the following in this order:

A. Table of Contents

    Include a Table of Contents with page numbers for each of the 
following sections:

B. Executive Summary

    An Executive Summary should be included that provides specific 
evidence that the applicant is eligible to apply (see section on 
Eligible Applicants). It should also briefly describe the overall 
project; intervention area and population size; and partnerships, 
intervention strategies, and predicted major short-term and 
intermediate outcomes.

C. Community Lead Agency

    A description of the lead agency should be provided, including 
fiduciary and programmatic capabilities, length of time in community, 
as well as an inventory of current agency activities and partnerships 
related to this announcement and confirmation of relevant agreements. 
For example, include a Memorandum of Understanding or other written 
agreement with appropriate partners to provide health care services to 
uninsured people identified to have high blood pressure as a result of 
activities of this initiative.

D. Intervention Area

    Provide a description of the community intervention area, including 
its demographic, geographic and political boundaries, target 
populations to receive special focus under the SBEI, as well as 
evidence of the burden of disease, and disparities in hypertension and 
stroke, and access to and use of proven prevention and control 
interventions. Description of current local, State, and already-active 
private-sector activities that focus on chronic conditions, especially 
hypertension and stroke, and each relevant HHS agency and national 
partner. Include a description of related assets and needs of the 
intervention area including a description of findings from any 
community assessments or asset mapping done in the past three years.

E. Staffing

    Provide a description of proposed program staff including resumes 
or job descriptions for full-time project coordinator and other key 
staff, the qualifications and responsibilities of each staff member, 
and percent of time each is committing to the program.

F. Stroke Belt Community Action Team

    Include a description of the proposed SBCAT including a list of key 
partners and documentation of their capabilities; their commitment to 
specific functions, responsibilities, and resources; and evidence of 
prior successful collaborations. The structure, decision making 
processes, and methods for accountability of the members should be 
described as well as how coordination and linkage with existing 
programs and interventions with similar focus will be maintained.

G. Community Action Plan

    Include a detailed plan for year one and a preliminary plan for 
years two through four. The community action plan for year one should 
include goals, objectives, a work plan, and timeline for carrying out 
the Required Activities (see section 1). The community action plan 
objectives should be time-phased, specific, measurable, and realistic 
and should clearly relate to attaining specific short-term and 
intermediate outcomes that are based on the needs of the community and 
gaps in current prevention and control activities. The

[[Page 21541]]

community action plan should identify likely approaches, strategies, 
and interventions to be used in year one and over the four-year project 
period to address stroke and high blood pressure. The organizations 
responsible for the interventions should be identified as well as the 
target populations to be addressed. The preliminary plan for years two 
though four should include the community interventions to be employed 
as well as a plan to ensure long-term sustainability of project efforts 
and outcomes.

H. Financial Contributions

    Provide a description of financial and in-kind resources, if any, 
that will be contributed toward activities initiated as part of the 
SBEI. Also discuss how these will enhance the likelihood of achieving 
sustainability of activities within the community.

I. Evaluation and Monitoring

    Include a plan for data identification, collection, and use for 
program planning and monitoring for the community that includes a 
commitment to work with HHS on baseline and subsequent data collection. 
Describe any additional efforts to obtain data and sources to better 
understand the burden and trends in stroke and high blood pressure and 
the effects of this initiative. Provide specific assurance that the 
community will track common performance measures and participate fully 
in an independent, external evaluation of initiative outcomes. Describe 
how the project is anticipated to improve specific performance measures 
and outcomes compared to baseline performance.

J. Communication Plan

    Provide a plan for the community to communicate and share 
information with the members of its SBCAT, other key partners, and its 
own community broadly, as well as with other communities funded under 
this initiative. This plan should describe the proposed exchange of 
information, proposed means and timing of communication, with an 
emphasis on communications innovations such as electronic formats or 
web forums.

K. Budget and Budget Justification/Narrative

    Provide a One-Year and Four-Year Budget. In support of the four-
year community action plans, provide a detailed budget and budget 
justification/narrative for the first budget year and a budget estimate 
for years two through four.
    i. Provide a detailed budget for the first budget year in support 
of each activity that must be completed in the first year of program 
operations to accomplish the short-term and intermediate outcomes 
specified in the five-year community action plan.
    This detailed budget must include:
    a. Community expenditures. A budget justification and narrative 
that describe all requested funds for the 501(c)(3) and other key 
community partners by category in support of first-year activities in 
the four-year community action plan. As part of the request for travel 
funds in FY 2004, applicants should budget for two trips to workshops 
and/or conferences for key community members. For planning purposes, 
use Atlanta and Washington, DC, as the travel destinations.
    b. The information above should be consistent with the first year 
budget information entered in Section B of Standard Form 424A (Budget 
Information---Non-Construction Programs).
    ii. Provide estimated budgets for funding years two to four that 
are linked to accomplishment of intermediate community outcomes. For 
each budget year, include budget estimates for two trips to workshops 
and/or conferences for key staff members of the lead/fiduciary 
organization and its key partners. For planning purposes, use Atlanta 
and Washington, DC as the travel destinations. Provide the estimated 
total budget for each year for each object class category in Section B 
of Standard Form 424A (Budget Information--Non-Construction Programs).

L. Letters of Support

    Provide letters of support and Memoranda of Understanding, as 
appropriate, from the local health departments, community-based health 
centers and other health care partners, and additional key members of 
the SBCAT, specifying their specific roles, responsibilities, and 
resources.
DUNS Number Requirement
    Beginning October 1, 2003, all applicants are required to obtain a 
Data Universal Numbering System (DUNS) number as preparation for doing 
business electronically with the Federal Government. The DUNS number 
must be obtained prior to applying for OMH funds. The DUNS number is a 
nine-character identification code provided by the commercial company 
Dun & Bradstreet, and serves as a unique identifier of business 
entities. There is no charge for requesting a DUNS number, and you may 
register and obtain a DUNS number by either of the following methods: 
Telephone: 1-866-705-5711; Web site: http://eupdate.dnb.com/requestoptions.html. Be sure to click on the link that reads, ``DUNS 
Number Only'' at the left hand bottom corner of the screen to access 
the free registration page. Please note that registration via the web 
site may take up to 30 business days to complete.

3. Submission Dates and Times

    Letter of Intent Deadline Date: Wednesday, May 12, 2004, by 4 p.m.
    Application Deadline Date: Thursday, June 17, 2004, by 4 p.m.
    Explanation of Deadlines: Applications must be received by the 
Office of Public Health and Science, Office of Grants Management by 4 
p.m. on Thursday, June 17, 2004, by 4 p.m. Applications will be 
considered as meeting the deadline if they are received on or before 
the deadline date. The application due date requirement in this 
announcement supercedes the instructions in the PHS 5161-1. 
Applications submitted by facsimile transmission (FAX) or any other 
electronic format will not be accepted. Applications that do not meet 
the deadline will be considered late and will be returned to the 
applicant unread.
    Applications must be submitted to Ms. Karen Campbell, Director, 
OPHS Office of Grants Management, Office of Public Health and Science, 
Department of Health and Human Services, 1101 Wootton Parkway, Suite 
550, Rockville, MD 20852.
    Applications will be screened upon receipt. Applications that are 
not complete or that do not conform to or address the criteria of the 
announcement will be returned without comment.
    Each organization may submit no more than one proposal under this 
announcement.
    Organizations submitting more than one proposal will be deemed 
ineligible. The proposals will be returned without comment.
    Accepted applications will be reviewed for technical merit in 
accordance with PHS policies.

4. Intergovernmental Review

    This program is subject to the requirements of Executive Order 
12372 which allows States the option of setting up a system for 
reviewing applications from within their States for assistance under 
certain Federal programs. The application kit available under this 
notice will contain a list of States which have chosen to set up a 
review system and will include a State Single Point of Contact (SPOC) 
in the State for review.

[[Page 21542]]

Applicants (other than federally recognized Indian tribes) should 
contact their SPOCs as early as possible to alert them to the 
prospective applications and receive any necessary instructions on the 
State process. For proposed projects serving more than one State, the 
applicant is advised to contact the SPOC of each affected State. The 
due date for State process recommendations is 60 days after the 
application deadline established by the Office of Public Health and 
Science Grants Management Officer. The OMH does not guarantee that it 
will accommodate or explain its responses to State process 
recommendations received after that date. (See ``Intergovernmental 
Review of Federal Programs'' Executive Order 12372 and 45 CFR part 100 
for a description of the review process and requirements).
    This program is subject to Public Health Systems Reporting 
Requirements. Under these requirements, a community-based non-
governmental applicant must prepare and submit a Public Health System 
Impact Statement (PHSIS). The PHSIS is intended to provide information 
to State and local health officials to keep them apprised of proposed 
health services grant applications submitted by community-based 
organizations within their jurisdictions.
    Community-based non-governmental applicants are required to submit, 
no later than the Federal due date for receipt of the application, the 
following information to the head of the appropriate State and local 
health agencies in the area(s) to be impacted: (a) A copy of the face 
page of the application (SF 424), and (b) a summary of the project 
(PHSIS), not to exceed one page, which provides: (1) A description of 
the population to be served; (2) a summary of the services to be 
provided; and (3) a description of the coordination planned with the 
appropriate State or local health agencies. Copies of the letters 
forwarding the PHSIS to these authorities must be contained in the 
application materials submitted to the OMH.

5. Funding Restrictions

    Cooperative agreement funds may be used to expand, enhance, or 
complement existing activities to accomplish the objectives of this 
program announcement. Funds may be used to pay for, but are not limited 
to: staffing, consultants, contractors, materials, resources, travel, 
and associated expenses to implement and evaluate intervention 
activities related to addressing stroke and high blood pressure. 
Activities might relate to such things as: Helping health care centers, 
worksites, schools, senior centers, faith-based organizations and other 
community locations educate people about stroke and high blood 
pressure, and making environmental changes to support prevention and 
control of stroke and high blood pressure in the community and among 
higher risk populations; educating health plans, purchasers, and 
providers regarding guidelines for preventive health care practices 
related to stroke and high blood pressure and how to fully implement 
them; enhancing office-based systems to ensure that persons with stroke 
and high blood pressure are called for routine exams and other follow-
up; using information technology (such as the web and email) to 
communicate with people with stroke and high blood pressure; developing 
community support groups for persons with stroke and high blood 
pressure; conducting awareness and media campaigns tied to prevention 
and outreach programs to educate persons about their risk of stroke and 
high blood pressure, the signs and symptoms of stroke and what actions 
to take; conducting community-based outreach to high-risk populations, 
encouraging them to seek appropriate care and increasing knowledge of 
self-management of high blood pressure; and training lay health workers 
to conduct health promotion programs and outreach into the community.
    Cooperative agreement funds may not be used for direct patient 
care, diagnostic medical testing, patient rehabilitation, 
pharmaceutical purchases, facilities construction, lobbying, basic 
research, or controlled trials. Applicants may not use these funds to 
supplant funds from State sources or the Preventive Health and Health 
Services Block Grant dedicated to stroke, high blood pressure, or the 
related risk factors of tobacco use, physical inactivity, overweight, 
and excessive salt intake.
    Although program funds under this Program Announcement are to be 
used to address stroke and high blood pressure, resources to address 
related risk factors (i.e., tobacco use, physical inactivity, 
overweight, and excessive salt intake) are important and can be 
reported as in-kind support.

6. Other Submission Requirements

    Applications may only be submitted in hard copy. Send an original, 
signed in blue ink, and two copies of the complete grant application to 
Ms. Karen Campbell, Grants Management Officer, Office of Grants 
Management, Office of Public Health and Science, Tower Building, 1101 
Wootton Parkway, Suite 550, Rockville, MD 20852. Applications submitted 
by e-mail, Facsimile transmission (FAX) or any other electronic format 
will not be accepted.

V. Application Review Information

1. Criteria

    A. Strength of Technical Approach (25 points). (1) Overall strength 
and creativity of proposed SBCAT technical approach in relation to 
stroke and high blood pressure; and (2) innovation of approach; extent 
to which the HHS Core Framework shapes the SBCAT's plan which must 
include goals, objectives, and measures; and commitment of partners to 
employ the enabling ring concept and to share existing or add new 
resources to help achieve goals/objectives and obtain measures to 
evaluate impact. In addition, likelihood that the proposed SBCAT plan, 
if implemented, will reduce mean high blood pressure as well as stroke 
mortality rate; and likelihood that efforts will be institutionalized 
within the community. The evaluation plan contains appropriate 
performance measures/indicators (of success) and data collection and 
analysis methodologies.
    B. Understanding of the Problem (20 points). Demonstrated 
understanding of: (1) Stroke (condition) and high blood pressure (risk 
factor) and their differential geographic and racial/ethnic impact in 
the Stroke Belt and within the target community; (2) local community 
health needs related to management and control of stroke and high blood 
pressure; (3) issues related to the underutilization of proven/science-
based modalities (e.g., guideline-based and case or disease management-
based interventions), both clinical and behavioral; and (4) relevance 
to eliminating disparities in stroke deaths and high blood pressure 
prevalence.
    C. Capacity and Commitment of Organization (20 points). 
Demonstrated capacity and documented past program success; existing 
infrastructure and strength of partnerships; evidence of past 
collaboration within the community and substantiated commitment to 
participate in the project via an ``enabling ring of collaborators'' 
who may already be involved in local activities. These may be 
representatives from the community sectors (i.e., government, 
education, business, faith, health care, media, and voluntary 
agencies); and documented commitment of resources to the proposed 
project in terms of dollars, staff, and/or administrative support.

[[Page 21543]]

    D. Staff Capability (20 points). Capacity and skills of proposed 
staff, including, but not limited to, project management experience, 
familiarity with stroke and high blood pressure activities and issues, 
understanding of cultural diversity, competence and sensitivity, 
knowledge of evaluation methodology, and understanding of and access to 
information technologies. The respondent must demonstrate existing and 
sufficient computer hardware and software capabilities, including the 
technical ability to access the Internet, and submit reports 
electronically.
    E. Understanding of Core SBEI Concept (15 points). Demonstrated 
understanding of core goals, core framework, and collaborative enabling 
ring concept of the SBEI.

2. Review and Selection Process

    Applications will be evaluated by an independent Objective Review 
Committee (ORC) appointed by HHS against specific criteria. The ORC 
members are chosen for their expertise in minority health and their 
understanding of the unique health problems and related issues 
confronted by the racial/ethnic minority populations in the United 
States. Funding decisions will be determined by the Deputy Assistant 
Secretary for Minority Health will take under consideration the 
recommendations and ratings of the ORC, and geographic and racial/
ethnic distribution.
    Funding Preferences: Preference in funding may be given to ensure:
     Geographic distribution of programs.
     Inclusion of geographic areas with high, age-
adjusted rates of stroke and high blood pressure.
     Inclusion of populations disproportionately 
affected by stroke and high blood pressure.
     Inclusion of communities of varying sizes, 
including rural and urban communities.

3. Anticipated Award Date

    Friday, July 30, 2004.

VI. Award Administration Information

1. Award Notices

    Successful applicants will receive a notification letter from the 
Deputy Assistant Secretary for Minority Health and a Notice of Grant 
Award (NGA), signed by the OPHS Grants Management Officer. The NGA 
shall be the only binding, authorizing document between the recipient 
and the Office of Minority Health. Notification will be mailed to the 
Program Director/Principal Investigator identified in the application.
    Unsuccessful applicants will receive a notification letter with the 
results of the review of their application from the Deputy Assistant 
Secretary for Minority Health.

2. Administrative and National Policy Requirements

    In accepting this award, the grantee stipulates that the award and 
any activities thereunder are subject to all provisions of 45 CFR parts 
74 and 92, currently in effect or implemented during the period of the 
grant.
    The Buy American Act of 1933, as amended (41 U.S.C. 10a-10d), 
requires that Government agencies give priority to domestic products 
when making purchasing decisions. Therefore, to the greatest extent 
practicable, all equipment and products purchased with grant funds 
should be American-made.
    A Notice providing information and guidance regarding the 
``Government-wide Implementation of the President's Welfare-to-Work 
Initiative for Federal Grant Programs'' was published in the Federal 
Register on May 16, 1997. This initiative was designated to facilitate 
and encourage grantees and their sub-recipients to hire welfare 
recipients and to provide additional needed training and/or mentoring 
as needed. The text of the notice is available electronically on the 
OMB home page at http://www.whitehouse.gov/omb.
    The HHS Appropriations Act requires that when issuing statements, 
press releases, requests for proposals, bid solicitations, and other 
documents describing projects or programs funded in whole or in part 
with Federal money, grantees shall clearly state the percentage and 
dollar amount of the total costs of the program or project which will 
be financed with Federal money and the percentage and dollar amount of 
the total costs of the project or program that will be financed by non-
governmental sources.

3. Reporting Requirements

    A successful applicant under this notice will submit: (1) Progress 
reports; (2) an annual Financial Status Report; and (3) a final 
progress report and Financial Status Report in the format established 
by the OMH, in accordance with provisions of the general regulations 
which apply under ``Monitoring and Reporting Program Performance,'' 45 
CFR part 74.51-74.52, with the exception of State and local governments 
to which 45 CFR part 92, subpart C reporting requirements apply.
Provision of Smoke-Free Workplace and Non-Use of Tobacco Products by 
Recipients of PHS Grants
    The PHS strongly encourages all grant recipients to provide a 
smoke-free workplace and to promote the non-use of all tobacco 
products. In addition, Public Law 103-227, the Pro-Children Act of 
1994, prohibits smoking in certain facilities (or in some cases, any 
portion of a facility) in which regular or routine education, library, 
day care, health care, or early childhood development services are 
provided to children.

VII. Agency Contacts

    Questions regarding programmatic information and/or requests for 
technical assistance in the preparation of the grant application should 
be directed to Ms. Cynthia H. Amis, Director, Division of Program 
Operations, Office of Minority Health, 1101 Wootton Parkway, Suite 600, 
Rockville, MD 20852, telephone (301) 594-0769. Technical assistance on 
budget and business aspects of the application may be obtained from the 
OPHS Office of Grants Management, 1101 Wootton Parkway, Suite 550, 
Rockville, MD 20852, telephone (301) 594-0758.
    For health information call the OMH Resource Center at 1-800-444-
6472.
    Special Guidelines for Technical Assistance Conference Call. A 
conference call will be held on Tuesday, April 27, 2004 to provide 
technical assistance to potential applicants. Interested parties must 
register for the conference call by calling (301) 594-0769, e-mail 
[email protected]. Information will be provided at that time on 
the date and time of the conference call, the call-in number and the 
access code.
    The purpose of the conference call is to help potential applicants 
to:
    1. Understand the scope and intent of the program; and
    2. Review application and evaluation procedures.
    Participation in this conference call is not mandatory.
    HHS ``One-Department'' Participating Entities: These include, but 
are not limited to, the Administration on Aging, Administration for 
Children and Families, Agency for Healthcare Research and Quality, 
Centers for Disease Control and Prevention, Centers for Medicare and 
Medicaid Services, Food and Drug Administration, Health Resources and 
Services Administration, Indian Health Service, National Institutes of 
Health, the Substance

[[Page 21544]]

Abuse and Mental Health Services Administration, and the Office of 
Disease Prevention and Health Promotion.

VIII. Other Information

1. Rationale

    The Stroke Belt is located in the southeastern region of the United 
States (U.S.) and primarily consists of contiguous states where rates 
of stroke death have exceeded the U.S. national average by more than 10 
percent since its initial identification in the 1980s. Accordingly, the 
Stroke Belt represents a long-standing geographic disparity. In 
addition, demographic disparities exist within many areas, including 
the Stroke Belt. The Stroke Belt Elimination Initiative is undertaken 
by the Department to complement and, where indicated, enhance existing 
local, regional, and national activities designed to contribute to 
reducing and ultimately eliminating excessive rates of stroke death in 
this geographic area. Where necessary, the SBEI will seek to encourage 
effective and innovative approaches to this problem. Focus on the 
Stroke Belt provides a unique opportunity to leverage and coordinate 
resources within a well-defined and contiguous region, with an 
opportunity to expand efforts at a later time should effectiveness be 
demonstrated. Focus on communities within the Stroke Belt recognizes 
the importance of identifying, enhancing, allocating, and coordinating 
resources at the level where individuals live, work, and play in 
efforts to further enable communities to more fully encircle or form a 
collaborative ring around the problem and ultimately reduce or 
eliminate excess stroke death rates. Focus on formation of an enabling 
ring of collaborative activities addressing the community's stroke 
problem is a required core component of this announcement. This is 
undertaken in view of the need for enhanced coordination of existing as 
well as newly developed stroke-reducing activities that typically occur 
concurrently with single communities. Focus on hypertension recognizes 
that (1) this is one of the most prevalent and significant modifiable 
risk factors contributing to stroke, (2) the risk of stroke death 
doubles as blood pressure rises 20 mm Hg and very importantly, it falls 
in a similar doubling-fashion as blood pressure is reduced, and (3) the 
need to provide simpler messages for lay individuals to build upon over 
time.
    Essential core components of the overall SBEI are detailed below.
    Core Goals: Short-term (by month 4)--to begin implementing core 
framework, including establishment of an effective enabling ring of 
collaborative activities around the problem of stroke death in the 
community. Mid-Term (by month 18)--to begin to reduce mean community 
blood pressure (BP) among adults =18 years of age living 
within the community and to begin to reduce mean subpopulation BP among 
at least one demographic subpopulation considered to be a higher risk 
for hypertension. Mean community and subpopulation BPs will be obtained 
via a representative cross-sectional sampling methodology under 
guidance and funding by HHS (see below, core framework component 6). 
Long-term (by month 36)--to begin to reduce mean community stroke death 
rate (SDR) among adults =18 years of age living within the 
community and to begin to reduce mean population SDR among at least one 
demographic subpopulation considered to be a higher risk for stroke 
death. The community may set other measurable goals; however, core 
goals must be included and additional ones approved by HHS. Mean 
community and subpopulation SDRs will be obtained under guidance from 
HHS using a process that includes a modified health behaviors and blood 
pressure readings survey.
    Core Framework: Each selected community is required to make use of 
a core framework for action. Additional activities may be pursued as 
determined by the community's Stroke Belt Community Action Team 
(SBCAT). Core framework component 1 (pre-award)--an SBCAT is being 
formed or designated and is comprised of representation from entities 
that formally agree to work collaboratively toward goals, submits 
application for funding, and is responsible for receiving and 
allocating funding under a cooperative agreement with HHS. Core 
framework component 2 (by month 3)--following notification of 
selection, the SBCAT will designate attendees of an orientation 
conference to be attended by national and regional members of a Stroke 
Belt Regional Action Team (SBRAT) (defined in section Core 
Collaboration Process, Regional Level). Core framework component 3 (by 
month 3)--the SBCAT reviews and adopts core goals, objectives, and 
process and creatively adapts them to their specific community. Other 
goals, objectives, and processes may be added by the SBCAT upon 
approval under terms of the cooperative agreement with HHS. Core 
framework component 4 (by month 3)--a full-time SBCAT Coordinator is 
hired or designated, whose experience includes leading effective 
community action interventions and has familiarity with health data, 
and who works directly and daily on the community's goals under the 
direction of the leadership of the SBCAT and in coordination with the 
SBRAT Coordinator. Core framework component 5 (by month 4)--an Enabling 
ring of collaborative activities is being formed or designated, 
including formal statements of the specific activity or activities that 
each enabling ring participant will coordinate or be responsible for in 
a collective effort to manage the priority condition (stroke) and 
priority risk factor (hypertension). Core framework component 6 (by 
month 6)--the HHS will work directly with the SBCAT to obtain baseline 
data on mean community blood pressure and basic health behaviors that 
impact hypertension and stroke. This step will consist of performing a 
representative sampling and will be technically coordinated and funded 
by HHS and performed in collaboration with the SBCAT. This survey 
includes an assessment of basic health behaviors and blood pressure and 
will be repeated at months 18 and 36. Core framework component 7 (by 
month 6)--the SBCAT coordinates with HHS to approve a framework for 
action and specific measures for evaluation of activities.
    Enabling Ring of Collaborative Activities: The need for enhanced 
systemic coordination of activities designed to improve health results 
and outcomes is well recognized. This announcement emphasizes the 
requirement that selected communities will identify existing activities 
at local, State, regional, and national levels that have direct or 
indirect impact on prevention and control of hypertension (priority 
risk factor) and stroke (priority condition) within the community.
    Once these activities and resources are identified, the community, 
via their SBCAT and SBCAT Coordinator, will work collaboratively with 
entities and individuals leading those activities to collaboratively 
encircle the problem, enabling the community to more effectively solve 
it (see Core Collaboration Process).
    Core Objectives: The SBCAT is required to review, adopt, and adapt 
the following core objectives in order to enhance the likelihood for 
reducing hypertension and stroke locally. Core objective 1--increase 
community awareness and knowledge of hypertension and stroke. This 
requires use of an educational campaign (HHS to make electronic 
templates available) and, in the month of May (beginning in 2005), 
annual recognition of National

[[Page 21545]]

Stroke Awareness Month, National High Blood Pressure Education Month, 
and National Physical Fitness and Sports Month. Core objective 2--
enhance early detection of hypertension and stroke with early referral 
to care. Formation of a volunteer information/notification network 
whereby community members are informed of when and where free blood 
pressure checks will be available. Core objective 3--increase the 
community's adoption and use of lifestyle behaviors known to promote 
prevention and control of hypertension and stroke. Strategically, these 
behaviors should be adopted by individuals/patients, families, health 
professionals/providers, health systems or plans, and by other 
community organizations and leaders including but not limited to 
schools, faith-based institutions, and work sites. Core objective 4--
enhance blood pressure control rates (the percentage of persons with 
hypertension whose blood pressure is treated and controlled to levels 
that are recommended by accepted clinical practice guidelines) among 
community persons who are known to have hypertension and who are 
members of a health plan or otherwise visit health systems, clinics, or 
medical offices. This objective requires inclusion of representatives 
of these health-related organizations in the SBCAT. Other objectives 
may be added by the SBCAT upon approval under terms of the cooperative 
agreement with HHS.
    Core Collaboration Process: to facilitate coordination of effort at 
local, State, regional, and national levels, and to achieve 
establishment of the community's Enabling ring, a core process for 
multi-level partnering will be utilized. National Level--HHS will be 
responsible for establishing and maintaining formal agreements of 
collaboration with non-Federal national organizations and other Federal 
entities for the purposes of this announcement and coordinating 
communications with entities at this level. The SBCAT will be required 
to coordinate with HHS to avoid multiple contacts from multiple 
communities to a single national entity. Regional Level--HHS will 
establish a SBRAT that includes appropriate HHS Regional Health 
Administrators and Regional Directors, pre-existing stroke consortia or 
networks as well as other national, regional, sub-regional, and local 
representatives. The SBRAT will be responsible for maintaining formal 
agreements of collaboration with regional entities for the purposes of 
this announcement and coordinating communications with entities at this 
level. The SBCAT will be required to coordinate with the SBRAT to avoid 
multiple contacts from multiple communities to a single regional 
entity. State and Local Levels--The SBCAT will be responsible for 
coordinating communications with entities at this level while keeping 
SBRAT and HHS point of contacts up to date as per final agreement. The 
key roles and responsibilities of partners and their specific enabling 
ring of activities must be clearly delineated.
    Core Measures for Evaluation and Process Improvement: While 
community-specific measures are important, a core set of measures is 
required to enhance opportunities to share insights and lessons-learned 
as well as facilitate assessment of progress across multiple 
communities. Core Process Measures--These are required to include 
documentation of (a) an effective SBCAT, (b) evidence of attendance at 
the initial awardees orientation meeting, (c) SBCAT Coordinator, (d) 
membership in the SBRAT, (e) an effective enabling ring of 
collaboration within the community, (f) an effective educational 
campaign that also makes use of existing efforts and materials by 
participating entities as well as SBEI-specific ones to be provided by 
HHS, (g) evidence of annual recognition in the Month of May of National 
Stroke Awareness Month, National High Blood pressure Education Month, 
and National Physical Fitness and Sports Month, (h) evidence from 
SBCAT-participating health professionals, medical societies, health 
systems and health plans, and other SBCAT-member community 
organizations of efforts to incorporate guideline-based hypertension 
and stroke reducing behaviors into their policies and practices, (i) 
evidence of an information network, formal or informal, that notifies 
the community of when and where blood pressure checks are available, 
(j) evidence of activities undertaken that are designed to increase BP 
control rates in community persons with hypertension, and (k) approval 
of an evaluation plan. Core Results Measures--Requirements include 
documentation of (a) SBCAT-facilitated and HHS coordinated and funded 
baseline and follow-up data on a timeline-appropriate basis (mean 
community adult BP and mean BP for at least one demographic 
subpopulation at higher risk for hypertension or stroke; mean community 
adult stroke death rate and SDR for at least one demographic 
subpopulation at higher risk for hypertension or stroke; and simple 
questionnaire-based survey of lifestyle behaviors; for example, self-
reported physical activity, weight control, salt use, smoking, 
consumption of fruits and vegetables, and other hypertension and 
stroke-related questions), (b) a summary of traditional metrics for the 
education campaign (e.g., extent and frequency of multi-media paid 
advertisements and public service announcements, and estimated number 
and demographics of community persons reached), and (c) estimated 
number of blood pressure screenings performed by participants in the 
volunteer informational blood pressure check network. Core Outcomes 
Measures--These include estimation by SBCAT, in collaboration with HHS, 
of the degree of change, if any, in: (a) Mean community adult BP and 
mean BP for at least one demographic subpopulation at higher risk for 
hypertension or stroke; (b) mean community adult SDR and SDR for at 
least one demographic subpopulation at higher risk for hypertension or 
stroke; and (c) surveyed hypertension and stroke-reducing lifestyle 
behaviors.

2. Background

    The Stroke Belt is an Important Geographic Disparity: The original 
Stroke Belt region was designated in 1980 by the National Heart, Lung, 
and Blood Institute and consisted of eleven States mainly in the 
southeast where the rate of death due to stroke was at least 10 percent 
higher than the U.S. national average. The original 11 Stroke Belt 
States are Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, 
Mississippi, North Carolina, South Carolina, Tennessee, and Virginia. A 
review of earlier statistical evidence indicates that excess rates of 
stroke-deaths have been present in this general region for a long 
period of time. As of 2001, the top seven of the original 11 Stroke 
Belt States, in terms of stroke death rates, are contiguous within the 
southeastern U.S. and include Alabama, Arkansas, Georgia, Mississippi, 
North Carolina, South Carolina, and Tennessee (the Seven Core Stroke 
Belt States).
    Stroke Burden: The overall burden of stroke is significant. Stroke 
is the third leading cause of death in the U.S., and, on average, 
someone living in the U.S. has a stroke about every 45 seconds. There 
are over 700,000 new strokes annually and about 29 percent of these are 
recurrent strokes. There are at least 4.7 million U.S. persons living 
with stroke. Stroke accounts for over 981,000 hospital discharges and 
over $51.2 billion in costs annually. Reductions in stroke mortality 
account for about 1 of 6 years gained in life expectancy from 1970-
2000. In 2001, approximately 163,538 U.S. deaths were directly

[[Page 21546]]

attributable to stroke. As of 2001, the average stroke death rate for 
the Seven Core Stroke Belt States was significantly higher than the 
U.S. national average or that for the remaining 43 states and the 
District of Columbia (about 22 percent and 26 percent higher, 
respectively).
    Stroke Risk Factors: Risk factors for stroke include high blood 
pressure, excess weight, and heart disorders such as atrial 
fibrillation, an irregular heart rhythm, or a large area of heart wall 
damage due to a heart attack. High cholesterol, smoking, significant 
carotid artery disease, markedly high red blood cell count, and sleep 
apnea are also risk factors. The risk of stroke increases with age, 
being over 25-times higher for persons 75 years and older, and over 11-
times higher for persons 65 to 74 years-old, compared to persons 35 to 
44 years of age. Men 75 years and older have a 16 percent higher risk 
of stroke compared to women. A history of a prior stroke or mini-stroke 
(transient ischemic attack, TIA) or a family history of stroke are 
associated with increased stroke risk. The presence of diabetes 
increases the risk of stroke by over 150 percent. The importance of 
risk factors is underscored by the fact that persons with a low risk 
profile for heart disease or stroke are almost 60 percent less likely 
to die prematurely. These persons are also estimated to live up to 9.5 
years longer. Accordingly, clinical practice guidelines for early 
intervention exist and have been recently updated.
    The Demographic Disparity of Death from Stroke: As of 2001, Latino/
Hispanic persons had the lowest stroke death rate (44.9 deaths per 
100,000, age-adjusted). Rates for non-Latino/Hispanic blacks, whites, 
and others were 74 percent, 25 percent and 29 percent higher, 
respectively. Lack of early clinical management of ischemic stroke 
increases the risk of disability and death.
    Hypertension Defined: Adult hypertension is currently defined as 
present when systolic blood pressure is = 140 mm Hg , or 
diastolic BP = 90 mm Hg on multiple readings over several 
different days, or when a person is taking anti-hypertensive medication 
to control BP over time. Blood pressure normally varies over time. 
Accordingly, a high blood pressure reading does not always constitute 
hypertension in a individual; the time element is an important 
component of the diagnosis. This is why referral to care for formal 
assessment and management is recommended following detection of 
elevated BP during a screening event.
    Hypertension Is a Potent Stroke Risk Factor: Hypertension is one of 
the most prevalent and powerful risk factors for stroke. The risk of 
dying from stroke rises rapidly as blood pressure increases above 115/
75 mm Hg. Stroke mortality doubles for every 20 mm Hg rise in systolic 
BP or for every 10 mm Hg rise in diastolic BP. Very importantly, the 
risk of stroke falls exponentially as high blood pressure is controlled 
to guideline-recommended levels in persons with hypertension. For this 
reason, the SBEI focuses on hypertension as the priority risk factor 
while facilitating activities that will also favorably impact other 
stroke risk factors. Hypertension is both preventable and treatable 
using a combination of lifestyle changes and medication.
    Hypertension Burden: The public health, health care, and economic 
burdens of hypertension are substantial. Hypertension is the most 
common cardiovascular disease and the most common primary care clinical 
diagnosis in the U.S. It is estimated that not fewer than 50 million 
U.S. adults have hypertension. The burden of hypertension rises with 
age; over 80 percent of U.S. adults with hypertension are = 
45 years of age. A person with normal blood pressure at 55 years of age 
has a 90 percent risk of developing hypertension over their remaining 
lifetime. Health care costs for patients with hypertension and 
complications due to high blood pressure are estimated at $109 billion 
for 1998 (over $120 billion in U.S. 2002 dollars). About $22 billion of 
the total estimate was spent for anti-hypertensive treatment alone 
(over $24 billion in U.S. 2002 dollars). The average amount spent 
annually per person with a hypertensive condition was about $3,787 and 
about $4,180 in U.S. 2002 dollars when hypertensive complications and 
co-morbid conditions are included. Carving out complications and 
hypertensive co-morbidities yielded an estimated total 2004 cost of 
$55.5 billion for hypertensive disease alone (at least $1,110 per 
person for hypertension alone).
    Why Hypertension Prevention and Control and Key Goals: It is 
estimated that almost 50,000 strokes could be prevented and more than 
28,000 U.S. lives saved each year if about 90 percent of persons with 
hypertension had their blood pressure controlled to guideline-
recommended levels. Intensified hypertension control was very cost-
effective in a recent cost-effectiveness analysis of patients with type 
2 diabetes. Nationally, in spite of notable successes over the years, 
only about 59 percent of adults with hypertension were being treated 
and only about 34 percent of adults with hypertension had their blood 
pressure controlled to guideline-recommended levels in 1999-2000. Mean 
high blood pressure control rates for the year 2002 for commercial 
health plans, Medicare and Medicaid were 58.4 percent, 56.9 percent and 
53.4 percent, respectively. These values represent significant 
improvements over year 2000 values and thus, serve as a basis for 
encouragement toward continued performance improvement. A recent 
analysis of data from the third National Health and Nutrition 
Examination Survey (NHANES III; 1988-1994) indicates that although 
there were some differences in health care access and utilization, 
about 92 percent of adults with uncontrolled hypertension reported 
having health insurance and 86 percent of them had a usual source of 
care. It was also found that U.S. adults with hypertension not 
controlled to guideline-recommended levels reported an average of over 
four visits per year to physicians. About 75 percent of U.S. adults in 
the NHANES III survey who were not aware that they had hypertension, 
had their blood pressure checked by a health professional at some time 
within the prior 12 months.

3. Healthy People 2010

    The PHS is committed to achieving the health promotion and disease 
prevention objectives of Healthy People 2010, a PHS-led national 
activity announced in January 2000 to eliminate health disparities and 
improve years and quality of life. More information may be found on the 
Healthy People 2010 Web site: http://www.healthypeople.gov. Copies of 
the Healthy People 2010: Volumes I and II can be purchased by calling 
(202) 512-1800 (cost $70.00 for printed version; $20.00 for CD-ROM). 
Another reference is the Healthy People 2000 Final Review 2001. For one 
free copy of Healthy People 2010, contact: The National Center for 
Health Statistics (NCHS), Division of Data Services, 3311 Toledo Road, 
Hyattsville, MD 20782; or, telephone (301) 458-4636. Ask for DHHS 
Publication No. (PHS) 99-1256. This document may also be downloaded 
from the http://www.healthypeople.gov.

4. Resources

    The following are Web sites from various Federal and non-Federal 
sources that may serve as resources as you develop your proposals 
related to stroke and/or high blood pressure prevention and control:
Agency for Healthcare Research & Quality
    Put Prevention Into Practice, http://www.ahrq.gov/clinic/ppipix.htm.

[[Page 21547]]

    Guide to Clinical Preventive Services, Chapters 19 & 21, http://hstat.nlm.nih.gov/hq.
Centers for Disease Control and Prevention
    Guide to Community Preventive Services, http://www.thecommunityguide.org.
    Promising Practices in Chronic Disease Prevention and Control, 
Chapter on Achieving a Heart-Healthy and Stroke-Free Nation, http://www.cdc.gov/nccdphp/promising_practices/index.htm.
    Overweight and Obesity, http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm.
    Centers for Excellence--Exemplary State Programs, http://www.cdc.gov/nccdphp/exemplary/heart_disease.htm and http://www.cdc.gov/nccdphp/exemplary/diabetes.htm.
    State Heart Disease and Stroke Prevention Program http://www.cdc.gov/cvh/stateprogram.htm.
    State-Based Nutrition and Physical Activity Program; Obesity; 5 A-
Day; Active Community Environments; Kids Walk to School; Physical 
Activity, http://www.cdc.gov/nccdphp/dnpa.
    Atlas of Stroke Mortality (county-level data), Cardiovascular 
Health Program, CDC, http://www.cdc.gov/cvh.
    WISEWOMAN (Well Integrated Screening & Evaluation for Women Across 
the Nation): Screening and Lifestyle Interventions for Many Low-Income, 
Uninsured Women, http://www.cdc.gov/wisewoman.
    Surgeon General's Report on Physical Activity, http://www.cdc.gov/nccdphp/sgr/sgr.htm.
    National Health and Nutrition Examination Survey, http://www.cdc.gov/nchs/nhanes.htm.
    Behavioral Risk Factor Surveillance System--State, city and county 
data, http://apps.nccd.cdc.gov/brfss/index.asp.
Centers for Medicare & Medicaid Services
    Quality Initiatives (main page summary), http://cms.hhs.gov/quality/.
    Quality Fact, Sheet http://cms.hhs.gov/quality/QualityFactSheet.pdf.
    Hospital Quality Initiative (National Voluntary Hospital Reporting 
Initiative), http://cms.hhs.gov/quality/hospital/.
    Medicaid Quality in Home and Community Based Services, http://cms.hhs.gov/medicaid/waivers/quality.asp.
    Quality in Managed Care, http://cms.hhs.gov/healthplans/quality/.
    Demonstration Projects and Evaluation Reports, http://cms.hhs.gov/researchers/demos/.
    Medicare Physician Group Practice Demonstration, http://cms.hhs.gov/researchers/demos/PGP.asp.
    CMS Research Activities: The Active Projects Report, 2003 Edition, 
Theme 7: Outcomes, Quality and Performance, http://cms.hhs.gov/researchers/projects/apr/ (complete report), http://cms.hhs.gov/researchers/projects/APR/2003/theme7.pdf.
    Quality Improvement Organizations (QIOs), http://cms.hhs.gov/qio/.
    Statistics and Data, http://cms.hhs.gov/researchers/.
Health Resources and Services Administration
    Find a Health Center; people looking for low cost health care, 
http://bphc.hrsa.gov/.
    Area Health Education Centers; Health Education Training Centers, 
http://bhpr.hrsa.gov/interdisciplinary/hetc.html.
Indian Health Service
    IHS National Diabetes Program; Diabetes topics; Nutrition topics; 
Pediatric Height and Weight Study; IHS Best Practice Model; Type 2 
Diabetes in Youth; School Health-Physical Activity and Nutrition; 
Pathways; Cardiovascular Disease, http://www.ihs.gov/MedicalPrograms/Medical_index.asp.
National Institutes of Health
    Evidence-Based Health Information for the Public, http://medlineplus.gov.
    NIDA Nicotine Information Page, http://www.drugabuse.gov/drugpages/nicotine.html.
    Evidence-Based Approaches for Implementation of 5 A Day for Better 
Health, http://dccps.nci.nih.gov/5ad_6_eval.html.
    Obesity Education Initiative, http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm.
    Hearts N' Parks, http://www.nhlbi.nih.gov/health/prof/heart/obesity/hrt_n_pk/index.htm.
    Heart Healthy Recipes, http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/recipes.htm.
    National High Blood Pressure Education Program, http://www.nhlbi.nih.gov/hbp/index.html.
    National Cholesterol Education Program, http://www.nhlbi.nih.gov/chd/index.htm.
    Information for Patients & General Public, http://www.nhlbi.nih.gov/health/public/heart/index.htm.
    Enhanced Dissemination & Utilization Centers (EDUCs) in 
communities, http://hin.nhlbi.nih.gov/educs/awardees.htm.
    The Heart Truth Campaign, http://www.nhlbi.nih.gov/health/hearttruth/index.htm.
    Act in Time to Heart Attack Signs, http://www.nhlbi.nih.gov/actintime/index.htm.
    Healthy People 2010 Cardiovascular Gateway, http://hin.nhlbi.nih.gov/cvd_frameset.htm.
    Clinical Guidelines on the Identification, Evaluation, and 
Treatment of Overweight and Obesity in Adults: The Evidence Report, 
http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm.
    Body Mass Index Calculator, http://www.nhlbisupport.com/bmi/bmicalc.htm.
    National Diabetes Education Program; Small Steps, Big Rewards--
Prevent Type 2 Diabetes, http://www.ndep.nih.gov.
    Diabetes Research and Training Centers Demonstration and Education 
Divisions; The Pima Indians--Pathfinders for Health; Diabetes 
Prevention Program Prevention Trial--Type 1 (DPT-1); Look Ahead (Action 
in Health for Diabetes), http://www.niddk.nih.gov/patient/show/lookahead.htm.
    Stroke Awareness, http://www.ninds.nih.gov/news_and_events/pressrelease_may_stroke_050801.htm.
    Weight Control Information Network, http://www.niddk.nih.gov/health/nutrit/win.htm.
    Exercise: A Guide from the National Institute on Aging, http://nia.nih.gov/exercisebook/.
Office of the Secretary
    HealthierUS, http://www.healthierus.gov/, http://www.whitehouse.gov/infocus/fitness/.
    Healthy People 2010, http://www.health.gov/healthypeople/document/html.
    Best Practices Initiative--Comprehensive Diabetes Control Program, 
http://www.osophs.dhhs.gov/ophs/BestPractice/MI.htm.
    Nutrition Guidelines (Developed by HHS and United States Department 
of Agriculture), http://www.health.gov/dietaryguidelines/ dietaryguidelines/.
    The Surgeon General's Call to Action to Prevent and Decrease 
Overweight and Obesity, http://www.surgeongeneral.gov/topics/obesity topics/obesity.
    Girls and Obesity Initiative, http://www.4woman.gov/owh/education.htm.
Non-Federal Resources
    Tri-state Stroke Network, http://www.tristatestrokenetwork.org.
    State Heart Disease and Stroke Prevention Programs, http://www.cdc.gov/cvh/stateprogram.htm.
    American Heart Association, http://www.americanheart.org.
    American Heart Association's Guide for Community-Wide 
Cardiovascular

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Health, http://www.americanheart.org/presenter.jhtml?identifier=3008344.
    American Stroke Association, http://www.strokeassociation.org.
    Comprehensive resource, for patients and families, http://www.medlineplus.org.
    Health Disparities Collaborative, http://www.healthdisparities.net/.
    National Stroke Association, http://www.stroke.org.
    National training program using community mobilization model, 
http://www.diabetestodayntc.org.
    University of Michigan's Mfit Community Nutrition Program, http://www.mfitnutrition.com/supermarketprogram.asp.
    Web-based training program on how to provide tobacco cessation 
counseling, http://oralhealth.dent.umich.edu/VODI/html/index.html.
    Writing in plain language, http://www.plainlanguage.gov/handbook/index.htm.
Evaluation and Logic Models
    CDC Office on Smoking and Health, http://www.cdc.gov/tobacco/evaluation_manual/app_b.html.
    CDC Division of Nutrition and Physical Activity, http://www.cdc.gov/nccdphp/dnpa/physical/handbook/step2.htm#logic.
    Kellogg Foundation Logic Model Development Guide (under ``Tools'', 
``Evaluation''), http://www.wkkf.org/.
    Promising Practices in Chronic Disease Prevention and Control: A 
Public Health Framework for Action, http://www.cdc.gov/nccdphp/promising_practices/pdfs/Heart.pdf.
    University of Wisconsin-Extension, http://www1.uwex.edu/ces/lmcourse.
    Kansas University Community Tool Box, http://ctb.ku.edu.

5. Basis for Focus on the Seven Core Stroke Belt States

    Using 1930-2001 age-adjusted stroke mortality rate data from the 
National Center for Health Statistics, South Carolina has ranked second 
or first in 8 of 8 decades (100 percent of the time), Georgia first or 
second in 6 of 8 decades (75 percent of the time), North Carolina 
seventh or higher in 8 of 8 decades (100 percent of the time), Alabama 
sixth or higher in 6 of 8 decades (75 percent of the time), Mississippi 
seventh or higher in 7 of 8 decades (97 percent of the time), Tennessee 
seventh or higher in 6 of 8 decades (75 percent of the time), and 
Arkansas ranks first as of the most recent 2001 analysis, demonstrating 
the most rapid increase of all states and the District of Columbia over 
the study period. Arkansas' stroke mortality rate ranking has moved 
dramatically from a rank of 36th in 1940 and 1950 to 15th in 1960, to 
7th or 8th in 1970-1980, to 3rd in 1990, and to 1st in 2001.

    Dated: April 15, 2004.
Nathan Stinson, Jr.,
Deputy Assistant Secretary for Minority Health.
[FR Doc. 04-9080 Filed 4-19-04; 8:45 am]
BILLING CODE 4150-29-P