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

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

In-Depth Assessment – Exploratory Assessment Partner Interview Guide – Community Clinical Links – The National Cardiovascular Health Program & The Innovative Cardiovascular Health Program

Note: Public reporting burden of this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-24XXX)

Exploratory Assessment

Partner Interview Guide

Date of Interview
Interviewer
Notetaker
Organization Name
Organization Type
State
Organization City		Zip Code
Cooperative Agreement	☐ The National CVH Program ☐ The Innovative CVH Program
Strategy	Strategy 3: Link Community Resources and Clinical Service
Interviewee Name(s)
Interviewee Role(s) or Title(s)

Introduction

Thank you for taking the time to participate in this interview. My name is <Insert name> and I am with the Deloitte evaluation team. Our team is working with the CDC Division for Heart Disease and Stroke Prevention to evaluate the <Insert Cooperative Agreement>. As part of the larger evaluation, we are seeking to learn more about the effectiveness of Strategy 3: Link Community Resources and Clinical Service at the site level and gain insights on sustainability and program replicability. The information you share will provide valuable insights on supporting engagement of community health workers in patient care, promoting use of self-measured blood pressure monitoring, and strengthening patient referrals to social support services to support the needs of populations at risk of CVD and help us understand which approaches seem to work well in specific contexts.

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

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

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

Do you consent to this interview?

☐ Yes

☐ No

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

Do we have your permission to record?

☐ Yes

☐ No

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

Background

Thank you again for agreeing to participate in this interview. For reference, for today’s interview we will be talking about Strategy 3, which is defined as

Link community resources and clinical services that support bidirectional referrals, self-management, and lifestyle change to address social determinants that put the priority populations at increased risk for CVD with a focus on hypertension and high cholesterol. (The National CVH Program)

Link community resources and clinical services that support comprehensive bidirectional referrals and follow-up systems aimed at mitigating social services and support barriers for optimal health outcomes within approved populations of focus. (The Innovative CVH Program)

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

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

3A: Create and enhance community-clinical links to identify SDOH (e.g., inferior housing, lack of transportation, inadequate access to care, and limited community resources) and respond to the social services and support needs

• of populations at highest risk of CVD with a focus on hypertension and high cholesterol The National CVH Program)

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

3B: Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social services and support needs leading to optimal health outcomes

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

3C: Promote use of self-measured blood pressure monitoring (SMBP) with clinical support

within populations at highest risk of hypertension The National CVH Program)

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

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

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

Probes:

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

• How long have you been in this role?

• Can you tell me about your role in relation to developing, modifying, enhancing, or otherwise supporting community clinical link (CCL) efforts within your organization?

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

Implementation of CCL Strategies

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

2. We last spoke about your activities related to <support for and implementation of community clinical links> during the key informant interviews for the Evaluability Assessment. Is this still true or has it changed since we last spoke?

Probes:

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

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

  • Can you please share any unique or novel activities that your organization has implemented that you are particularly proud of or would like to highlight?

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

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

3. Is <partner organization> involved with the LC?

Probe:

• [If yes] Please describe your organization’s role in the LC.

4. 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?

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

Probes:

• What has changed in the past two years?

  • How has the LC’s support for <partner’s CCL strategy implementation activities> changed?

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

Probes:

• In what other ways has the LC supported your work?

• How has the LC influenced partnership networking?

• How has the LC impacted program reach?

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

Probe:

• What are the gaps in your current partnerships?

• What are the gaps in your LC?

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

Next, we’d like to discuss any new or ongoing challenges that <partner organization> is encountering when implementing <activities related to CCL strategy> and ways that your organization has overcome these challenges or any additional support the organization may need to overcome them.

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

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

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

Probes:

• Have challenges persisted with:

  • 3A: enhancing CCLs?

  • 3B: integrating CHWs into the continuum of care?

  • 3C: promoting the use of self-measured blood pressure monitoring (SMBP)?

• How did your organization resolve these challenges?

9. Have any new challenges emerged?

Probes:

• How is your organization addressing these challenges?

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

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

Probe:

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

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

11. During the Evaluability Assessment it was shared that <contextual factors that support or hinder activities related to linking community resources and clinical services>. Have there been any changes in these contextual factors?

Probe:

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

Effectiveness of CCL

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

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

[Interviewer Note: For Questions 12 through 14, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

12. [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?

13. [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?

14. [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?

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

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

Probes:

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

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

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

• How does your organization define reach?

  • What metrics did your organization use to measure reach?

  • What are the findings?

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

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

  • What has helped your organization reach your population?

[Interviewer Note: For Question 16, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

16. How do <partner’s CCL activities> contribute to patient level outcomes?

Probes:

• How do <your CCL activities> support patients to control their blood pressure?

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

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

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

17. 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?

[Interviewer Note: For Question 18, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

18. 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?

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

Probe:

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

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

Sustainability [The National CVH Program]

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

21. [3A] What steps has your organization taken to help sustain community-clinical links?

Probe:

• Can you share any challenges faced in establishing and strengthening community-clinical links and how they were addressed?

22. [3B] What steps has your organization taken to help sustain use of CHWs to provide a continuum of care?

Probe:

• Can you share any challenges faced in engaging CHWs in the continuum of care and how they were addressed?

23. [3C] What steps has your organization taken to help sustain the use of SMBP with clinical support?

Probe:

• Can you share any challenges faced in using SMBP and how they were addressed?

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

Probe:

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

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

25. [3A] How do you plan to proceed with <partner activities related to community-clinical links> after <September 2028 or date that partner is no longer engaged with NOFO>?

26. [3B] How do you plan to proceed with <partner activities related to engaging CHWs> after <September 2028 or date that partner is no longer engaged with NOFO>?

27. [3C] How do you plan to proceed with <partner activities related to using SMBP> after <September 2028 or date that partner is no longer engaged with NOFO>?

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

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

Scalability and Replicability [The Innovative CVH Program]

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

30. Can you describe the <partner’s community clinical link activities> that have been successful in your organization and could potentially be scalable or replicable?

Probe:

• What factors contribute to their scalability?

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

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

Probe:

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

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

34. Is there anything else you would like to add about implementation, scalability, or replicability of <partner’s CCL strategies>?

Close

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

Thank you for your time. This concludes our interview about the clinical-community link strategy for the <Insert cooperative agreement>. If you have any additional questions, please feel free to contact the Comprehensive Evaluation Team, hdsp_nofo_eval@cdc.gov.