Innovating from our Hearts to a Healthier Rondo: Frequently Asked Questions

All questions regarding this RFP must be submitted by email to health.heart@state.mn.us. All questions and answers will be posted on this page within seven business days.

Please submit questions no later than 4:30 p.m. Central Time on Oct. 16, 2024.

What is considered a clinical and community sector?

• Clinical Sector: Composed of organizations that provide services, programs, or resources directly related to medical diagnoses or treatment of community members by health care workers in health care settings.
• Community Sector: Composed of organizations that provide services, programs, or resources to community members in non-health care settings.

Can you provide examples on community-clinical links?

Community-clinical links are connections between community and clinical sectors to improve population health.  Examples can be found in CDC’s Community-Clinical Linkages for the Prevention and Control of Chronic Diseases: A Practitioner’s Guide (PDF). 

How long is the grant period?

This RFP is designed to fund grantees over 33 months (2 years and 9 months). It follows the fiscal calendar set forth by the CDC’s Innovative Cardiovascular Health Program (DP23-0005) grant, which matches the federal fiscal year. The next federal fiscal year starts on Oct. 1, 2024, ending on September 30, 2025. We anticipate a start date of Jan. 2, 2025 in order to select grantees and fully execute grant agreements.

Is ‘social services and support needs’ the same as ‘social determinates of health risk factors?

The World Health Organization (WHO) defines Social Determinants of Health as, “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” A social need on the other hand, is better described as the need of an individual as a result of social determinants of health.

What social determinants focus areas can we address?

The National Center for Disease Prevention and Health Promotion aims to address the five social determinants of health that are strongly tied to chronic disease conditions and communities that are most affected.

• Neighborhood & Built Environment: Human-made surroundings that influence overall community health and people’s behaviors that drive health.  Example areas of focus include crime and safety, pedestrian safety and walkability, parks and green space, all-weather opportunities for physical activity, or access to broadband.
• Food and Nutrition Security: Having reliable access to enough high-quality food to avoid hunger and stay healthy. Examples include availability and/or access to healthy food options, household hunger, food deserts, or availability and access to culturally appropriate foods.
• Social Connectedness: When people or groups have relationships that create a sense of belonging and being cared for, valued and supported. Examples areas of focus include engagement of communities experiencing social isolation, culturally responsive emotional wellbeing and resilience, or social support (intergenerational connections and support, support for caregivers, workplace wellness, peer support, etc.)
• Community-Clinical Linkages: Required. See RFP, 2.4 Mandatory Project Requirements for specific details
  • Tobacco Free Policy: *Tobacco Free Policy work is not fundable.
• Other: Grantee will describe in application. Examples include health literacy, culturally responsive and linguistically appropriate care, healthcare access –incarceration, mental health integration, peri pregnant, pregnant, and postpartum people.

What evidence-based lifestyle change programs are included?

The evidence-based lifestyle change programs must primarily address heart health or high blood pressure. Programs such as the Diabetes Prevention Program, Diabetes Self-Management Education Support, and Walk with Ease are not approved programs to address heart health.  

What is the MN 2035 State Plan?

Created with the support and input of the communities and organizations most impacted by these diseases, Minnesota’s Action Plan to Address Cardiovascular Disease, Stroke, and Diabetes 2035 is a road map and call to action for communities, health care organizations, community and organizational leaders, and individuals to collaborate to prevent, treat, and manage cardiovascular disease, stroke, and diabetes through 2035.

Are there data sources that can help us describe health disparities and social determinants of health?

The Minnesota Department of Health has a Cardiovascular Health Data webpage with access to current data on heart disease, stroke, and high blood pressure for Minnesota communities. Minnesota Compass can provide detailed demographic and social determinants of health data on communities throughout Minnesota. The Minnesota EHR Consortium provides data on chronic diseases and risk factors by census tract geography in Minnesota, including special populations through their Health Trends Across Communities in Minnesota website. The CDC’s Division for Heart Disease and Stroke Prevention also has Heart Disease and Stroke Maps and Data.

For the geographic area, do the people receiving the services need to reside or be located in the target region or do the organizations or partners need to be located within the target region? 

Proposals must be focused on residents of the Rondo and Capitol Heights neighborhoods in St. Paul, Minnesota. Please see the RFP for a map of the Census Tracts that encompass these neighborhoods. 

Applicants must be located in and conduct grant activities in the state of Minnesota, but fiscal agents may be located outside of Minnesota. 

What is the Community Health Worker or CHW component?

Applications that propose engaging community health workers (CHWs) or other patient navigators as an evidence-based strategy to connect clinics with community resources and services will be given additional points. Community health workers (CHW) are frontline public health workers who are trusted members of and/or have a close understanding of the community served. CHWs includes patient navigators, Promotores de Salud, community representatives, community health advisors, and others.

Including a CHW component is not required, but including CHWs in the application will make the applicant eligible for all 100 possible points. Without a CHW component, applications can receive a maximum score of 95 points.

Is the Conway neighborhood in East St. Paul within the geographic region for this grant?

The Conway neighborhood is not within the geographic region focus for this grant. Please see the RFP for a map of the geographic region this grant is designed to serve.

Is this RFP open to researchers as well or only community organizations who provide direct practice?

Eligible applicants may include but are not limited to: community-based organizations, neighborhood associations, nonprofit organizations, faith-based organizations, Local Public Health/local government, social service organizations, clinics or health care organizations, and others.

Researchers may apply, but the proposed work may not include research activities, per CDC funding restrictions. Mandatory Project Requirements can be found in section 2.4 of the RFP.

Are Omron blood pressure cuffs an eligible expense on the grant?

Blood pressure cuffs are ineligible for purchase using these grant funds.

Does the clinic need to be in Rondo or just the patients being served need to live in Rondo?

The clinic does not need to be physically in Rondo or Capitol Heights, but the patients that benefit from the proposed initiative need to be residents of the Rondo and/or Capitol Heights communities as detailed in the RFP. See Section 1.2 on Page 3, which states:

“The Minnesota Department of Health (MDH) Cardiovascular Health Unit is requesting proposals to connect community and clinical services among Minnesota adults in St. Paul’s Rondo and Capitol Heights neighborhoods, especially those disproportionally impacted by health inequities, to improve heart health and reduce impacts of heart disease, hypertension, and hypercholesterolemia. Proposals must be focused on residents in these two geographic areas, as described below…”

Do we have to have a clinical site/partner identified by RFP submission or can that be established during the planning process?

As described in 1.4 Eligible Applicants: Collaboration on Page 6 you’ll see “As described below in Section 2.4 Mandatory Project Requirements: Community Clinical Linkage, collaboration between community-based and clinical organizations is required to build or enhance clinical-community linkages to address social needs and supports. Organizations will demonstrate in the application how they plan to engage with other clinical or community partners. Letters of support from collaborators are required for all applicants. A single application should be submitted on behalf of all partners in the collaboration, with one organization identified as the lead. That organization will be the fiscal agent to receive and manage the grant funds.”

It may be possible to apply to without naming a clinical partner, but an application will be stronger if both clinical and community partners are named or included in the proposed work.

How many letters of support are required and what is the max number of Letters of Support?

We require at least one letter of support from the partnering organization. There is no maximum, but it should be proportional to the collaborators that are name in the application.

What does the relationship between the clinical sector and community sector required to look like (if there are any requirements at all), some examples of linkages are included with the CDC practitioner guide - is this a suggestion or model to follow?

As stated in Section 2.4 Mandatory Project Requirements: Community Clinical Linkages on page 12 we state, “Funded projects must focus on building or enhancing existing community clinical linkages that can be sustained after grant funding with the goal of increasing referrals to social services, supports, culturally responsive education and prevention, and lifestyle change programs as described. Community clinical linkages are connections made between health care, public health, and community organizations to improve population health. Letters of support from collaborators are required for all applicants. Example activities include:

• Building a relationship with a clinic or community partner and establishing a bidirectional referral system for social needs support addressing a SDOH.
• Engaging Community Health Workers to support clients in self-managing their high blood pressure, including facilitating connection to primary care services.
• Building a relationship with a clinic or community partner and establishing a bidirectional referral system to an evidence-based lifestyle change program or culturally responsive education and support for chronic condition management.”

These are just examples of potential community clinical linkages, there are many other possible approaches that an applicant could take. This grant funding comes from CDC through the Innovative Cardiovascular Health Program. We are looking for innovative, community-driven solutions to increase sustainable community clinical linkages that as described in the paragraph above. The CDC practitioner guide provides a framework for designing an effective community-clinical linkage.

Are there any selection criteria that takes citations/cited works into consideration?

While not required, it would be helpful to include citations that support the proposed approach in any application.