Request for Application (RFA) for the Mississippi Delta Health Collaborative Clinical Community Health Workers Initiative

The Request for Application will be specifically concentrated in the counties of Bolivar, Carroll, Coahoma, DeSoto, Holmes, Humphreys, Issaquena, Leflore, Panola, Quitman, Sharkey, Sunflower, Tallahatchie, Tate, Tunica, Warren, Washington, and Yazoo. Healthcare systems will participate in the Clinical Health Worker Initiative (CCHWI), providing primary care to support needs to improve the detection of healthcare disparities and the identification, management, and treatment within populations with and at the highest risk of hypertension and high cholesterol. Healthcare systems will secure Community Health Workers (CHW) to serve as a liaison/linkage between the patient and the healthcare provider. The CHW, a layperson, facilitates continued care and management of high blood pressure and cholesterol, increases the community's health awareness, and provides informal blood pressure self-management education. Approximately, up to fifteen awards will be issued upon execution of both parties through September 29, 2029, contingent upon availability of funds, achievement of program deliverables, compliance with reporting requirements, and demonstrated performance outcomes. All awards are based on the applicant's ability to meet the deliverables. Healthcare systems will receive funding based on program outcomes, with a maximum of up to $140,000.00 allocated per Community Health Worker (CHW) to manage a caseload of 100 qualified and approved patients. Eligible healthcare systems, participating in the CCHWI with two CHWs (caseload of 100 each), may request funding of up to $140,000.00. Healthcare systems will also be required to establish an interprofessional team and participate in the Mississippi Alliance for Cardiovascular Health Learning Collaborative.

Background

Since 2008, the Mississippi State Department of Health (MSDH), through the Mississippi Delta Health Collaborative (MDHC), has received cooperative agreement funding from the Centers for Disease Control and Prevention to support efforts aimed at reducing the burden of heart disease, stroke, and related health disparities across eighteen (18) counties within the Mississippi Delta region. Through these efforts, MDHC has worked to strengthen cardiovascular disease prevention and management by implementing evidence-based strategies focused on hypertension prevention and control, cholesterol management, community-clinical linkages, health equity, and chronic disease self-management support.

Recognizing that sustainable improvements in cardiovascular health outcomes require coordinated, multidisciplinary approaches, MDHC has established and strengthened partnerships with healthcare systems, community-based organizations, faith-based organizations, pharmacies, public health agencies, and other stakeholders throughout the Mississippi Delta region. These partnerships have supported implementation of evidence-based interventions designed to improve access to care, strengthen care coordination, address social determinants of health (SDOH), and improve health outcomes among populations disproportionately impacted by cardiovascular disease and related chronic conditions.

In August 2024, MDHC was awarded a new five-year cooperative agreement from the Centers for Disease Control and Prevention to further expand and strengthen equity-focused cardiovascular disease prevention and management efforts across the Mississippi Delta region. This cooperative agreement is designed to support implementation of evidence-based strategies that prevent, detect, control, and manage hypertension and high cholesterol among adults and older adults at highest risk for poor cardiovascular health outcomes.

Building upon lessons learned from previous funding cycles, this initiative emphasizes the importance of strengthening healthcare system capacity, improving community-clinical partnerships, expanding team-based care approaches, integrating Community Health Workers (CHWs), enhancing referral coordination, and addressing social determinants of health that contribute to health disparities and barriers to care. The cooperative agreement also supports implementation of policy, systems, and environmental (PSE) change strategies designed to improve cardiovascular health outcomes and create sustainable improvements within healthcare systems, clinical settings, and communities throughout the Mississippi Delta region.

Through this Request for Applications (RFA), MDHC seeks to engage healthcare systems that demonstrate the capacity and commitment to implement evidence-based, data-driven, and equity-focused interventions that improve hypertension and high cholesterol prevention, treatment, management, and control while strengthening coordination between healthcare providers, patients, and community resources.

Project Details

• Reference ID: 2025-REQ-309
• Department: Preventive Health and Health Equity
• Department Head: Cassandra Brown (Director, Office of Preventive Health)

Evaluation Criteria

• Organizational Capacity Overview (15) (15 pts) —

  Applicants will receive high scores if they have a defined and clear organizational structure; organizational experience in federal grants; qualified and capable personnel with experience in federal grants or equivalent credentials or experience; or can otherwise demonstrate that they will be a reliable subgrantee who will use all awarded funds in a manner consistent with law and the requirements of this RFA.

  • Describes the type of organization applying and its organizational structure. (5)
  • Describes the services provided. (5)
  • Describes the healthcare system established an interdisciplinary care team that includes all required roles (senior leader, physician champion, nurse/clinical lead, social worker/care coordinator, data analyst/IT staff, CHW, community partners). (5)
• Project Management (35) (35 pts) —
  • Describes team roles, responsibilities, and decision-making structures. (10)
  • Demonstrate capacity to report aggregated metrics, including hypertension control, cholesterol management, referrals, and completion rates (10)
  • Describes who will be responsible for monitoring the project’s ongoing progress, preparation of reports, program evaluation, and communication with partners. (5)
  • Describes a functional EHR or other approved HIT system capable of documenting, tracking, monitoring, and reporting clinical and social service data (5)
  • Describes the staff’s ability to participate in all phases of the Learning Collaborative, including Learning Sessions and Clinical Community Health Worker Initiative. (5)
• Data Collection and Reporting (35) (35 pts) —
  • Clearly articulates the Health Information Technology support, including IT staff and EHR vendor information. (5)
  • Describe how the organization uses Health Information Technology to identify patient populations and use data to improve patient CVD health outcomes. (5)
  • Explains if Cardiovascular Risk Screening can be completed in the EHR (5)
  • Documents whether the EHR system can collect data on Cancer screenings. (5)
  • Explains the referral process and receives patient progress reports from lifestyle change and Healthy behavior support programs (5)
  • Provides data supporting the system to identify, recruit, and enroll eligible patients (adults with hypertension, high cholesterol, uncontrolled BP, and HIPS patients). (5)
  • Provides data at a population level. (5)
• Collaboration (10) (10 pts) —
  • Describes how the healthcare system utilizes team-based care (e.g., nurses, nurse practitioners, dentists, pharmacists, nutritionists, physical therapists, social workers, and community-based workers) to identify patients' social services and support needs and to improve the management and treatment of hypertension and cholesterol. (3)
  • Describes the healthcare system's ability to secure a Community Health Worker to recruit population at the highest risk of hypertension and train patients on how to use a home blood pressure monitor with CHW clinical support. (4)
  • Describe any collaboration with community-based organizations and partnerships to address the barriers to social services and support needs. (3)
• Project Resources (5) (5 pts) —
  • Describes established active partnerships with community-based organizations, pharmacists, behavioral health providers, social service agencies, and other relevant partners. (3) 
  • Describes the healthcare system's ability to coordinate referrals to evidence-based programs such as MTM, SMBP, HHA, cardiac rehab, and lifestyle change programs. (2)
     
     
     

Submission Requirements

• Healthcare Organization Name (required) —

  Please provide the full legal name of the Applicant Organization that should be listed on an agreement or contract. Be sure to include any other "doing business as" names, or any previous names the organization used.

  NOTE: Name must match the UEI Number

• Healthcare Organization Type: (required) —

  Please provide the type of Healthcare Organization: (Private, FQHC, RHC, Other)

• Please provide a copy of the entity’s license as an attachment. (required) —

  Entities must be licensed by the Mississippi State Department of Health and/or the Mississippi State Board of Medical Licensure. 

• Applicant Organization UEI Number (required) —

  Please enter the full UEI Number of the Applicant Organization here.

• UEI Number Upload (required) —

  Please upload a copy or printout of your registration from SAM.gov.

• Healthcare Organization Address (required) —

  What is the full physical/mailing address of the healthcare system?

   Please be sure to include the full street name and address, City, State, and Zip Code.

• Healthcare Organization Contact Information (required) —

  Please provide the following contact information (including area code): 

  A) Telephone Number

  B) Fax Number

• Executive Director / Chief Executive Officer / Owner Name (required) —

  Please provide the following information: Full Name, Title, Phone Number, and Email Address.

• Chief Financial Officer (required) —

  Please provide the following information: Full Name, Phone Number, and Email Address.

• Chief Technical Officer/IT Director (required) —

  Please provide the following information: Full Name, Phone Number, and Email Address.

• Lead Project Contact (required) —

  Please provide the following information: Full Name, Title, Phone Number, and Email Address.

• Clinical Community Health Worker (required) —

  Please provide the full name, office phone number, fax number, and email address of the point of contact, including their address and zip code, for this application.

• Do all of the healthcare providers work full-time, 40 hours or more? (required)
• On average, how many hours do the part-time providers work per week? (required)
• Eligible Entity (required) —

  Party submitting this application certifies that the Healthcare Organization is an eligible entity as defined by this RFA.

• Debarment or Suspension Confirmation (required) —

  Party submitting this application certifies that Healthcare Organization is not presently debarred or suspended.

• W9 (required) —

  Upload a copy of your current W9 here.

• Did your health system participate in MS Delta Health Collaborative during the last grant cycle? (required)
• Healthcare Organizational Overview (required) —

  The Applicant’s Organization Overview section shall contain the following information about the Applicant. If the Application is a cooperative or joint venture between two or more entities, all information required in this section shall be provided for all entities, even if a new legal entity has been created or is planned to be created for the Subgrant. 

• Describe the overall organizational structure and services provided. (Please include the counties served, satellite clinic sites, providers, and services offered) (required) —

  Please describe how your organization will manage day-to-day project operations, including the number of providers & staff members:

  A) Project leadership and oversight
  B) Roles and responsibilities of project team members 
  C) Processes for monitoring project implementation and progress
  D) Processes for preparing reports
  E) Communication and coordination with partners and stakeholders
  F) Capacity and commitment to participate in required trainings, CHW Learning Sessions, MTM Advisory Task Force meetings, and MACH Learning Collaborative activities

• Electronic Health Records: Describe your IT Support.
• Name of Electronic Health Record (EHR) Vendor? (required)
• Does the clinic or health care system have policies/protocols in place requiring the use of EHRs and standardized clinical quality measures by race, ethnicity and other populations of focus? (required)
• Does the clinic or health system have policies or protocols in place requiring the use of clinical data from EHRs to support communication within the care team to coordinate care for hypertension and high cholesterol within populations with and at the highest risk of hypertension and high cholesterol. (required)
• Does the clinic or health care system use standardized processes or tools to identify, assess, track, and address social services support needs within populations with and at the highest risk of hypertension and high cholesterol. (required)
• Does the clinic or health system have policies or protocols for communication, coordination and collaboration among the care team that enhances engagement and follow up of program participants. (required)
• Do you have personnel support who can assist in extracting data? (Indicate if support is Onsite, contractual, or if there is no personnel support) (required)
• Can Cardiovascular Risk Assessments be completed in the Electronic Health Record (EHR)? (required)
• Does your EHR have the capability to refer patients to resources that address social needs and behavioral health resources and services? (Check all areas that you can address with your current referral network) (required)
• Does your EHR have the capability to track the utilization of social needs and behavioral health referrals? (required)
• What is the name of the social needs assessment tool utilized by your organization? (ex: PRAPARE, AAFP social Needs Screening, Health Impact assessments, CRISP) (required)
• Is the social needs assessment tool embedded within your EHR? (required)
• Does your electronic health record collect and report information on cancer screenings? (required)
• Is your healthcare system a Breast and Cervical Cancer Program (BCCP) provider? (required)
• Explain how your organization make referrals and receive patient progress reports from lifestyle change and healthy behavior support programs (Healthy Heart Ambassador, Tobacco Cessation Programs, Weight Watchers, Diabetes Prevention Programs, etc.) (required)
• Please provide information about the unduplicated patient population served from March 2025 to March 2026 in questions 21.1 - 21.30. —

   

   

• Total number of patients referred to evidence based/evidence-informed lifestyle change programs/social service needs (required)
• How many adults (18 years and older) with and at highest risk of having hypertension and/or high cholesterol were referred to an evidence-based and evidence-informed lifestyle change program or social services and support? (required)
• How many adults(18 years and older) with and at the highest risk of having hypertension and/ or high cholesterol who were referred to social support services and accessed those services? (required)
• Total number of patients attended SMBP (required)
• Total number of patients who received BP cuff for SMBP (required)
• Total number of patients within high burden subpopulation with known high blood pressure who have achieve blood pressure control <140/90 by race/ethnicity (required)
• Total number of patients within high burden subpopulations who are considered at high risk of cardiovascular events who have their cholesterol managed with statin therapy (required)
• Total number of patients within high burden subpopulations with the diagnosis of high cholesterol (required)
• Total number of patients within high burden subpopulations with the diagnosis of high blood cholesterol who were referred to social support and accessed those services (required)
• Total number of patients within high burden subpopulations with the diagnosis of high blood pressure (required)
• Total number of patients within high burden subpopulation (required)
• Total number of patients within high burden subpopulation who achieved blood pressure control < 130/80
• Number of drug therapy problems resolved (required)
• Total number of patients who are eligible for Medication Therapy Management (MTM) service (required)
• Number of patients with telehealth technologies to manage their high blood pressure (required)
• Number of patients with telehealth technologies to manage their high blood cholesterol (required)
• Number of patients with R03.0 code (undiagnosed hypertension)
• Demographic Characteristics: Unduplicated number of adult patients 18 years and older serve (required) —

  A) Number of Patients

• Total number of patients with Blood Pressure >140/90, age 35-64, and uninsured. (required) —

   

  A) Total Number of Male Patients

  B) Total Number of Female Patients

• Total number of patients with the diagnosis of High Blood Pressure (required)
• Total number of patients with the diagnosis of high blood pressure who have their blood pressure in control (required)
• Total number of patients with the diagnosis of high blood cholesterol (required)
• Total number of patients with the diagnosis of high blood cholesterol who have their cholesterol in control.
• Total number of patients with diagnosis with high cholesterol, who are on statin therapy (required)
• Gender of adults 18 years and served: List total numbers per gender category. (required) —

  A) Male

  B) Female

  C) Prefer Not to Respond/ Unknown

• Race of adult patients 18 years and older served: (required)
• Ethnicity of adult patients 18 years and older served: (required) —

  Hispanic

  Non-Hispanic

• Insurance Status of adult patients 18 years and older served. (required)
• Disease Diagnosis and Patient Characteristics: Number of Patients for Each (required) —

  A) Housing (ICD-10-CM Z codes: Z59.0 Z59.00, Z59.01)

  B) Transportation Services (ICD-10-CM Z codes: Z59.82) 

  C) Food Bank/Insecurity (ICD-10-CM Z59.41) 

  D) Mental Health Services (ICD-10-CM Z codes: Z13.30) 

  E) Heart disease (ICD-10 codes: 391.xx-392.0x; 410.xx - 429.xx) 

  F) Hypertension (ICD-10 Codes:  401.0 - 405.99) 

  G) Dyslipidemia (ICD-codes: 272.0 - 272.4) 

  H) Dual Diagnoses (Hypertension and Diabetes) 

  I) Obese males (ICD- Codes E66. *, Z68.25-Z68.29, Z68.30-Z68.39, Z68.4) 

  J) Obese females (ICD- Codes E66. *, Z68.25-Z68.29, Z68.30-Z68.39, Z68.4*)

  K) Unsure 

   L) Age 35 to 64

• Does the healthcare system train patients on self-measured blood pressure monitoring (SMBP) and provide clinical support to populations at highest risk of hypertension. (required) —

  If "No" Answer with N/A

  If "Yes" Proceed with your response.

• Please upload files for section 20.1 to 20.30 (required) —

  Please upload any relevant data files that you have available. Please ensure the files are in an accessible format and include all necessary information for our review. 

• Agreements Terminated or Costs Disallowed (required) —

  Applicant must provide a summary of any agreements executed within the last five (5) years with federal awarding agencies or pass-through entities (either as grant agreements, cooperative agreements, subawards, or contracts) that:

  • Were terminated for cause; or
  • Where Specific Conditions were placed on Applicant (see 2 CFR § 200.208 or 45 CFR § 75.207).
• Utilization of a Multidisciplinary Team —

  Identifying patients' social services and support needs and to improve the management and treatment of hypertension and high cholesterol

• Describe how your healthcare system utilizes a multidisciplinary team (e.g., nurses, nurse practitioners, dentists, pharmacists, nutritionists, physical therapists, social workers, and community-based workers) to identify patients' social services and support needs and to improve the management and treatment of hypertension and high cholesterol. (required)
• Describe any collaborations with community-based organizations and partnerships that address the barriers to accessing social services and support needs? (required)
• Referrals
• Please list the partnering organizations that your healthcare system collaborates with. Are referrals facilitated to these partnering organizations? Please specify which organizations receive referrals. (required)
• Please upload files for the referrals section 22. (required) —

  Please upload any relevant data files that you have available. Please ensure the files are in an accessible format and include all necessary information for our review. 

• Conflicts of Interest
• Other Current MSDH Contracts (required) —

  List all other current agreements/contracts with MSDH, including the dollar amount associated with the agreement/contract and the beginning and ending dates. If no other funds are received, please mark N/A.

  Please provide each entry in the following format:

  MSDH Program or Agreement/Contract Name #1

  • Dollar Amount
  • Contract Beginning Date
  • Contract Ending Date
• Organization Governing Body (required) —

  Please list the name of each member of your organization’s Board of Directors or other governing body (i.e., trustee, alderman, partner, owner).

• Governing Body or Project Staff Affiliations (required) —

  Are any members of the governing body or project staff also MSDH employees, MSDH Board Members, or spouses, parents, or children of MSDH employees?

• Conflict of Interest Certification (required) —

  I hereby certify that the information set forth above is true and complete to the best of my knowledge and that no MSDH employee, spouse, parent, or child of an MSDH employee, serves as a member of the governing body, project staff, or has an ownership or pecuniary interest in the agreement/contract or organization. I agree to notify MSDH within thirty (30) days if any of these conditions change during the agreement/contract.

• Other
• Debarment, Suspension, and Eligibility (required) —

  The applicant certifies that they or any of its principals _____ presently debarred, suspended, proposed for debarment, or declared ineligible for award of federal or state contracts.

  Select the answer which best fills in the blank for the applicant.

• Charges From A Government Agency (required) —

  The applicant certifies that they or any of its principals _____ presently indicted for, or otherwise criminally or civilly charged by a government entity.

  Select the answer which best fills in the blank for the applicant.

• Conviction or Acknowledgment of Fault (required) —

  The applicant certifies that they or any of its principals _____ within the last five (5) years, been the subject of a federal or state criminal proceeding resulting in a conviction or other acknowledgment of fault, been the subject of a federal or state civil or administrative proceeding resulting in a finding of fault with a monetary fine, penalty, reimbursement, restitution, and/or damages greater than $5,000 or other acknowledgment of fault;  convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) contract or subcontract; violation of Federal or State antitrust statues relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements or receiving stolen property.

  Select the answer which best fills in the blank for the applicant.

• Contract Termination By Default (required) —

  The applicant certifies that they or any of its principals _____ within the last three (3) years preceding this offer, had one or more contracts terminated for default by any federal agency.

  Select the answer which best fills in the blank for the applicant.

• Felony Criminal Violations (required) —

  The applicant certifies that they or any of its principals _____ within the last twenty-four (24) months, been convicted of a felony criminal violation under federal or state law.

  Select the answer which best fills in the blank for the applicant.

• Financial Records (required) —

  Does the applicant have a financial management system that provides records that can identify the source and award-supported activities and provides control and accountability of project funds, property, and other assets?

• Audit Status / Fiscal Responsibility (required) —

  Does the applicant receive an annual audit in accordance with Uniform Guidance §200.514 (formerly A-133)?

• Most Recent Audit (required) —

  What is the most recent fiscal year for which this audit was completed?

• Report Findings (required) —

  Were there any audit findings in the most recent report?

  If "Yes", please be sure to provide an explanation in the applicable upcoming question. Failure to provide an explanation may cause your submittal to be deemed non-responsive.

• Recent Audit Report —

  Please upload a copy of your most recent Uniform Guidance §200.514 (formerly A-133) Audit Report.

• Explanation or Other Information (required) —

  Please provide any additional information around your Audit Status that you feel is necessary here. This includes an explanation regarding any audit findings in your most recent audit.

  If you have nothing to add here, please state that you have no additional information to provide.

• No Annual Audit (required) —

  You have stated that the applicant does not receive an annual audit in accordance with Uniform Guidance §200.514 (formerly A-133).

  Please select the option which best fits the reason why.

• No Annual Audit - Other (required) —

  If you selected "Other" in the previous question regarding why you do not receive an annual audit in accordance with Uniform Guidance §200.514 (formerly A-133) please specify here.

  If your answer to the previous question was not "Other", please respond here with "N/A".

• Supplemental Information —

  Applicant will provide any required supplemental information as outlined in this Request to be submitted with the Application. 

• Competition/Joint Efforts Verbiage (required) —

  Should the language for Competition/Joint Efforts be used in this RFA?

• Statement of Need (required) —

  Is there a Statement of Need required with submittals for this RFA?

• Estimated Dollar Amount (required) —

  What is the estimated dollar amount budgeted for this request?

• Funding Information —

  Be sure that the following three financial info pieces add up to 100% or this will not be approved.

• Internal Order (required) —

  Please specify the internal order information. Be sure to include the % of each internal order. If there are multiple internal orders, please separate each with a comma and be sure they add up to 100% or your posting will not be approved.

  EXAMPLE 1
  30000035771  100%

• Functional Area (required) —

  Please specify the functional area information. Be sure to include the % of each functional area. If there are multiple functional areas, please separate each with a comma and be sure they add up to 100% or your posting will not be approved.

  EXAMPLE 1
  13010101000000DV  100%

• Cost Center (required) —

  Please specify the cost center information. Be sure to include the % of each cost center. If there are multiple cost centers, please separate each with a comma and be sure they add up to 100% or your posting will not be approved.

  EXAMPLE 1
  1301010707  100%