September Amendment 35 Program Evaluation Group

Transcription

1 Amendment 35 Program Evaluation Group Reach and Implementation of Amendment 35 Funded Programs Addressing Cancer, Cardiovascular and Pulmonary Disease and Health Disparities, Fiscal Year September 2011 Prepared for the Epidemiology, Planning and Evaluation Branch, Colorado Department of Public Health & Environment

2 Table of Contents Executive Summary... i Background... 1 Guiding frameworks... 1 Project-level reporting... 3 Data preparation and quality review... 4 Assumptions and limitations... 4 Amendment 35 Program Portfolio Overview... 6 Funding... 6 Geographic coverage... 6 Implementation...10 Cancer, Cardiovascular and Pulmonary Disease (CCPD) Funding...12 Geographic coverage...12 Reach...13 Implementation...15 Health Disparities Grants Program Funding...26 Geographic coverage...26 Reach...27 Implementation...29 Conclusions and Recommendations Appendix 1: CCPD and HDGP projects by disease category Appendix 2: CCPD grantees and project titles Appendix 3: CCPD project strategies, reach and frequency Appendix 4: Organizations and Project Titles for HDGP Appendix 5: HDGP project strategies, reach and frequency... 47

3 Executive Summary Background In November 2004, Coloradans approved Constitutional Amendment 35 (A35) to increase the tobacco tax by $0.64 per cigarette pack and a percentage-of-price on other tobacco products, with the revenues earmarked for health care services, tobacco education, and cessation programs. A portion of revenues was allocated for prevention, early detection, and treatment of cancer, cardiovascular disease, and pulmonary disease. The funds are awarded in competitive grants under two programs administered by Colorado Department of Public Health and Environment (CDPHE): Cancer, Cardiovascular Disease and Pulmonary Disease (CCPD) Grants Program; Health Disparities Grants Program (HDGP). Under a contract with CDPHE, the A35 Program Evaluation Group (APEG) in the University of Colorado Cancer Center evaluates the CCPD and HDGP A35-funded grants portfolios. Fiscal year (FY) was the third year in which the evaluation is based on standardized data elements that both programs grantees report. Key metrics include Reach and Implementation, defined as follows: Reach Implementation Number of individuals known to have received an intervention designed to improve their health and/or lower their disease risk. Reach does not include people who are trained to deliver an intervention. The processes of delivering an intervention, including who delivered it, where, how, and how much was delivered. Implementation may involve direct delivery to patients or community members, or indirect delivery to health care providers, organizations or infrastructures that in turn deliver services to patients or community members. Reach is applicable only to direct delivery. The current report describes overall activities of HDGP and CCPD projects and provides detail on program-specific activities. Funding During FY , the grant making programs awarded $7,090,777 to twenty-one projects; ten CCPD (totaling $6,378,465 in awards) and eleven HDGP which were all continued from the previous fiscal year (totaling $712,312 in awards). The number of projects and awards were lower than previous years due to statewide budget reductions for FY and Table 1 displays the combined CCPD and HDGP number of projects and total awards for each disease area. Collectively, the greatest number of funded projects targeted cardiovascular disease (10 projects) and received 34% of CCPD/HDGP funding ($2,444,979). Two projects were funded addressing cancer and received 52% of the combined funding ($3,690,429). The majority of cancer funding went to a large scale colorectal cancer screening project. All projects addressing i

4 pulmonary disease were awarded through the CCPD program while all crosscutting awards were funded through the HDGP. CCPD and HDGP projects by disease area, FY Number of projects Total awarded Cancer 2 $ 3,690,429 Cardiovascular Disease (CVD) 10 $ 2,444,979 Chronic Pulmonary Disease (CPD) 3 $ 557,165 Cross-cutting 6 $ 398,204 TOTAL (CCPD/HDGP) 21 $7,090,777 Geographic distribution of awards Collectively, A35-funded programming had activity in all Colorado counties with the exception of Sedgwick. The greatest project densities were seen in Denver (11 projects), Arapahoe (8 projects), Adams (7 projects) and Pueblo (5 Projects). Twenty five counties had three to four projects while thirty four counties were served by one to two projects. CCPD served 63 Colorado counties with a range of 1-6 projects in each county. HDGP served 19 of the 64 counties with 1-5 projects each. Reach Estimates of total reach. Table 2 shows the combined reach of CCPD and HDGP funding by disease area. Collectively, all strategies were funded by the A35 grants programs. CCPD projects reported on all direct and indirect strategies while HDGP reported all direct strategies with the exception of Treatment, and reported four of the six indirect strategies (no activity was reported for Infrastructure and Policy). Nine projects implemented Disease Management and Follow Up activities, reportedly reaching nearly 20,800 participants. Over 12,000 screening activities were implemented by thirteen projects. Because it is extremely difficult to determine the reach (as defined in this report) for awareness/media activities, grantees were asked to report the number of media impressions generated by these efforts. Using this metric, projects reported more than 1.3 million impressions across the CCPD and HDGP. The numbers of individuals reached by CCPD and HDGP combined programming are estimates, and over-counting cannot be ruled out. Totals by column are not shown because of the likelihood that individuals were reached by more than one strategy. For example, it is reasonable that an individual would be both screened and treated or screened and referred to a risk factor reduction or disease management program. Assuming that individuals received appropriate services, totals in tables represent reasonable estimates of the number of services delivered (excluding awareness). Using this approach, CCPD and HDGP provided 52,172 distinct service events in FY ii

5 Estimated direct reach (# projects)* by strategy and disease area, FY Strategy Access to care Awareness / media Disease management / follow up Education / training Referrals Risk factor reduction CVD (9) 3,736 (3) 398,967 (5) 17,611 (5) 3,757 (6) 2,220 (5) 1,184 (4) 5,575 (8) Disease Area Cross- Cancer cutting (6) 2,771 1,563 (3) 900,412 2, ,137 iii ,763 Pulmonary (3) 116 (3) 1,311 1,010 1,685 (3) 146 Total (20) 8,186 1,302,827 2,203 1,912 Screening Treatment * Includes CCPD (9) and HDGP (11) funded projects that implemented direct strategies. Column totals are not presented because some individuals were reached by more than one strategy. 20,797 7,006 2,385 1,214 12,453 Grantees were requested to collect demographic data for race/ethnicity, gender, age group and known low income or Medicaid status. There were substantial unknown or unreported demographics for awareness strategies across both programs (because it is often difficult to determine the reach, it is not unexpected to have limited demographic data for awareness). Overall, CCPD demographic reporting showed continued improvement over previous years with 87% 100% demographics reported for all direct strategies (outside of awareness). HDGP reported substantially lower percentages of known demographics (73% unknown for disease management, 41% for screening). This may, in part, be due to staff turnover experienced in some of the HDFG programs. Projects reached all racial and ethnic groups. Whites and Latinos were reported to be the populations with the largest reach across strategies. Women were consistently reached more often than men and adults ages were reached most often, although a sizeable number of youth (0-17) were targeted through screening (1,848) and education/training (1,027). Seniors (65 and older) were most often reached though disease management. Implementation HDGP/CCPD Implementation. Grantees were requested to select a specific disease focus area for each strategy within each disease area for example, Cancer: breast, cervical or colorectal), or multiple diseases and conditions (such as CVD: multiple areas or Cross-Cutting: risk factors). CCPD grantees reported on nine disease specific focus areas (one in cancer, four in CVD, two in cross cutting and two in PD). Seven of these categories included direct strategies with associated reach. HDGP reported on six disease specific areas (two each in cancer, CVD and cross cutting). Implementation of individual strategies varied widely across funded projects in terms of the reach, dose, and how they were implemented. For example, risk factor reduction programs activities ranged from one project implementing a curriculum calling for twelve two-hour sessions on 134

6 nutrition, exercise and wellness, to another project providing tailored letters addressing risk factors. The most frequently used strategies for CCPD across all disease areas were screening, access to care, education/training (both direct and indirect), and disease management. Activities were typically delivered in clinics, community settings, schools/worksites, or on the Web. The most frequently used strategies for HDGP were collaboration/partnerships, screening, and education/training (direct and indirect). Activities were usually delivered in community settings, schools and worksites, and clinics. Conclusions FY was the third year that the CCPD and OHD grant programs used a standardized reporting form, enabling analysis of combined data. Although limitations continued to exist, the data reporting system enables analysis of combined activities to address each program s evaluation questions. Together, the programs reached an estimated 20,797 to 52,172 participants with services that included almost 21,000 disease management activities and 7,000 health education activities, plus more than 1.3 million health-related media impressions. Recommendations Identify one or two overarching questions per funding cycle that the grantmaking programs would like to study closely, and modify the reporting form to capture relevant data to address those questions. The R&I reporting system can readily be modified to collect more specific data to address areas of interest and answer specific evaluation questions. Further refine the reporting form to enhance overall combined reporting. o Link Disease Area(s) to Disease Focus to eliminate the potential for grantees to misalign disease areas and focus. o Collect specific data regarding numbers of positive screenings and follow up care. o Add simple data entry interface elements (e.g., radio buttons, drop down lists) to report the number of times that a strategy (such as screening) is delivered to individual participants, in order to enhance evaluation, program decision-making, and adherence to evidence. o Add simple data entry interface elements (e.g., drop down lists) to report the number of strategies (such as screening, referral, and disease management) delivered to individual participants, to refine precision of overall reach estimates. Provide training and technical assistance to grantees to ensure best data entry practices. Provide grantees with demographic data collection tools and training to reduce reporting of unknown status on demographic variables. Explore the feasibility of comparing reach data with external data on the demographic distribution of needs. Such comparisons could support evaluation of the alignment between strategic program directions and the health disparities being targeted by A35 grantees. iv

7 Background In November 2004, Coloradans approved Constitutional Amendment 35 (A35) to increase the tobacco tax by $0.64 per cigarette pack and a percentage-of-price on other tobacco products, with the revenues earmarked for health care services, tobacco education, and cessation programs. A portion of revenues was allocated for prevention, early detection, and treatment of cancer, cardiovascular disease, and pulmonary disease. The funds are awarded in competitive grants under two programs administered by Colorado Department of Public Health and Environment (CDPHE): Cancer, Cardiovascular Disease and Pulmonary Disease (CCPD) Grants Program; Health Disparities Grants Program (HDGP). Under a contract with CDPHE, the A35 Program Evaluation Group (APEG) in the University of Colorado Cancer Center evaluates the CCPD and HDGP A35-funded grants portfolios. Fiscal year (FY) (July 1, 2010, through June 30, 2011) was the third year in which evaluation was based on standardized data elements reported by both programs grantees. The current report is based on combined data across the CCPD and HDGP A35 funded programs. The report presents overall and program-specific summaries of activities addressing cancer, cardiovascular and pulmonary diseases among Coloradans generally and specific populations with disparately high rates of the diseases. The report is designed to address the following questions: What are the key activities being conducted in each grant program? What specific focal areas were targeted within the larger disease categories? What strategies are used to address disease focal areas? What is the estimated reach of A35 CCPD and HDGP projects during FY ? What populations were reached? How were projects implemented? Guiding frameworks APEG designed the analytic framework for CCPD and HDGP funded projects using elements from the RE-AIM model. The RE-AIM model of Russell Glasgow and others ( recommends that an intervention s impact be evaluated by considering its Reach, Effectiveness, Adoption, Implementation, and Maintenance. For the current evaluation, APEG focused on Reach and Implementation, which can be measured retrospectively without waiting for long-term effects such as reduced disease or death, and can be summarized across many projects. We applied the following definitions for aggregated data collection and review of project reports: Reach Implementation Number of individuals known to have received an intervention designed to improve their health and/or lower their disease risk. Reach does not include people who are trained to deliver an intervention. The processes of delivering an intervention, including who delivered it, where, how, and how much was delivered. 1

8 Estimates of reach can be used in planning to project estimated program coverage for specific disease areas, populations, and strategies. Information about implementation helps explain how projects are carried out and can help interpret outcomes reported at the end of a project. Evaluation of reach and implementation also helps identify information gaps that may be addressed for future evaluation. Program Delivery Strategies The CCPD and HDGP funded projects are highly diverse in the objectives they pursue and the approaches they apply. To assess similar delivery methods across multiple projects and activities, APEG developed a list of approaches called strategies. List development involved an iterative process of reviewing funded proposals and progress reports, developing a preliminary list of strategies, and verifying that list categories included all project activities. Program delivery strategies are further defined according to whether they deliver services directly to end-users (patients or community members) or indirectly to entities that in turn serve endusers. Examples of direct delivery include a blood-lipid screening project, an exercise class, nutrition presentation, or disease management curriculum. Direct delivery projects can count the number of people reached and, in some cases, describe participant characteristics. Indirect delivery targets groups, organizations, or infrastructures to have them adopt an intervention and, in turn, deliver it to patients or community members. Examples include training physicians to use a specific protocol when treating patients, and the development of community collaborations to enhance access to care and referrals. The reach of indirect delivery strategies is often hard to measure. Direct Delivery Strategies Strategy Awareness / Media Education / Training Access to Care Disease Management Referrals Risk Factor Reduction Screening Activities Brochures, posters, handouts, presentations, newsletters, broadcast media (e.g., TV and radio spots, purchased or via media releases), newspaper articles and ads. Health education for patients or community members. Fee reduction, vouchers, and transportation services for patients. Patient navigation, case management, self-management programs. Refer identified individuals to follow-up care or services. Weight loss or exercise programs, nutrition programs, smoking cessation, sun protection. Screen individuals for specific illnesses or risk factors. Treatment Provide specific appropriate treatment. 2

9 Indirect Delivery Strategies Strategy Awareness/Media Collaboration / Partnership Data collection / Analysis Education / Training Infrastructure Policy Activities Brochures, posters, handouts, presentations, newsletters, broadcast media targeted toward professionals or staff Build or enhance joint efforts with other agencies, organizations, or businesses. Collect or analyze primary or secondary data. Training of clinicians, providers or other health care workers; continuing education Acquire equipment, staff/personnel, supplies, administrative skills or systems, or other resources. Develop, ratify, or implement policies that promote health, reduce exposure to harm, or build capacity. Project-level reporting CCPD and HDGP reporting Projects provided quarterly progress reports using a reporting form with a standardized spreadsheet for reach and implementation (R&I) by strategy. FY was the second year in which projects used Version 2 of the form. Improvements in Version 2 included reporting R&I in one spreadsheet; inclusion of a drop-down box to report the disease focus; and addition of fields to report use of patient navigators or promotoras for each strategy. The current data elements are: Objective Disease area Disease focus o Cancer; breast, cervical, colon, hereditary, prostate, skin, multiple. o CVD; cholesterol/lipids, diabetes, hypertension/blood pressure, stroke, multiple. o Pulmonary Disease; asthma, COPD, multiple. o Crosscutting; risk factor reduction, non-specific. Target population Counties served Strategy Quarters active Does this strategy use promotores(as) or outreach workers, patient navigators Total reached Reach by gender (male, female, gender unknown) Reach by race/ethnicity (African American, Hispanic/Latino, Asian/Pacific Islander, American Indian/Alaska Native, white, other race/ethnicity, race/ethnicity unknown) Reach by age group (0-17, 18-34, 35-39, 50-64, 65+, age unknown) Reach by low income/medicaid (if applicable) Where? (setting) How many total sites? How many are new sites? Who received or participated? What was delivered, implemented? How was the content, program, or service delivered? How many total received/participated? How many are new? (since the previous quarter) How many times? For what length of time? Notes 3

10 Data preparation and quality review APEG reviewed quarterly reports to learn the nature of the data and help grantees improve subsequent quarterly reports. Review focused on strategies selected by grantees and missing or misplaced data. The analytic categories for quarterly reviews are shown below. misclassification of strategy missing data misplaced data misalignment of reach/implementation inappropriate data type (i.e. text instead of numeral) duplicate data incorrect data reported other: (specify) APEG review summaries included project-specific requests for data clarification, additional information, and/or grantee reconsideration of selected strategies in light of the associated category definitions. For CCPD grantees, review summaries were provided to contract monitors, who forwarded them on to grantees. HDGP grantees received electronic review summaries directly from APEG (contract monitors were included on the ). Some grantees were advised to contact APEG or their contract monitors for individual technical assistance by telephone. Data for this report Each quarterly report cumulates data for the fiscal year to date. The current report is based on cumulated data in Quarter 4 progress reports. Ten CCPD projects and 11 HDGP projects provided data for this report. Reach data APEG designed a custom software application to import data from Microsoft Excel spreadsheets into Microsoft Access. The data were sorted and merged in Access, then exported into Excel for cleaning. Data cleaning included removal of obvious duplication in reach (based on original grantee reports with appropriate modifications), and removal of null activities under a selected strategy. The cleaned data were imported into SAS for data summary, which included total reach by strategy, disease area, disease focus, race/ethnicity, age, gender, and low income/medicaid status. Counts of projects and strategies were obtained by strategy, disease area, disease focus, and use of promotores or patient navigators. Implementation data Implementation data were analyzed qualitatively, grouped by disease focus and coded and summarized by target population, content, dose, and other disease-specific areas. As a method of triangulating the analysis, an additional team member reviewed the summaries of the implementation data. Analysts referred to the source data to resolve questions about data interpretation. Assumptions and limitations A35 services were delivered to individuals for whom they were appropriate. Data are self-reported by grantees. 4

11 Data are assumed to be accurate as reported (with attempts to clarify missing or ambiguous data). Grantees used their own judgment in applying APEG s reporting recommendations. Grantees may have miscategorized some data in terms of strategies or disease focus (APEG attempted to correct obvious miscategorization). In some cases, grantee-selected disease area did not align with selected disease focus. As a result, reported reach by disease may differ between tables in this report. Reach estimates may count individuals more than once, e.g., by counting the number of procedures performed on the individual, or serving the same individual in multiple quarters. Reach estimates may erroneously include indirect target audiences (e.g., number of teachers trained to improve pupils health behaviors). Reach may be underreported if projects did not fully record or report data. Not all projects collected demographic details. Strategies were not reported by county, thus some project-level activities may not have occurred in each county reported by the overall project. Implementation data, although standardized, consists of brief text entries that may not include what was delivered, to whom, how, for how long, or how often. Implementation data were incomplete for some strategies. Reach does not necessarily equal impact. For example, screening 20 people for hypertension does not have the same impact as treating 20 people with precancerous colorectal polyps. 5

12 Amendment 35 Program Portfolio Overview Funding The CCPD and HDGP A35 programs awarded $ $7,090,777 in grants to 10 CCPD and 11 HDGP projects addressing tobacco-related diseases for FY (table 1). As in the previous FY, total funding was reduced from constitutional levels after the General Assembly declared a fiscal emergency and redirected a majority of A35 funds to other health-related purposes. Project numbers and award amounts for the past three FYs are provided in Appendix 1. A majority of projects (10/21) addressed cardiovascular disease (CVD) and received 34 percent of funds, while two cancer projects received 52 percent of funds, much of which supported large scale colon cancer screening. Projects to address pulmonary disease (n=3) were funded solely by CCPD, while all crosscutting projects (n=6) were funded solely by HDGP. Table 1. CCPD and HDGP projects by disease area, FY Number of projects Total awarded Cancer 2 $ 3,690,429 Cardiovascular Disease (CVD) 10 $ 2,444,979 Chronic Pulmonary Disease (CPD) 3 $ 557,165 Cross-cutting 6 $ 398,204 Total 21 $7,090,777 Geographic coverage Collectively, A35 projects reported activities in all Colorado counties except Sedgwick during at least one quarter. Many counties had multiple A35 projects. Four counties each had five or more projects, 25 counties each had three to four projects, and 34 counties had one to two projects (map 1). 6

13 Map 1. Density of CCPD and HDGP projects (n=21) by county, FY Combined CCPD and HDGP data Twenty of the 21 projects had activities with direct reach (table 2). Strategies with the largest reported reach included awareness (>1.3 million), disease management (almost 21,000) and screening (more than 12,000). Direct delivery strategies were used in all disease categories except referral and risk factor reduction for cancer; treatment for CVD and crosscutting, and risk factor reduction for pulmonary disease. Table 2. Estimated direct reach (# projects)* by strategy and disease area, FY Strategy Access to care Awareness / media** Disease management / follow up Education / training Referrals Risk factor reduction CVD (9) 3,736 (3) 398,967 (5) 17,611 (5) 3,757 (6) 2,220 (5) 1,184 (4) 5,575 (8) Disease Area Cancer 2, , Crosscutting (6) 1,563 (3) 2,137 2, ,763 Pulmonary (3) 116 (3) 1,311 1,010 1,685 (3) 146 Total (20) 8,186 1,302,827 20,797 7,006 2,385 1,214 2,203 1,912 12,453 Screening Treatment * Includes CCPD (9) and HDGP (11) funded projects that implemented direct strategies. ** The unit of reach for awareness/media is the impression = one individual receiving one message one time. Column totals are not presented because some individuals were reached by more than one strategy.

14 Awareness. Project efforts to raise awareness were generally aimed at community members (direct) or health professionals/educators (indirect). Topics included availability of services, general health information, and disease-specific information. Media included printed materials such as brochures and posters, and in-person communications (presentations, health fairs, one-on-one discussions. Projects reported a total of more than 1.3 million impressions. * Limitations of estimated reach. The numbers of individuals reached are estimates, and duplicate counting cannot be ruled out. For this reason, totals by column are not shown because of the likelihood that individuals were reached by more than one strategy. For example, some individuals who were screened were then treated or referred to risk factor reduction or disease management. CCPD and HDGP provided 52,172 distinct service events in FY One way to estimate the likely range of individuals reached by these events is to apply two bracketing assumptions first, that every strategy reached a different individual (highest estimate), and second, that every strategy reached the same individuals (lowest estimate). The truth lies somewhere in this range (table 3), although where cannot be determined. Using this approach, an estimated 20,797 to 52,172 Coloradans were reached by strategies other than awareness/media, and 1,302,827 to 1,354,999 including awareness/media impressions. Table 3. Range of CCPD and HDGP combined estimated reach, FY Lower bound (based on single strategy with highest reach) Upper bound (based on summation across strategies) Excluding awareness 20,797 52,172 Including awareness 1,302,827 1,354,999 Reach by race/ethnicity, sex, age, and income. Projects reported demographic reach information for strategies, with completeness ranging from 83% for education/training to 100% for treatment, except that demographic information was unavailable data for awareness strategies. Nearly all racial and ethnic groups were reached by all strategies (table 4). Across disease areas, whites were the largest group reached, followed by Hispanics/Latinos. Adult women aged were generally the largest sex-by-age group reached (table 5). Treatment strategies reached similar numbers of men and women, and also reached more than twice as many youth (ages 0-17) as adults or seniors. School asthma projects account for much of the large treatment reach among youth, as well as screening activities and education activities (15% each). Seniors were reached by all strategies except treatment, with the largest proportion occurring in disease management (19%) and screening (6%). * One impression = one individual receiving one message one time. 8

15 Table 4. Total estimated individuals (row %) reached by strategy and race/ethnicity, FY (20 projects) Strategy Access to care Awareness / media** Disease mgt. / follow up Education / training Referrals Risk factor reduction Screening Treatment African Amer. / Black 391 (5%) (2%) 908 (13%) 186 (8%) 102 (8%) 551 (4%) 35 Hispanic / Latino 2,428 (30%) 883 6,334 (31%) 2,180 (31%) 646 (27%) 490 (40%) 3,206 (26%) 65 Reach by race/ethnicity (% of total reach*) Asian / Pacific Islander 674 (8%) (3%) 722 (6%) Amer. Indian / Alaska Native 708 (9%) (2%) 304 (2%) 1 White 3,659 (45%) ,596 (56%) 2,494 (36%) 1,441 (60%) 536 (44%) 5,957 (48%) 30 Other (2%) reported as unknown 1,300,770 (100%) 2,272 (11%) 1,088 (16%) 8 1 1,626 (13%) (26%) (49%) (22%) * Totals may be greater than row-sum of cells due to multi-ethnic individuals. ** The unit of reach for awareness/media is the impression = one individual receiving one message one time. Column totals are not presented because some individuals were reached by more than one strategy. Strategy Access to care Awareness / media* Disease mgt. / follow up Education / training Table 5. Total estimated reach by strategy and gender, age group and income/medicaid status, FY (20 projects) male Total* 8,186 1,302,827 Gender Age Low female reported as unknown youth (0-17) adults (18-64) seniors (65+) reported as unknown 20,797 7,006 2,385 1,214 12, income / Medicaid 2,702 4, , , ,995 1,291, ,302, ,412 8,184 10,385 2, ,895 3,913 2,175 8,602 1,203 4, ,027 4, ,189 4,749 Referrals 942 1, , Risk factor reduction 79 1, , Screening 3,648 6,081 2,724 1,848 7, ,454 5,488 Treatment Column totals are not presented because some individuals were reached by more than one strategy * The unit of reach for awareness/media is the impression = one individual receiving one message one time. 9

16 Implementation All but one HDGP/CCPD projects implemented multiple strategies, with a mean of five and a range of one to 11. Several projects also implemented specific strategies more than once, in which case the strategies were reported separately and involved differences either in implementation or in stated objectives (but possibly the same or overlapping groups of participants). The most frequently reported direct strategies were screening, education, and access to care; least frequent were treatment and risk factor reduction (figure 1). The most frequently reported indirect strategies were education/training and collaboration/partnerships. Figure 1. Number of CCPD and HDGP projects by reported strategy* and disease category, FY (n=21) * Projects that implemented a strategy more than once are counted only once in the figure. Projects were conducted in a variety of settings (figure 2). Many were conducted in clinical or community settings. Schools and worksites were also common. 10

17 Figure 2. Implementation settings for CCPD and HDGP strategies, FY (n=21)* * Total number of settings shown exceeds the number of projects or strategies because some strategies were implemented in multiple settings. 11

18 Cancer, Cardiovascular and Pulmonary Disease (CCPD) Funding Ten projects received a total of $6.4 million through the CCPD program in FY to address cancer, cardiovascular and pulmonary diseases. The largest proportion of funds (57 percent) went to a colorectal screening project (table 6). CVD received about 34 percent of funds with 6 projects, while three pulmonary disease projects received approximately nine percent of total funding. No projects specifically aimed to address crosscutting diseases. Table 6. CCPD projects (n=10) by disease area, FY Disease Area Number of projects Funds received Cancer 1 $3,651,615 Cardiovascular disease 6 $2,169,685 Chronic pulmonary disease 3 $ 557,165 Crosscutting TOTALS 10 $6,378,465 Geographic coverage CCPD projects were active in all but one county (Sedgwick) during at least one quarter of FY 11 (map 2). Most counties had one or two projects (19 and 23 counties respectively), while 19 counties had three to four projects, and Pueblo and Denver counties each had five or six projects. Map 2. Density of CCPD projects by county, FY (n=10) 12

19 Reach Nine of 10 CCPD funded projects conducted direct delivery strategies to reach patients or individual community members. Awareness strategies delivered over 1 million awareness impressions, the majority of which targeted CVD and cancer (table 7). Nearly 9,000 screening activities were reported, more than half of which related to CVD. Disease management and follow up activities addressed all disease areas and reached >18,000 participants. Risk factor reduction activities were focused on CVD interventions. No risk factor reduction activities addressed cancer or pulmonary disease. (Specific activities are described by disease area, starting at page 17). Table 7. CCPD estimated reach (# projects) by strategy and disease area,* FY Disease area Strategy Crosscuttinnary Pulmo- Total CVD Cancer (9) Access to care (7) 3,081 2, (3) 5,520 Awareness / 180, ,023 1,311 1,072,563 media** (4) Disease mgt. / 17, ,010 18,286 follow up (6) (3) Education / training (6) 2,266 (3) 1,685 (3) 3,951 Referrals (5) Risk factor reduction Screening (7) Treatment 1,739 (4) 1,016 4,559 (4) 2, , ,885 1,016 8,674 * Reach is categorized by grantees selection of disease focus area for each strategy (not disease focus). ** The unit of reach for awareness/media is the impression = one individual receiving one message one time. Column totals are not presented because some individuals were reached by more than one strategy. The quality of demographic reporting continued to improve during FY Excluding awareness strategies (which reported 100% unknown demographic information), projects reported demographic information for 87% to 100% of individuals reached. All racial and ethnic groups were reached by all strategies (excluding awareness), except that Asian/Pacific Islander individuals did not receive treatment activities (table 8). Whites were generally the largest recipient category, although Latinos/Hispanics received a majority of treatment efforts, followed by African Americans. In general, more females than males were reached (table 9). Most strategies reached adults aged 18-64, though many youth and seniors were reached through access to care, disease management and follow up, education/training, and screening efforts

20 Table 8. CCPD estimated reach by strategy and race/ethnicity, FY (9 projects) Strategy African Amer. / Black Hispanic / Latino Reach by race/ethnicity (% of total reach*) Asian / Pacific Islander Amer. Indian / Alaska Native White Other Access 389 1, , to care (7%) (31%) (58%) (2%) Awareness / media** Disease mgt. / 336 6, , follow up (2%) (34%) (61%) Education / 343 1, , training (8%) (27%) (2%) (48%) Referrals 111 (6%) Risk factor 78 reduction (8%) Screening 467 (5%) Treatment (31%) 340 (34%) 2,967 (34%) (3%) ,092 (58%) 536 (53%) 4,915 (57%) 30 (22%) 34 (2%) (2%) reported as unknown 51 1,072,563 (100%) 446 (2%) 353 (9%) 8 (0.4%) 1 (0.1%) 63 3 (2%) (26%) (49%) * Totals may be greater than row-sum of cells due to multi-ethnic individuals. ** The unit of reach for awareness/media is the impression = one individual receiving one message one time. Column totals are not presented because some individuals were reached by more than one strategy. Table 9. CCPD total estimated reach by strategy and gender, age group and income/medicaid status, FY (9 projects) Strategy Access to care Awareness / media* Disease mgt. / follow up Education / training male Total* 5,520 1,072,563 18,286 Gender Age Low female reported as unknown youth (0-17) adults (18-64) seniors (65+) reported as unknown 3,951 1,885 1,016 8, income / Medicaid 2,138 3, , ,535 1,072,334 1,072, ,023 7,971 10, ,417 3, , , , ,187 Referrals 712 1, , Risk factor reduction , Screening 3,129 5, ,807 6, ,359 Treatment Column totals are not presented because some individuals were reached by more than one strategy * The unit of reach for awareness/media is the impression = one individual receiving one message one time. 14

21 Implementation Most CCPD projects reported using a range of strategies (one to eleven) the average number of strategies implemented was six. Overall, screening, access to care, education (direct and indirect) and disease management were most frequently reported strategies. Figure 3 shows the number of projects reporting strategies by disease area. Figure 3. Number of CCPD projects by reported strategy* and disease category, FY (n=10) * Projects that implemented a strategy more than once are counted only once in the figure. Most CCPD strategies were conducted in clinical settings (figure 4). Many were carried out in schools or community settings such as health fairs. Web and phone activities were reported, particularly for disease management interventions and indirect education. 15

22 Figure 4. Implementation settings for CCPD strategies, FY (n=10)* * Total number of settings shown exceeds the number of projects or strategies because some strategies were implemented in multiple settings. Patient navigators (PNs) and community health workers/promotores (CHW/Ps): PNs, or both PNs and CHW/Ps were often employed to implement direct strategies (figure 5). Disease management and access to care strategies used these health professionals most often. Figure 5. Use of patient navigators (PN) and/or community health workers/ promotores (CHW/P), FY (9 projects*) *Number of projects that reported implementation of direct strategies. 16

23 CCPD disease-specific data During FY , CCPD grantees addressed nine disease-specific areas. The following sections describe key elements of these project activities by disease focus. For cancer, screening was the primary strategy and included colorectal cancer screens for more than 2,000 low income, under- or uninsured Coloradans. Disease management activities were a major component of CVD activities, while in pulmonary disease, education and screening reached large numbers of mostly young asthma sufferers. Cancer Cancer was addressed in one CCPD funded project, a large-scale program focused on colorectal cancer (table 10). Table 10. Estimated reach for one colon cancer project, by strategy and race/ethnicity, FY Strategy African Amer. / Black Hispanic / Latino Reach by race/ethnicity (% of total reach*) Asian / Pacific Islander 17 Amer. Indian / Alaska Native White/ other reported as unknown Total* Access to care , ,203 (4%) (29%) (66%) (2%) Awareness / media** 891, ,023 (100%) Disease mgt. / follow up 2 (5%) 9 (23%) 1 (3%) 27 (69%) 39 Screening , ,203 (4%) (29%) (66%) (2%) Treatment (5%) (24%) (2%) (68%) * Totals may be greater than row-sum of cells due to multi-ethnic individuals. * The unit of reach for awareness/media is the impression = one individual receiving one message one time. Column totals are not presented because individuals were reached by more than one strategy. Direct strategies Who received/participated: The project targeted clinic clients who were low-income, uninsured, and out of compliance with colorectal screening guidelines. Content/how delivered: Screening activities occurred in medical clinics statewide and were performed by qualified medical personnel. Treatment was provided in cases where polyps were detected or in the event of complications of the screening process. The disease management strategy was used when follow up was required. Treatment was often combined with access to care due to patients income or insurance status. Awareness/media involved information about colon cancer and the need for screening, using brochures, posters, informational cards, program referral information, and advertisements. Dose: Screening and access to care occurred one time for most participants. Where screening found polyps or cancer, or an adverse event occurred, additional screening, treatment, and dis-

24 ease management services were provided, ranging from 1 to >50 events per patient. Awareness activities were estimated at one, 5-minute event per participant. Indirect strategies: Indirect education provided information to health care providers about the colorectal screening program, including eligibility; reading and understanding endoscopy and pathology reports, and programmatic information related to patient navigation. These activities occurred one time per participant for 1-2 hours. Data collection/analysis was used to track program and client data, and a patient satisfaction survey was administered. Cardiovascular disease Six projects addressed cardiovascular disease (CVD), including one project that focused on stroke. Five projects addressed multiple CVD areas, and one of the five targeted cholesterol/lipids and hypertension (table 11). Table 11. Estimated reach (# projects) for cardiovascular disease projects (n=6), by strategy, focus area and race/ethnicity, FY Strategy Disease mgt. / follow up Disease mgt. / follow up Access to care Awareness / media Disease mgt. / follow up (3) Education / training (3) Referrals (4) Risk factor reduction Screening (4) African Amer. / Black Hispanic / Latino Reach by race/ethnicity (% of total reach*) Asian / Pacific Islander 18 Amer. Indian / Alaska Native cholesterol / lipids (n=1) 1,292 (36%) hypertension / blood pressure (n=1) 1,010 (33%) multiple CVD areas (n=5) 252 1, (8%) (33%) 312 (3%) 128 (6%) 111 (6%) 78 (8%) 315 White/ other 2,298 (64%) 1,797 (64%) 1,718 (56%) reported as unknown ,000 (100%) 3,544 (33%) 522 (23%) 507 (29%) 340 (33%) 1, (3%) 27 (2%) 35 (3%) ,847 (63%) 1,514 (67%) 1,070 (62%) 546 (54%) 2, Total* 3,590 2,807 (7%) (29%) (62%) * Totals may be greater than row-sum of cells due to multi-ethnic individuals. Column totals are not presented because some individuals were reached by more than one strategy. Direct strategies 3, ,229 10,840 2,266 1,739 1,016 4,559 Who received/participated: Projects primarily served community members, especially the low SES or underserved populations. The project addressing cholesterol/lipids and hypertension directed efforts toward their database of existing CVD patients, using the disease management

25 strategy. Low income women were targeted with strategies including screening, education, risk factor reduction, and referrals for care. Content/how delivered: Risk factor reduction was the most frequently used strategy for CVD. Activities included dietary and nutritional counseling; exercise programs; information about the QuitLine for tobacco users; telephone counseling and support for lifestyle changes; and tailored letters addressing specific risk factors. This strategy was often supported by the education, screening, disease management, and referrals strategies. The education/training strategy was reported eight times across three projects. Frequently targeting women, education activities encompassed CVD prevention; healthy lifestyle choices; goal setting to improve risk factors; nutrition and physical activity information and classes; smoking cessation resources; and signs and symptoms of stroke and CVD. Screening and referrals strategies were reported five times each from four projects. Screenings included blood pressure, lipids, and glucose. Some projects also screened for height, weight, BMI, and performed a cardiac risk assessment. All screenings were accompanied by additional services, such as referral to a health care provider, a risk factor reduction program, or information about CVD/risk factors. One project, in addition to screening for physical risk factors, conducted a health history assessment including personal and family health history, current medication use, psychosocial stressors, and behavioral risk factors. All projects gave referrals for free or low-cost medical visits to participants identified as being at risk for CVD. One project also referred clients to lifestyle resources to help clients improve their health and lower their risk of CVD. No details were provided about these resources. Another project reported only Low cost or no cost CVD screening. At risk participants received disease management services including follow up testing of indicators such as blood pressure and glucose level; phone follow ups for referrals and to support action plans; consultations with public health nurses; and self-management goal setting and support. Electronic medical records were utilized to monitor CVD patients status. Awareness/media strategy was implemented by two projects; one used hand delivered flyers, ed newsletters, radio interviews, and newspaper and online articles to distribute information about CVD risk factors, stroke and heart attack warning signs, diabetes, smoking cessation, and available services such as screenings, the other used informed their clients about eligibility and services. Two projects used the access to care strategy which included risk factor screenings and vouchers for a primary care visit for those at risk, specifying that the participants would otherwise be unable to access these services. Dose: Most activities occurred one time per participant, although a cooking class was offered 6 times and an exercise class was offered 9 times per participant. The amount of time spent on activities ranged from a few minutes up to 2 hours. Most activities fell within the minute range; however, one project offered dietary counseling for 90 minutes while the cooking class was reported to last for 2 hours. 19

26 Indirect strategies Two CVD projects reported indirect strategies, one in the disease focus CVD: multiple and the other in CVD: Stroke. Strategies reported were awareness/media: indirect, collaboration/partnerships, data collection/analysis, and education/training: indirect. The target populations for the CVD: multiple activities included community health workers and patient navigators and other health care professionals. The stroke project directed their activities toward hospital staff and administrators and associated health care professionals. Each of these projects used multiple indirect strategies to describe extensive activities. One project reported implementing only indirect strategies. Therefore, these projects activities will be described separately below. CVD: Multiple: One project reported data for the indirect strategies awareness/media, collaboration/partnerships, and education/training. Activities included: Awareness/media: phone calls and meetings providing information to health professionals about project activities and the latest information about cardiovascular disease Collaboration/partnerships: conference calls and visits with supervisors of community health workers (CHWs) to discuss routine program operations and best practices, and site performance; working with CHWs and their supervisors to assess community resources for healthy behaviors Education/training: training CHWs, patient navigators, and supervisors in program activities and cardiovascular disease information using conference calls, web training, a workshop, and in person visits; educating health professionals via about the latest CVD research CVD: Stroke: One project reported data for collaboration/partnerships, data collection, and education/training. The following activities were reported: Collaboration/partnerships: review of the Get With the Guidelines (GWTG) program and data review with clinicians, hospital administrators and staff, using in person meetings, conference calls, and webinars Data collection: collection and analysis of statewide stroke trend data, project performance data, and project member stroke data. Participants included the project s data committee as well as partnering organizations. Education/training: data collected in the previous strategy was reported to project administrators using in person meetings, phone calls and s; health care professionals participated in mentor meetings involving review of the GWTG stroke program, best practice sharing, and data review. In person meetings, conference calls and a webinar were used for these educational efforts. Dose: The project implementing indirect awareness in the CVD: Multiple disease focus area reported activities occurring once per participant for 60 minutes. Collaboration/partnerships, reported activities involved conference calls and site visits, also occurring once for 60 minutes. Surveys of participating CHWs and their supervisors regarding community resources were reported to have happened one time for 20 minutes each. Education/training activities included conference calls and web training, occurring 2-3 times and lasting 90 minutes, and an educational workshop occurring 4 times per participant for 5 hours. In addition, an informative was sent to health professionals once per month. 20

27 The CVD: stroke project reported collaborative activities occurring 1-2 times per participant for 1 hour. Education/training activities were somewhat more varied, occurring 1-2 times for an hour (mentor meetings) and 9-10 times for 30 minutes (site visits and calls). Pulmonary Disease Three projects addressed pulmonary disease. All focused on asthma and two also conducted activities in the pulmonary: multiple disease focus area (table 12). Table 12. Estimated reach (# projects) for pulmonary disease projects (n=3), by strategy, focus area and race/ethnicity, FY Strategy Access to care (3) Awareness / media Disease mgt. / follow up Education / training (3) Referrals Screening Treatment Education / training African Amer. / Black Hispanic / Latino Asthma (n=3) (21%) (35%) 22 (2%) 137 (10%) Reach by race/ethnicity (% of total reach*) Asian / Pacific Islander 21 Amer. Indian / Alaska Native White/ other 50 (43%) reported as unknown 1,311 (100%) 353 (35%) 494 (36%) (27%) 254 (19%) 84 (58%) 56 (38%) (4%) (53%) (2%) (43%) (35%) (59%) (5%) Multiple pulmonary areas (n=2) (25%) (13%) (61%) Total* 116 1, (39%) 1, (25%) 1, , Screening (60%) (40%) * Totals may be greater than row-sum of cells due to multi-ethnic individuals. Column totals are not presented because some individuals were reached by more than one strategy. Direct strategies Who received/participated: Projects primarily targeted persons diagnosed with asthma providing services to the homeless (both adults and children) and public school students. Activities were also directed to public school nurses and staff, parents of students with asthma, and community residents. Content/how delivered: Educational activities were conducted by all projects in the pulmonary disease area. Five of the seven education strategies were reported under the Pulmonary: Asthma focus and involved asthma education and included the Open Airways for Schools and Kickin Asthma (American Lung Association) programs; asthma education (NJH & ALA) and individualized information regarding asthma medications and trigger avoidance; asthma 103

28 education self-management sessions (details not reported); family self-management skills for parents/guardians of students; and education about the project with basic asthma information, in meetings and by letter. Most activities occurred in group or individual sessions, while some used phone calls or mailings. One project presented asthma education to homeless families at a Back to School fair. One project also reported educational activities in the Pulmonary: Multiple disease focus area. In addition to basic asthma education and the development of an Asthma Action Plan, education was provided on the use of inhalers (proper dosage, use, and times) during in-person sessions with a respiratory therapist or pulmonary specialist. Access to care was reported four times across three projects. Activities included providing nebulizers to patients, respiratory screening and education to homeless individuals, and assisting public school students and their families in finding healthcare resources and a primary care provider, and making appointments. Numerous interventions in disease management activities included presenting results of asthma control assessments and indicators of poor asthma control, lung function tests and referral for further asthma evaluation and management; offering free spirometry and/or peak flow tests; working with families and healthcare providers on Asthma Action plans, case management, and navigation support; working with school staff and families to implement Asthma Action plans and coordinate care with healthcare providers; providing asthma assessment and education during school sports events; supporting schools in monitoring students with poorly controlled asthma and coordinating visits to healthcare providers; and providing follow up testing, education, and counseling to residents with abnormal spirometry results at a community health event. Screening was implemented by two projects and was reported twice in the Pulmonary: Asthma focus and once for Pulmonary: Multiple. Methods used to screen for asthma included a health risk assessment survey completed by parents of public school students, and a lung health assessment and asthma case identification performed during school registration and at sports physicals events for public school students. Screening in the Pulmonary: Multiple areas consisted of spirometry tests at a community health event for local residents. Screening results were often supported by activities reported under other strategies such as education and referrals. Referrals were reported twice by one project. Activities consisted of supporting school nurses in identifying a provider and making appointments for public school students with asthma. Additionally, residents identified with abnormal spirometry results were advised to seek care and received a note about their results to take to their provider. One project reported providing inhaled corticosteroid medication to eligible public school students under the strategy treatment. Some students were also provided with rescue inhalers to use at school. Awareness/media activities were reported by one project in the Pulmonary: Asthma focus area. Printed asthma education materials, posters, and a website were made available to public school students, their families, and school nurses. Asthma information booths at school registration were also utilized to raise awareness. 22

29 Dose: Most activities reported to have occurred 1 to 2 times per participant and lasting from 5 minutes to a few hours. For example, awareness activities commonly occurred only once per participant for minutes, although posters that remained up for the length of the school year likely was seen many times by an individual. One project reported access to care through sessions with an asthma counselor lasting up to 2 or 3 hours. Disease management activities a ranged from 15 minutes to 2 hours. The education strategy reported more frequent contacts with various lengths of time. Students participating in the asthma education programs attended 4-6 weekly classes for minutes, and those in the asthma self-management classes attended 1 to 6 times for minutes. Other educational activities occurred in a range of 1-2 times for anywhere from 5 minutes to 2 hours. Referrals, screening, and treatment activities were reported to occur one time per participant. Indirect strategies Data collection/analysis and education/training were the most frequently reported indirect strategies at seven and six times respectively, followed by infrastructure (3 times), and collaboration/partnerships and policy with two each. Participants for indirect strategies include clinic healthcare providers; various public school districts and school staff; various health organizations and agencies, and their staff; Department of Education staff; local healthcare providers; asthma counselors; community volunteers; CDPHE staff; members of an executive planning committee; and project staff. Content/how delivered: Two projects reported data collection/analysis strategies seven times. One project (report data collection 5 times), conducted random chart audits on their patient database to track project performance and progress toward objectives. The other project used the data collection strategy to capture activities which involved determining and monitoring the prevalence of asthma in public schools. Education/training was reported by two projects a total of 6 times. Activities included conducting a Certified Asthma Educator Prep Course for school nurses and other school staff using small group discussions and workshops; training school staff in asthma basics, asthma action plans, and use of inhalers by asthma counselors and nurse liaisons; presentations, hands on training, and group discussion at the annual meeting of school nurses about asthma and asthma management; webinar, presentations, and meetings for physicians and other healthcare professionals about implementing a school-based asthma management program and current trends in managing asthma and pulmonary function testing; developed a plan for training school nurses to implement asthma control monitoring tool on a trial basis; developed a mentorship program to train nurses on best practice for asthma management based on the national asthma guidelines; provided scholarships to school nurses to take a review course for asthma educator certification exam; trainings for partner staff to implement project objectives, review of asthma assessment and control, NHLBI asthma guidelines, and student programs, in meetings, teleconferences, and a workshop. Two projects reported infrastructure activities including evaluating project processes to modify and guide interventions and introduce new components and to report the introduction of a new asthma tracking component into their partner school district s existing database. They also de- 23

30 veloped clinical pathways for regional emergency departments and outpatient clinics to support asthma care. Two projects reported collaboration/partnerships activities. The first project worked with various groups within its partner school district to establish program procedures, align goals, promote Asthma Friendly Schools practices, and share data, in meetings, interviews, and small group discussions. The second project held meetings and teleconferences with local health organizations and public school groups for planning, coordinating, and integrating services among its various partner organizations in an effort to support their goal of determining and monitoring asthma prevalence, severity and control and delivery of asthma care. One project reported policy to describe activities involving the adoption of the Colorado Asthma Care Plan in partnering schools. The Plan was developed and introduced, and feedback was solicited from users and focus groups. Another project worked with school nurses to develop an asthma related policy for the school district. Dose: The data on dose is reported for collaboration and education: indirect strategies. For two projects reporting on collaboration activities, participants met 1 to 8 times ranging from 10 minutes to 2 hours. Projects reported education activities as meetings and small group discussions that generally occurred once or twice lasting approximately an hour and more involved workshops and classes meeting more than one time for several hours. Other activities such as phone calls, meetings, and s were reported also education strategy. Cross-cutting One CCPD project (noted in the funding category as a pulmonary disease project) reported strategies addressing cross-cutting diseases and conditions (table 13). Strategy Table 13. Estimated reach for one crosscutting project by strategy, focus area and race/ethnicity FY African Amer. / Black Hispanic / Latino Reach by race/ethnicity (% of total reach*) Asian / Pacific Islander 24 Amer. Indian / Alaska Native White/ other reported as unknown Total* Multiple risk factors (e.g., diet, exercise, BMI) Access to care 32 (27%) 18 (15%) 70 (58%) 120 * Totals may be greater than row-sum of cells due to multi-ethnic individuals. Column totals are not presented because some individuals were reached by more than one strategy. Access to care was implemented by providing health care services to the homeless population. Who received/participated: This project targeted homeless, low-income, adult tobacco users of various race/ethnicities. Content/how delivered: The primary activity was smoking cessation education and access to nicotine replacement therapies. Clinic clients were referred to the respiratory therapist for a one on one session.

31 Dose: Participants received one visit with the respiratory therapist, which lasted from 30 minutes to an hour. Indirect strategies This project reported indirect strategies of data collection/analysis and education/training for Cross-cutting: non-specific and Cross-cutting: risk factors disease focus areas respectively. The data collection activities consisted of random chart audits to assess whether providers were offering smoking cessation advice and referrals to the clinic respiratory therapist. Results of the chart audits were then discussed with providers during regularly scheduled meetings. The education activity trained clinic health care providers on promoting smoking cessation through the implementation of a single two hour session presented by the American Lung Association. 25

32 Health Disparities Grants Program (HDGP) Funding Eleven projects (all continuing from FY ) received a total of $712,312 through the HDGP in FY to address cancer, cardiovascular disease (CVD), pulmonary, and cross-cutting diseases and conditions among racial and ethnic minority populations. This report includes data from all projects; however, one project only submitted data for quarters 1 and 2. The largest proportion of funds (56 percent) went to six crosscutting projects (table 14). CVD received 39 percent with 4 projects, while 1 cancer project received 5 percent. There were no projects specifically aimed to address pulmonary disease. Each of the racial/ethnic populations (African Americans/Black, Hispanic/Latino, Asian Pacific Islanders and Native/American Indians) were targeted by at least one funded project during FY The largest proportion of funding (54 percent) went to 6 projects targeting Hispanic/Latino populations; 2 projects targeting Native Americans received 23 percent of the funds, while 1 project targeting Asian American/Pacific Islander populations received 13 percent of the funds and 2 projects targeting African American/Black received 10 percent. Table 14. HDGP funding* (# projects) by disease area and target population, FY (11 projects) Target population Cancer CVD (4) Pulmonary disease Crosscutting Total Funding (0) (6) $41,152 African American/ Black $28,437 $69,589 Hispanic/ $38,814 $146,042 $197,634 $382,490 Latino (6) (3) Native American/ $100,815 $64,278 $165,093 American Indian Asian American / $95,140 $95,140 Pacific Islander Total $38,814 $275,294 $0 $398,204 $712,312 * Amounts recommended to the Colorado Board of Health. Geographic coverage HDGP projects were active in nineteen counties during at least one quarter of FY 11 (map 3). The Denver metro area was the area with the greatest density of projects; Denver County had activity from 5 projects, Arapahoe had 4, and Adams County had 3. The remaining sixteen counties had activity from one project. No projects were reported to have been conducted in counties in white in the map below during FY

33 Map 3. Density of HDGP projects by county, FY (n=11) Reach All of the 11funded HDGP projects conducted direct delivery strategies to reach individual community members or patients (table 15). All strategies were implemented in the CVD and crosscutting disease areas with the exception of treatment which was not implemented by any project during FY Awareness/media strategy delivered over 23,000 awareness impressions by 5 projects most of which addressed CVD. Nearly 4,000 screening activities were reported (crosscutting and CVD). Education/training was implemented by 6 projects reaching more than 3,000. Access to care strategies reportedly reached 2,666 community members through four projects. Risk factor reduction strategies were reported by three projects reaching 198 community members. Although some reported numbers of individuals reached through activities are lower, it is important to note that in some cases, these interventions have a higher dose in that they require more active participation often over multiple and longer time periods. 27