Chronic Disease Management Navigation and Education Initiative

The Chronic Disease Management Navigation and Education Initiative, administered by the Nebraska Department of Health and Human Services (DHHS), is designed to support community-based efforts that enhance chronic disease education and care navigation throughout Nebraska. Funded through the Rural Health Transformation Project (4.4A), this initiative seeks to address the growing need for comprehensive, accessible chronic disease management, particularly in underserved rural areas. The initiative emphasizes improving health outcomes for individuals living with long-term health conditions such as diabetes, cardiovascular disease, asthma, and similar chronic illnesses by bridging gaps in education, care access, and health system navigation. Eligible applicants include a wide range of rural health organizations such as Rural Clinics, Federally Qualified Health Centers (FQHCs), Certified Community Behavioral Health Clinics (CCBHCs), Local Health Departments (LHDs), Critical Access Hospitals (CAHs), Rural Emergency Hospitals (REHs), Rural Hospitals (non-CAH), and Tribal Health Facilities. The application guidelines also emphasize openness to additional applicant types, encouraging all interested organizations to apply regardless of whether they are specifically listed. This inclusive approach underscores DHHS's aim to ensure broad and equitable access to support across Nebraska’s rural and frontier communities. The program scope includes activities such as chronic disease education workshops, individual and group-based learning tailored to participant needs, care navigation and referral support, and assistance with navigating the health system. This includes helping individuals make appointments, understand insurance plans, follow up on care plans, and access appropriate services and medications. Applicants are expected to design workplans that are structured, evidence-based, and sustainable. Applications must justify how the proposed work expands, rather than duplicates, existing efforts. All projects must include a detailed workplan and budget not exceeding $400,000, with administrative and indirect costs limited to 7.5% of the total award. The performance period for awarded projects extends through October 30, 2026, with final invoices due by November 30, 2026. Work may begin upon receipt of an Intent to Award notification. DHHS reserves the right to renew selected programs for future years, contingent on performance and available funding. Applicants are also required to propose targets and provide baseline data for key outcome metrics such as the number of participants enrolled and assisted through the initiative. These metrics will be tracked quarterly throughout the performance period. Applications will be evaluated based on eight criteria: alignment with the initiative’s purpose, project design and sustainability, anticipated impact, integration of care navigation, demonstration of program expansion, organizational capacity, budget effectiveness, and, optionally, innovation or Tribal engagement. Applications that receive a base score of 75 or higher may qualify for bonus points under the optional criteria. Strong applications will also demonstrate robust partnerships, such as collaboration with local hospitals, behavioral health providers, and community organizations to facilitate seamless service delivery and ensure coordination between clinical and community systems. Interested applicants must submit their draft workplan and budget by March 17, 2026, to Brianna Cochran at [email protected]. Templates for these documents are provided by DHHS. Award notices will be issued shortly after the deadline, and work may commence immediately upon notification. The initiative is fully funded by the Centers for Medicare & Medicaid Services (CMS) under Award Number RHTCMS332086-01-00. With a total program budget of $218,529,075.01, the initiative reflects a significant investment in rural health transformation and represents a major opportunity for Nebraska communities to improve health outcomes for residents living with chronic conditions.

Ensure proposals clearly avoid duplication, include sustainability, and stay under 7.5% admin cost.