Foa_Content_of_HHS-2023-ACL-CIP-NWCH-0036.pdf

Administration for Community Living

Center for Innovation and Partnership

Center of Excellence to Align Health and Social Care: Enhancing Community-Based Aging and Disability Organizations to Improve Access to Long-Term Services and Supports

HHS-2023-ACL-CIP-NWCH-0036

06/26/2023

Table of Contents Executive Summary

Additional Overview Content/Executive Summary

I. Funding Opportunity Description

II. Award Information

III. Eligibility Information

1. Eligible Applicants

2. Cost Sharing or Matching

3. Responsiveness and Screening Criteria

IV. Application and Submission Information

1. Address to Request Application Package

2. Content and Form of Application Submission

Letter of Intent

Project Narrative

Project Abstract

Project Relevance and Current Need

Approach

Outcomes and Evaluation

Organizational Capacity

Budget Narrative/Justification

Work Plan

3. Unique Entity Identifier and System for Award Management (SAM)

4. Submission Dates and Times

5. Intergovernmental Review

6. Funding Restrictions

7. Other Submission Requirements

V. Application Review Information

1. Criteria

2. Review and Selection Process

3. Anticipated Announcement Award Date

VI. Award Administration Information

1. Award Notices

2. Administrative and National Policy Requirements

3. Reporting

4. FFATA and FSRS Reporting

VII. Agency Contacts

VIII. Other Information

The Paperwork Reduction Act of 1995 (P.L. 104-13)

Appendix

Instructions for Completing Required Forms

Budget Narrative/Justification- Sample Format

Instructions for Completing the Project Summary/ Abstract

ACL Center:

Center for Innovation and Partnership Funding Opportunity Title:

Center of Excellence to Align Health and Social Care: Enhancing Community-Based Aging and Disability Organizations to Improve Access to Long-Term Services and Supports Funding Opportunity Number:

HHS-2023-ACL-CIP-NWCH-0036

Primary CFDA Number:

93.048 Due Date for Letter of Intent:

05/30/2023 Due Date for Applications:

06/26/2023 Date for Informational Conference Call:

05/16/2023 Applications that fail to meet the application due date will not be reviewed and will receive no further consideration. You are strongly encouraged to submit your application a minimum of 3-5 days prior to the application closing date. Do not wait until the last day in the event you encounter technical difficulties, either on your end or, with https://www.grants.gov. Grants.gov can take up to 48 hours to notify you of a successful submission.

Executive Summary

Additional Overview Content/Executive Summary

Through this funding opportunity, the U.S. Administration for Community Living (ACL) plans to award a cooperative agreement with a single entity to serve as a national Center of Excellence (COE) to support the development and enhancement of aging and disability organizations funded by ACL to become community care hubs (CCHs). The successful recipient must demonstrate their capacity to work collaboratively across relevant stakeholders to provide technical assistance that improves access to long-term services and supports (LTSS) through CCHs as well as the ability to rapidly deploy and manage competitive subawards directly to an estimated 20 aging and disability organizations. The COE will ensure coordination and https://www.grants.gov/ engagement with other relevant national partners such as USAging’s Aging and Disability Business Institute (ADBI), ADvancing States, Independent Living Research Utilization (ILRU), and the Partnership to Align Social Care. The COE will have the capacity and expertise to work with multiple types of health care partners to facilitate collaboration with CCHs. The COE will provide support and capacity building for CCHs by leading a National Learning Community (NLC) to bring together CCHs to take part in shared learning, information and resource sharing, and coordinated technical assistance. The COE will be required to participate in an evaluation designed by ACL and its contractor to assess the impact of CCHs on the delivery and coordination of services that address health-related social needs (HRSNs).

Applicants may request a total budget from $10.5 million to a maximum of $12.7 million for the three-year project period. Of the amount available for this program, the successful applicant shall be permitted to retain up to 20% for administrative and technical assistance purposes, with the remainder allocated to subawards. The budget and budget narrative should clearly delineate how funds intended for administrative and technical assistance purposes will be allocated. The organization selected will be funded for a 36-month project period, contingent upon the availability of federal funds. Successful applicants must demonstrate the ability to quickly make subawards; engage in strong oversight of subawards; and work closely with ACL and applicable partners to facilitate technical assistance.

Project Annual Budget

Year 1: $5.0 to $6.0 million (including subawards for up to 20 CCHs) Year 2: $5.0 to $6.0 million (including subawards for up to 20 CCHs) Year 3: $500,000 to $700,000 (no subawards anticipated)

An informational conference call will be held on May 16, 2023, from 2:00pm to 3:00pm ET.

Toll Free Number: 800-857-9782

Passcode: 2078572

A recording will be available approximately one hour after the call concludes at the following number: 866-405-9076.

I. Funding Opportunity Description

A. Statement of Need

Background

Substantial evidence demonstrates that a wide array of social needs – such as housing instability, food insecurity, lack of transportation, and unaffordable utilities – impact an individual’s ability to maintain their health and quality of life. Such social needs are referred to as health-related social needs (HRSNs). Cross-sector partnerships among social service providers, public health departments, health care, and community members are necessary to address the varied social needs of individuals.

Health care in the United States continues to undergo rapid change, presenting both opportunities and challenges for community-based aging and disability organizations (CBOs). These organizations address many HRSNs of older adults and people with disabilities, such as providing nutritious meals, securing transportation to medical appointments, assisting with https://innovation.cms.gov/innovation-models/ahcm https://innovation.cms.gov/innovation-models/ahcm vaccine access, and providing personal assistance with daily activities, allowing people to live in their own homes. Demand for CBO assistance with HRSNs continue to grow, but funding and other resources for community organizations are often scarce. As indicated in A National Imperative: Joining Forces to Strengthen Human Services in America, 30% of human service CBOs have cash reserves that cover less than one month of expenses. It was also reported that one in eight human service CBOs are technically insolvent, with liabilities exceeding assets.

In recent years there has also been a marked increase in adoption of technology platforms that send electronic referrals from health care to community-based organizations, often disintermediating the role of CBOs such as Area Agencies on Aging and Aging and Disability Resource Centers that already perform information and referral functions with a curated network of community service providers. Since 1965, the aging and disability networks have been a trusted resource for providing information, referral, and linkages to home and community-based services to roughly one in five older adults, as well as people of all ages with disabilities. The lack of coordination and interoperability across information and referral systems has created siloed development, resulting in inefficiency in managing referrals across health and social services; duplicative workflows in an already strained system; and impeding opportunities to provide better support and care for the people served by either system.

In addition to individuals directly accessing social services, the need for such services will increasingly be identified through routine screening during health care encounters, stemming in part from federal regulations and state policy. Increased attention to addressing health-related social needs is evident in states recent adoption of Medicaid 1115 demonstration waivers to address housing instability, food insecurity, employment, personal safety, lack of transportation, affordable utilities, and more. Additionally, Centers for Medicare and Medicaid Services regulations are requiring hospitals, physicians, and Special Needs Plans to implement new HRSN screening measures which are anticipated to increase referrals to CBOs. It is critical that any approach to address HRSNs reflects community-wide governance and planning that can ensure an efficient, community and person-centered approach be taken in accessing community services that account for an individual’s values, preferences, and holistic needs. Expanding the number of referrals to CBOs without necessary financing to coordinate and deliver services will further exacerbate resource restraints and prevent individuals from accessing desired social care services.

Health plans and systems are partnering with CBOs to coordinate and deliver services that address HRSNs. Increasingly, CBOs are organizing into community provider networks led by a community care hub (CCH) to allow for a more efficient, scalable, and equitable approach to health care/CBO partnerships. A CCH is a community-focused entity that organizes and supports a network of CBOs providing services to address health-related social needs. It has trusted relationships with and understands the capacities of local community-based and health care organizations and fosters cross-sector collaborations that practice community governance with authentic local voices. The CCH centralizes administrative functions and operational infrastructure, including but not limited to:

Contracting with health care organizations Payment operations Management of referrals Service delivery fidelity and compliance https://www.alliance1.org/web/resources/pubs/national-imperative-joining-forces-strengthen-human-services-america.aspx https://www.alliance1.org/web/resources/pubs/national-imperative-joining-forces-strengthen-human-services-america.aspx https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/

Technology, information security, data collection, and reporting

A November 2022 Health Affairs article co-authored by U.S. Department of Health and Human Services (HHS) leaders noted that CCHs can provide the connective tissue within a community to ensure that a coordinated system of health and social care is working equitably to meet an individual’s needs. A CCH operates an overarching structure to support other CBO members by centralizing administrative functions and offering a single point of contracting for health care providers and payers. CBOs are increasingly contracting with health care organizations to address HRSNs, with the percentage of CBOs contracting as part of a network doubling between 2017 and 2021, from 20% to 40%. In addition to strengthening and formalizing CBO/health care partnerships to align health and social care, this contracting serves a crucial role in diversifying funding streams to promote the financial solvency of CBOs.

States also have an opportunity to strengthen and support the evolution of the aging and disability networks to deliver high quality, coordinated services in an increasingly value-based, integrated care environment. With the support and leadership of state No Wrong Door (NWD) Systems, CCHs can continue playing a vital role in facilitating alignment across health care and social services. For example, a playbook was recently created by Manatt Health in collaboration with the Partnership to Align Social Care specifically for state Medicaid agencies seeking to partner with CCHs to address social drivers of health. ACL’s aging and disability networks can impact health equity in this country by addressing both 1) equitable access to services that address HRSNs through a culturally competent and coordinated statewide access system by leveraging a state’s existing NWD System; and 2) equitable distribution of services that address HRSNs by aligning health care and social services through the enhancement and expansion of CCHs to increase service availability and delivery.

B. Other Federal Efforts to Align Health Care and Social Services

For over two decades, ACL and its federal partners have invested in state-level infrastructure and systems change to enhance and streamline access and align social services in communities for all populations and payers. These investments have been supported by a variety of initiatives, including the Aging and Disability Resource Center (ADRC) program, Real Choice Systems Change grants, the Balancing Incentive Program, Money Follows the Person (MFP), and Veteran Directed Care (VDC). ACL has helped states to streamline processes and implement person-centered community service systems, as people who try to access needed services from these systems often experience inefficient, uncoordinated care that can result in higher health care costs, lower satisfaction with care, and poor outcomes. As health care and social service systems embrace person-centered approaches to address health determinants, aligning systems and leveraging strengths has been a successful approach to coordinated, holistic, person-centered care as outlined in the ACL issue brief: An Organizing Model Connecting Health Care and Social Services.

To align these federal initiatives, ACL, with its federal partners, developed the No Wrong Door (NWD) System vision, which includes national standards, tools, metrics, and best practices that all states can use to develop a single “high performing” access system. In these systems, multiple agencies at the state and local level coordinate to create a simplified process through which individuals of all ages, abilities, and incomes can get unbiased information and one-on-one counseling on the options available in their communities.

https://www.healthaffairs.org/content/forefront/improving-health-and-well-being-through-community-care-hubs https://www.brookings.edu/research/building-connective-tissue-for-effective-housing-health-initiatives/ https://www.aginganddisabilitybusinessinstitute.org/wp-content/uploads/2022/03/2022-Advancing-Partnerships.pdf https://nwd.acl.gov/ https://nwd.acl.gov/ https://www.partnership2asc.org/medicaidplaybook2022/ https://nwd.acl.gov/ https://www.medicaid.gov/medicaid/long-term-services-supports/balancing-incentive-program/balancing-incentive-program/index.html#:~:text=The%20Balancing%20Incentive%20Program%20(BIP,created%20by%20the%20Affordable%20Care https://www.medicaid.gov/medicaid/long-term-services-supports/money-follows-person/index.html https://nwd.acl.gov/vdc.html https://nwd.acl.gov/vdc.html https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf

The foundation of NWD Systems is supported by four key functions:

State governance and administration Public outreach and coordination with key referral sources Person-centered counseling and care transitions Streamlined eligibility to public programs

The NWD System is designed to serve all populations who may need long-term services and supports (LTSS), regardless of payer. This includes people who represent a variety of ages, incomes, nationalities, citizenship statuses, cultures, gender identities and expressions, sexual orientations, languages, or disabilities. At its core, a state NWD System is a network of CBOs comprised of staff, such as information and assistance specialists, person-centered counselors, etc., that assist individuals navigating health and social care services and are supported by a governance structure that ensures these functions are available and coordinated across the state.

These NWD partners have unmatched expertise in understanding local culture and needs, service coordination and delivery, and securing benefits, services, and supports that maximize independence. In addition, the workforce residing in a state’s NWD system are best positioned to understand a person’s preferences for community living; these preferences may differ depending on an individual’s age, race, culture, social and family support, as well as which applicable services and supports are important to a person and for a person.

ACL has also made substantial investments in CBO capacity to effectively partner with health care organizations to address HRSNs. From 2012-2019, ACL worked with national partners to create a series of learning collaboratives for aging and disability CBOs to enable partnerships with health care entities and address related challenges, including an emphasis on partnerships with Medicare Advantage plans, building CBO information technology capacity to support contracting, and building capacity of community-based disability organizations to partner with health care entities.

In 2020, ACL convened a national summit which brought together executive leaders from HHS, health plans, health systems, CBOs, state governments, and philanthropy to advance the integration of medical and social care to improve health outcomes for particularly complex, high-need populations. Also in 2020, ACL awarded $50 million in emergency funding to support ADRC efforts to increase and enhance specific services and functions, including care transitions, in response to the COVID-19 pandemic.

In response to the lack of coordination of referrals across health and social services, ACL designed the Social Care Referrals Challenge, which was a three-phased challenge competition to catalyze development and optimization of interoperable and scalable technology solutions that leverage national standards for data exchange and common formats for resource directories. A bonus round was created to address taxonomy mapping, which emerged as an additional need for seamless exchange of referrals while optimizing individual level social care data. Through this effort, Challenge teams like the Missouri Aging Services Data Collaborative were able to develop an interoperability hub to facilitate information sharing between organizations, systems, and platforms. The project also developed the Aging Services Dataset and Interoperability Standards (ASDIS), which categorize and organize hundreds of commonly used data elements and can be used to exchange data between partners and payers, regardless of which existing data system or vendor they use. The team enabled replicability and scalability of the project, https://acl.gov/sdohsummit https://acl.gov/socialcarereferrals including expanding technical components to include interoperability hubs for behavioral health services, disability services, veterans’ services, homelessness services, and more.

In 2021, ACL provided funding directly to CBOs serving as a network lead entity (now known as community care hub) to develop integrated health networks that partner with health care entities. In the same year, ACL collaborated with ADvancing States to convene a group of state representatives and emerging network lead entities that came together to collectively explore respective roles and opportunities in supporting development and enhancement of CBO networks. In 2022, ACL, with support from the Centers for Disease Control and Prevention, launched a National Learning Community to bring together organizations serving as CCHs that are either in development or interested in expansion. Participants take part in shared learning, information and resource sharing, and coordinated technical assistance with the goal of strengthening each hub’s ability to address HRSNs and public health needs through partnerships with health care entities.

Coordination across the health and social care sectors was further encouraged through the National Strategy for COVID Response and Pandemic Preparedness which highlights the need to facilitate linkages between clinical and social services given the increased need for social services during the COVID-19 pandemic, as well as the need to work with community-based, multi-sector organizations to align health and social interventions. Integration of care allows for the provision of services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-clinical risk factors.

These essential services are shown to improve health outcomes and reduce the cost of care. This is particularly true for “high-need, high-cost” populations who have complex health conditions and social risk factors and who often have significant functional limitations.

C. Program Goals

Part I: Develop and Implement Subawards to CCHs

A central deliverable in Year One will be the disbursement of subawards to CCHs within three to six months of receipt of funds. The successful recipient is expected to use a transparent and open process for soliciting, reviewing, selecting, and making the required subawards via grants to CCHs. Applicants should describe how such a process will be designed and administered.

Additionally, the recipient is responsible for the monitoring and oversight of all subawards, and the process to solicit, objectively evaluate, select, and make subawards. Applicants should carefully consider and describe the subaward process. Further, the successful recipient shall adhere to all requirements, including those for making and monitoring subawards, as outlined in 45 CFR Part 75.

Guidance on Purpose and Intent of Subawards

The subaward funding opportunity aims to support aging and disability organizations funded by ACL to improve access to LTSS through CCHs as part of a broader NWD System. For further information about NWD access functions please see NWD National Elements. ACL envisions funding will be able to support up to 20 CCHs each year over a two-year timeframe with grants to improve their access functions, with specific emphasis on CCH capacity to coordinate referrals across health and social services as well as support individuals transitioning from hospital to home. Both information and referral and supporting care transitions across various https://www.ta-community.com/category/cch-national-learning-community https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.pdf https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://nwd.acl.gov/pdf/NWD-National-Elements.pdf settings are core components of a state’s NWD System functions, providing person-centered support and connections to services at times when people are making important decisions and often desire to return home with the services and support they need to be independent.

The COE and sub-award grantees will have flexibility to address priority needs, including:

Supporting care transitions from hospital to home, including business and operational relationships with health care organizations needed for a sustainable partnership such as the shared workforce to screen for HRSNs, development of person-centered plans, service activation, and follow up to ensure coordination and integration of community and health care services post discharge.

Coordinating resource directories and referral management systems to support efforts to streamline and improve systems for connecting older adults and people with disabilities to long-term services and supports.

Implementing collaborative approaches for information and referral workflows that efficiently leverage health care and community workforce, along with technology solutions for electronic closed loop referrals.

A CCH is an organization that helps to create a network of CBO providers at the regional, statewide, or multistate level. The CCH directs the development and design of a network structure and facilitates services, administrative oversight, and governance responsibilities.

CCHs and their networks are organized and governed in numerous ways. While each CCH is unique in how it builds and sustains its network, there are foundational business processes that leading CCHs are performing. Leading CCHs are characterized by their ability to sustain multi-year contracting with multiple health sector partners, follow strategic planning and standard business processes, and employ at least one full-time staff member committed to network management. The aggregation of these business processes has been informed by best practices observed in the field as well as best practices from business and management to generate a profile of a leading CCH. The processes of the leading CCHs can be organized into six domains:

1. Leadership and governance

2. Strategic business development

3. Network recruitment, engagement, and support

4. Contract administration and compliance

5. Operations

6. Information technology and security

Each CCH sub awardee will be required to complete a CCH organizational capacity assessment through an existing tool developed by ACL to identify strengths and technical assistance needs.

Part II: Creation of Center of Excellence (COE) and Facilitated Technical Assistance

The primary responsibility of the COE will be to serve as a national focal point to provide technical assistance to scale and support new and existing CCHs, with an emphasis on organizations in ACL’s aging and disability networks. The COE will ensure coordination and engagement with other relevant national partners such as USAging’s Aging and Disability Business Institute (ADBI), ADvancing States, Independent Living Research Utilization (ILRU), and the Partnership to Align Social Care. The COE will also have the capacity and expertise to work with multiple partners across the health care sector (i.e., health plans, systems, and providers) to advance collaborative approaches to address HRSNs through meaningful partnerships with CCHs. The COE will convene a multi-stakeholder group to advise on and/or develop consensus-based solutions that support the maturation of CCHs, consistent with all federal and state policies.

Throughout the first year, the COE will provide technical assistance and capacity building for CCHs by collaborating with ACL to co-lead a National Learning Community (NLC). In year two of the project period, the COE will transition to a lead role for the NLC in collaboration with existing key partners. Priority technical assistance topics for future phases of the NLC include:

Developing CCHs in geographies without existing capacity Billing, coding, and payment for services that address HRSNs Information technology infrastructure/shared services for CCHs CCH reporting of health equity quality measures (including screening and referral for

HRSNs) CCH alignment with Medicaid 1115 waiver demonstrations that address HRSNs CCH governance structures and business operations, including ensuring integrity of CBO mission with respect to leading or participating in a CCH

Delivery of technical assistance should be interactive and engaging, with an approach that balances content delivery by subject matter experts with an “all teach, all learn” peer-based learning framework (e.g., Project ECHO model). ACL envisions that the COE will collaborate with experts regarding developing an approach to identify and publicly report qualified CCHs, including recommendations for ongoing sustainability of this process. The COE will also develop and maintain a searchable national listing/map of qualified CCHs to help support “matchmaking” across CCHs and potential health care partners.

The COE will work through a multi-stakeholder group to advance priority administrative codes for services that address HRSNs for consistent implementation across CCHs and reimbursement.

Based on priorities identified by the workgroup, a common set of codes should be identified for consistent implementation across health care and CCHs.

Part III: Participate in Evaluation of Community Care Hubs

The COE will work with ACL and its contractor to participate in the design and implementation of an evaluation to assess the impact of CCHs on the delivery and coordination of services that address HRSNs. The successful applicant commits to playing a key role with respect to data collection and coordination on behalf of participating CCHs, to include any sub awardees.

Frequency of reporting and the range of data collected will be finalized by ACL and the recipient following award.

D. Partnership and Stakeholder Collaboration

ACL expects that no single organization will be able to completely fulfill the priority areas expected to be addressed in this project. Therefore, applicants should describe how they plan to partner with other organizations to address the expectations of this funding opportunity. While the applicant organization must be the fiscal and programmatic lead, applicants should clearly define their key partners’ roles throughout the application materials (e.g., work plan, budget, project narrative). Applicants should include letters of commitment from initial partners in this https://www.ta-community.com/category/cch-national-learning-community application. Applicants should also describe how they will engage with external stakeholders such as those on the non-exhaustive list below:

ACL-funded aging and disability network organizations and other grantees National organizations representing state/local aging and disability organizations National organizations representing the interests of public health stakeholders National organizations/initiatives with multi-sector (e.g., state, CBO, health plan, health system) participation focused on the alignment of health and social care Key subject matter experts with expertise related to addressing HRSNs through partnerships between aging/disability CBOs, public health, and the health care sector

Statutory Authority The statutory authority for grants under this funding opportunity is contained in Title IV of the Older Americans Act (OAA) (42U.S.C. 3032), as amended by the Older Americans Act Amendments of 2006, P.L. 109-365.

II. Award Information

Funding Instrument Type:

CA (Cooperative Agreement) Estimated Total Funding:

$11,500,000 Expected Number of Awards:

Award Ceiling:

$12,700,000 Per Project Period

Award Floor:

$10,500,000 Per Project Period

Length of Project Period:

36-month project period with three 12-month budget periods Additional Information on Project Periods and Explanation of 'Other' Cooperative Agreement Terms

This award will be a new cooperative agreement. As a cooperative agreement, ACL will have substantial involvement in the activities of the funded project. The successful applicant will receive a Notice of Award which makes the below terms and conditions of the cooperative agreement effective immediately upon award notification and drawdown of funds from the Payment Management System.

The ACL will carry out the following activities for the cooperative agreement:

1. ACL Project Officer will perform the day-to-day Federal responsibilities of managing a grant initiative and will work with the grantee to ensure that the necessary requirements for the grant are met.

2. Assist the grantee project leadership in understanding the policy concerns and/or priorities of ACL by conducting periodic briefings and by carrying out ongoing consultations.

3. Within 30 days post-award, work cooperatively with the grantee to clarify the programmatic and budgetary issues to be addressed by the project. If issues are identified, work with the grantee to revise the project work plan, detailing expectations for major activities and products during the grant.

4. Provide technical assistance to the grantee on the provision of technical support and associated tasks related to the fulfillment of the goals and objectives of this grant.

5. Provide consultation to the grantee in identifying emerging issues as they relate to the goals and objectives of this grant program.

6. Work with the grantee on the development and implementation of data and quality assurance systems to ensure that performance is measured and continuous improvement occurs.

7. Provide guidance to the grantee, as necessary, in making subawards (i.e., sub-grants/contracts) as permitted in this funding opportunity announcement.

8. Review and provide technical advice to the grantee on all work products and other project deliverables and processes.

9. Attend and participate in major project events as appropriate.

10. ACL liaisons will participate in multi-stakeholder consortia or groups that provide coordination and/or strategic direction to the COE.

The Grantee will execute the responsibility of the grant as listed below:

1. Fulfill all the requirements of the grant initiative as outlined in this program announcement, as well as carry out project activities as reviewed, approved, and awarded.

2. Participate in ACL education and communication activities (including teleconferences and webinars) provided that ACL provides reasonable notice of the subject, date, and time of the teleconference.

3. Comply with all other reporting requirements, as outlined in Section VI of this Funding Opportunity and the Notice of Award.

4. Include ACL disclaimer language on all products produced using this grant funding.

5. Engage with ACL and its contractor on CCH evaluation, including input into evaluation design and implementation, assisting with the collection and housing of required data, and sharing data with ACL and its contractor upon request

6. Work with ACL and its contractor on developing the application criteria for subawards, including Agreement Terms to include participation in CCH evaluation and completion of CCH capacity assessment.

III. Eligibility Information

1. Eligible Applicants

For FY 2023 the below guidance is provided to advance the Administration’s policy, as stated in E.O. 13985, to “pursue a comprehensive approach to advancing equity for all, including people of color and others who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.” This guidance is intended to begin to address inequities in

HHS programs, processes, and policies that may serve as barriers to equal opportunity. By advancing equity in our NOFOs, we can “create opportunities for the improvement of communities that have been historically underserved, which benefits everyone.”

Domestic public or private non-profit entities including state and local governments, Indian tribal governments and organizations (American Indian/Alaskan Native/Native American), faith-based organizations, community-based organizations, hospitals, and institutions of higher education.

2. Cost Sharing or Matching

Cost Sharing / Matching Requirement:

No For awards that do not require matching or cost sharing by statute, recipients are not expected to provide cost sharing or matching. However, recipients are allowed to voluntarily propose a commitment of non-federal resources. If an applicant decides to voluntarily contribute non-federal resources towards project costs and the costs are accepted by ACL, the non-federal resources will be included in the approved project budget. The applicant will be held accountable for all proposed non-federal resources as shown in the Notice of Award (NOA). A recipient's failure to meet the voluntary amount of non-federal resources that was accepted by ACL as part of the approved project costs and that was identified in the approved budget in the NOA, may result in the disallowance of federal funds. Recipients will be required to report these funds in the Federal Financial Reports.

3. Responsiveness and Screening Criteria

Application Responsiveness Criteria Not applicable.

Application Screening Criteria All applications will be screened to assure a level playing field for all applicants. Applications that fail to meet the three screening criteria described below will not be reviewed and will receive no further consideration.

In order for an application to be reviewed, it must meet the following screening requirements:

1. Applications must be submitted electronically via https://www.grants.gov by 11:59 p.m., Eastern Time, by the due date listed in section IV.3 Submission Dates and Times.

2. The Project Narrative section of the Application must be double-spaced, on 8.5” x 11” plain white paper with 1” margins on both sides, and a standard font size of no less than 11 point, preferably Times New Roman or Arial.

3. The Project Narrative must not exceed 20 pages. Project Narratives that exceed 20 pages will have the additional pages removed and only the first 20 pages of the Project Narrative will be provided to the merit reviewers for funding consideration. NOTE: The Project Work Plan, Letters of Commitment, and Vitae of Key Project Personnel are not counted as part of the Project Narrative for purposes of the 20-page limit.

IV. Application and Submission Information

1. Address to Request Application Package

Application materials can be obtained from https://www.grants.gov or https://www.acl.gov/grants/applying-grants.

Please note, ACL requires applications for all announcements to be submitted electronically through http://www.grants.gov in Workspace. Grants.gov Workspace is the standard way for organizations and individuals to apply for federal grants in Grants.gov. An overview and training on Grants.gov Workspace can be found here at:

https://www.grants.gov/web/grants/applicants/workspace-overview.html

The Grants.gov registration process can take several days. If your organization is not currently registered, please begin this process immediately. For assistance with https://www.grants.gov, please contact them at support@grants.gov or 800-518-4726 between 7:00 a.m. and 9:00 p.m.

Eastern Time.

At the https://www.grants.gov website, you will find information about submitting an application electronically through the site, including the hours of operation. ACL strongly recommends that you do not wait until the application due date to begin the application process because of the time involved to complete the registration process.

All applicants must have a UEI and be registered with the System for Award Management (SAM, www.sam.gov) and maintain an active SAM registration until the application process is complete, and should a grant be made, throughout the life of the award. Effective June 11, 2018, when registering or renewing your registration, you must submit a notarized letter appointing the authorized Entity Administrator. Please be sure to read the FAQs located at www.sam.gov to learn more. Applicants should allot sufficient time prior to the application deadline to finalize a new, or renew an existing registration. This action should allow you time to resolve any issues that may arise. Failure to comply with these requirements may result in your inability to submit your application or receive an award. Maintain documentation (with dates) of your efforts to register or renew at least two weeks before the deadline. See the SAM Quick Guide for Grantees at:

https://www.sam.gov/SAM/pages/public/help/samQUserGuides.jsf.

Note: Once your SAM registration is active, allow 24 to 48 hours for the information to be available in Grants.gov before you can submit an application through Grants.gov. This action should allow you time to resolve any issues that may arise. Failure to comply with these requirements may result in your inability to submit your application or receive an award.

Note: Failure to submit the correct EIN Suffix can lead to delays in identifying your organization and access to funding in the Payment Management System.

Effective October 1, 2010, HHS requires all entities that plan to apply for and ultimately receive federal grant funds from any HHS Operating/Staff Division (OPDIV/STAFFDIV) or receive subawards directly from the recipients of those grant funds to:

1. Register in SAM prior to submitting an application or plan;

2. Maintain an active SAM registration with current information at all times during which it has an active award or an application or plan under consideration by an OPDIV; and

3. Provide its UEI number in each application or plan to submit to the OPDIV.

https://www.grants.gov/ https://www.acl.gov/grants/applying-grants http://www.grants.gov/ https://www.grants.gov/web/grants/applicants/workspace-overview.html https://www.grants.gov/ mailto:support@grants.gov https://www.grants.gov/ http://www.sam.gov/ https://www.sam.gov/SAM/pages/public/help/samQUserGuides.jsf

Additionally, all first-tier subaward recipients must have a UEI number at the time the subaward is made.

The Federal Government will transition from the DUNS Number to the New Unique Entity Identifier. As of April of 2022, the federal government stopped using the DUNS number to uniquely identify entities. At that point, entities doing business with the federal government will use a Unique Entity Identifier (SAM) created in SAM.gov. It is entered on the SF-424. It is a unique, nine-digit identification number, which provides unique identifiers of single business entities.

You must submit all documents electronically, including all information included on the SF424 and all necessary assurances and certifications. In accordance with the Federal Government’s efforts to reduce reporting burden for recipients of federal financial assistance, the general certification and representation requirements contained in the Standard Form 424B (SF-424B) – Assurances – Non-Construction Programs, and the Standard Form 424D (SF-424D) – Assurances – Construction Programs, have been standardized federal-wide.

Effective January 1, 2020, the updated common certification and representation requirements will be stored and maintained within SAM. Organizations or individuals applying for federal financial assistance as of January 1, 2020, must validate the federally required common certifications and representations annually through SAM located at SAM.gov.

After you electronically submit your application, you will receive an automatic acknowledgment from https://www.grants.gov that contains https://www.grants.gov tracking number. The Administration for Community Living will retrieve your application form from https://www.grants.gov.

U.S. Department of Health and Human Services Administration for Community Living

2. Content and Form of Application Submission

Letter of Intent

05/30/2023 Applicants are requested, but not required, to submit a letter of intent to apply for this funding opportunity to assist ACL in planning for the application independent review process. The purpose of the letter of intent is to allow our staff to estimate the number of independent reviewers needed and to avoid potential conflicts of interest in the review. Letters of intent should be sent to:

U.S. Department of Health and Human Services

Administration for Community Living

Lauren Solkowski

Office of Network Advancement

Email: Lauren.Solkowski@acl.hhs.gov https://www.grants.gov https://www.grants.gov https://www.grants.gov

Project Narrative

The Project Narrative must be double-spaced, on 8.5” x 11” paper with 1” margins on both sides, and a standard font size of no less than 11 point, preferably Times New Roman or Arial. You can use smaller font sizes to fill in the Standard Forms and Sample Formats. The suggested length for the Project Narrative is 15 to 20 pages; 20 pages is the maximum length allowed. Project Narratives that exceed 20 pages will have the additional pages removed and only the first 20 pages of the Project Narrative will be provided to the merit reviewers for funding consideration.

The Project Work Plan, Letters of Commitment, and Vitae of Key Personnel are not counted as part of the Project Narrative for purposes of the 20-page limit, but all of the other sections noted below are included in the limit. A new requirement for all Project Narratives is a section that explains the equity experience of the project team.

The components of the Project Narrative counted as part of the 20-page limit include:

• Project Abstract

• Project Relevance and Current Need

• Approach

• Outcomes and Evaluation

• Organizational Capacity

To assist reviewers in scoring your application, we suggest that applicants organize their proposals using the headings above.

Project Abstract

This section should include a brief (265 words maximum) description of the proposed project, including: goal(s), objectives, outcomes, and products to be developed. Detailed instructions for completing the summary/abstract are included in the “Instructions for Completing the Project Summary/Abstract.”

Project Relevance and Current Need

This section should:

Describe your knowledge of the current landscape with respect to creating a person-centered community infrastructure that aligns health and social care and allows individuals to remain independent in the community, including opportunities and challenges related to federal and state policy, financing strategies, etc.

Demonstrate your understanding of the types of issues that CCHs within the aging and disability networks experience as they develop their capacity and build sustainable community care networks, including any additional burdens placed on CCHs when social care referrals are not standardized, coordinated, and adequately funded across health care and social services.

Approach

Project Description

This section should:

State the project’s result-based goals and major objectives.

Describe the applicant’s plan to develop and implement a process to transparently compete and issue approximately 20 subawards within three to six months of award receipt to support CCH capacity at the local/regional/state level, with a specific emphasis on the delivery of care transitions interventions through the hub.

Describe the applicant’s strategy to engage a consortia of various stakeholder groups that respects and is grounded in community interests, with the common goal of serving individuals in need through partnerships between CCHs and the health care sector to address HRSNs.

Provide a detailed description of the applicant’s plans to develop and implement technical assistance support and resources that support expansion of new CCHs and strengthen capacity of existing of CCHs. Priority areas of interest (to be finalized throughout the project period) include:

o Developing CCHs in geographies without existing capacity o Billing, coding, and payment for services that address HRSNs o Information technology infrastructure/shared services for CCHs o CCH reporting of health equity quality measures (including screening and referral for HRSNs) o CCH governance structures, including ensuring integrity of CBO mission with respect to leading/participating in a CCH

Describe applicant’s capacity to develop and maintain a searchable national listing/map of qualified CCHs to help support “matchmaking” across CCHs and health care partners.

Special Target Populations/Organizations

Describe how the applicant will provide support to CCHs to reach diverse consumers and traditionally hard-to-reach populations (as defined by Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government).

Outcomes and Evaluation

Outcomes

This section must clearly identify the outcomes that will result from your comprehensive strategy to implement this project. Any proposed outcomes should address the goals of this funding opportunity, and be quantifiable, measurable, and likely to be achieved during the project period.

List measurable outcomes in the Work Plan grid under “Measurable Outcomes,” in addition to any discussion included in the narrative.

Evaluation

This section should describe the method(s), techniques, and tools that will be used to: 1) determine whether the proposed intervention achieved its anticipated outcome(s), and 2) document the “lessons learned” – both positive and negative – from the project that will be useful to people interested in replicating the intervention if it proves successful.

Dissemination https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/ https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/ https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/

This section should describe the method that will be used to disseminate the project’s results and findings in a timely manner and in easily understandable formats, to parties who might be interested in using the results to inform practice, service delivery, program development, and/or policymaking, including and especially those parties who would be interested in replicating the project.

Applicants should also highlight their willingness to participate in conferences, webinars, and other presentation formats to share project-relevant information with interested parties.

Organizational Capacity

Organizational Capacity

Describe the applicant’s knowledge and expertise in working at the national level on the issues to be addressed by this funding opportunity.

Describe the applicant’s experience working with aging and disability organizations funded by ACL to improve access to home and community-based services.

Describe the applicant’s expertise, established history/relationships in working collaboratively across the targeted stakeholder audiences (i.e., aging and disability CBOs, CCHs, public health, health care organizations, etc.).

Describe experience competing, issuing, and monitoring funding to community-based…