FORHP HRSA-22-063 (U2W) Flex EMS Supplement_FINAL.pdf

U.S. Department of Health and Human Services

Federal Office of Rural Health Policy

Hospital State Division

Medicare Rural Hospital Flexibility Program- Emergency Medical Services Competing Supplement

Funding Opportunity Number: HRSA-22-063 Funding Opportunity Type: Competing Supplement

Assistance Listings (AL/CFDA) Number: 93.241

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2022

Application Due Date: March 4, 2022

Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

HRSA will not approve deadline extensions for lack of registration.

Registration in all systems may take up to 1 month to complete.

Issuance Date: December 2, 2021

Tahleah Chappel Project Officer, Federal Office of Rural Health Policy Telephone: (301) 443-0197 Email: TChappel@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: Title XVIII, §1820(g)(2) of the Social Security Act (42 U.S.C. 1395i-4(g)(2)) mailto:TChappel@hrsa.gov

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508 COMPLIANCE DISCLAIMER

Note: Persons using assistive technology may not be able to fully access information in this file. For assistance, please email or call one of the HRSA staff listed in Section VII.

Agency Contacts.

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for the fiscal year (FY) 2022 Medicare Rural Hospital Flexibility Program (Flex Program) Emergency Medical Services (EMS) Competing Supplement. The purpose of this supplement is to encourage rural EMS agencies to increase accurate EMS reporting and educate EMS staff and leadership on using the data to drive quality improvement efforts at the agency level.

Funding Opportunity Title: Medicare Rural Hospital Flexibility Program EMS Competing Supplement

Funding Opportunity Number: HRSA-22-063 Due Date for Applications: March 4, 2022

Anticipated Total Annual Available FY 2022 Funding:

Approximately $1,800,000

Estimated Number and Type of Awards: Up to 6 cooperative agreements Estimated Award Amount: Approximately $300,000 Cost Sharing/Match Required: No Period of Performance: September 1, 2022 through

August 31, 2024 (2 years) Eligible Applicants: Eligible applicants must be current recipients funded under HRSA-19-024, Medicare Rural Hospital Flexibility Program cooperative agreement. This competitive supplemental funding opportunity is only open to current award recipients of the Medicare Rural Hospital Flexibility Program cooperative agreement. Only states (current Medicare Rural Hospital Flexibility Program award recipients in states with certified critical access hospitals) are eligible to apply for funding under this notice. See Section III-1 of this notice of funding opportunity (NOFO) for complete eligibility information.

https://www.hrsa.gov/grants/find-funding/hrsa-19-024

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Application Guide You (the applicant organization/agency) are responsible for reading and complying with the instructions included in HRSA’s SF-424 Application Guide, available online, except where instructed in this NOFO to do otherwise.

Technical Assistance HRSA has scheduled the following technical assistance:

Webinar

Day and Date: Wednesday, December 15, 2021 Time: 3 – 4 p.m.

Call-In Number: 1-833-568-8864 Webinar ID: 160 610 8512 Participant Passcode: 41054895 Weblink: https://hrsa-gov.zoomgov.com/j/1606108512?pwd=WlBpdFF2TU5RVlpKVzhsZ0d2bWF5QT09

Participants also have the option of using VOIP (Computer Audio).

HRSA will record the webinar. Please contact TChappel@hrsa.gov for playback Information.

http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://hrsa-gov.zoomgov.com/j/1606108512?pwd=WlBpdFF2TU5RVlpKVzhsZ0d2bWF5QT09 https://hrsa-gov.zoomgov.com/j/1606108512?pwd=WlBpdFF2TU5RVlpKVzhsZ0d2bWF5QT09 mailto:TChappel@hrsa.gov

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. Purpose

2. Background

II. AWARD INFORMATION

1. Type of Application and Award

2. Summary of Funding

III. ELIGIBILITY INFORMATION

1. Eligible Applicants

2. Cost Sharing/Matching

3. Other

IV. APPLICATION AND SUBMISSION INFORMATION

1. Address to Request Application Package

2. Content and Form of Application Submission

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number Transition to the Unique Entity Identifier (UEI) and System for Award Management (SAM)

4. Submission Dates and Times

5. Intergovernmental Review

6. Funding Restrictions

V. APPLICATION REVIEW INFORMATION

1. Review Criteria

2. Review and Selection Process

3. Assessment of Risk

VI. AWARD ADMINISTRATION INFORMATION

1. Award Notices

2. Administrative and National Policy Requirements

3. Reporting

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Medicare Rural Hospital Flexibility Program (Flex Program) Emergency Medical Services (EMS) Competing Supplement. Throughout this NOFO, the term Flex Program will refer to the larger, primary program while Flex EMS Supplement will refer to the supplemental projects that are the focus of this NOFO.

The goal of this supplemental funding is to expand upon the current Flex program by encouraging rural EMS agencies to educate staff and leadership on the importance of accurate reporting, and how it drives quality improvement efforts at the agency level.

Improving and/or adding quality improvement activities allows EMS agencies to enhance clinical care, and find efficiencies which has the potential to both expand their ability to care for patients, and allow them to expand needed services. Additionally these supplements will serve as examples to other EMS agencies interested in this topic.

The state Flex programs that choose to apply for this supplement should propose a project that identifies at least three specific EMS measures to improve on during the period of performance. The applicant should remember to take into account applicable health disparities and health equity measures when planning the project. The applicant should also include appropriate education/training on the use of data and quality improvement efforts.

2. Background

The Flex program is authorized by Title XVIII, §1820(g)(2), of the Social Security Act (42 U.S.C. 1395i-4(g)(2)), which authorizes funding “for the establishment or expansion of a program for the provision of rural emergency medical services.”

With declining numbers of volunteers to staff ambulances, declining financial support from local governments, and increased educational standards for emergency medical technicians and paramedics, access to emergency care is at risk in many rural communities. Flex Program stakeholders have identified addressing the needs of struggling EMS agencies as a key issue to maintaining access to emergency care in rural communities. Stakeholders have also identified EMS quality improvement as a key challenge for both EMS sustainability and EMS participation in value-based care.

The Flex Program provides a platform and resources for states to strengthen rural health care by supporting improvement initiatives with Critical Access Hospitals (CAH) and rural EMS agencies. State Flex programs have supported EMS improvement activities in the past, but have faced challenges with limited capacity to address EMS needs given other rural health care priorities. This supplemental funding opportunity enables up to six state Flex programs to implement focused EMS improvement projects that address the challenges faced by rural EMS agencies, while contributing to the rural https://www.govinfo.gov/app/details/USCODE-2009-title42/USCODE-2009-title42-chap7-subchapXVIII-partA-sec1395i-4 https://www.govinfo.gov/app/details/USCODE-2009-title42/USCODE-2009-title42-chap7-subchapXVIII-partA-sec1395i-4

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EMS evidence base.

The EMS Agenda 2050, published in 2019, incorporates the 14 key attributes of an EMS agency from the 2004 Rural and Frontier Emergency Medical Services Agenda for the Future report, and creates a people-centered approach to EMS. This updated report notes, “Many organizations lack the resources, initiative or desire needed to implement meaningful performance measurement and quality improvement systems.” The Flex EMS Supplement will provide needed funding to enhance the use of quality improvement systems that currently exist. This funding will also assist in addressing two of the six guiding principles listed in the 2019 report, “Inherently safe and effective” and “Integrated and seamless” EMS systems.

II. Award Information

1. Type of Application and Award

Type of applications sought: Competing Supplement.

HRSA will provide funding in the form of a cooperative agreement.

HRSA program involvement will include:

• Collaborating with award recipients to review and provide input on the Work Plans in alignment with HRSA priorities, state needs, and changes in the rural EMS environment through such activities as identifying and prioritizing needs to be addressed using federal funds;

• Monitoring and supporting implementation of the Work Plan through progress report reviews; and

• Collaborating with technical assistance providers that are developing tools and resources for state Flex program use.

The cooperative agreement recipient’s responsibilities will include:

• Collaborating with HRSA on refining and implementing the Work Plan according to HRSA priorities, state needs, and changes in the rural EMS environment;

• Negotiating with HRSA to update Work Plans at least annually, or more frequently as needed (e.g., in response to identified challenges);

• Developing and implementing a state Flex EMS Supplement as described in this notice: HRSA-22-063;

• Participating in information sharing and program improvement activities coordinated by HRSA’s designated Flex EMS Supplement technical assistance providers; and

• Participating in the national evaluation of the Flex EMS Supplement.

https://www.ems.gov/projects/ems-agenda-2050.html https://www.ems.gov/pdf/advancing-ems-systems/Provider-Resources/EMS_Rural_Frontier_Agenda.pdf https://www.ems.gov/pdf/advancing-ems-systems/Provider-Resources/EMS_Rural_Frontier_Agenda.pdf

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2. Summary of Funding

HRSA estimates approximately $1,800,000 to be available annually to fund up to six recipients. The actual amount available will not be determined until enactment of the final FY 2022 federal appropriation. You may apply for a ceiling amount of up to $300,000 total cost (includes both direct and indirect, facilities and administrative costs) per year for the Flex EMS Supplement.

The period of performance for the Flex EMS Supplement is September 1, 2022, through August 31, 2024 (2 years). Funding of the Flex EMS Supplement beyond the first year is subject to the availability of appropriated funds for the Medicare Rural Hospital Flexibility Program in subsequent fiscal years, satisfactory recipient performance, and a decision that continued funding is in the best interest of the Federal Government.

All HRSA awards are subject to the Uniform Administrative Requirements, Cost Principles, and Audit Requirements at 45 CFR part 75.

This program notice is subject to the appropriation of funds, and is a contingency action taken to ensure that, should funds become available for this purpose, HRSA can process applications and award funds appropriately.

Limitations on Indirect Cost Rates

Authorizing legislation (Title XVIII, §1820(g)(4) of the Social Security Act (42 U.S.C.

1395i-4(g)(4)), as amended) limits indirect costs under the Flex Program. Indirect costs will be budgeted and reimbursed at the lesser of 15 percent of total direct costs or the applicant’s negotiated Indirect Cost Rate Agreement (ICRA). The 15 percent limit is inclusive of direct and indirect costs. This limitation on indirect cost rates is a requirement of this federal award and, as required in 45 CFR § 75.351-353, the limitation includes subrecipients.

III. Eligibility Information

1. Eligible Applicants

Eligible applicants must be current recipients funded under HRSA-19-024, Medicare Rural Hospital Flexibility Program cooperative agreement. This competitive supplemental funding opportunity is only open to current award recipients of the Medicare Rural Hospital Flexibility Program cooperative agreement. Only states (current Medicare Rural Hospital Flexibility Program award recipients in states with certified critical access hospitals) are eligible to apply for funding under this notice.

2. Cost Sharing/Matching

Cost sharing/matching is not required for this program.

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 https://www.hrsa.gov/grants/find-funding/hrsa-19-024

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3. Other

HRSA may not consider an application for funding if it contains any of the non-responsive criteria below:

• Exceeds the ceiling amount

• Fails to satisfy the deadline requirements referenced in Section IV.4

NOTE: Multiple applications from an organization are not allowable.

HRSA will only accept your last validated electronic submission, under the correct funding opportunity number, before the Grants.gov application due date as the final and only acceptable application.

IV. Application and Submission Information

1. Address to Request Application Package

HRSA requires you to apply electronically. HRSA encourages you to apply through Grants.gov using the SF-424 workspace application package associated with this notice of funding opportunity (NOFO) following the directions provided at Grants.gov: HOW TO

APPLY FOR GRANTS.

The NOFO is also known as “Instructions” on Grants.gov. You must select “Subscribe” and provide your email address for HRSA-22-063 in order to receive notifications including modifications, clarifications, and/or republications of the NOFO on Grants.gov.

You will also receive notifications of documents placed in the RELATED DOCUMENTS tab on Grants.gov that may affect the NOFO and your application. You are ultimately responsible for reviewing the For Applicants page for all information relevant to this

NOFO.

2. Content and Form of Application Submission

Application Format Requirements Section 4 of HRSA’s SF-424 Application Guide provides general instructions for the budget, budget narrative, staffing plan and personnel requirements, assurances, certifications, etc. You must submit the information outlined in the HRSA SF-424 Application Guide in addition to the program-specific information below. You are responsible for reading and complying with the instructions included in HRSA’s SF-424 Application Guide except where instructed in the NOFO to do otherwise. You must submit the application in the English language and in the terms of U.S. dollars (45 CFR § 75.111(a)).

https://www.grants.gov/ http://www.grants.gov/applicants/apply-for-grants.html http://www.grants.gov/applicants/apply-for-grants.html https://www.govinfo.gov/content/pkg/GPO-STYLEMANUAL-2016/pdf/GPO-STYLEMANUAL-2016.pdf https://www.cdc.gov/socialdeterminants/index.htm https://www.hrsa.gov/sites/default/files/hrsa/HRSA-strategy-intimate-partner-violence.pdf https://www.hrsa.gov/sites/default/files/hrsa/HRSA-strategy-intimate-partner-violence.pdf

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See Section 8.5 of the HRSA SF-424 Application Guide for the Application Completeness Checklist.

Application Page Limitation The total size of all uploaded files included in the page limit shall be no more than the equivalent of 40 pages when printed by HRSA. The page limit includes the project and budget narratives, and attachments required in the Application Guide and this NOFO.

Please note: Effective April 22, 2021, the abstract is no longer an attachment that counts in the page limit. The abstract is the standard form (SF) "Project_Abstract Summary.” Standard OMB-approved forms included in the workspace application package do not count in the page limit. If you use an OMB-approved form that is not included in the workspace application package for HRSA-22-063, it may count against the page limit. Therefore, we strongly recommend you only use Grants.gov workspace forms associated with this NOFO to avoid exceeding the page limit. Indirect Cost Rate Agreement and proof of non-profit status (if applicable) do not count in the page limit. It is therefore important to take appropriate measures to ensure your application does not exceed the specified page limit. Any application exceeding the page limit of 40 will not be read, evaluated, or considered for funding.

Applications must be complete, within the maximum specified page limit, and validated by Grants.gov under HRSA-22-063 before the deadline.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

1) You certify on behalf of the applicant organization, by submission of your proposal, that neither you nor your principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

2) Failure to make required disclosures can result in any of the remedies described in 45 CFR § 75.371, including suspension or debarment. (See also 2 CFR parts 180 and 376, and 31 U.S.C. § 3321).

3) If you are unable to attest to the statements in this certification, you must include an explanation in Attachment 7: Other Relevant Documents.

See Section 4.1 viii of HRSA’s SF-424 Application Guide for additional information on all certifications.

Program-Specific Instructions In addition to application requirements and instructions in Section 4 of HRSA’s SF-424 Application Guide (including the budget, budget narrative, staffing plan and personnel requirements, assurances, certifications, and abstract), include the following:

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1371 http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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i. Project Abstract Use the Standard OMB-approved Project Abstract Summary Form 2.0 that is included in the workspace application package. Do not upload the abstract as an attachment or it will count toward the page limitation. For information required in the Project Abstract Summary Form, see Section 4.1.ix of HRSA’s SF-424 Application Guide.

The project abstract must be single-spaced, and limited to one page in length.

Please include the following information at the top of the abstract:

• Project Title

• Applicant Organization Name

• Applicant Organization Address

• Applicant Organization Web Site Address, if applicable

• Project Director Name (if applicable, state that the Project Director is also the

State Flex Coordinator)

• State Flex Coordinator Name (if different from Project Director)

• State Flex Coordinator Contact Phone Number(s)

• State Flex Coordinator E-Mail Address(es)

In addition, please include the following:

• A brief description of the project including the proposed type of quality improvement education/training(s) to be provided, to whom, and how often.

• A statement to identify the measures (at least three) the project will work to improve

• A statement to identify the ambulance agencies (at least five) that have agreed to participate

• Goals and specific measurable objectives of the proposed project.

NARRATIVE GUIDANCE

To ensure that you fully address the review criteria, the table below provides a crosswalk between the narrative language and where each section falls within the review criteria. Any forms or attachments referenced in a narrative section may be considered during the objective review.

Narrative Section Review Criteria

Introduction (1) Need

Needs Assessment (1) Need

Methodology (2) Response, (3) Evaluative Measures, (4) Impact, and (5) Resources/Capabilities

Work Plan (2) Response

Resolution of Challenges (2) Response https://sharepoint.hrsa.gov/ofam/dgp/PolicySOP/Grants%20Policy%20Bulletin%202019-04%20Eligible%20Applicants.pdf

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Narrative Section Review Criteria

Evaluation and Technical Support Capacity

(3) Evaluative Measures, (4) Impact, and

(5) Resources/Capabilities

Organizational Information (5) Resources/Capabilities

Budget Narrative (6) Support Requested

ii. Project Narrative This section provides a comprehensive description of all aspects of the proposed project. It should be succinct, self-explanatory, consistent with forms and attachments, and organized in alignment with the sections and format below so that reviewers can understand the proposed project.

Use the following section headers for the narrative:

INTRODUCTION -- Corresponds to Section V’s Review Criterion #1 Need

Provide a brief overview of the purpose of the proposed project, the overall strategy and reasoning, and your projected outcomes and goals for the two-year period of performance. Explain the importance of the project. Describe how the measures chosen will be used to enhance quality improvement efforts at the agency level.

NEEDS ASSESSMENT -- Corresponds to Section V’s Review Criterion #1 Need

Describe the needs of the participating EMS agencies and rural communities in the state, as they relate quality improvement and data collection efforts. This section identifies and describes the problem your project seeks to address, with appropriate supporting data. This section should help reviewers understand the state context, environment, rural EMS agencies, and rural communities that will be served by the proposed Flex EMS Supplement.

Clearly identify data sources and data timeframes to show that this assessment is based on the most recent information available.

The assessment should:

• Provide an environmental scan assessing rural EMS in the state, focused on the participating agencies and the problem your project will address;

• Clearly define the problem(s) that the project aims to address;

• Provide data in support of your assessment of the problem; consider how health disparities and health equity may contribute to the problem;

Your chosen measures may affect only certain populations. If applicable, describe the implications for populations or subpopulations that have historically suffered from poorer health outcomes, health disparities, and other inequities compared to the rest of the target population. These populations may include, but are not limited, to homeless populations, racial and ethnic minorities, pregnant women, adolescents and youth, etc.

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• Identify potential partners that you can engage; and

• Describe how the proposed project advances the overall goal of improving access to quality emergency medical care in rural communities.

METHODOLOGY -- Corresponds to Section V’s Review Criteria #2 Response, #3 Evaluative Measures, #4 Impact, and #5 Resources and Capabilities

This section should demonstrate a clear understanding of how the education and quality improvement activities proposed will result in improved pre-hospital care for the participating communities

Describe the methods you plan to use to address and improve your chosen EMS measures and related quality improvement activities. The methods should include how you intend to increase accurate EMS reporting while using the data to drive quality improvement at the agency level.

Describe how you will educate/train EMS staff and leadership on the use of data and quality improvement efforts (including the importance of accurate reporting). Discuss the educational resources that will be the basis for your education/training and why you chose them.

Discuss how you will account for applicable health disparities and health equity measures outlined in your needs assessment.

Project proposals must include at least five rural EMS agencies. Critical access hospitals and/or other key stakeholders may also be included as appropriate. Letters of support (Attachment 6) to participate from at least five EMS agencies must also be included. Each letter must specify the EMS agency’s willingness and intent to participate in the program for the entire duration of the project.

Explain the plan for project support and sustainability after the period of federal funding ends. HRSA expects recipients to sustain key elements of their projects, e.g., strategies or services and interventions, which have been effective in improving practices and those that have led to improved outcomes for the target population.

WORK PLAN -- Corresponds to Section V’s Review Criterion #2 Response

Describe the activities or steps that you will use to achieve each of the objectives proposed during the entire period of performance in the Methodology section. Use a time line that includes each activity and identifies responsible staff. Include your anticipated outputs and proposed outcome measures you are hoping to achieve. As appropriate, identify meaningful support and collaboration with key stakeholders in planning, designing, and implementing all activities. Provide a complete work plan that describes each of the activities to be conducted related to at least three identified rural EMS measures.

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Refer to the Flex Program Funding Guidance section of the Technical Assistance & Services Center website (TASC) for more information on the structure of the work plan.

Include the work plan as Attachment 1.

RESOLUTION OF CHALLENGES -- Corresponds to Section V’s Review Criterion #2 Response

Provide details on the approaches that you will use to mitigate risks and resolve any challenges so the project can continue as planned. Describe how your management plan will promote accountability and an effective execution. You should discuss any challenges that could be encountered, especially related to keeping project participants, including EMS agencies and other partners, actively engaged for the duration of the project, including the completion of final reporting. Discuss approaches that you will use to resolve such challenges.

EVALUATION AND TECHNICAL SUPPORT CAPACITY -- Corresponds to Section V’s Review Criteria #3 Evaluative Measures, #4 Impact, and #5 Resources/Capabilities

Please use the following sub-headings in responding to this section: Project Monitoring and Evaluation Capability.

Project Monitoring and Evaluation Capability Use this section to describe your resources and capacity to collect data throughout the project and meet the requirements of the final report.

This section should show your capacity and ability to plan for effective program management for the duration of the proposed project.

• Describe current experience, skills, and knowledge base that will contribute to monitoring and evaluation of the proposed project, including individuals on staff, materials published, and previous work of a similar nature.

• Identify the three EMS measures you chose for your project; explain the process used to decide on the measures, and why they were chosen.

• Describe the goals/desired outcomes the project aims to achieve by the end of the two-year period of performance.

• Explain how you will use the identified baseline data to evaluate ongoing processes and the progress towards the goals and objectives of the project.

• Describe the systems and processes that your organization will use to collect and manage data needed for accurate and timely performance reporting.

Evaluation Plan https://www.ruralcenter.org/content/flex-program-funding-guidance

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• Describe how you will analyze and assess your data in a way that will increase the knowledge on accurate EMS reporting and quality improvement efforts at the agency level.

• Explain how the proposed evaluation plan will assess the effectiveness of the project. Describe your approach to disseminating project results.

• Describe how you will assess sustainability of the activities, and how you will determine whether further implementation is or is not recommended.

ORGANIZATIONAL INFORMATION -- Corresponds to Section V’s Review Criterion #5 Resources/Capabilities

Refer to the organizational chart in Attachment 4 and explain (as applicable) how the state Flex program fits within its larger parent organization.

Describe the approaches (including staff, contracts, and subawards) you will use to achieve program objectives and how you will ensure coordination between staff, contractors, and subrecipients, as applicable. Describe how you will organize the project to use federal funds as effectively and efficiently as possible.

Describe relationships with partners or contracts and subawards that will help the state Flex program successfully implement and evaluate the proposed Flex EMS Supplement.

Include a description of your monitoring and assessment processes for subrecipients, subawards, and/or contractors, if applicable.

Refer to your Staffing Plan and Biographical Sketches of Key Personnel as Attachment 2 and 3 respectively, as needed, to justify the information presented in this section.

iii. Budget The directions offered in the SF-424 Application Guide may differ from those offered by Grants.gov. Follow the instructions in Section 4.1.iv of HRSA’s SF-424 Application Guide and the additional budget instructions provided below. A budget that follows the Application Guide will ensure that, if HRSA selects your application for funding, you will have a well-organized plan and, by carefully following the approved plan, may avoid audit issues during the implementation phase.

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Reminder: The Total Project or Program Costs are the total allowable costs (inclusive of direct and indirect costs) you incur to carry out a HRSA-supported project or activity.

Total project or program costs include costs charged to the award and costs borne by you to satisfy a matching or cost-sharing requirement, as applicable.

If indirect costs are included in the budget, attach a copy of the indirect cost rate agreement as Attachment 5.

As required by the Consolidated Appropriations Act, 2021 (P.L. 116-260), Division H, § 202 and Division A of the FY 2022 Extending Funding and Emergency Assistance Act (P.L. 117-43), “None of the funds appropriated in this title shall be used to pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of Executive Level II.” See Section 4.1.iv Budget – Salary Limitation of HRSA’s SF-424 Application Guide for additional information. Note that these or other salary limitations may apply in the following fiscal years, as required by law.

Authorizing legislation (Title XVIII, §1820(g)(4) of the Social Security Act (42 U.S.C.

1395i-4(g)(4)), as amended) limits indirect costs under the Flex Program. Indirect costs will be budgeted and reimbursed at the lesser of 15 percent of total direct costs or the applicant’s negotiated Indirect Cost Rate Agreement (ICRA). This limitation on indirect cost rates is a requirement of this federal award and, as required in 45 CFR § 75.351- 353, the limitation includes subrecipients.

iv. Budget Narrative See Section 4.1.v. of HRSA’s SF-424 Application Guide.

In addition, the EMS Supplement program requires the following:

This award will have a two-year period of performance. The budget narrative should describe expected spending for all two years of the project and align with the timeline in the work plan. The annual progress reports will include an annual update to the budget narrative.

The budget narrative should justify all requested costs for the supplemental award, including all contracts or subawards. It should be clearly explained how the costs were determined or estimated, and the specific contract deliverables for each contractor or subrecipient. Funds requested for the Flex EMS Supplement may not duplicate costs already provided under the primary Flex Program cooperative agreement award. The corresponding budget narrative must justify only funds to be used to support additional activities derived from the supplemental funds.

Note that supplemental funds can only be used to purchase equipment and supplies necessary to implement the project and cannot be used to purchase equipment or supplies for general use. As applicable, you must explain in the budget narrative how each equipment item will be used and how sustainability will be assured, including how the equipment will be inventoried, maintained, and used after the end of the supplemental funding. Supply purchases must also be listed and justified in the budget narrative.

http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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Allowable uses of funds under this notice include, but are not limited to, the following purposes:

• Salaries for project management personnel

• Training/education on accurate data collection and entry, system use, NEMSIS v3.5, quality improvement methodology

• Regional or state-wide EMS conferences that highlight EMS quality improvement initiatives

• Data collection tools including software and information technology devices such as computers or tablets and telehealth connection services or devices

• Reimbursement of EMS agency staff time, for data collection and reporting

v. Attachments

Provide the following items in the order specified below to complete the content of the application. Unless otherwise noted, attachments count toward the application page limitation. Your indirect cost rate agreement and proof of non-profit status (if applicable) will not count toward the page limitation. Clearly label each attachment. You must upload attachments into the application. Any hyperlinked attachments will not be reviewed/opened by HRSA.

Attachment 1: Work Plan Attach the work plan for the proposed project that includes all information detailed in Section IV. ii. Project Narrative. . Include output and outcome measures for the Flex EMS Supplement.

Attachment 2: Staffing Plan (see Section 4.1.vi. of HRSA’s SF-424 Application Guide) Include a staffing plan and provide a justification for the plan that includes a rationale for each award-funded staff position. Include position descriptions with the roles, responsibilities, and qualifications of proposed project staff. Keep each position description to one page in length or less.

Attachment 3: Biographical Sketches of Key Personnel Include biographical sketches for Key Personnel, less than one page in length per person. In the event that a biographical sketch is included for an identified individual not yet hired, include a letter of commitment from that person with the biographical sketch.

Key Personnel are the Principal Investigator/Project Director (PI/PD) and other individuals who contribute to the programmatic development or execution of a project or program in a substantive, measurable way, whether or not they receive salaries or compensation under the award.

Attachment 4: Project Organizational Chart Provide a one-page figure or diagram that depicts the organizational structure of the project. Include subrecipients and contractors that are integral to the success of the project in the figure.

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Attachment 5: Indirect Cost Rate Agreement (NOT counted in page limit) If applicable, provide the current federally negotiated indirect cost rate agreement used to substantiate indirect costs in the proposed budget.

Attachment 6: Letters of Support Provide letters of support from at least five rural EMS agencies that specifies the agency’s willingness and intent to participate in the program for the entire duration of the project. Letters of support must be dated and specifically indicate a commitment to the project/program (in-kind services, dollars, staff, space, equipment, etc.).

Attachments 7–15: Other Relevant Documents Include here any other documents that are relevant to the application.

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number Transition to the Unique Entity Identifier (UEI) and System for Award Management (SAM)

You must obtain a valid DUNS number, also known as the Unique Entity Identifier (UEI), and provide that number in the application. In April 2022, the DUNS number will be replaced by the UEI, a “new, non-proprietary identifier” requested in, and assigned by, the System for Award Management (SAM.gov). For more details, visit the following webpages: Planned UEI Updates in Grant Application Forms and General Service Administration’s UEI Update.

You must register with SAM and continue to maintain active SAM registration with current information at all times during which you have an active federal award or an application or plan under consideration by an agency (unless you are an individual or federal agency that is exempted from those requirements under 2 CFR § 25.110(b) or (c), or you have an exception approved by the agency under 2 CFR § 25.110(d)). For your SAM.gov registration, you must submit a notarized letter appointing the authorized Entity Administrator.

If you are chosen as a recipient, HRSA will not make an award until you have complied with all applicable SAM requirements. If you have not fully complied with the requirements by the time HRSA is ready to make an award, you may be deemed not qualified to receive an award, and HRSA may use that determination as the basis for making an award to another applicant.

If you have already completed Grants.gov registration for HRSA or another federal agency, confirm that the registration is still active and that the Authorized Organization Representative (AOR) has been approved.

Currently, the Grants.gov registration process requires information in three separate systems:

https://www.govinfo.gov/content/pkg/GPO-STYLEMANUAL-2016/pdf/GPO-STYLEMANUAL-2016.pdf http://www.plainlanguage.gov/howto/guidelines/FederalPLGuidelines/FederalPLGuidelines.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://sharepoint.hrsa.gov/ofam/dgp/Web%20Pages/Contacts.aspx?sysparm_kbid=d2e67885db0d5f00b3257d321f96194b&sysparm_search=kb0013183

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• Dun and Bradstreet (https://www.dnb.com/duns-number.html)

• System for Award Management (SAM) (https://sam.gov/content/home | SAM.gov Knowledge Base)

• Grants.gov (https://www.grants.gov/)

For more details, see Section 3.1 of HRSA’s SF-424 Application Guide.

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. Effective January 1, 2020, the forms themselves are no longer part of HRSA’s application packages instead, 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.gov.

If you fail to allow ample time to complete registration with SAM or Grants.gov, you will not be eligible for a deadline extension or waiver of the electronic submission requirement.

4. Submission Dates and Times

Application Due Date

The due date for applications under this NOFO is March 4, 2022 at 11:59 p.m. ET.

HRSA suggests submitting applications to Grants.gov at least 3 calendar days before the deadline to allow for any unforeseen circumstances. See Section 8.2.5 – Summary of emails from Grants.gov of HRSA’s SF-424 Application Guide for additional information.

5. Intergovernmental Review

The Medicare Rural Health Flexibility Program is not a program subject to the provisions of Executive Order 12372, as implemented by 45 CFR part 100.

See Section 4.1 ii of HRSA’s SF-424 Application Guide for additional information.

https://www.dnb.com/duns-number.html https://sam.gov/content/home https://www.fsd.gov/gsafsd_sp?id=gsa_kb_view2&kb_id=f66d8e6cdb76d4100d73f81d0f9619c6 https://www.fsd.gov/gsafsd_sp?id=gsa_kb_view2&kb_id=f66d8e6cdb76d4100d73f81d0f9619c6 https://www.grants.gov/ https://www.gpo.gov/fdsys/pkg/USCODE-2010-title25/pdf/USCODE-2010-title25-chap14-subchapII-sec450b.pdf https://www.govinfo.gov/content/pkg/COMPS-8771/pdf/COMPS-8771.pdf https://www.ssa.gov/OP_Home/ssact/title11/1101.htm https://sharepoint.hrsa.gov/ofam/dgp/PB2020/Grants%20Policy%20Bulletin%202020-01-Eligibility%20Cost%20Share%20and%20Matching.pdf

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6. Funding Restrictions

You may request funding for a period of performance of up to 2 years, at no more than $300,000 per year (inclusive of direct and indirect costs). This program notice is subject to the appropriation of funds, and is a contingency action taken to ensure that, should funds become available for this purpose, HRSA can process applications and award funds appropriately. Awards to support projects beyond the first budget year will be contingent upon Congressional appropriation, satisfactory progress in meeting the project’s objectives, and a determination that continued funding would be in the best interest of the Federal Government.

The General Provisions in Division H of the Consolidated Appropriations Act, 2021 (P.L.

116-260) and Division A of the FY 2022 Extending Funding and Emergency Assistance Act (P.L. 117-43) apply to this program. See Section 4.1 of HRSA’s SF-424 Application Guide for additional information. Note that these or other restrictions will apply in following fiscal years, as required by law.

Program authorizing legislation (Title XVIII, §1820(g)(4) of the Social Security Act (42 U.S.C. 1395i-4(g)(4)), as amended) limits indirect costs under the Flex Program.

Indirect costs will be budgeted and reimbursed at the lesser of 15 percent of total direct costs or the applicant’s negotiated Indirect Cost Rate Agreement (ICRA). The 15 percent limit is inclusive of direct and indirect costs. This limitation on indirect cost rates is a requirement of this federal award and, as required in 45 CFR § 75.351-353, the limitation includes subrecipients.

You cannot use funds under this notice for the following purposes:

• For direct patient care services;

• To purchase ambulances and any other vehicles;

• To purchase or improve real property; or

• For any purpose which is inconsistent with the language of this NOFO or Section

1820(g)(2) of the Social Security Act (42 U.S.C. 1395i-4(g)(2)).

You are required to have the necessary policies, procedures, and financial controls in place to ensure that your organization complies with all legal requirements and restrictions applicable to the receipt of federal funding including statutory restrictions on use of funds for lobbying, executive salaries, gun control, abortion, etc. Like all other applicable grants requirements, the effectiveness of these policies, procedures, and controls is subject to audit.

Be aware of the requirements for HRSA recipients and subrecipients at 2 CFR §

200.216 regarding prohibition on certain telecommunications and video surveillance services or equipment. For details, see the HRSA Grants Policy Bulletin Number: 2021- 01E.

https://www.hrsa.gov/sites/default/files/hrsa/grants/manage/grants-policy-bulletin-2021.pdf https://www.hrsa.gov/sites/default/files/hrsa/grants/manage/grants-policy-bulletin-2021.pdf

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All program income generated as a result of awarded funds must be used for approved project-related activities. Any program income earned by the recipient must be used under the addition/additive alternative. You can find post-award requirements for program income at 45 CFR § 75.307.

V. Application Review Information

1. Review Criteria

HRSA has procedures for assessing the technical merit of applications to provide for an objective review and to assist you in understanding the standards against which your application will be reviewed. HRSA has critical indicators for each review criterion to assist you in presenting pertinent information related to that criterion and to provide the reviewer with a standard for evaluation.

These criteria are the basis upon which the reviewers will evaluate and score the merit of the application. The entire proposal will be considered during objective review, except for the progress report submitted with a competing continuation application, which will be reviewed by HRSA program staff after the objective review process.

Six review criteria are used to review and rank the EMS Supplement Program applications. Below are descriptions of the review criteria and their scoring points.

Criterion 1: NEED (18 points) – Corresponds to Section IV’s Introduction and Needs Assessment

The extent to which the Introduction section (6 points):

• Provides a clear overview of purpose of the proposed project.

• Explains the strategy and reasoning for the proposed project.

• Describes the projected outcomes and goals of the proposed project.

• Explains the importance of the project.

• Provides an explanation of how the measures chosen will be used to enhance quality improvement efforts at the agency level.

The extent to which the Needs Assessment section (12 points):

• Demonstrates a clear and complete understanding of the needs of the participating EMS agencies and rural communities as they relate to quality improvement and data collection.

• Provides appropriate supporting data to help reviewers understand the state context, environment, rural EMS agencies, and communities to be served by the proposed project.

• Identifies all data sources used in the assessment, as well as data timeframes to show that the assessment is based on the most recent information available.

• Includes a comprehensive environmental scan assessing the rural EMS agencies that intend to participate.

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75

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• Clearly defines the problem(s) to be addressed.

• Provides the most recent and relevant data in support of the problem identified.

The data should account for applicable health disparities and equity measures that are thought to contribute to the problem. If applicable, the application should clearly describe the implications of the chosen measures on populations, or subpopulations that have historically suffered from poorer health outcomes, health disparities, and other inequities comparted to the rest of the target population.

• Identifies potential partners to engage in the proposed project.

• Clearly describes how the proposed project can advance the goal of improving access to quality emergency medical care in rural communities.

Criterion 2: RESPONSE (25 points) – Corresponds to Section IV’s Methodology, Work Plan, and Resolution of Challenges

The extent to which the Methodology section (8 points):

• Clearly describes the educational resources that will be used for education/training, improvement of measures, and why they were chosen.

• Describe how the education will be provided (series of classes, online, in-person, train the trainer etc.).

The extent to which the Work Plan (11 points):

• Describes the activities or steps to achieve each of the objectives proposed during the entire period of performance in the Methodology section.

• Provides a complete work plan that describes each of the activities to be conducted related to at least three identified rural EMS measures.

• Includes a timeline within the work plan for each activity and defines responsible staff.

• Includes anticipated outputs and outcomes to be achieved.

• Identifies meaningful support and collaboration with key stakeholders in planning, designing, and implementing all activities.

The extent to which the applicant’s Resolution of Challenges Section (6 points):

• Provides details on the approaches that will be used to mitigate and resolve any potential challenges.

• Includes a management plan that will promote accountability and effective project execution.

• Discusses any challenges that could be encountered, especially related to keeping project participants, including EMS agencies and other partners, actively engaged for the duration of the project, including the completion of final reporting.

• Discusses approaches to resolve such challenges.

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Criterion 3: EVALUATIVE MEASURES (25 points) – Corresponds to Section IV’s Methodology and Evaluation and Technical Support Capacity

The extent to which the Methodology section (10 points):

• Demonstrates a clear understanding of how the education and quality improvement activities proposed will result in improved pre-hospital care for the participating communities.

• Clearly and thoroughly describes the methods to be used to address and improve the chosen EMS measures and related quality improvement activities.

• Explains how the proposed project intends to increase accurate EMS reporting while using the data to drive quality improvement at the agency level.

• Outlines how the project will account for applicable health disparities and health equity measures described in the needs assessment.

The extent to which the Evaluation and Technical Support Capacity section (15 points):

Project Monitoring and Evaluation Capability

• Identifies and explains the process used to choose the three EMS measures proposed for the project.

• Describes the goals/desired outcomes the project aims to achieve by the end of the two-year period of performance.

• Describes a plan to use identified baseline data to evaluate ongoing processes and the progress towards the goals and objectives of the project.

• Describes the systems and processes to collect and manage data needed for accurate and timely performance reporting.

Evaluation Plan

• Describes a plan to analyze and assess data in a way that will increase the knowledge on accurate EMS reporting and quality improvement efforts at the agency level.

• Explains how the proposed evaluation plan will assess the effectiveness of the project and clearly outlines the approach to disseminating project results.

• Describes a plan to assess sustainability of the tested model or tested quality measures data reporting, and how they will determine whether further implementation is, or is not recommended.

Criterion 4: IMPACT (12 points) – Corresponds to Section IV’s…