FORHP HRSA-23-043 (U27) Flex CA_FINAL.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2023

Federal Office of Rural Health Policy

Hospital State Division

Medicare Rural Hospital Flexibility Program Evaluation Cooperative Agreement Funding Opportunity Number: HRSA-23-043

Funding Opportunity Types: New, Competing Continuation

Assistance Listings (AL) Number: 93.155

Application Due Date: October 31, 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: August 25, 2022

Kathleen Connors de Laguna Health Insurance Specialist, Federal Office of Rural Health Policy Telephone: (301) 287-0166 Email: kconnorsdelaguna@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: §711(b)(5) of the Social Security Act (42 U.S.C. 912(b)(5)) mailto:kconnorsdelaguna@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, 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 2023 Medicare Rural Hospital Flexibility Program Evaluation Cooperative Agreement. Data collected and analyzed through this program will help improve health care in rural areas by helping Critical Access Hospitals (CAHs) better understand areas for improvement and efficiently target limited resources.

CAHs will have access to analyses of national, state, and hospital-level data, including reports for the Medicare Beneficiary Quality Improvement Program (MBQIP), as well as evidence-based best practices to improve their outcomes. Additionally, work evaluating CAH improvement efforts will inform CAHs and State Flex Programs. This work can also include data analysis and evaluation of best practices of CAH associated Provider- Based Rural Health Clinics. This program directly supports CAHs as Medicare Rural Hospital Flexibility (Flex) Program beneficiaries in carrying out activities of the Flex Program.

This notice is a contingency action taken to ensure that, should funds become available for this purpose, HRSA can process applications and award funds appropriately. You should note that this program may be cancelled before award.

Funding Opportunity Title: Medicare Rural Hospital Flexibility Program Evaluation Cooperative Agreement

Funding Opportunity Number: HRSA-23-043

Due Date for Applications: October 31, 2022

Anticipated FY 2023 Total Available Funding:

$1,615,000

Estimated Number and Type of Award: 1 cooperative agreement

Estimated Annual Award Amount:

Up to $1,615,000 per year, subject to the availability of appropriated funds

Cost Sharing/Match Required: No http://www.hrsa.gov/

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Period of Performance: July 1, 2023 through June 30, 2028 (5 years)

Eligible Applicants: Eligible applicants include domestic public or private, non-profit entities. Faith-based and community-based organizations, tribes, and tribal organizations are eligible to apply.

See Section III.1 of this notice of funding opportunity (NOFO) for complete eligibility information.

Application Guide

You (the applicant organization/agency) are responsible for reading and complying with the instructions included in this NOFO and in HRSA’s SF-424 Application Guide. Visit HRSA’s How to Prepare Your Application page for more information.

Technical Assistance

HRSA has scheduled the following webinar:

Day and Date: September 19, 2022 Time: 3 – 4 p.m. ET Weblink: https://hrsa-gov.zoomgov.com/j/1603697218?pwd=ekhrYWVDcUUvZ1pUSXZuUmt6VHdodz09 Participants also have the option of using VOIP (Computer Audio).

Attendees without computer access or computer audio can use the dial-in information below.

Call-In Number: 1-833-568-8864 Passcode: 42275355

HRSA will record the webinar. Please contact kconnorsdelaguna@hrsa.gov for playback information 48 hours after the live event.

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AW ARD

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

vi. Attachments

3. UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AW ARD 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. AW ARD 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 Evaluation Cooperative Agreement. The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) is accepting applications for the fiscal year FY 2023 Medicare Rural Hospital Flexibility Program Evaluation Cooperative Agreement. The purpose of this program is to improve healthcare in rural areas by analyzing and presenting Critical Access Hospital (CAH) data and capturing best practices to inform improvement efforts and efficiently target limited resources in CAHs. As Flex Program beneficiaries, CAHs will benefit by having resources that provide recommendations related to a number of national priorities:

• Quality of care reporting and improvement

• Financial and operational improvement

• Population health activities

• Emergency medical services integration

Through this program, CAHs will have access to analyses of national, state, and hospital-level data, including reports for the Medicare Beneficiary Quality Improvement Program (MBQIP), as well as evidence-based best practices to improve their outcomes.

Additionally, work evaluating CAH-focused improvement efforts will inform CAHs and State Flex Programs. This work can also include data analysis and evaluation of best practices of CAH associated Provider-Based Rural Health Clinics. This program directly supports CAHs as Medicare Rural Hospital Flexibility (Flex) Program beneficiaries in carrying out activities of the Flex Program.

2. Background

The Medicare Rural Hospital Flexibility Evaluation Cooperative Agreement is authorized by Section 711(b)(5) of the Social Security Act (42 U.S.C. 912(b)(5))

There are 1,356 CAHs throughout the country that serve as first line health care providers to patient populations living in rural communities. The health care environment has changed drastically in recent years, affecting how hospitals operate financially, manage the quality of care, and participate in their communities, especially during the COVID-19 pandemic. 181 rural hospitals have closed since 2005, and the remaining rural hospitals are at a higher risk of closure. As the healthcare landscape continues to change, there is increased pressure on CAHs to become more efficient and effective in meeting the health needs of their communities to remain financially viable and continue to provide needed services. The Flex Program provides support to these hospitals to improve quality of care as well as financial and operational processes. Data collected and analyzed by this program evaluation will help improve health care in rural areas by helping CAHs better understand areas for improvement and efficiently target limited resources. These efforts tie into the FORHP priorities for programs to improve access, expand capacity and services, enhance outcomes, and build sustainability. FORHP https://www.ssa.gov/OP_Home/ssact/title07/0711.htm https://www.flexmonitoring.org/critical-access-hospital-locations-map https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/

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works to improve health care in rural areas through a range of HRSA-funded programs that include:

• FORHP Rural Hospital Programs that provide technical assistance and support to address the unique needs of rural hospitals;

• The Technical Assistance and Services Center (TASC) provides broad educational materials and training to assist CAHs and state Flex Programs in more effectively meeting their performance goals; and

• The Rural Quality Improvement Technical Assistance Cooperative Agreement (RQITA) provides in depth technical assistance to benefit CAHs around quality reporting and improvement challenges, specifically related to the Medicare Beneficiary Quality Improvement Project (MBQIP). This initiative is aimed at increasing the number of CAHs that publicly report data on a set of rural-relevant quality measures, and using that data to drive quality improvement.

The Medicare Rural Hospital Flexibility Program Evaluation Cooperative Agreement will work in cooperation with all of the above programs to monitor and evaluate state-level grant activities to provide resources that provide analysis of best practices related to a number of national priorities, including quality of care reporting and improvement, financial and operational improvement, population health activities, and emergency medical services integration. This program evaluation data will be used by CAHs to improve health care in rural areas.

II. Award Information

1. Type of Application and Award

Type of applications sought: New, Competing Continuation

HRSA will provide funding in the form of a cooperative agreement. A cooperative agreement is a financial assistance mechanism where HRSA anticipates substantial involvement with the recipient during performance of the contemplated project.

In addition to the usual monitoring and technical assistance (TA) provided directly to award recipients, HRSA program involvement will include:

• Participate in the planning and development of the annual program evaluation portfolio, to include informing award recipient on national Flex Program goals, CAH issues, and information gaps each year.

• Provide input on materials to be publicly distributed.

https://www.hrsa.gov/rural-health/grants/rural-hospitals https://www.ruralcenter.org/tasc https://stratishealth.org/ https://stratishealth.org/ https://www.hrsa.gov/rural-health/grants/rural-hospitals/medicare-benificiary-quality-improvement https://www.hrsa.gov/rural-health/grants/rural-hospitals/medicare-benificiary-quality-improvement

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• Facilitate collaboration between the award recipient and Flex Program recipients, TASC, and RQITA to link needs discovered in relevant CAH research to the provision of targeted technical assistance.

• Share relevant program information related to state Flex programs and CAH performance activities.

• Utilize HRSA communications resources, as needed, to support the cooperative agreement.

• Collaborate with other FORHP research cooperative agreement program coordinators to avoid duplication of any Rural Health Research Center projects.

In addition to adhering to all applicable federal regulations and public policy requirements, the cooperative agreement recipient’s responsibilities will include:

• Adhere to HRSA guidelines pertaining to acknowledgement and disclaimer on all products produced by HRSA award funds, per Section 2.2 of the HRSA’s SF-424 Application Guide (Acknowledgement of Federal Funding).

• Analyze CAH data in the areas of quality improvement reporting measures, financial and operational improvement indicators, population health, and EMS data. Present the data in a manner that it can be used for driving improvement at the CAH and state Flex program level.

• Capture best practices to inform effective investments, service gaps, and improvement efforts in CAHs. Best practices will include analysis of national, state, and hospital-level data and be related to a number of national priorities listed in the purpose, as well as identification of promising health equity1 initiatives.

• Develop products that aim to improve health care in rural areas by sharing pertinent findings and evidence-based best practices regarding State Flex Program-level and CAH-level performance activities to key stakeholders such as, but not limited to:

• State Offices of Rural Health (SORH)

1 Promoting equity is essential to the Department’s mission of protecting the health of Americans and providing essential human services. This view is reflected in the following Executive Order:

Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, 86 FR 7009, at § 2(a) (Jan. 20, 2021), https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf.

See also Executive Order 13988 on Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation, 86 FR 2023, at § 1 (Jan. 20, 2021), https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01761.pdf.

https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01761.pdf

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• National Organization of State Offices of Rural Health (NOSORH)

• National Rural Health Association (NRHA)

• State Flex programs

• Technical Assistance and Services Center (TASC)

• Quality Improvement Organizations (QIO)

• Rural Quality Improvement Technical Assistance (RQITA)

• National Association of Rural Health Clinics (NARHC)

• CAHS, RHCs, and other rural providers.

• Collaborate with HRSA and other Flex Program partners such as TASC and

RQITA to link needs discovered in relevant CAH research to the provision of targeted technical assistance.

• Align research projects and data analysis with national Flex Program goals, CAH issues, and information gaps to inform overall Flex Program impact.

• Conduct trend data analysis and long-term national evaluative studies.

• Establish or maintain a list and map of all CAHs, made available to the public and updated regularly.

2. Summary of Funding

HRSA estimates approximately $1,615,000 to be available annually to fund one (1) recipient. The actual amount available will not be determined until enactment of the final FY 2023 federal appropriation. You may apply for a ceiling amount of up to $1,615,000 annually (reflecting direct and indirect, facilities and administrative costs) per year. 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.

The period of performance is July 1, 2023 through June 30, 2028 (5 years). Funding beyond the first year is subject to the availability of appropriated funds for the Medicare Rural Hospital Flexibility Cooperative Agreement in subsequent fiscal years, satisfactory progress, 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.

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III. Eligibility Information

1. Eligible Applicants

Eligible applicants include domestic public or private, non-profit or for-profit organizations. Institutions of higher education, faith-based and community-based organizations, tribes, and tribal organizations are eligible to apply.

2. Cost Sharing/Matching

Cost sharing/matching is not required for this program.

3. Other

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

• Exceeds the funding ceiling amount

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

NOTE: Multiple applications from an organization are not allowed. HRSA will only accept and review your last validated electronic submission before the Grants.gov application due date.

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. If you use an alternative electronic submission, see Grants.gov:

APPLICANT SYSTEM-TO-SYSTEM.

The NOFO is also known as “Instructions” on Grants.gov. You must select “Subscribe” and provide your email address for HRSA-23-043 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.

https://www.grants.gov/ http://www.grants.gov/applicants/apply-for-grants.html http://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/web/grants/s2s/applicant-system-to-system.html https://www.grants.gov/web/grants/s2s/applicant-system-to-system.html https://www.grants.gov/web/grants/applicants.html

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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, and certifications. You must submit the information outlined in 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 this NOFO and HRSA’s SF-424 Application Guide. You must submit the application in the English language and in the terms of U.S. dollars (45 CFR § 75.111(a)).

See Section 8.5 of the HRSA SF-424 Application Guide for the Application Completeness Checklist to assist you in completing your application.

Application Page Limit The total of uploaded attachment pages that count against the page limit shall be no more than the equivalent of 80 pages when printed by HRSA. Standard OMB-approved forms included in the workspace application package do not count in the page limit. The abstract is the standard form (SF) "Project_Abstract Summary.” If there are other attachments that do not count against the page limit, this will be clearly denoted in Section IV.2.vi Attachments.

The abstract is no longer an attachment that counts in the page limit. Additionally, Indirect Cost Rate Agreement and proof of non-profit status (if applicable) do not count in the page limit. However, if you use an OMB-approved form that is not included in the workspace application package for HRSA-23-043, it will 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.

It is important to take appropriate measures to ensure your application does not exceed the specified page limit. Any application exceeding the page limit 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-23-042 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. § 3354).

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3) If you are unable to attest to the statements in this certification, you must include an explanation in Attachment 9: 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:

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

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

Work Plan (2) Response and (4) Impact

Resolution of Challenges (2) Response

Evaluation and Technical Support Capacity (3) Evaluative Measures

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.

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Successful applications will contain the information below. Please use the following section headers for the narrative:

INTRODUCTION -- Corresponds to Section V’s Review Criterion 1: Need Provide a brief overview of how the proposed project aligns with the purpose of this cooperative agreement to improve healthcare in rural areas by analyzing and presenting CAH data and capturing best practices to inform improvement efforts and efficiently target limited resources.

NEEDS ASSESSMENT -- Corresponds to Section V’s Review Criteria 1: Need

Provide a detailed discussion of the information gaps related to the Flex Program areas of quality improvement, financial and operational improvement, population health, and EMS integration. The issues, challenges, and data needs of CAHs should be clearly articulated.

METHODOLOGY -- Corresponds to Section V’s Review Criteria 2: Response Propose methods that you will use to address the identified needs and meet each of the Cooperative Agreement Recipient’s responsibilities. As appropriate, include development of effective tools and strategies for data collection and analysis as well as evidence-based best practices for ongoing outreach to CAHs.

The methodology should cover a five year period of performance explaining activities to begin July 1, 2023 and going no longer than June 30, 2028. This narrative should expand upon the work plan matrix addressing the following:

o Clearly demonstrate activities intended to be completed in the period of performance;

o Describe how the project will be implemented;

o Provide evidence and direct linkage to how the work plan addresses the needs identified in the Needs Assessment section above; and o Describe how each activity will improve healthcare in rural areas.

WORK PLAN -- Corresponds to Section V’s Review Criterion 2: Response and 4:

Impact Describe the activities or steps that you will use to achieve each of the objectives proposed in the Methodology section. Use a time line that includes each activity, identifies responsible staff, and indicate whether a project is a one-year or multi-year project. As appropriate, identify meaningful support and collaboration with key stakeholders in planning, designing, and implementing all activities, including developing the application. Clearly demonstrate the progression of implementation through final outcomes. These outcomes should include short, intermediate, and long-term outcomes reflective of the intent of the goals and objectives, as appropriate.

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Present a work plan matrix that illustrates the goals, objectives, strategies, and activities representing year one of the period of performance in Attachment 1.

Include a full description of each project proposed, as outlined in Attachment 6.

RESOLUTION OF CHALLENGES -- Corresponds to Section V’s Review Criteria 2:

Response Discuss challenges that you are likely to encounter in designing and implementing the activities described in the work plan, and approaches that you will use to resolve such challenges.

EVALUATION AND TECHNICAL SUPPORT CAPACITY -- Corresponds to Section V’s Review Criteria 3: Evaluative Measures Describe the plan for program performance evaluation that will contribute to continuous quality improvement. Describe the systems and processes that will support your organization's performance management requirements through effective tracking of performance outcomes, including a description of how the organization will collect and manage data (e.g., assigned skilled staff, data management software) in a way that allows for accurate and timely reporting of performance outcomes. Describe current experience, skills, and knowledge, including individuals on staff, materials published, and previous work of a similar nature. As appropriate, describe the strategy to collect, analyze, and track data to measure process and impact/outcomes, and explain how the data will be used to inform program development. Describe any potential obstacles for implementing the program performance evaluation and your plan to address those obstacles.

The evaluation plan should also include, but not be limited to, the tracking of:

• Types of requests for more information as related to products, including challenges in understanding and use of data and analysis.

• Number of reports disseminated.

• Number of presentations in conferences and meetings related to the work completed under the cooperative agreement.

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ORGANIZATIONAL INFORMATION -- Corresponds to Section V’s Review Criteria 5: Resources/Capabilities

Organizational Capacity

Succinctly describe your organization’s current mission, structure, and scope of current activities, and how these elements all contribute to the organization’s ability to implement the program requirements and meet program expectations. Include an organizational chart as Attachment 5. Discuss how the organization will follow the approved plan, as outlined in the application, properly account for the federal funds, and document all costs to avoid audit findings. Describe how you will routinely assess and improve the unique needs of target populations of the communities served.

Discuss the organization’s capability to execute the proposed work plan. Describe any established relationships or previous collaboration with other important Flex Program stakeholders such as, but not limited to:

• State Offices of Rural Health (SORH)

• National Organization of State Offices of Rural Health (NOSORH)

• National Rural Health Association (NRHA)

• State Flex programs

• Technical Assistance and Services Center (TASC)

• Quality Improvement Organizations (QIO)

• Rural Quality Improvement Technical Assistance (RQITA)

• National Association of Rural Health Clinics (NARHC)

• CAHS, RHCs, and other rural providers.

Describe the current experience, knowledge, and skills, including subject matter expertise of staff. Include a staffing plan and job descriptions for key personnel as Attachment 2. Include biographical sketches for all personnel as Attachment 3

If your organization will form a consortium, describe the capabilities and roles of each member organization. A complete list of consortium members must be submitted in Attachment 5. Ensure that the organization chart shows the applicant organization that is responsible for the overall management of the program and the relationship of all other involved partner organizations. Discuss the capability of the applicant organization to provide overall program management. If as part of the application you are integrating partner organizations to fulfil work plan requirements, include Letters of Agreement, MOU, etc. in Attachment 4.

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Organizational Expertise

Demonstrate your organization’s significant past experience conducting similar work.

Include specific examples of:

• Access to and experience with relevant data sets currently maintained by the applicant that will contribute to the ability of the organization to meet program expectations and analysis. Some examples include the following: AHA Annual Survey of Hospitals, County Health Rankings, Care Compare Quality Data, CMS Quality Measure Data, and Hospital Cost Reporting Information System, or other nationally representative surveys.

• Expertise identifying, analyzing, and disseminating best practices around rural hospital activities, including quality reporting, financial and operational improvement, population health, and EMS integration.

• Evidence demonstrating experience or relationships working with rural hospital, federal, and state stakeholders.

• Any relevant published materials or experience from key individuals on staff.

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.

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.

As required by the Consolidated Appropriations Act, 2022 (P.L. 117-103), Division H, § 202, “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.

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

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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 limit. Your indirect cost rate agreement and proof of non-profit status (if applicable) will not count toward the page limit. Clearly label each attachment. You must upload attachments into the application. HRSA and the objective review committee will not open/review any hyperlinked attachments.

Attachment 1: Work Plan Attach the work plan for the project that includes all information detailed in Section IV.2.ii. Project Narrative. If you will make subawards or expend funds on contracts, describe how your organization will ensure proper documentation of funds.

Attachment 2: Staffing Plan and Job Descriptions for Key Personnel (see Section 4.1. of HRSA’s SF-424 Application Guide)

Keep each job description to one page in length as much as is possible. Include the role, responsibilities, and qualifications of proposed project staff. Also include a description of your organization’s timekeeping process to ensure that you will comply with the federal standards related to documenting personnel costs.

Attachment 3: Biographical Sketches of Key Personnel Include biographical sketches for persons occupying the key positions described in Attachment 2, not to exceed two pages 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.

Attachment 4: Letters of Agreement, Memoranda of Understanding, and/or Description(s) of Proposed/Existing Contracts (project-specific)

Provide any documents that describe working relationships between your organization and other entities and programs cited in the proposal. Documents that confirm actual or pending contractual or other agreements should clearly describe the roles of the contractors and any deliverable. Make sure any letters of agreement are signed and dated.

Attachment 5: Project Organizational Chart Provide a one-page figure that depicts the organizational structure of the project.

Attachment 6: Project Proposals Each of the proposed projects submitted by the applicant should include a full project description that will serve to provide more detailed information about each written product that will be developed. Each individual project description should be limited to four pages in length and should include the following information: proposed title; objectives of the project; background; relevance to the national Flex Program goals and CAHs improvement strategies; overview of the project being proposed;

brief description of the design of the project; products and dissemination strategy;

references (if applicable). If multi-year projects are proposed, there should be a brief

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description of the expected phases of the multi-year project in future years as well as a discussion of how progress will be tracked each year.

Attachment 7: For Multi-Year Budgets--5th Year Budget After using columns (1) through (4) of the SF-424A Section B for a 5-year period of performance, you will need to submit the budget for the 5th year as an attachment.

Use the SF-424A Section B, which does not count in the page limit; however, any related budget narrative does count. See Section 4.1.iv of HRSA’s SF-424 Application Guide.

Attachment 8: Progress Report (FOR COMPETING CONTINUATIONS ONLY) A well-documented progress report is a required and important source of material for HRSA in preparing annual reports, planning programs, and communicating program-specific accomplishments. The accomplishments of competing continuation applicants are carefully considered; therefore, you should include previously stated goals and objectives in your application and emphasize the progress made in attaining these goals and objectives. HRSA program staff reviews the progress report after the Objective Review Committee evaluates the competing continuation applications. See Section V.2 Review and Selection Process for a full explanation of funding priorities and priority points.

The progress report should be a brief presentation of the accomplishments, in relation to the objectives of the program during the current period of performance.

The report should include:

(1) The period covered (dates).

(2) Specific objectives - Briefly summarize the specific objectives of the project.

(3) Results - Describe the program activities conducted for each objective.

Include both positive and negative results or technical problems that may be important.

Attachments 9–15: Other Relevant Documents Include here any other documents that are relevant to the application, including letters of support. Letters of support must be dated and specifically indicate a commitment to the project/program (in-kind services, dollars, staff, space, equipment, etc.).

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

Effective April 4, 2022:

• The UEI assigned by SAM has replaced the Data Universal Numbering System (DUNS) number.

• Register at SAM.gov and you will be assigned a UEI.

http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://sam.gov/content/home https://sam.gov/content/home

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You must register with SAM and continue to maintain active SAM registration with current information at all times when you have: an active federal award, an active application, or an active 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 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.

The Grants.gov registration process requires information in two separate systems:

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

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

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

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 application due date under this NOFO is October 31, 2022 at 11:59 p.m. ET.

HRSA suggests you submit your application 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 in HRSA’s SF-424 Application Guide for additional information.

5. Intergovernmental Review

Medicare Rural Hospital Flexibility Program Evaluation Cooperative Agreement is 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://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/ http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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6. Funding Restrictions

You may request funding for a period of performance of up to 5 years, at no more than $1,615,000 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, 2022 (P.L.

117-103) apply to this program. See Section 4.1 of HRSA’s SF-424 Application Guide for additional information. Note that these and other restrictions will apply in following fiscal years, as required by law.

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

• Purchasing or improving real estate

• Foreign travel

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 specific uses of funding. It is imperative that you review and adhere to the list of statutory restrictions on the use of funds detailed in Section 4.1 of HRSA’s SF-424 Application Guide. 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.

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 indicators for each review criterion to assist you http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf 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 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.307

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in presenting pertinent information related to that criterion and to provide the reviewer with a standard for evaluation.

Reviewers will evaluate and score the merit of your application based upon these criteria. However, if a progress report is submitted with a competing continuation application, HRSA program staff will review the report after the objective review process.

Six (6) review criteria are used to review and rank Medicare Rural Hospital Flexibility Evaluation Cooperative Agreement applications. Below are descriptions of the review criteria and their scoring points.

Criterion 1: NEED (10 points) – Corresponds to Section IV’s Introduction and Needs Assessment

The extent to which the application:

• Provides a detailed discussion of the information gaps related to the Flex Program areas of quality improvement, financial and operational improvement, population health, and EMS integration, and clearly articulates the issues, challenges, and data needs of CAHs.

Criterion 2: RESPONSE (30 points) – Corresponds to Section IV’s Methodology, Work Plan, and Resolution of Challenges

Methodology: (15 points)

The quality and extent to which the application:

• Responds to the “Purpose” included in the program description and meets each of the Cooperative Agreement Recipient responsibilities:

o Adhere to HRSA guidelines pertaining to acknowledgement and disclaimer on all products produced by HRSA award funds, per Section

2.2 of the HRSA’s SF-424 Application Guide (Acknowledgement of Federal Funding).

o Analyze Critical Access Hospital data in the areas of quality improvement reporting measures, financial and operational improvement indicators, population health, and EMS data. Present the data in a manner that it can be used for driving improvement at the CAH and state Flex program level.

o Capture best practices to inform effective investments, service gaps, and improvement efforts in CAHs. Best practices will include analysis of national, state, and hospital-level data and be related to a number of

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national priorities listed in the purpose, as well as identification of promising health equity2 initiatives.

o Develop products that aim to improve health care in rural areas by sharing pertinent findings and evidence-based best practices regarding State Flex Program-level and CAH-level performance activities to key stakeholders such as, but not limited to:

o State Offices of Rural Health (SORH) o National Organization of State Offices of Rural Health (NOSORH) o National Rural Health Association (NRHA) o State Flex programs o Technical Assistance and Services Center (TASC) o Quality Improvement Organizations (QIO) o Rural Quality Improvement Technical Assistance (RQITA) o National Association of Rural Health Clinics (NARHC) o CAHS, RHCs, and other rural providers.

o Collaborate with HRSA and other Flex Program partners such as TASC and RQITA to link needs discovered in relevant CAH research to the provision of targeted technical assistance.

o Align research projects and data analysis with national Flex Program goals, CAH issues, and information gaps to inform overall Flex Program impact.

o Conduct trend data analysis and long-term national evaluative studies.

o Establish or maintain a list and map of all CAHs, made available to the public and updated regularly.

• Includes development of effective tools and strategies for data collection, analysis, and evidence-based best practices for ongoing outreach to CAHs;

• Clearly demonstrates activities intended to be completed in the period of performance;

• Describes how the project will be implemented;

2 Promoting equity is essential to the Department’s mission of protecting the health of Americans and providing essential human services. This view is reflected in the following Executive Order:

Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, 86 FR 7009, at § 2(a) (Jan. 20, 2021), https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf.

See also Executive Order 13988 on Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation, 86 FR 2023, at § 1 (Jan. 20, 2021), https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01761.pdf.

https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01761.pdf

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• Provides evidence and direct linkage to how the work plan addresses the needs identified in the Needs Assessment section above; and o Provide a detailed discussion of the information gaps related to the Flex Program areas of quality improvement, financial and operational improvement, population health, and EMS integration. The issues, challenges, and data needs of CAHs should be clearly articulated.

• Describes how each activity will improve healthcare in rural areas.

Work Plan (10 points)

The quality and extent to which the application:

• Describes the activities or steps that will be used to achieve each of the objectives proposed in the Methodology section;

• Uses a time line that includes each activity, identifies responsible staff, and indicates whether a project is a one-year or multi-year project;

• Identifies meaningful support and collaboration with key stakeholders in planning, designing, and implementing all activities, including developing the application;

• Presents a full description of each project proposed, outlined in Attachment 6.

Resolution of Challenges (5 points)

The quality and extent to which the application:

• Discusses challenges likely to be encountered in designing and implementing the activities described in the work plan, and approaches that will be used to resolve such challenges.

Criterion 3: EVALUATIVE MEASURES (20 points) – Corresponds to Section IV’s Evaluation and Technical Support Capacity

The quality and extent to which the application:

• Describe the plan for program performance evaluation that will contribute to continuous quality improvement.

• Monitors ongoing processes and the progress towards the goals and objectives of the project, including how projects provide context for improvement activities;

• Includes descriptions of the inputs (e.g., organizational profile, collaborative partners, key personnel, budget, and other resources), key processes, and expected outcomes of the funded activities;

https://sharepoint.hrsa.gov/teams/forhp/hsd/FMT/NOFO%20FY23/HRSA-23-043_U27_SF-424%20Program%20Specific%20NOFO%20Version%202.docx#NEEDS_ASS…