FORHP HRSA-23-049 (UK9) RMOMS FINAL.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2023 Federal Office of Rural Health Policy

Community-Based Division

Rural Maternity and Obstetrics Management Strategies Program Funding Opportunity Number: HRSA-23-049

Funding Opportunity Type(s): New Assistance Listings Number: 93.912

Application Due Date: July 7, 2023

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: May 15, 2023

Victoria (Vicky) Tsai, MPH Public Health Analyst, Federal Office of Rural Health Policy Phone: (301) 443-8930 Email: RMOMS@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 U.S.C. § 254c-1b (§ 330A-2 of the Public Health Service Act) mailto:RMOMS@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 Rural Maternity and Obstetrics Management Strategies (RMOMS) program. The purpose of this program is to establish or continue collaborative improvement and innovation networks to improve access to and delivery of maternity and obstetrics care in rural areas.

Funding Opportunity Title: Rural Maternity and Obstetrics Management Strategies Program

Funding Opportunity Number: HRSA-23-049 Due Date for Applications: July 7, 2023 Anticipated FY 2023 Total Available Funding:

$2,000,000

Estimated Number and Type of Award(s): Up to 2 cooperative agreements Estimated Annual Award Amount: Up to $1,000,000 per award Cost Sharing/Match Required: No Period of Performance: September 30, 2023 through September

29, 2027 (4 years) Eligible Applicants: All entities providing prenatal care, labor care, birthing, and postpartum care services in rural areas, frontier areas, or medically underserved areas, or to medically underserved populations or Indian Tribes or Tribal organizations.

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.

http://www.hrsa.gov/ http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application

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Technical Assistance

HRSA has scheduled the following webinar:

May 31, 2023 from 2 p.m. – 3 p.m. ET

Weblink: https://hrsa-gov.zoomgov.com/j/1603630214?pwd=eGpkSHFwS0s4d3BWWm5xamFrUE5zZz09

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

Call-In Number: 1-833-568-8864 Meeting ID: 160 363 0214 Passcode: 42409094

HRSA will record the webinar. Please email RMOMS@hrsa.gov 24 hours after live event for a link to the recording.

https://hrsa-gov.zoomgov.com/j/1603630214?pwd=eGpkSHFwS0s4d3BWWm5xamFrUE5zZz09 https://hrsa-gov.zoomgov.com/j/1603630214?pwd=eGpkSHFwS0s4d3BWWm5xamFrUE5zZz09 mailto:RMOMS@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

PLEASE REFERENCE THE PROGRAM REQUIREMENTS AND EXPECTATIONS SECTION FOR

ADDITIONAL GUIDANCE

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. 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

APPENDIX A: RMOMS PROGRAM GLOSSARY

APPENDIX B: RMOMS DATA REQUIREMENTS

APPENDIX C: RMOMS PROGRAM RESOURCES

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Health Resources and Services Administration’s (HRSA) Rural Maternity and Obstetrics Management Strategies (RMOMS) program. The purpose of the RMOMS program is to establish or continue collaborative improvement and innovation networks to improve access to and delivery of maternity and obstetrics care in rural areas.

The goals of the RMOMS program are to:

(i) Identify and implement evidence-based and sustainable delivery models for the provision of maternal and obstetrics care in rural hospitals and communities;

(ii) Enhance and preserve access to maternal and obstetric services in rural hospitals that includes developing an approach to aggregate, coordinate, and sustain the delivery and access of preconception, prenatal, pregnancy, labor and delivery, and postpartum services;

(iii) Provide training for professionals in health care settings that do not have specialty maternity care;

(iv) Collaborate with academic institutions that can provide regional clinical expertise (such as specialty expertise and provider support using a variety of modalities including telehealth services) and help identify barriers to providing maternal health care, including strategies for addressing such barriers; and

(v) Assess and address disparities in infant and maternal health outcomes, including among rural racial and ethnic minority populations and underserved populations.

Applicants are encouraged to propose novel ways to achieve these goals through the establishment or continuation of collaborative improvement and innovation networks.

The RMOMS program seeks to document and monitor progress on these goals through the collection of aggregate data from each RMOMS award recipient and their network members. All network members will be REQUIRED to collect and share aggregate data.

This program intends to preserve access to and continuity of maternal and obstetrics care in rural communities that address the following RMOMS Focus Areas:

1) Rural Hospital Obstetric Service Aggregation A regional network with several rural hospitals that are facing challenges in providing obstetric services could aggregate obstetric services to a targeted rural hospital or Critical Access Hospital (CAH) within the rural region to revive or sustain rural obstetric and maternal services.

2) Approaches to Risk-Appropriate Care Pregnant patients in a rural region should receive care in a facility that best meets their needs and those of their neonates through appropriate risk stratification.

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3) Financial Sustainability Rural hospitals who have coordinated and aggregated their obstetrics services, in partnership with Medicaid and other payers, should aim to demonstrate improved outcomes and potential savings with the goal of ensuring ongoing support of the network once federal funding ceases.

For more details, see Program Requirements and Expectations.

2. Background

RMOMS is authorized by 42 U.S.C. § 254c-1b (§ 330A-2 of the Public Health Service Act), which provides for grants or cooperative agreements to establish or continue collaborative improvement and innovation networks to improve maternal and infant health outcomes and reduce preventable maternal mortality and severe maternal morbidity by improving maternity care and access to care in rural areas, frontier areas, maternity care health professional target areas (MCTAs), or jurisdictions of Indian Tribes and Tribal organizations.

National trends in maternal health have worsened over time1,2 and risk from maternal mortality is unevenly distributed across African Americans, American Indian/Alaskan Natives, low-income persons, and rural residents. Rural residents have a 9 percent greater chance of experiencing severe maternal morbidity and mortality compared with urban residents.3

Many factors affect the sustainability of rural obstetric care, including obstetric workforce recruitment and skill maintenance, birth volume, financial viability, resources, and infrastructure of prenatal and postnatal services. Over half of rural counties have no hospital-based obstetric services and rural counties face greater risk of further loss of services compared to urban counties.4 Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce.5 One way of addressing this issue is to form a regional network made up of several rural hospitals that are facing challenges in providing obstetric services and coordinating within the network to aggregate obstetric services to a targeted rural hospital or Critical Access Hospital (CAH) within the rural region in order to revive or sustain rural obstetric and maternal services. For example, volume may be too low at an individual rural hospital or CAH in the network; however, if deliveries were aggregated at one of the rural hospitals, the financial viability of rural obstetric services in the rural region could be increased.

1 Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System.

www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm. Accessed 9/13/21 2 Centers for Disease Control and Prevention. Severe Maternal Morbidity in the United States.

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html Accessed on 9/13/2021.

3 Kozhimannil K, Interrante J, Henning-Smith C, Admon K. Rural-Urban Differences in Severe Maternal Morbidity and Mortality in the US, 2007-2015. Health Affairs. 2019; 38 (12): 2077-2085. doi: 10.1377/hlthaff.2019.00805 4 Kozhimannil KB, Interrante JD, Tuttle MKS, Henning-Smith C. Changes in Hospital-Based Obstetric Services in Rural US Counties, 2014-2018. JAMA. 2020;324(2):197. doi:10.1001/jama.2020.5662 5 Hung P, Kozhimannil K, Casey M, Moscovice I. Why Are Obstetric Units in Rural Hospitals Closing Their Doors? Health Services Research. 2016; 51: 1546-1560. doi: 10.1111/1475-6773.12441

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State Medicaid agencies are an important partner in improving access to and delivery of maternity and obstetrics care in rural areas. Medicaid pays for nearly half of all births nationally and covers a greater share of births in rural areas,6 making Medicaid payment policies a key factor in developing sustainable services.

The RMOMS program is intended to provide start-up funding to awardees to test out new approaches to supporting, enhancing, and expanding maternal and obstetrics care.

Award recipients are expected to utilize these start-up funds to implement strategies that demonstrate the success of their approach and work with payers and network partners to continue these strategies after federal funding ends. These awards are to support the networks in the development of new approaches that seek to improve outcomes, service coordination and achieve sustainability.

II. Award Information

1. Type of Application and Award

Type of applications sought: New

HRSA will provide funding in the form of cooperative agreements. 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:

• Providing common measures and data elements that must be reported by all recipients (See Appendix B);

• Participating in the planning and development of the qualitative and quantitative data collection methods (See Appendix B);

• Reviewing and providing recommendations on the Regional Obstetrics Service Aggregation Plan;

• Reviewing award activities on an ongoing basis and providing input on strategies or approach;

• Participating, as appropriate, in the planning and implementation of any meetings, training activities or workgroups conducted during the period of performance; and

• Providing consultation with the maternal and obstetrics services rural health network, as appropriate, in outreach and dissemination activities.

6 Medicaid and CHIP Payment and Access Commission. (2020). Medicaid’s Role in Financing Maternity Care [Fact Sheet].

https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid%E2%80%99s-Role-in-Financing-Maternity-Care.pdf

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

• Adhering to HRSA guidelines pertaining to acknowledgement and disclaimer on all products produced with HRSA award funds;

• Complying with program terms and reporting requirements detailed in the notice of award;

• Participating in conference calls and/or meetings with HRSA;

• Responding timely to requests for information, including requests for data submissions from HRSA;

• Establishing relationships and collaborations to leverage other federal and state supported Maternal and Child Health programs and state Medicaid agencies;

• Completing activities included in the Regional Obstetrics Service Aggregation Plan, specifically data collection and active participation in HRSA-funded efforts to contribute to the rural maternal health evidence base;

• Cooperating with a HRSA-funded Technical Assistance Provider and Data Support Provider during the period of performance (and potentially share project updates and information with them after the period of performance ends);

• Leading the network in data collection and reporting activities, including:

o Working with a HRSA-funded Data Support Provider to collect and report aggregate data at least twice a year throughout the course of the 4-year period of performance; and o Timely development of a data collection strategy and infrastructure to satisfy aggregate data reporting requirements in the planning period (year

1) and throughout implementation (years 2-4).

Data collection and reporting requirements, including anticipated measures, are detailed in Appendix B.

• Establishing a shared network governance model that incorporates perspectives from all members in its decision-making and resource allocation to meet program goals while ensuring and demonstrating high-level engagement from every member. The shared governance model structure should provide safeguards to ensure a collaborative decision-making process that empowers all network members to address program goals. HRSA strongly encourages that the governing body adopts a document (e.g., bylaws, charter, memorandum of understanding/agreement, etc.) that clearly defines the roles and responsibilities of each member and the decision-making structure of the governing body.

• Adjusting approach based on HRSA feedback and priorities.

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2. Summary of Funding

HRSA estimates approximately $2,000,000 to be available annually to fund up to two recipients. You may apply for a ceiling amount of up to $1,000,000 annually (reflecting direct and indirect costs) per year.

The period of performance is September 30, 2023 through September 29, 2027 (4 years). Funding beyond the first year is subject to the availability of appropriated funds for RMOMS 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.

III. Eligibility Information

1. Eligible Applicants

Eligible applicants are non-profit or for-profit entities providing prenatal care, labor care, birthing, and postpartum care services in rural areas, frontier areas, or medically underserved areas, or to medically underserved populations or Indian Tribes or Tribal organizations.

Please reference the Program Requirements and Expectations section for additional guidance.

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.

• Fails to propose a service area that is entirely rural, as defined by the Rural

Health Grants Eligibility Analyzer. All services supported by the RMOMS Program must exclusively occur in HRSA-designated rural areas. Please reference the Program Requirements and Expectations section for additional guidance.

• Applicant organization fails to demonstrate that it is part of a network comprised of at least three health care provider organizations (including the applicant organization) and includes the three required network partner types defined in http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 https://data.hrsa.gov/tools/rural-health https://data.hrsa.gov/tools/rural-health

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the glossary. Please reference the Program Requirements and Expectations section for additional guidance.

Multiple Applications

Multiple applications from an organization with the same Unique Entity Identifier (UEI) are allowed if the applications propose separate and distinct projects.

Applications associated with the same DUNS number or EIN should be independently developed and written. HRSA reserves the right to deem applications that provide insufficient information in Attachment 3 or are nearly identical in content, to be ineligible. In this instance, assuming all other eligibility criteria are met, 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.

Multiple Submissions

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. 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-23-049 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, and https://www.gsa.gov/about-us/organization/federal-acquisition-service/office-of-systems-management/integrated-award-environment-iae/iae-information-kit/unique-entity-identifier-update 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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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 budget figures expressed in 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. If you use an OMB-approved form that is not included in the workspace application package for HRSA-23-049, 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.

HRSA will flag any application that exceeds the page limit and redact any pages considered over the page limit. The redacted copy of the application will move forward to the objective review committee.

It is important to ensure your application does not exceed the specified page limit.

Applications must be complete and validated by Grants.gov under HRSA-23-049 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).

3) If you are unable to attest to the statements in this certification, you must include an explanation in Attachment 12: Other Relevant Documents.

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

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

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Program Requirements and Expectations

Note that failure to meet the below program requirements, in addition to the criteria outlined in the Eligibility section, may result in HRSA deeming your application nonresponsive.

Applicant Organization Specifications:

The applicant organization should be a domestic public or private, non-profit or for-profit entities, including faith-based, community-based, tribes and tribal organizations. The applicant organization may be located in a rural or urban area, and must have demonstrated experience serving, or the capacity to serve, rural underserved populations.

The applicant organization may not have previously received federal funding for the same project. However, you are eligible to apply for funding under this announcement if the original period of performance for your previous award has ended by the start date for this funding opportunity (September 30, 2023) and if your newly proposed project (1) seeks to expand services or expand your service areas, (2) includes new or additional network member organizations, or (3) targets a new population or new focus area are eligible to apply if the original period of performance for their previous award has ended.

Network Specifications:

For the purposes of the RMOMS program, HRSA is employing a network model to encourage hospitals to aggregate services and work together in a collective manner to improve access to and sustain maternal and obstetric services in a rural region.

The applicant organization must be part of a group of entities that are either an established or a formal network, which may need to be expanded to meet this program’s network definition. A network is defined as an organizational arrangement among three or more separately owned domestic public and/or private health care organizations, including the applicant organization. The overall network must be able to provide prenatal care, labor care, birthing, and postpartum care services in rural areas, frontier areas, or medically underserved areas, or to medically underserved populations or Indian Tribes or Tribal organizations.

Each network member must demonstrate involvement in the project and contribute to the project goals, including data sharing and reporting capabilities (See Appendix B).

For the purposes of this program, the applicant must have a network composition that includes:

1) at least three rural hospitals or Critical Access Hospitals (CAHs);

2) at least one academic or tertiary institution that can provide regional clinical expertise (such as specialty expertise and provider support using a variety of modalities including telehealth services) and help identify barriers to providing maternal health care, including strategies for addressing such barriers; and

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3) the state Medicaid agency.

Partnership with the state Medicaid agency is beneficial, as rural populations have a large share of Medicaid recipients and networks are to plan for financial sustainability.

Medicaid covers nearly 50 percent of all births nationally and the engagement, expertise, and support of state Medicaid agencies will be critical to the long-term success of the program and may also provide opportunities to achieve long-term savings.7 Accordingly, successful applicants are required to obtain at least a letter of commitment from the state Medicaid agency within 90 days of the project period start date and a signed Memorandum of Agreement or Understanding (MOA/U) with the state Medicaid agency by the end of the planning year (September 29, 2024).

Given the specialized nature of maternal health, network members should be equipped to manage and coordinate care throughout preconception, pregnancy, labor, delivery, and postpartum periods. Other potential partners include, but are not limited to:

• Accredited birth centers

• Community organizations

• Emergency medical services entities

• Federally Qualified Health Center (FQHC) or FQHC look-alike

• Health Center Controlled Networks

• Level III and/or Level IV facility8

• CMS-certified Rural Health Clinic (RHC)

• Primary care providers/offices

• Primary care associations

• Regionally and/or locally available social services in the continuum of care (i.e., state Home Visiting and Healthy Start Programs)

• Rural Emergency Hospitals

• State Offices of Rural Health

Include the signed MOA/U that defines the roles and responsibilities for network partners 1 and 2:

1) at least three rural hospitals or Critical Access Hospitals (CAH)

2) at least one academic or tertiary institution that can provide regional clinical expertise and help identify barriers to providing maternal health care, including strategies for addressing such barriers

Depending on your network structure, HRSA may ask for further clarification upon receiving the award.

If you are an established network, please include a summary, no longer than one page, detailing your network’s history of working together and highlighting your network’s

7 Rossier Markus A, et al. Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform.

Women's Health Issues. 2013; 23 (5): e273-e280. DOI: 10.1016/j.whi.2013.06.006 8 Level III (Subspecialty Care) and Level IV (Regional Perinatal Health Care Centers) facilities are defined by Levels of Maternal Care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. American Journal of Obstetrics and Gynecology 2019;134:e41e55. doi: 10.1016/j.ajog.2019.05.046.

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products, services, and sources of sustainability as Attachment 2. If you are an existing RMOMS network, please also detail how you are proposing to expand the scope of the project or the area that will be served through the project in Attachment 2.

Geographic Requirements:

The applicant organization, along with each network member who will receive any of the awarded funds, must have separate and different Employer Identification Numbers (EINs).

The intent of this program is to establish or continue collaborative improvement and innovation networks that improve and expand access to maternal and obstetric services in rural, frontier and tribal areas as well as communities identified as maternity care health professional target areas (MCTAs). At least one network member must be located in a HRSA-designated rural county or rural census tract in an urban county;

however, the applicant organization may be located in an urban area. All services supported by this program must exclusively be provided in, and must target populations residing in, HRSA-designated rural counties or rural census tracts in urban counties.

RMOMS Focus Areas:

Applicants are required to incorporate all of the RMOMS Focus Areas in their proposals.

Additionally, applicants are required to address the focus-specific prompts listed below as they prepare a response. Responses do not have to be limited to these items and may include additional information related to the RMOMS Focus Areas.

Rural Hospital Obstetric Service Aggregation

a. Demonstrate how a regional network with several rural hospitals that are facing challenges in providing obstetric services could aggregate obstetric services to a targeted rural hospital or Critical Access Hospital (CAH) within the rural region to revive or sustain rural obstetric and maternal services. For example, volume may be too low at an individual rural hospital or CAH in the network; however, if deliveries were aggregated at one of the rural hospitals, the financial viability of rural obstetric services in the rural region could be increased.

b. Provide training for professionals in health care settings that do not have specialty maternity care so that professionals are prepared to deliver babies and provide obstetrics care in birthing-ready environments.

c. Collaborate with academic or tertiary institutions that can provide regional clinical expertise (such as specialty expertise and provider support using a variety of modalities including telehealth services)

Approaches to Risk Appropriate Care

• Show how the network will ensure pregnant patients in the rural region receive care in a facility that best meets their needs and those of their neonates through appropriate risk stratification. For example, lower-risk and routine pregnancies may be delivered in rural settings and policies and procedures may be in place to transfer higher-risk deliveries to a tertiary facility.

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• Address how rural regions can approach care practices to prioritize referral to an appropriate facility during pregnancy rather than emergent transfer during labor.

• Illustrate how telehealth platforms can support rural clinicians and the obstetric patients they serve and connect patients to specialty care that is otherwise unavailable in the region.

• Assess and address disparities in infant and maternal health outcomes, including among racial and ethnic minority populations and underserved populations in rural areas, frontier areas, maternity care health professional target areas, or jurisdictions of Indian Tribes and Tribal organizations.

Financial Sustainability

• Show how rural hospitals who have coordinated and aggregated their obstetrics services, in partnership with Medicaid and other payers, can demonstrate improved outcomes and potential savings with the goal of ensuring ongoing support of the network once federal funding ceases.

State Office of Rural Health Notification:

Each state has a State Office of Rural Health (SORH), and HRSA encourages applicants to make every effort to contact the SORH entity early in the application process to advise them of your intent to apply. The SORH may be able to provide consultation, information regarding model programs, data resources, and technical assistance for networks, evaluation, partner organizations, or support of information dissemination activities. A list of the SORHs can be accessed at:

https://nosorh.org/nosorhmembers/nosorh-members-browse-by-state/.

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.

Applicants should list the rural areas (counties) that will be served. Proposed counties should be fully rural, but if counties are partially rural counties, please include the rural census tract(s) in the Project Abstract. It is important that applicants list the rural counties (or rural census tract(s) if the county is partially rural) that will be served through their proposed project as this will be one of the factors that will determine whether the application is non-responsive.

https://nosorh.org/nosorhmembers/nosorh-members-browse-by-state/

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ABSTRACT HEADER CONTENT

Applicant Organization Information Organization Name, Address (street, city, state, ZIP code), Facility/Entity Type (e.g., CAH, State Office of Rural Health, tribal organization, FQHC, RHC, public health department, etc.) and Website Address (if applicable) Designated Project Director Information Project Director Name & Title, Contact Phone Number and E-Mail Address RMOMS Project

• Project Title and Goal(s)

• Requested award amount for each project year (1-4)

ABSTRACT BODY CONTENT

Network Composition

• Briefly describe the network, including name and goal(s). Indicate if you are a formal or established network, and if you expanded your network membership for this program, detail which network members were added.

• Indicate the number of network members involved in the project who have signed a MOA/U; indicate organization facility type (e.g., CAH, State Office of Rural Health, tribal organization, health center, RHC, public health department, etc.)

Target Service Area It is recommended that applicants provide this information in a table format.

• Entirely Rural Counties (list county name(s))

• Partially Rural Counties (list city, state, zip code, and census tract) Applicants should specify whether the area is in a HRSA-designated rural county or rural census tract in an urban county. To ascertain whether a particular county or census tract is rural, please refer to https://data.hrsa.gov/tools/rural-health?tab=Address

Target Population Briefly describe the target population the project proposes to serve and track.

Service Delivery Briefly describe the type of services provided (i.e., information demonstrating the provision of prenatal care, labor care, birthing, and postpartum care services) in rural areas, frontier areas, or medically underserved areas, or to medically underserved populations or Indian Tribes or Tribal organizations).

https://data.hrsa.gov/tools/rural-health?tab=Address

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Capacity to Serve Rural Underserved Populations

• Applicants must demonstrate their experience serving or the capacity to serve rural, underserved populations. Examples to show a history or ability to serve in this capacity may include, but is not limited to:

o Identifying formal partnerships/formalized MOA/Us with rural health care organizations (if applicable).

o Identifying activities that aggregate, strengthen, and maintain the necessary competencies and resources needed to sustain obstetrics service in a rural region.

o Discussing organizational expertise and capacity as it relates to the scope of work proposed. Include a brief overview of the organization’s assets, skills and qualifications to carry on the project.

o Describing current experience, including partnerships, activities, program implementation and previous work of a similar nature.

o Discussing the effectiveness of methods and/or activities employed to improve pregnancy and obstetrics health care services in rural communities.

• HRSA requires that applicants describe the geographic relationship to the proposed target rural service population, as well as the plans to ensure that the target rural populations are served.

Project Activities/Services Briefly describe the proposed project activities and/or services.

Expected Outcomes Briefly describe the proposed project’s expected outcomes.

Funding Opportunity Notification Briefly describe how the applicant organization learned about this funding opportunity.

(Select one: State Office of Rural Health, HRSA News Release, Grants.gov, HRSA Project Officer, HRSA Website, Technical Assistance Provider, State/Local Health Department, Other (please explain) Funding Priority Points Requested To receive a funding priority, please include a statement that you qualify for a funding priority and identify the priority in the abstract. HRSA highly recommends that the applicant use the language below to identify their funding priority request:

“[Applicant organization name] is requesting a funding priority. The proposed RMOMS program will [insert program goals] in [state Z], one of the states with the top 10 highest average MCTA scores.”

Refer to Section V.2 for further information.

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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 and

(5) Resources/Capabilities

Organizational Information (5) Resources/Capabilities

Budget Narrative (6) Support Requested

ii. Project Narrative

This section provides a comprehensive but succinct description of all aspects of the proposed project.

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 The introduction should provide a brief overview of the target population(s) and service area and the network members involved in the project. This section should outline the project’s purpose, goals, activities and expected outcomes as they relate to each of the RMOMS Focus Areas: rural hospital obstetric service aggregation, approaches to risk appropriate care, and financial sustainability approaches.

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

This section outlines the community’s need for the proposed project, and how the rural underserved populations in the local community or region to be served will be involved in the development and ongoing operations of the project. Describe how the target population was involved in determining the need and relevant barriers the project intends to overcome and provide a geographical snapshot of the targeted service area(s). A list of resources is located in Appendix C.

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Please use the following four sub-headings for this section: (1) Target Population Details and Maternal Health Indicators, (2) Stakeholder Involvement, (3) Target Service Area Details, (4) Maternal and Obstetrics Health Care Availability in Service Area

(1) Target Population Details and Maternal Health Indicators

a. Describe the target population. Detail the number of people in the target population; number of births in the last 3 years in the service area and the projected number of births going forward for the period of performance.

Also, include applicable information regarding the social determinants of health and health disparities.

b. Describe the associated unmet health needs of the target population of the proposed project. Identify and describe any national and/or local rankings data to include the number of maternal deaths and or most recent maternal mortality ratio; rate of Severe Maternal Morbidity (SMM); and other maternal health indicators (e.g., percentage of pregnant patients with health insurance, median age at time of first birth, rate of cesarean section deliveries, percentage of birth parents who received a postpartum visit, teen birth rate; low birth weight rate, etc.). When possible, disaggregate health indicators by race and ethnicity or other demographic characteristics and/or discuss and contextualize your target population with respect to racial and ethnic disparities or other demographic characteristics in maternal health.

(2) Stakeholder Involvement

a. Describe how you identified the needs of the target region. Further, describe the involvement of the network members to ensure the project is responding to the target population’s needs. Highlight the extent to which all stakeholders are represented among your network partners.

b. Discuss the manner and degree to which the region’s stakeholders were included in planning the activities of the project, specifically the involvement of the target population in the program development.

(3) Target Service Area Details

a. Identify and describe the target service area(s) for the proposed project.

b. Describe the hospital service region for the network service area including both rural and Critical Access Hospitals as well as upstream tertiary referral partners with which your network has procedures in place for transfer of high-risk patients.

c. Provide a map that shows the location of network members, the geographic area that will be served by your network and include any other information that will help reviewers visualize and understand the scope of the proposed activities. Please include the map as Attachment 4. Note:

Maps should be legible and in black and white.

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(4) Maternal and Obstetrics Health Care Availability in Service Area

a. Describe the health care services available in or near the target service area and any gaps in services, including whether the service area is an identified maternity care health professional target area (MCTA) or health care professional shortage area (HPSA). Specifically detail the current obstetric services available or not available in the region and recent or pending changes to those services (i.e., lost or at risk of closing), average travel time between facilities, provision of prenatal and postnatal care, lack of a coordinated and continuum of care at various stages of pregnancy, financial sustainability issues as it relates to obstetric care, etc.

b. Prior RMOMS cohorts faced challenges related to competition between providers that negatively affected program goals. Describe how the MOUs of separately owned network members will focus on program outcomes for the population served regardless of patient choice of where services are received as well as the seamless sharing of program data across network members.

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

This section outlines, in a narrative format, the methods that you will use to address and respond to the aforementioned needs and meet each of the program activities and expectations in this NOFO. The following items must be addressed within the methodology sections. Please use the headings: (1) Methods for Fulfilling Planning Year 1 Activities, (2) Methods for Fulfilling Implementation Years 2-4 Activities, (3) Methods for Sustainability Planning, and (4) Methods for Maintaining Network and Stakeholder Commitment.

(1) Methods for Fulfilling Planning Year 1 Activities

Detail the methods you will use to complete each first-year activity, which include:

a. Engage in network capacity building and infrastructure development. This can include, but is not limited to:

o acquire appropriate staffing and equipment needs to support your Regional Obstetrics Service Aggregation Plan;

o develop a network business model;

o identify how network members can integrate their functions and share clinical and/or administrative resources; and o identify and establish ways to obtain regional and/or local community support/buy-in around the aggregation of obstetric services.

b. Utilize the Regional Obstetrics Service Aggregation Plan (Attachment 5) to guide the planning of program implementation in years 2-4.

c. Establish data collection strategy. Both quantitative and qualitative data will be used by the network and the HRSA-funded Data Support Provider to

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inform progress on the Regional Obstetrics Service Aggregation Plan;

perform continuous quality improvement; and identify gaps in the aggregation of obstetric care within the targeted rural service area. Network leads must establish a process to gather and store data from all network partners and report aggregate data from network partners. Sample data elements are included in Appendix B. The HRSA-funded Data Support Provider will work with network leads to determine a secure method to transfer aggregate data.

o Review Appendix B: RMOMS Data Requirements and detail how your network proposes to gather, share, and store data from all network partners, and report aggregate data from network partners to the HRSA-funded Data Support Provider. If your network has partners with different ownership status and you plan to provide funds to compensate partners for data collection time and resources, please ensure that these funds are reflected in your budget.

o Note: a data collection strategy must be finalized during year 1 for data collection and storage of aggregate data. A signed and dated Data Usage/Sharing Agreement with all network partners must be submitted at the time of application as Attachment 10.

(2) Methods for Fulfilling Implementation Years 2-4 Activities

Detail the methods you will use to complete activities in years 2-4, which include:

a. Implement the program using the approved Regional Obstetrics Service Aggregation Plan.

b. Ensure the ongoing and full participation of each network member in a shared governance model.

c. Collect aggregate data from network partners and report data to the HRSA-funded Data Support Provider.

(3) Methods for Sustainability Planning The RMOMS program is intended to provide start up-funding to awardees to test out new approaches to supporting, enhancing and expanding maternal and obstetrics care. Awardees are expected to work with payers and network partners to continue these core program activities after HRSA funding ends. Describe a plan for sustaining the model funded by the RMOMS award and discuss the following:

a. How the strategies planned to aggregate rural obstetric services and appropriately stratify risk (e.g., lower-risk and routine pregnancies delivered in rural network settings and higher-risk deliveries handled at a referral hospital in the network) will lead to long-term sustainable rural hospital obstetric services in the service area.

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b. The strategies you will utilize to achieve the desired sustainability of the project as a result of the RMOMS funding. You must detail how to sustain your RMOMS funded programs beyond the 4-year period of performance.

This should include an examination of support via payers (public and private) or a dues-structure or contributions by network members as part of a sustainability plan.

c. How to leverage the partnership with the state Medicaid agency and other payers to develop innovative reimbursement strategies for sustainability.

d. The potential sources of support for achieving sustainability with a program emphasis on testing and innovating financial models to support maternal health. Most successful sustainability strategies include a variety of sources of support and do not depend on federal funding to maintain program activities.

Note: As part of receiving the award, recipients are required to submit a final sustainability plan during the final year of their period of performance. Further information will be provided upon receipt of the award.

(4) Methods for Maintaining Network and Stakeholder Commitment

Describe how your network will maintain members’ commitment throughout the period of performance to: fulfill the proposed activities, engage members in a shared governance model, promote efficient decision-making, assure accurate and timely data collection & reporting, undertake sustainability planning, and ensure that the rural underserved populations in the local community or region to be served will be involved in the development and ongoing operations of the project.

Describe how the network will build and maintain stakeholder involvement and commitment to developing strategies responsive to the RMOMS focus areas, and inclusive of engaging partnerships with organizations to improve health equity throughout the period of performance.

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