FORHP HRSA-24-022 RRPD Final.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2024

Federal Office of Rural Health Policy

Policy Research Division

Rural Residency Planning and Development (RRPD) Program

Funding Opportunity Number: HRSA-24-022

Funding Opportunity Type(s): New

Assistance Listing Number: 93.155

Application Due Date: February 12, 2024 Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

We will not approve deadline extensions for lack of registration.

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

Issuance Date: November 14, 2023

Jason Steele, MPH Public Health Analyst, Policy Research Division Federal Office of Rural Health Policy Call: 301-443-2203 Email: ruralresidency@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 U.S.C. § 912(b)(5) (§711(b)(5) of the Social Security Act) mailto:ruralresidency@hrsa.gov

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508 COMPLIANCE DISCLAIMER

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.

SUMMARY

Funding Opportunity Title: Rural Residency Planning and Development (RRPD) Program

Funding Opportunity Number: HRSA-24-022

Assistance Listing Number: 93.155

Due Date for Applications: February 12, 2024

Purpose: The purpose of this program is to improve health care in rural areas by developing new, sustainable rural residency programs, including rural track programs (RTPs), that are accredited by the Accreditation Council for Graduate Medical Education (ACGME) to address the physician workforce shortages and challenges faced by rural communities. There are two pathways for this program: General Primary Care and High Need Specialty Pathway and Maternal Health and Obstetrics Pathway.

Program Objective(s): Objective 1: Establish a new rural residency program that is accredited by ACGME by the end of the period of performance, that will begin training its first resident class no later than academic year 2028.

Objective 2: Finalize a validated program sustainability plan that includes ongoing funding stream(s) to sustain long-term resident training once the program is established.

Objective 3: Develop a graduate tracking plan and publicly report on residents’ career outcomes after graduation for at least five years.

https://www.grants.gov/web/grants/view-opportunity.html?oppId=349410 https://www.acgme.org/initiatives/medically-underserved-areas-and-populations/rural-tracks/

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Eligible Applicants:

Eligible applicants are domestic public or private nonprofit or for-profit entities. These organizations may include, but are not limited to:

1) rural hospitals;

2) rural community-based ambulatory patient care centers, including Rural Health Clinics;

3) Native American tribal governments (federally recognized), tribal organizations (other than federally recognized tribal governments), or health centers operated by a tribal government or tribal organization;

4) graduate medical education consortiums, including institutions of higher education, such as, schools of allopathic medicine or osteopathic medicine or Historically Black Colleges and Universities (HBCUs).

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

Anticipated FY 2023 Total Available Funding:

$11,250,000

We’re issuing this notice to ensure that, should funds become available for this purpose, we can process applications and award funds appropriately. You should note that we may cancel this program notice before award if funds are not appropriated.

Estimated Number and Type of Award(s):

Up to 15 new grants

Estimated Total Award Amount: Up to $750,000 over the 3-year period of performance subject to the availability of appropriated funds. You will receive the full award amount in the first year of the period of performance. You must allocate the award across all three years.

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Cost Sharing or Matching Required:

No

Period of Performance: August 1, 2024 through July 31, 2027 (3 years)

Agency Contacts: Business, administrative, or fiscal issues:

Beverly Smith Grants Management Specialist Division of Grants Management Operations, OFAM Email: bsmith@hrsa.gov

Program issues or technical assistance:

Jason Steele, MPH Public Health Analyst, Policy Research Division Federal Office of Rural Health Policy Email: ruralresidency@hrsa.gov

Application Guide

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

Technical Assistance

We have scheduled the following webinar:

Friday, November 17, 2023 1 – 2:30 p.m. ET Weblink: https://hrsa-gov.zoomgov.com/j/1602612877?pwd=K3Y4WEVhZmpXV2Mxd2JOcGhTWVpwQT

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

Call-In Number: 1-833-568-8864 Meeting ID: 04553755

We will record the webinar.

mailto:bsmith@hrsa.gov mailto:ruralresidency@hrsa.gov http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application https://hrsa-gov.zoomgov.com/j/1602612877?pwd=K3Y4WEVhZmpXV2Mxd2JOcGhTWVpwQT09 https://hrsa-gov.zoomgov.com/j/1602612877?pwd=K3Y4WEVhZmpXV2Mxd2JOcGhTWVpwQT09 https://hrsa-gov.zoomgov.com/j/1602612877?pwd=K3Y4WEVhZmpXV2Mxd2JOcGhTWVpwQT09

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING OR 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: PAGE LIMIT WORKSHEET

APPENDIX B: RESOURCES

APPENDIX C: REVISED DELINEATIONS OF METROPOLITAN STATISTICAL AREAS

APPENDIX D: PROGRAM DEFINITIONS

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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 (HRSA) Rural Residency Planning and Development (RRPD) Program. The purpose of this program is to improve and expand access to health care in rural areas by developing new, sustainable rural residency programs, including rural track programs (RTPs), that are accredited by the Accreditation Council for Graduate Medical Education (ACGME), to address the physician workforce shortages and challenges faced by rural communities. This program provides start-up funding to RRPD award recipients to create new rural residency programs that will be sustainable long-term through viable and stable funding mechanisms, such as, Medicare, Medicaid, and other public or private funding sources.

For the purposes of this notice of funding opportunity (NOFO), rural residency programs are accredited physician residency programs that train residents in rural training sites for greater than 50 percent of their total time in residency, and focus on producing physicians who will practice in rural communities. This includes programs that meet ACGME RTP Designation, including both new programs and permanent complement increases for new rural training site(s) for existing programs.

There are two pathways for this program: General Primary Care and High Need Specialty Pathway and Maternal Health and Obstetrics Pathway.

General Primary Care and High Need Specialty Pathway: This pathway supports the development of new rural residency training programs that focus on training to meet significant rural health needs. The eligible specialties in this pathway are family medicine, internal medicine, preventive medicine1, psychiatry, and general surgery.

Maternal Health and Obstetrics Pathway: This pathway supports the development of new rural residency programs with a focus on training to provide high quality, evidence-based maternity care and obstetrical services in rural areas. The eligible specialties in this pathway are obstetrics-gynecology and family medicine with enhanced obstetrical training. Enhanced obstetrical residency training must provide family medicine residents with extensive clinical experience in comprehensive maternity care, as outlined in ACGME’s program requirements, including dedicated training on labor and delivery and operative obstetrics. These programs must have faculty with clinical expertise to prepare family medicine residents for the independent practice of obstetrics in rural communities. 2

1 For the purposes of this NOFO, only occupational and environmental medicine and public health and general preventive medicine are eligible specialties. Refer to program definitions for more information.

2 Effective July 1, 2023, ACGME revised family medicine program requirements contain updates for maternity care, including robust requirements on comprehensive pregnancy-related care. Refer to ACGME’s Family Medicine Program Requirements for more information.

https://www.acgme.org/initiatives/medically-underserved-areas-and-populations/rural-tracks/ https://www.acgme.org/globalassets/pfassets/programrequirements/120_familymedicine_2023.pdf

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Program Goals

The goal for the RRPD program is for each recipient to establish a new rural residency program (including RTPs) by the end of the period of performance that is accredited by ACGME and will be sustainable long-term through viable and stable funding mechanisms, such as, Medicare, Medicaid, and other public or private funding sources.

RRPD-funded rural residency programs will effectively train physicians to practice in and meet the clinical needs of rural populations. As a result, we expect that the proportion of graduates from these programs entering careers in practices primarily serving rural populations will markedly exceed that seen in other programs across the nation.

Program Objectives

Objective 1: Residency Program Development

a. Appoint a residency program director or identify a residency program director in development by the start of year 2 of the grant (August 1, 2025).

b. Submit ACGME application for the new rural residency program or RTP by the start of year 3 of the grant (August 1, 2026).

c. Establish a new rural residency program or RTP in eligible specialties that is ACGME accredited by the end of the period of performance (July 31, 2027).

d. Train first resident class no later than the academic year (AY) immediately following the end of the RRPD period of performance (AY 2028).

Objective 2: Program Sustainability

a. Finalize a validated sustainability plan that includes ongoing funding stream(s) to sustain long-term resident training once the program is established through one or more of the following options:

i. Qualifying under current regulatory authority for Medicare graduate medical education (GME) payments in rural hospitals starting a new residency training program. Specifically, the recipients:

1. Either have a viable direct GME Per Resident Amount (PRA) or are eligible to establish one after training residents for the first time in a new program; and

2. Are eligible for viable indirect medical education (IME) and/or direct GME (DGME) resident cap adjustment.3

3 The Consolidated Appropriations Act (CAA), 2021 (P.L. 116-260) authorized changes to Medicare GME regulations that expanded indirect and direct GME payment policies for Rural Track Programs (RTPs).

Refer to the implementation of the CAA in the FY22 Inpatient Prospective Payment System (IPPS) Final Rule with Comment Period and Section IV.2.ii. Program Sustainability for more information.

https://www.govinfo.gov/content/pkg/FR-2021-12-27/pdf/2021-27523.pdf https://www.govinfo.gov/content/pkg/FR-2021-12-27/pdf/2021-27523.pdf

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ii. Creating an RTP program in accordance with Medicare regulations that qualifies for viable IME and/or DGE payments;

iii. Qualifying for Medicaid GME, other state, or public and/or private support; or

iv. Combining multiple funding streams (e.g., a hospital may have a mix of Medicare and other public funding).

b. Finalize a detailed pro forma for program sustainability by the start of year 2 of the grant (August 1, 2025).

Objective 3: Graduate Tracking Plan

a. Develop a structured plan to track and publicly report on resident career outcomes after graduation for a period of at least 5 years after the first graduating class to determine retention in rural communities.

b. Identify and establish data collection elements for the graduate tracking plan.

Examples of information collected may include, but are not limited to, practice specialty/sub-specialty and location, patient population served, service time committed to the care of safety net patients, part/full-time clinical practice status, services offered, proportion of clinical time in inpatient and outpatient settings, and any additional training opportunities pursued after residency completion.

c. Finalize a detailed graduate tracking plan by the start of year 3 of the grant (August 1, 2026).

2. Background

RRPD is authorized by 42 U.S.C. § 912(b)(5) (§711(b)(5) of the Social Security Act) and administered by the HRSA’s Federal Office for Rural Health Policy (FORHP), in consultation with the Bureau of Health Workforce (BHW).

About 20 percent of the population or 60 million individuals, live in rural communities.4 People living in rural communities have higher rates of chronic conditions, preventable hospitalizations, and lack access to timely care compared to their urban counterparts.5 However, 70 percent of areas designated as primary medical health professional shortage area (HPSA) are located in rural or partially rural areas.6 At the same time, national trends show the demand for physicians will continue to grow, outpacing the projected supply. Recent data from the Association of American Medical Colleges (AAMC) projects a shortage of between 37,800 and 124,000 physicians across primary

4 U.S. Department of Health and Human Services, Health Resources and Services Administration. HRSA Defining Rural Population. Retrieved from https://www.hrsa.gov/rural-health/about-us/what-is-rural 5 Streeter RA, Snyder JE, Kepley H, Stahl AL, Li T, et al. The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health. PLOS ONE 24 April 2020 15(4): e0231443. Retrieved from https://doi.org/10.1371/journal.pone.0231443 6 U.S. Department of Health and Human Services, Health Resources and Services Administration Data Warehouse. Accessed July 2023 from https://data.hrsa.gov/topics/health-workforce/shortage-areas https://www.hrsa.gov/rural-health https://bhw.hrsa.gov/ https://www.hrsa.gov/rural-health/about-us/what-is-rural https://doi.org/10.1371/journal.pone.0231443 https://data.hrsa.gov/topics/health-workforce/shortage-areas

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care and non-primary care specialties by 2034.7 Contributing to the overall shortages is the maldistribution of the physician workforce. Urban areas have more physicians and rural and underserved communities experience the greatest need for health care providers.

Retaining and recruiting physicians continues to remain a critical issue for rural communities. One proven strategy is rural residency training. A recent study found that rural exposure during family medicine residency training is associated with a 5- to 6-fold increase in choosing rural practice.8 A second study found that rural training is more strongly associated with rural practice than having a rural background.9 Despite the demonstrated successes of rural training, research finds persistently limited opportunities for residents to train in rural communities. According to the U.S.

Government Accountability Office, only 2 percent of residency training occurred in rural areas between 2014-2015 and 2019-2020 and residency training is highly concentrated in urban areas, particularly in the southern and northeastern regions.10

However, rural residency programs often face financial, human resource and organizational capacity constraints, such as lack of sustainable financing, faculty support, and recruiting residents. To secure institutional recognition and support, rural residency programs need both academic partnerships and rural community faculty champions. Rural residency programs also report specific accreditation challenges, such as lacking sufficient specialty and subspecialty preceptors willing to sponsor residents for clinical rotations and meeting the appropriate level of scholarly activity required for busy community faculty.

The urgent need to address these challenges in developing new rural training opportunities resulted in the conception of the HRSA RRPD program. In FY18 and again in FY21, HRSA funded the RRPD-Technical

7 IHS Markit Ltd. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034.

Washington, DC: AAMC. 2021. Retrieved from https://www.aamc.org/media/54681/download 8 Russell, DJ, Wilkinson E, Petterson S, Chen C, Bazemore, A; Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice. J Grad Med Educ 1 August 2022; 14 (4): 441–450. doi: https://doi.org/10.4300/JGME-D-21-01143.1 9 Patterson, DG, Shipman, SA, Pollack, SW, et al. Growing a rural family physician workforce: The contributions of rural background and rural place of residency training. Health Serv Res. 2023; 1-7.

doi:10.1111/1475-6773.14168 10 United States Government Accountability Office. Graduate Medical Education: Programs and Residents Increased during Transition to Single Accreditor; Distribution Largely Unchanged. GAO-21-

329. April 2021. Retrieved from https://www.gao.gov/products/gao-21-329 11 HRSA has funded 73 awards, with some recipients developing multiple specialties under one award.

Figure 1: Map of RRPD rural counties https://www.hrsa.gov/library/rural-residency-planning-development https://www.aamc.org/media/54681/download https://doi.org/10.4300/JGME-D-21-01143.1 https://doi.org/10.1111/1475-6773.14168 https://www.gao.gov/products/gao-21-329

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Assistance Program, a cooperative agreement to establish the RRPD-TA Center to identify and share resources with RRPD applicants and support RRPD Program award recipients.

HRSA funded its inaugural RRPD cohort in FY19 and additional cohorts in FY20-23.

HRSA has made 73 RRPD Program awards across 36 states and 1 territory developing rural residencies or RTPs in family medicine (56), internal medicine (8), psychiatry (10), preventive medicine (1), general surgery (2), and obstetrics-gynecology (1).11 Recipients include rural hospitals, such as Critical Access Hospitals, Sole Community Hospitals, and Medicare Dependent Hospitals, tribal entities, Historically Black Colleges and Universities (HBCU), federally qualified health centers (FQHC), and graduate medical education consortiums.

As of July 1, 2023, 38 RRPD Program awardees have created new rural residency programs or RTPs for a total of 503 approved residency positions and 31 of these programs have matriculated over 300 physician residents. To navigate the complexities of accreditation and GME financing, all RRPD Program award recipients are required to collaborate with the HRSA-funded RRPD-TA Center and attend a 2-day Annual RRPD meeting throughout the duration of their period of performance. To learn more about the RRPD-TA center, visit www.ruralgme.org. Please see Appendix B for additional resources and Appendix D for important program definitions.

II. Award Information

1. Type of Application and Award

Application type(s) New

We will fund you via a grant.

2. Summary of Funding

We estimate $11,250,000 will be available to fund 15 recipients for the 3-year period of performance. You may apply for a ceiling amount of up to $750,000 total cost (reflecting direct and indirect costs) for the entire 3-year period of performance.

The period of performance is August 1, 2024, through July 31, 2027 (3 years). You will receive the full award amount in the first year of the three-year period of performance.

You must allocate the award funding across each of the three years. You must submit a budget and budget narrative for each of the three years of the period of performance.

While you must distribute the funding across each of the three years, the budget does not need to be evenly split across the three-year period of performance and can vary based on your community’s needs.

11 HRSA has funded 73 awards, with some recipients developing multiple specialties under one award.

https://www.hrsa.gov/library/rural-residency-planning-development http://www.ruralgme.org/

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This program notice depends on the appropriation of funds. If funds are appropriated for this purpose, we will proceed with the application and award process.

45 CFR part 75 - Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards applies to all HRSA awards.

If you’ve never received a negotiated indirect cost rate, you may elect to charge a de minimis rate of 10 percent of modified total direct costs (MTDC)*. You may use this for the life of the award. If you choose this method, you must use it for all federal awards until you choose to negotiate for a rate. You may apply to do so at any time. See Section 4.1.v. Budget Narrative in the Application Guide.

*Note: One exception is a governmental department or agency unit that receives more than $35 million in direct federal funding.

III. Eligibility Information

1. Eligible Applicants

Applicants must meet all of the following criteria in order to be considered eligible for RRPD funding. HRSA will not consider applicants that fail to meet any eligibility criteria for funding under this notice.

Eligible Entities

Eligible entities are domestic public or private nonprofit, or for-profit entities. These organizations may include, but are not limited to:

1) rural hospitals;

2) rural community-based ambulatory patient care centers, including Rural Health Clinics;

3) Native American tribal governments (federally recognized), tribal organizations (other than federally recognized tribal governments), or health centers operated by a tribal government or tribal organization;

4) graduate medical education consortiums, including institutions of higher education, such as, schools of allopathic medicine or osteopathic medicine or Historically Black Colleges and Universities (HBCUs).

https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75

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Rural Status

The applicant organization must propose rural residency programs that will train residents for greater than 50 percent of total residency training in a clinical training site (e.g., hospital, clinic, etc.) physically located in a rural area as defined by CMS and/or

FORHP:

• For applications proposing a sustainability plan that relies on Medicare GME funding, greater than 50 percent of total resident training must take place in a clinical training site physically located in a rural area that meets both CMS and FORHP definitions of rural.

• For this funding opportunity, applicants proposing a sustainability plan using Medicare GME must also demonstrate that their clinical training site(s) currently meeting both CMS and FORHP definitions of rural will meet CMS rural requirements in future years by documenting that the county is not in a metropolitan area delineated in OMB Bulletin No. 23-01, release July 21, 2023.

See Appendix C.

• For applicants proposing sustainability plans with no Medicare GME funding, greater than 50 percent of total resident training must take place in a clinical facility physically located in a rural area that meets FORHP's definition of rural.

In the case of an RTP, where the applicant organization is located in an urban area, the GME consortium must include at least one consortium member that operates a clinical training site located in a rural area that meets CMS and/or FORHP rural definitions. The relationship between the consortium members must be legally binding and the agreement establishing the relationship must describe the roles and responsibilities of each entity. Applicants must submit Letters of Agreement in Attachment 4.

Refer to Appendix D: Program Definitions for more information on how to confirm rural status. You must attach proof of CMS and/or FORHP rural status in Attachment 1.

New Rural Residency Programs & Eligible Specialties

Applications must propose to develop a new, sustainable rural residency program in family medicine or family medicine with enhanced obstetrical training, internal medicine, preventive medicine, psychiatry, general surgery, or obstetrics and gynecology that is accredited by ACGME. ACGME requires each Sponsoring Institution to achieve and maintain institutional accreditation prior to program accreditation. Entities who receive ACGME program accreditation for the proposed rural residency program by the application closing date are not eligible for this grant, however, applicants that achieve institutional accreditation by the application closing date are eligible.

We will only make award under this NOFO to applicants that propose to develop new rural residency programs. Programs applying for ACGME RTP Designation for a permanent resident complement increase by adding a new rural training site(s) to an existing program of the same specialty are considered new rural residency programs for the purposes of this NOFO. However, programs increasing resident FTE(s) at an https://www.whitehouse.gov/wp-content/uploads/2023/07/OMB-Bulletin-23-01.pdf

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existing RTP site without adding new rural training site(s) are not considered new rural residency programs. Programs that have already applied for ACGME RTP designation and received a permanent complement increase for the new RTP site by the application closing date are not considered new rural residency programs.

2. Cost Sharing or Matching

Cost sharing or matching is not required for this program.

3. Other

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

• Exceeds the funding ceiling amount

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

Award recipients under the previous RRPD Program funding notices (HRSA-19-088, HRSA-20-107, HRSA-22-094, and HRSA-23-037) and the Teaching Health Center Planning and Development (THCPD) Program (HRSA-22-107 and HRSA-23-015) are eligible to apply under this RRPD funding opportunity, if proposing a new rural residency program or RTP in a different specialty from the previously funded award. The recipient of RRPD-TA Program (HRSA-21-102) award is not eligible under this RRPD funding opportunity.

Multiple Applications

We will only review your last validated application before the Grants.gov due date.

We anticipate that most awards will be for one rural residency program, you may apply for funding to support developing multiple rural residency programs under one award, but you must clearly demonstrate in the application your ability to establish more than one.

Notifying State Office(s) of Rural Health

You are required to notify the State Office of Rural Health (SORH) in the state(s) where you are proposing to conduct rural training of your intent to apply to this program. You can access a list of the SORHs at https://nosorh.org/nosorh -members/nosorh-members-browse-by-state/. You must include in Attachment 8 a copy of the letter or email sent to the SORH(s) describing your project and any response received from the SORH(s).

Each state has a SORH, and HRSA recommends making 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 some consultation to you regarding model programs, data resources, consortiums, evaluation, and/or support of information dissemination activities. If you do not receive a response, you must still include the original letter or email you sent to the SORH(s).

https://nosorh.org/nosorh%20-members/nosorh-members-browse-by-state/ https://nosorh.org/nosorh%20-members/nosorh-members-browse-by-state/

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IV. Application and Submission Information

1. Address to Request Application Package

We require you to apply online through Grants.gov. Use the SF-424 workspace application package associated with this notice of funding opportunity (NOFO). Follow these directions: How to Apply for Grants. If you choose to submit using an alternative online method, see Applicant System-to-System.

Note: Grants.gov calls the NOFO “Instructions.”

Select “Subscribe” and enter your email address for HRSA-24-022 to receive emails about changes, clarifications, or instances where we republish the NOFO. You will also be notified by email of documents we place in the RELATED DOCUMENTS tab that may affect the NOFO and your application. You’re responsible for reviewing all information that relates to this NOFO.

2. Content and Form of Application Submission

Application Format Requirements Submit your information as the Application Guide and this program-specific NOFO state. Do so in English and budget figures expressed in U.S. dollars. There’s an Application Completeness Checklist in the Application Guide to help you.

Application Page Limit The total number of pages that count toward the page limit shall be no more than 60 pages when we print them. We will not review any pages that exceed the page limit.

Using the pages within the page limit, HRSA will determine eligibility using Section III.

Eligibility Information of the NOFO.

These items don’t count toward the page limit:

• Standard OMB-approved forms you find in the NOFO’s workspace application package

• Abstract (standard form (SF) "Project_Abstract Summary”)

• Indirect Cost Rate Agreement

• Rural Status Confirmation

• Biographical Sketches of Key Personnel

• SORH Letter(s) of Intent

• Proof of non-profit status (if it applies)

If there are other items that do not count toward the page limit, we’ll make this clear in Section IV.2.v Attachments and Appendix A.

If you use an OMB-approved form that is not in the HRSA-24-022 workspace application package, it may count toward the page limit.

https://www.grants.gov/ https://www.grants.gov/applicants/grant-applications/how-to-apply-for-grants https://www.grants.gov/system-to-system/applicant-system-to-system/

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Applications must be complete and validated by Grants.gov under HRSA-24-022 before the deadline.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

• When you submit your application, you certify that you and your principals12 (for example, program director, principal investigator) can participate in receiving award funds to carry out a proposed project. That is, no federal department or agency has debarred, suspended, proposed for debarment, claimed you ineligible, or you have voluntarily excluded yourself from participating.

• If you fail to make mandatory disclosures, we may take an action like those in 45 CFR § 75.371. This includes suspending or debarring you.13

• If you cannot certify this, you must include an explanation in Attachment 10-15:

Other Relevant Documents.

(See Section 4.1 viii “Certifications” of the Application Guide)

Program-Specific Instructions Include application requirements and instructions from Section 4 of the Application Guide (budget, budget narrative, staffing plan and personnel requirements, assurances, certifications, and abstract). Also include the following:

i. Project Abstract

Use the Standard OMB-approved Project Abstract Summary Form that you’ll find in the workspace application package. Do not upload the abstract as an attachment or it may count toward the page limit. For information you must include in the Project Abstract Summary Form, see Section 4.1.ix of the Application Guide.

In addition to the SF-424 Application Guide requirements, the project abstract must contain the following information below:

Abstract Header Content:

• Eligible Entity/Facility Type (e.g., rural hospital, refer to Section III.1 Eligible Entities)

• Project Director (PD) Name & Contact Information

• Residency Program Director Name & Contact Information (if applicable)

• Program Pathway (select one): General Primary Care and High Need Specialty Pathway Residency or Maternal Health and Obstetrics Pathway Residency

• Residency Specialty

12 See definitions at eCFR :: 2 CFR 180.995 -- Principal. and eCFR :: 2 CFR 376.995 -- Principal (HHS supplement to government-wide definition at 2 CFR 180.995).

13 See also 2 CFR parts 180 and 376, 31 U.S.C. § 3354, and 45 CFR § 75.113.

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 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 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-I/part-180/subpart-I/section-180.995 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376/subpart-I/section-376.995 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376/subpart-I/section-376.995 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-I/part-180 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376 https://uscode.house.gov/view.xhtml?req=granuleid%3AUSC-prelim-title31-chapter33&edition=prelim https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-B/section-75.113

HRSA-24-022 RRPD 11

• Residency Format (select one): Rural residency program (non-RTP), New RTP (New Program Accreditation), or Existing RTP (Adding New Rural Training Site to Existing Program)

• Sponsoring Institution Name, Location, and ACGME Sponsor Program Code (if applicable)

• Rural Target Area(s)

• Funding Amount Requested

• Program Sustainability Option (refer to Section IV.2.ii. Program Sustainability)

• Projected Total Number of Residents

• Expected ACGME Accreditation and Residency Matriculation Dates

• Funding Priority Points Requested, if applicable (refer to Attachment 9 and Section V.2 Review and Selection Process)

• List of Recent HRSA Awards received within the last 5 years, if applicable, by Program Name and Grant Number (e.g., Rural Residency Planning and Development Program, Grant No. P13RH99999).

Abstract Body Content:

• Brief overview of the project including description of geographic area, target patient population and needs, consortium members (if applicable) and clinical collaborations (e.g., training partners and types of clinical facilities); and

• Specific measurable objectives and expected outcomes of the project, how you will accomplish the proposed project (i.e., the “who, what, when, where, why and how” of a project).

NARRATIVE GUIDANCE

The following table provides a crosswalk between the narrative language and where each section falls within the review criteria. Make sure you’ve addressed everything. We may consider any forms or attachments you reference in a narrative section during the merit review.

Narrative Section Review Criteria

Introduction Criterion 1: NEED

Organizational Information Criterion 4: RESOURCES/CAPABILITIES

Need Criterion 1: NEED

Approach Criterion 2a: RESPONSE: APPROACH

HRSA-24-022 RRPD 12

Narrative Section Review Criteria

Work Plan Criterion 2b: RESPONSE: WORK PLAN

Resolution of Challenges Criterion 2c: RESPONSE: RESOLUTION OF

CHALLENGES

Evaluation and Technical Support Capacity

Criterion 3a: IMPACT: EVALUATION AND

TECHNICAL SUPPORT CAPACITY

Program Sustainability Criterion 3b: IMPACT: PROGRAM

SUSTAINABILITY

Budget Narrative Criterion 5: SUPPORT REQUESTED

ii. Project Narrative

This section must describe all aspects of the proposed project. Make it brief and clear.

Provide the following information in the following order. Please use the section headers.

This ensures reviewers can understand your proposed project.

Introduction – Corresponds to Section V’s Review Criterion 1 NEED

Briefly describe the purpose of the proposed project and clearly identify specific project goals, objectives, and expected outcomes. Summarize how the proposed project will address the population health needs and expansion of family medicine or family medicine with enhanced obstetrics, internal medicine, preventive medicine, psychiatry, general surgery, or obstetrics and gynecology care and access for the proposed target area(s).

Organizational Information – Corresponds to Section V’s Review Criterion 4:

RESOURCES/CAPABILITIES

In this section, you must demonstrate your organizational capacity to carry out the proposed project activities and ability to meet program expectations (e.g., reporting requirements and other grant administrative activities). Specifically, you must:

1. Succinctly describe your organization’s current mission and structure, scope of current activities, and how these elements all contribute to the organization’s ability to effectively manage the programmatic, fiscal, and administrative aspects of the proposed project.

2. Provide a project organizational chart in Attachment 5 that identifies the applicant organization, the residency program sponsoring institution, and all relevant collaborators, including clinical training partners involved in the development of the new rural residency program. Letters of Agreement with all key collaborators, clinical training site(s), and the sponsoring institution, if different from the applicant organization, must be included in Attachment 4.

HRSA-24-022 RRPD 13

3. Describe your organization’s experience developing rural residency programs, and how the expertise of collaborators will contribute to successfully implementing a new rural residency program.

4. Describe how you will routinely assess and improve the unique needs of target populations and communities served.

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.

6. If your organization is applying as part of a GME consortium, you must list out all members of the GME consortium, key personnel, responsibilities of each consortium member involved with the grant, and explain the flow of grant funds between members of the consortium (if applicable).

7. If funds will be sub-awarded or expended on contracts, explain how your organization will ensure these funds are properly used and monitored, including having policies and procedures in place that meet or exceed the requirements in 45 CFR part 75 regarding sub-recipient monitoring and management.

Include the staffing plan and job descriptions for key faculty/staff in Attachment 2 (Staffing Plan and Job Descriptions for Key Personnel). Include biographical sketches for each person occupying the key positions, not to exceed two pages in length each in Attachment 3. If you include a biographical sketch for an identified individual who is not yet hired, include a letter of commitment from that person with the biographical sketch. When applicable, biographical sketches should include training, language fluency, and experience working with diverse populations served by their programs.

Biographical sketches, not exceeding two pages per person, should include the following information:

• Key personnel name

• Position Title

• Education/Training – beginning with baccalaureate or other initial professional education, such as nursing, including postdoctoral training and residency training if applicable:

o Institution and location o Degree (if applicable) o Date of degree (MM/YY) o Field of study

HRSA-24-022 RRPD 14

• Section A (required) Personal Statement. Briefly describe why the individual’s experience and qualifications make him/her particularly well suited for his/her role (e.g., PD/PI) in the project that is the subject of the award.

• Section B (required) Positions and Honors. List in chronological order previous positions, concluding with the present position. List any honors. Include present membership on any Federal Government public advisory committee.

• Section C (optional) Peer-reviewed publications or manuscripts in press (in chronological order). You are encouraged to limit the list of selected peer-reviewed publications or manuscripts in press to no more than 15. Do not include manuscripts submitted or in preparation. The individual may choose to include selected publications based on date, importance to the field, and/or relevance to the proposed research. Citations that are publicly available in a free, online format may include URLs along with the full reference (note that copies of publicly available publications are not acceptable as appendix material).

• Section D (optional) Other Support. List both selected ongoing and completed (during the last 3 years) projects (federal or non-federal support). Begin with any projects relevant to the project proposed in this application. Briefly indicate the overall goals of the projects and responsibilities of the Key Person identified on the Biographical Sketch.

Need – Corresponds to Section V’s Review Criterion 1 NEED

Provide an overview of the health workforce and health care needs of the target area(s) served by the proposed project. This section should primarily focus on assessing the current health care infrastructure (e.g., graduate medical education landscape) and describing the resources needed to develop a new rural residency program. You must use and cite demographic data (e.g., local, state, federal) whenever possible to support the information provided.

Specifically, you must include the following information:

1. Description of the geographic area where the new rural residency program will be located, the justification for selecting this area, and the unmet need(s) that your residency program will address. To the extent possible, include data on the population demographics, social determinants of health, health disparities faced by, and health care needs of the population served, barriers to access and care, and any other unmet needs. Indicate the presence of Medically Underserved Communities (MUC) and/or Health Professional Shortage Areas

(HPSA).

2. Description of health workforce shortages and need for primary care and other high need physicians in the specialty for which you are applying for funding, including current (within 3 years) information and data demonstrating the need for the proposed specialty in the target area(s).

HRSA-24-022 RRPD 15

3. Description of the rural health care delivery system and the specific needs of the facility(s) hosting the rural residency program. Include information on the organization’s structure and the clinical and faculty capacity needed to support the new rural residency program.

4. Description of any residency programs (existing or in development) in the specialty area for which you are applying for funding, that serve the target area(s) where the proposed new rural residency program will be located.

5. Description of any progress that has already been made towards developing a rural residency program.

6. Describe existing residency program collaborations and explain how strengthening academic and community linkages with private sector or safety net providers will support the development of clinical training sites and preceptor development and retention, to deliver high-quality, culturally competent training to residents.

7. Description of any consultations with the State Office of Rural Health related to the planning and development of the new rural residency program.

Applicants pursuing the Maternal Health and Obstetrics Pathway must also include:

1. Current state or county-level data on demographics, social determinants of health and health disparities faced by the target population and their maternal health needs, including prevention and treatment of risk factors such as diabetes, heart disease, hypertension, obesity, depression, and OUD and SUD in pregnancy. You may use maternal health indicators from HRSA’s Maternal and Infant Mapping Tool located at https://data.hrsa.gov/maps/mchb/.

2. Description of gaps in the obstetrics services and existing resources available to care for individuals and families with high risk factors in pregnancy.

This section will help reviewers understand whom you will serve with the proposed project.

https://data.hrsa.gov/maps/mchb/

HRSA-24-022 RRPD 16

Approach – Corresponds to Section V’s Review Criterion 2a RESPONSE:

APPROACH

Propose methods that you will use to address the stated needs and meet each of the previously described program goals and objectives in Section I.1 Purpose of this NOFO. Describe how the proposed methods will overcome challenges and barriers in developing the new rural residency program and bridge any gaps identified in the “Needs” section above. Specifically, this section must include how you plan to achieve:

1. ACGME accreditation for the new rural residency program or permanent complement increase for the new RTP no later than the end of the program performance period (i.e., July 31, 2027). Applicants must describe:

a. Plan to ensure clinical capacity meets ACGME program accreditation requirements including sufficient numbers of dedicated supervisory faculty, adequate patient care volume, and appropriate resident training time in relevant medical specialties and subspecialties (e.g., obstetrics training). If a clinical training partner(s) addresses gaps in existing clinical capacity to meet ACGME requirements and provides significant support, you must submit Letters of Agreement from the clinical partner describing their committed resources and clinical capacity in Attachment 4.

b. Current organizational capacity and program governance structure to meet ACGME sponsoring institution and program accreditation requirements, including acquiring access to electronic health records, library services, learning management systems, etc.

c. Plan to appoint a residency program director by the start of year 2 of the grant (if not already hired) and a faculty recruitment and development plan, including recruiting specialty faculty to meet ACGME requirements for the proposed specialty.

d. Curriculum and training plan, including incorporation of interprofessional training, culturally and linguistically appropriate care, and training to address the health inequities and disparities of the patient population in rural target area(s). The curriculum plan must be high quality, leading to successful board certification of graduates and readiness for clinical practice following completion of training.

2. Resident matriculation no later than the AY immediately following the end of the program period of performance (i.e., AY 2028). Applicants must describe a plan to:

a. Recruit and support a diverse cohort of high-quality residents, including outreach to medical students with rural and disadvantaged backgrounds.

b. Recruit and train at least the minimum number of residents required to achieve and maintain accreditation for the proposed specialty.

HRSA-24-022 RRPD 17

c. Promote retention among residents and graduates to practice in rural communities.

3. Tracking residents’ career outcomes for a period of at least 5 years post-graduation from the rural residency program. Applicants must describe a plan to:

a. Develop a new tracking tool, or enhance or leverage an existing graduate tracking system, to track and publicly report (e.g., on program website) on graduates’ career outcomes and retention in rural and underserved areas.

b. At a minimum, the graduate tracking plan should accurately collect the following graduate outcomes:

i. National Provider Identifier (NPI)

ii. Practice location(s)

iii. Medical Specialty/Sub-specialty

iv. Employment Status (i.e., Part-time or full-time)

c. Describe a plan to disseminate reports, products, and/or project outputs so project information may inform other rural residency programs to pursue this model as a strategy for recruiting and retaining physicians.

Note: Award recipients should consider adding tracking performance measures related to accredited positions, admissions, and residents by year of training, by age, gender, race, ethnicity, location of training, new curriculum development, and faculty development, to the plan for tracking characteristics of graduates, practice locations, and intent to be employed in rural areas. HRSA will request award recipients to report on selected characteristics of residents and graduates during the period of performance. Refer to https://grants4.hrsa.gov/WebBPMHExternal/Interface/ProgramManual HTML.aspx?FormCode=1&IsPM=True&EHBActivityCode=p13 for examples of performance data.

Applicants pursuing the Maternal Health and Obstetrics Pathway must also include:

1. Description of the type(s) of training sites for obstetrics training, number of anticipated vaginal deliveries and C-sections, along with the range of services at the clinical training sites including ambulatory care for maternal health in the locality of the program.

2. If applicable, describe how you plan to enhance the family medicine residency program in maternal health and obstetrical training, referencing current ACGME requirements, and how you plan to meet these requirements in order https://grants4.hrsa.gov/WebBPMHExternal/Interface/ProgramManualHTML.aspx?FormCode=1&IsPM=True&EHBActivityCode=p13 https://grants4.hrsa.gov/WebBPMHExternal/Interface/ProgramManualHTML.aspx?FormCode=1&IsPM=True&EHBActivityCode=p13

HRSA-24-022 RRPD 18

to train family medicine residents for the…