FORHP HRSA-24-082 Rural Hospital Stabilization_FINAL.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2024

Federal Office of Rural Health Policy

Hospital State Division

Rural Hospital Stabilization Pilot Program Funding Opportunity Number: HRSA-24-082

Funding Opportunity Type(s): New

Assistance Listing Number: 93.155

Application Due Date: July 26, 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: June 18, 2024

Christy Edwards Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy Call: 301-945-5217 Email: RuralHospitals@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:RuralHospitals@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 Hospital Stabilization Pilot Program

Funding Opportunity Number: HRSA-24-082

Assistance Listing Number: 93.155

Due Date for Applications: July 26, 2024

Purpose: The purpose of the Rural Hospital Stabilization Pilot Program is to improve health care in rural areas by providing in-depth technical assistance (TA) to rural hospitals to enhance and/or expand service lines to meet local need and keep health care services available locally.

Program Objective(s): Improve health care in rural areas by working with rural hospitals to:

• Identify clinical areas where expansion would help keep health care services available locally and improve hospital finances and operations;

• Implement new service lines by providing support for initial operating and equipment costs that provides the participating hospital the ability to build up patient volume for the new service line to eventually become self-sustaining.

Eligible Applicants: You can apply if your organization is in the United States, the Commonwealth of Puerto Rico, the Northern Mariana Islands, American Samoa, Guam, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau, and is:

https://www.grants.gov/search-results-detail/349413

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• Public or private, non-profit or for-profit

• Community-based

• Native American tribal governments

• Native American tribal organizations

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

Anticipated FY 2024 Total Available Funding:

Up to $4,000,000

Estimated Number and Type of Award(s):

Approximately 1 new cooperative agreement

Estimated Annual Award Amount:

Up to $4,000,000 per award

Cost Sharing or Matching Required:

No

Period of Performance: September 30, 2024 through September 29, 2027 (3 years)

Agency Contacts: Business, administrative, or fiscal issues:

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

Program issues or technical assistance:

Christy Edwards Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy Email: RuralHospitals@hrsa.gov mailto:bsmith@hrsa.gov

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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, June 28, 2024 2:00 p.m. – 3:30 p.m. ET Weblink: https://hrsa-gov.zoomgov.com/j/1611018940?pwd=Vkd6UW5LYWM0cmM1ZzlzUUVvTHhqZz09

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

Call-In Number: 1-833-568-8864 Meeting ID: 161 101 8940 Passcode: 52671363

We will record the webinar. Please contact RuralHospitals@hrsa.gov to request playback.

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/1611018940?pwd=Vkd6UW5LYWM0cmM1ZzlzUUVvTHhqZz09 https://hrsa-gov.zoomgov.com/j/1611018940?pwd=Vkd6UW5LYWM0cmM1ZzlzUUVvTHhqZz09

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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: PAGE LIMIT WORKSHEET

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Rural Hospital Stabilization Pilot Program. The purpose of this program is to improve health care in rural areas by providing in-depth technical assistance (TA) to rural hospitals to enhance and/or expand service lines to meet local need and keep health care services available locally. Service lines may include, but are not limited to pulmonary rehabilitation, infusion/chemotherapy, inpatient psychiatric services, outpatient behavioral health services, obstetric services, cardiac rehabilitation, and expanded primary care.

The Rural Hospital Stabilization Pilot Program aims to increase service volume and revenue to improve hospital financial sustainability in rural hospitals that have limited access to resources needed to expand their services.

The TA provider(s) funded under this cooperative agreement will work with individual hospitals to meet the following program objectives:

• Identify clinical areas where expansion would meet local medical need, help keep health care services available locally and improve hospital finances and operations;

• Implement new service lines by providing support for initial operating and equipment costs that provides the participating hospital the ability to build up patient volume for the new service line to eventually become self-sustaining.

For the purposes of this notice of funding opportunity (NOFO), “rural hospitals” are defined as short-term, non-federal general facilities located outside Metropolitan Core- Based Statistical Areas (CBSAs) or located within Metropolitan areas in locations with Rural-Urban Commuting Area (RUCA) codes of four (4) or greater, facilities in any location participating in Medicare as Critical Access Hospitals (CAHs), or facilities in any location participating in Medicare as Rural Emergency Hospitals (REHs). Hospitals operated by tribes and tribal organizations under the Indian Self-Determination and Education Assistance Act (Public Law 93-638, as amended) may also receive technical assistance if they meet this definition of “rural hospitals.”

For more details, see Program Requirements and Expectations.

2. Background

The Rural Hospital Stabilization Pilot Program is authorized by 42 U.S.C. 912(b) (§ 711(b) of the Social Security Act).

Rural hospitals provide essential health care to the nearly 60 million people who live in rural areas. However, since 2005 there have been 191 rural hospitals closures across

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the United States, including nine closures in 2023.1 A 2022 study conducted by the North Carolina Rural Health Research Program found that rural hospitals that closed between 2017 to 2020 were more unprofitable and much less liquid. The study reports that in the year leading up to a closure, most rural hospitals tend to have few days cash on hand, a negative operating margin, and a negative total margin.2

A related and ongoing concern is the financial sustainability of the remaining facilities.

Based on the Federal Office of Rural Health Policy-funded financial distress index, 9.2 percent (196) of rural hospitals were predicted to be at high risk of financial distress in

2019.3 Hospitals experiencing high financial distress often reduce services, limiting access to care for vulnerable populations and worsening health disparities. Another challenge that impacts the financial sustainability of rural hospitals is serving small populations. With smaller patient populations, rural hospitals have low patient volume and may not have enough patients to cover high fixed operating costs.4

Hospital bypass (the trend of rural residents to opt for healthcare outside their community rather than at their closest hospital) is another concern.5 Literature suggests that hospital bypass contributes to significant loss of potential revenue for rural hospitals. 6,7 A study funded by the Centers for Medicare & Medicaid Services (CMS) reports that rural patients are more likely to bypass their local hospital for elective or scheduled care and for services they consider to be complicated.8

II. Award Information

1. Type of Application and Award

Application type(s): New

1 University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research. “Rural Hospital Closures” https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/. Accessed Jan 2024.

2 Osgood AS, Pink GH. Rural Hospitals that Closed between 2017-20: Prof itability and Liquidity in the Year before Closure. NC Rural Health Research Program, UNC Sheps Center. November 2021.

https://www.shepscenter.unc.edu/download/23647/ 3 Thomas SR, Pink GH, Reiter K. Geographic Variation in the 2019 Risk of Financial Distress among Rural Hospitals. NC Rural Health Research Program, UNC Sheps Center. April 2019.

https://www.shepscenter.unc.edu/wp-content/uploads/dlm_uploads/2019/04/FDI-Geo-1.pdf 4 American Hospital Association. Rural Report. (2019). https://www.aha.org/system/f iles/2019-02/rural-report-2019.pdf 5 Malone, T.L. and Holmes, G.M. (2020). Patterns of Hospital Bypass and Inpatient Care-Seeking by Rural Residents. https://www.shepscenter.unc.edu/product/patterns-of-hospital-bypass-and-inpatient-care-seeking-by-rural-residents/ 6 Radcliff T., Brasure, M., Moscovice, I., Stensland, J. Understanding rural hospital bypass behavior. The Journal of Rural Health, 2003;19(3):252-259.

7 Weigel P., Ullrich, F., Finegan, C., Ward, M. Rural bypass for elective surgeries. The Journal of Rural Health, 2017;33(2):135-145.

8 CMS. (2020). Examining Rural Hospital Bypass for Inpatient Services.

https://www.cms.gov/f iles/document/ruralhospitalbypassf inalreport.pdf https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/ https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/ https://www.shepscenter.unc.edu/download/23647/ https://www.shepscenter.unc.edu/wp-content/uploads/dlm_uploads/2019/04/FDI-Geo-1.pdf https://www.aha.org/system/files/2019-02/rural-report-2019.pdf https://www.aha.org/system/files/2019-02/rural-report-2019.pdf https://www.shepscenter.unc.edu/product/patterns-of-hospital-bypass-and-inpatient-care-seeking-by-rural-residents/ https://www.shepscenter.unc.edu/product/patterns-of-hospital-bypass-and-inpatient-care-seeking-by-rural-residents/ https://www.cms.gov/files/document/ruralhospitalbypassfinalreport.pdf

HRSA-24-082 3

We will fund you via a cooperative agreement.

A cooperative agreement is like a grant in that we award money, but we are substantially involved with program activities.

Aside from monitoring and technical assistance (TA), we also get involved in these ways:

• Providing potential TA to help prioritize program activities and assess progress in achieving the goals of this cooperative agreement;

• Facilitating introductions to other HRSA programs, federal agencies and other HRSA award recipients as their work may pertain to assisting rural hospitals;

• Sharing of relevant program data to ensure the greatest impact of TA efforts of retaining health services in the rural areas served;

• Providing TA, upon request, on processes for on the identification and selection of sub-contractors, hospital technical experts, rural hospitals to receive TA, and other key stakeholders involved in the program;

• Reviewing and providing feedback and recommendations on TA products and proposed outcome measures specific to TA provided; and

• Participating, as appropriate, in the planning and implementation of any meetings, webinars, advisory committees, or work groups.

You must follow all relevant federal regulations and public policy requirements. Your other responsibilities will include:

• Consulting with HRSA in marketing available services, benefits of participation, and ongoing implementation of proposed activities;

• Engaging with key stakeholders such as state hospital associations, State Offices of Rural Health, and State Rural Health Associations to market services and identify potential hospitals to receive TA;

• Working with the selected rural hospitals to improve financial sustainability by enhancing and/or expanding new service lines to increase service volume and revenue and keep health care services available in rural areas by reducing hospital bypass; and

• Ensuring interventions are responsive to the needs of the hospital community to gain community buy-in, as well as commitment from key hospital and community leaders for active engagement during the project and sustaining activities after TA is provided.

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2. Summary of Funding

We estimate $4,000,000 will be available each year to fund approximately 1 recipient.

You may apply for a ceiling amount of up to $4,000,000 annually (reflecting direct and indirect costs).

The period of performance is September 30, 2024 through September 29, 2027.

Support beyond the first budget year will depend on:

• Appropriation of funds for this purpose

• Satisfactory progress in meeting the project’s objectives

• A decision that continued funding is in the government’s best interest

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

You can apply if your organization is in the United States, the Commonwealth of Puerto Rico, the Northern Mariana Islands, American Samoa, Guam, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau, and is:

• Public or private, non-profit or for-profit

• Community-based

• Native American tribal governments

• Native American tribal organizations

2. Cost Sharing or Matching

Cost sharing or matching is not required for this program.

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

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3. Other

Entities must have the capability to manage a national network of rural hospital technical experts to help rural hospitals enhance and/or expand service lines to improve hospital financial sustainability.

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

Multiple Applications

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

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-24-082 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 50 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.

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

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These items do not 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

• 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.vi Attachments.

If you use an OMB-approved form that is not in the HRSA-24-082 workspace application package, it may count toward the page limit.

Applications must be complete and validated by Grants.gov under HRSA-24-082 before the deadline.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

• When you submit your application, you certify that you and your principals9 (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.10

• If you cannot certify this, you must include an explanation in Attachment 6-15:

Other Relevant Documents.

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

Program Requirements and Expectations

1. You must develop and manage a network of nationally known, rural hospital technical experts (which will be heavily focused on finance issues but may also include operational and clinical experts) to provide onsite and virtual consultations to rural hospitals with the goal to enhance or expand service lines that will meet local medical need, help keep health care services available locally and improve hospital finances and operations. At a minimum, this network of experts must conduct market assessments, analyze bypass, and complete financial and operational assessments for each rural hospital.

2. You must identify and market to rural hospitals who will benefit from TA.

9 See def initions at eCFR :: 2 CFR 180.995 -- Principal. and eCFR :: 2 CFR 376.995 -- Principal (HHS supplement to government-wide def inition at 2 CFR 180.995).

10 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

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3. You are expected to utilize existing national standards for assessing financial risk, such as the University of North Carolina’s Financial Distress Index, as part of the selection of hospitals.

4. You must develop a TA plan that meets the objectives of this program that includes a process for identifying service lines that meet local need and would be cost efficient, financially viable, and able to be implemented.

5. Based on expert recommendations, you will provide funding to participating hospitals to cover initial operating and equipment costs associated with the enhanced or expanded new services lines that provides hospitals the ability to sustainably build patient volume in the new service line. HRSA recommends that you use at least 20 percent of your budget for this purpose. You must monitor to ensure that the funding is spent in support of program objectives.

6. HRSA expects you to work with each selected rural hospital to gain commitment for participating and implementing the recommended activities from TA consultations.

7. You are expected to provide services only to rural hospitals not actively receiving TA from other federal programs.

8. You are expected to share data collected as a part of the program with HRSA.

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.

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.

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Narrative Section Review Criteria

Introduction Criterion 1: NEED

Organizational Information Criterion 5: RESOURCES/CAPABILITIES

Criterion 6: SUPPORT REQUESTED

Need Criterion 1: NEED

Approach Criterion 2: RESPONSE

Work Plan Criterion 2: RESPONSE

Resolution of Challenges Criterion 2: RESPONSE

Evaluation and Technical Support Capacity

Criterion 3: EVALUATIVE MEASURES

Criterion 4: IMPACT

Budget Narrative Criterion 6: 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 for providing in-depth TA to rural hospitals to enhance and/or expand new service lines to increase service volume and revenue and keep health care services available in rural areas by reducing hospital bypass.

Organizational Information -- Corresponds to Section V’s Review Criterion (5) RESOURCES/CAPABILITIES and Criterion (6) SUPPORT REQUESTED o Briefly describe your organization’s mission, structure, scope of current activities, and key stakeholders/consultants’ abilities to carry out all aspects of the proposed project. Explain how these elements all contribute to your ability to meet all program requirements and program expectations. Include a project organizational chart in Attachment 5. Include staffing plan and job descriptions as Attachment 2, and biographical sketches for all key personnel as Attachment 3.

o Demonstrate your organization’s capacity to develop and manage a network of nationally known hospital technical experts with financial, operational, and clinical expertise and a strong track record of working with rural hospitals.

Discuss your plan for governance and decision making as it relates to

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selecting and managing technical experts. Include signed Letters of Agreement from all key stakeholders and consultants in Attachment 4.

o Demonstrate your organization’s and your network of rural hospital technical experts’ experience providing TA to rural hospitals at a national level.

Include a discussion on the implementation, outcomes and results of the TA provided.

o Document your organization and your network of rural hospital technical experts’ past work providing technical assistance to rural hospitals across the country.

o Discuss how you’ll follow the approved plan, account for federal funds, and record all costs to avoid audit findings. If funds will be sub-awarded or expended on contracts, explain how your organization will provide overall program management and 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.

Need-- Corresponds to Section V’s Review Criterion (1) NEED

The needs assessment should demonstrate a strong understanding of specific challenges rural hospitals face in building financial sustainability. You must use and cite data (e.g., local, state, federal) whenever possible to support the information provided.

o Discuss the need for in-depth TA to support rural hospitals to identify gaps in services that meet local need and increase service volume revenue to improve hospital financial sustainability.

o Demonstrate understanding of the impact of hospital bypass issues on rural hospital financial sustainability. Describe the specific challenges rural hospitals face in keeping health care services available locally.

Approach -- Corresponds to Section V’s Review Criterion (2) RESPONSE

Your approach should demonstrate how you will meet the program requirements and expectations described in this NOFO.

o Discuss the strategy for assessing a selected hospital’s community health care needs, market share, and financial and operational performance to inform program recommendations. Discuss your process for identifying service lines that meet local need as well as your methodology for ensuring any recommended service lines will be cost efficient, financially viable, and able to be implemented.

o Describe the types of TA resources that will be provided to rural hospitals participating in the program.

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o Describe the approach you will use to identify and select rural hospitals to receive in-depth TA each year.

o Describe how you will prioritize rural hospitals based on selection criteria.

o Discuss how you will market the benefits of participation and the availability of services through this program to hospitals.

o Discuss the strategy for determining a hospital’s readiness for TA, including commitment from hospital board/ leadership, adequacy of resources and support to participate fully in the program and implement program recommendations.

o Discuss how you will continue to foster engagement from key hospital leadership throughout the project and strategy for sustaining activities after the TA services end.

o Describe a plan to track and report on rural hospital progress in meeting TA recommendations, including disseminating best practices, reports, products, or project outputs to HRSA and target audiences.

o Identify meaningful support from and collaboration with key stakeholders in planning, designing, and implementing all activities.

o Describe how you will provide funding to participating hospitals to cover initial operating and equipment costs associated with the enhanced or expanded new services lines that provides hospitals the ability to sustainably build patient volume in the new service line, and how you will monitor those projects to ensure that the funds are spent in support of program objectives.

o Describe approximately what percentage of your budget will be used to provide funding to participating hospitals.

Work Plan -- Corresponds to Section V’s Review Criterion (2) RESPONSE o Provide a detailed work plan in Attachment 1 that describes the activities or steps you will use to implement a national network of rural hospital technical experts to achieve program goals, objectives, and requirements.

o Include a timeline that outlines each activity for the entire period of performance and identifies the responsible staff for each activity. As needed, identify meaningful support from and collaboration with key stakeholders that will help plan, design, and carry out all activities.

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Resolution of Challenges -- Corresponds to Section V’s Review Criterion (2)

RESPONSE

o Discuss challenges that you are likely to encounter in designing and carrying out the activities in the work plan. Explain approaches that you will use to resolve them.

o Describe specific, unique challenges that rural hospitals experience in keeping health care services available locally, and the plan you will use to address them.

Evaluation and Technical Support Capacity -- Corresponds to Section V’s Review Criteria (3) EVALUATIVE MEASURES and (4) IMPACT o Briefly describe your organizational profile, budget, key stakeholders/ consultants, and key staffs’ experience, skills, and knowledge, key processes, and expected outcomes of the funded activities. Discuss how the proposed project will impact the availability of health care services in rural areas.

o Describe the systems and processes that you’ll use to track performance outcomes. Describe how you’ll collect and manage data (for example, assigned skilled staff, data management software) in a way that allows for accurate and timely reporting of those outcomes.

o Describe your plan to monitor project implementation and provide the specific process measures you will use to monitor how well you implement your project as planned.

o Describe your plan to evaluate how effective your project is in meeting the program objectives, the specific outcome measures you will use (such as reduced hospital bypass, increase in revenue, and increase in patient volume), as well as how you will use process and outcome measure data to improve your project over the three-year project period.

o Describe how your outcome measures will effectively evaluate how successful each hospital project is and how successful the hospital projects are collectively over the three-year project period.

o Describe barriers to collecting and using process and outcome measure data and your plan to address those barriers.

iii. Budget

The Application Guide directions may differ from those on Grants.gov.

Follow the instructions in Section 4.1.iv Budget of the Application Guide and any specific instructions listed in this section. Your budget should show a well-organized plan.

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Reminder: The total project or program costs are all allowable (direct and indirect) costs used for the HRSA activity or project. This includes costs charged to the award and non-federal funds used to satisfy a matching or cost-sharing requirement (which may include MOE, if applicable).

Program Income

You must use any program income you generate from awarded funds for approved project-related activities. Use program income under the addition alternative (45 CFR § 75.307(e)(2)). Find post-award requirements for program income at 45 CFR § 75.307.

As required by the Further Consolidated Appropriations Act, 2024 (P.L. 118-47), Division D, Title II, § 202, “None of the funds appropriated in this title shall be used to pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of Executive Level II.” Effective January 2024, the salary rate limitation is $221,900. As required by law, salary rate limitations may apply in future years and will be updated.

iv. Budget Narrative

See Section 4.1.v. of the Application Guide.

v. Attachments

Provide the following attachments in the order we list them.

Most attachments count toward the application page limit. Indirect cost rate agreement and proof of non-profit status (if it applies) are the only exceptions. They will not count toward the page limit.

Clearly label each attachment. Upload attachments into the application. Reviewers will not open any attachments you link to.

Attachment 1: Work Plan

Attach the project’s work plan. Make sure it includes everything that Section IV.2.ii.

Project Narrative details.

Attachment 2: Staffing Plan and Job Descriptions for Key Personnel (see Section

4.1. of the Application Guide)

Keep each job description to one page as much as possible. Include the role, responsibilities, and qualifications of proposed project staff. Describe your organization’s timekeeping process. This demonstrates that you’ll comply with federal standards related to recording personnel costs.

https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.307

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Attachment 3: Biographical Sketches of Key Personnel

Include biographical sketches for people who will hold the key positions you describe in Attachment 2. Keep it to two pages or less per person. Do not include addresses or SSNs. If you include someone you have not hired yet, include a letter of commitment from that person with the biographical sketch.

Attachment 4: Letters of Agreement, Memoranda of Understanding

Provide any documents that describe working relationships between your organization and other entities and programs you cite in the proposal. Documents that confirm actual or pending contracts or agreements should clearly describe the roles of the contractors and any deliverable. Make sure you sign and date any letters of agreement.

Attachment 5: Organizational Chart

Provide a one-page figure that shows the project’s organizational structure.

Attachments 6–15: Other Relevant Documents

Include any other documents that are relevant to the application.

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

A UEI is required to apply for this funding. You must register in the SAM.gov to receive your UEI.

You cannot use a DUNS number to apply. For more details, visit the following webpage:

General Service Administration’s UEI Update

After you register with SAM, maintain it. Keep your information updated when you have:

an active federal award, application, or plan that an agency is considering.11

When you register, you must submit a notarized letter naming the authorized Entity Administrator.

We will not make an award until you comply with all relevant SAM requirements. If you have not met the requirements by the time we’re ready to make an award, we will deem you unqualified and award another applicant.

If you already registered on Grants.gov, confirm that the registration is active and that the Authorized Organization Representative (AOR) has been approved.

To register in Grants.gov, submit information in two systems:

• System for Award Management (SAM) (SAM Knowledge Base)

11 Unless 2 CFR § 25.110(b) or (c) exempts you f rom those requirements or the agency approved an exemption for you under 2 CFR § 25.110(d)).

https://www.gsa.gov/entityid https://sam.gov/content/home https://www.fsd.gov/gsafsd_sp?id=gsa_kb_view2&kb_id=f66d8e6cdb76d4100d73f81d0f9619c6

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• Grants.gov

Effective March 3, 2023, individuals assigned a SAM.gov Entity Administrator role must be an employee, officer, or board member, and cannot be a non-employee. This change is to ensure entities are in control of who has permission to control roles within their entity.

Here’s what this means:

• Entity Administrators assigning roles to non-employees will only be able to assign a Data Entry role or lower.

• Any entities assigning Entity Administrator roles using an Entity Administrator Role Request Letter (formerly called “notarized letter”) will no longer be able to assign the Entity Administrator role to a non-employee.

• Entity Administrator roles assigned to non-employees will be converted to Data Entry roles. With a Data Entry role, non-employees can still create and manage entity registration data entry but cannot manage roles.

If you are an entity using a non-employee or if you are a non-employee working with an entity to manage registrations, please read (and share) more about this change on the BUY.GSA.gov blog to know what to expect.

For more details, see Section 3.1 of the Application Guide.

Note: Allow enough time to register with SAM and Grants.gov. We do not grant application extensions or waivers if you fail to register in time.

4. Submission Dates and Times

Application Due Date Your application is due on July 26, 2024, at 11:59 p.m. ET. We suggest you submit your application to Grants.gov at least 3 calendar days before the deadline to allow for any unexpected events. See the Application Guide’s Section 8.2.5 – Summary of emails from Grants.gov.

5. Intergovernmental Review

The Rural Hospital Stabilization Pilot Program must follow the terms of Executive Order 12372 in 45 CFR part 100.

See Section 4.1 ii of the Application Guide for more information.

6. Funding Restrictions

The General Provisions in Division D, Titles II and V, that reference the Further Consolidated Appropriations Act, 2024 (P.L. 118-47) apply to this program. See Section

4.1 of the Application Guide for information. Note that these and other restrictions will apply in fiscal years that follow, as the law requires.

https://www.grants.gov/ https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.fsd.gov%2Fgsafsd_sp%3Fid%3Dkb_article_view%26sysparm_article%3DKB0017347&data=05%7C01%7CDDixon%40hrsa.gov%7C80dfe1e3c58a4e26cd0008db143e65c3%7C14b77578977342d58507251ca2dc2b06%7C0%7C0%7C638126030447564740%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=nnDr7%2B8Bn1g9416eowK4Vwfx%2BO2%2BuUP1Nlu9KkvZoa4%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fbuy.gsa.gov%2Finteract%2Fcommunity%2F47%2Factivity-feed%2Fpost%2Fa14726f4-e2a9-47b3-80ec-7ceff5108706%2FA_Change_in_SAM_gov_will_Affect_Access_for_Some_Entity_Administrators&data=05%7C01%7CDDixon%40hrsa.gov%7C80dfe1e3c58a4e26cd0008db143e65c3%7C14b77578977342d58507251ca2dc2b06%7C0%7C0%7C638126030447564740%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=ZTRBuys3iNJZeAUQ7rDx56aVR1BrI3wE4z%2FHBoFbQTU%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fbuy.gsa.gov%2Finteract%2Fcommunity%2F47%2Factivity-feed%2Fpost%2Fa14726f4-e2a9-47b3-80ec-7ceff5108706%2FA_Change_in_SAM_gov_will_Affect_Access_for_Some_Entity_Administrators&data=05%7C01%7CDDixon%40hrsa.gov%7C80dfe1e3c58a4e26cd0008db143e65c3%7C14b77578977342d58507251ca2dc2b06%7C0%7C0%7C638126030447564740%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=ZTRBuys3iNJZeAUQ7rDx56aVR1BrI3wE4z%2FHBoFbQTU%3D&reserved=0 https://www.archives.gov/federal-register/codification/executive-order/12372.html https://www.archives.gov/federal-register/codification/executive-order/12372.html

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You must have policies, procedures, and financial controls in place. Anyone who receives federal funding must comply with legal requirements and restrictions, including those that limit specific uses of funding.

• Follow the list of statutory restrictions on the use of funds in Section 4.1 (Funding Restrictions) of the Application Guide. We may audit the effectiveness of these policies, procedures, and controls.

• 2 CFR § 200.216 prohibits certain telecommunications and video surveillance services or equipment. For details, see the HRSA Grants Policy Bulletin Number:

2021-01E.

If funded, for-profit organizations are prohibited from earning profit from the federal award (45 CFR § 75.216(b)).

V. Application Review Information

1. Review Criteria

We review your application on its technical merit. We have measures for each review criterion to help you present information and to help reviewers evaluate the applications.

We use six review criteria to review and rank Rural Hospital Stabilization Pilot Program applications. Here are descriptions of the review criteria and their scoring points.

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

• How well the application describes the purpose of the proposed project for providing in-depth TA to rural hospitals to enhance and/or expand new service lines that meet local medical needs, increase service volume and revenue and keep health care services available in rural areas.

• The extent to which the application describes the needs of rural hospitals using local, state, and/or federal data, including population health outcomes and data on the needs for specific health care services in rural communities.

• The extent to which the application demonstrates an understanding of the impact of hospital bypass and other issues in the rural health environment on rural hospital financial sustainability.

Criterion 2: RESPONSE (35 points) – Corresponds to Section IV’s Approach, Work Plan, and Resolution of Challenges

Approach (20 points):

• How well the applicant’s proposed project responds to the program’s Purpose and the program requirements and expectations, including the strength of the proposed goals and objectives and how well they relate to the project.

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

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• How well the activities described in the application will address the problem and meet project objectives.

• The extent to which the application:

o Discusses the strategy for assessing a selected hospital’s community health care needs, market share, and financial and operational performance to inform program recommendations;

o Discusses the methodology for identifying service lines that meet local medical need and ensuring that any recommended service lines will be cost efficient, financially viable, and able to be implemented by the participating hospital;

o Describes the types of TA resources that will be provided to rural hospitals participating in the program;

o Describes the approach to identify and select rural hospitals to receive in-depth TA each year;

o Describes how it will prioritize rural hospitals based on selection criteria;

o Discusses marketing the benefits of participation and the availability of services through this program to rural hospitals;

o Discusses the strategy for determining a hospital’s readiness for TA, including commitment from hospital board/ leadership, adequacy of resources and support to participate fully in the program and implement program recommendations;

o Describes a plan to track and report on rural hospital progress in meeting TA recommendations, including disseminating best practices, reports, products, or project outputs to HRSA and target audiences;

o Discusses the approach to foster engagement from key hospital leadership throughout the project and strategy for sustaining activities after the TA services end; and o Identifies meaningful support from and collaboration with key stakeholders in planning, designing, and implementing all activities.

o Describes a plan to provide funding to participating hospitals to cover initial operating and equipment costs associated with the enhanced or expanded new services lines that provides hospitals the ability to sustainably build patient volume in the new service line.

o Describes how they will monitor those projects to ensure that the funds are spent in support of program objectives.

o Devotes adequate resources to providing funding to participating hospitals.

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Work Plan (10 points):

• How well the work plan attachment describes the activities or steps to implement a network of rural hospital financial experts to achieve program goals, objectives, and requirements.

• How well the work plan presents a clear timeline for the three-year period of performance.

Resolution of Challenges (5 points):

• The extent to which the application discusses current and potential challenges that may be barriers to implementing the planned program and approaches to overcome these challenges, such as changes to the project timeline, hospital leadership turnover, challenges with hospital board of directors, and recruitment challenges associated with new service lines.

• How well the application describes the specific challenges rural hospitals face in keeping health care services available locally and the strength of the plan to mitigate these challenges.

Criterion 3: EVALUATIVE MEASURES (10 points) – Corresponds to Section IV’s Evaluation and Technical Support Capacity

• How effective the proposed method and process measures are to monitor how well the project is implemented as planned.

• How effective the proposed systems and processes are that will be used to track, collect, and report on process and outcome measures.

• How effective the plan to use process and outcome measure data to improve the project over the three-year project period.

• Demonstrates that the applicant organization has a strong understanding of the barriers to collecting and using process and outcome measure data and a workable plan to address those barriers.

Criterion 4: IMPACT (10 points) – Corresponds to Section IV’s Evaluation and Technical Support Capacity

• How effective the proposed method and outcome measures are to evaluate how successful the proposed project will be in meeting program objectives.

• Evidence that the measures will assess how well program objectives have been met and to what extent the results are attributed to the project.

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Criterion 5: RESOURCES/CAPABILITIES (25 points) – Corresponds to Section IV’s Organizational Information

• The extent to which the applicant organization, project staff, and network of rural hospital technical experts have the capabilities to fulfill the needs of the proposed project, as evidenced in Attachment 5 (project organizational chart), Attachment 2 (staffing plan and job descriptions), and Attachment 3 (biographical sketches for all key personnel).

• The extent to which the application demonstrates the capacity and planning for effective program management to meet all program requirements and expectations, including a plan for governance and decision making for managing of a network of rural hospital technical experts.

• Assesses whether the application’s Staffing Plan in Attachment 2 provides sufficient detail about the role and responsibilities of all key personnel.

• The extent to which the application demonstrates the organization’s capacity to develop a network of hospital technical experts with financial, operational, and clinical expertise and a strong track record of working with rural hospitals.

• The extent to which signed Letters of Agreement from all key stakeholders and consultants in Attachment 4 support the development of a network of rural hospital technical experts capable of providing the technical assistance specified in this Notice of Funding Opportunity.

• The strength of the applicant organization and their network of rural hospital technical experts’ experience providing TA to rural hospitals to enhance and/or expand service lines and improve hospital financial sustainability.

Criterion 6: SUPPORT REQUESTED (10 points) – Corresponds to Section IV’s Budget and Organizational Information

• How reasonable the proposed budget is for each year of the period of performance.

• Whether costs, as outlined in the budget and required resources sections, are reasonable and align with the scope of work.

• Whether key staff have adequate time devoted to the project to achieve project objectives.

• Whether the application describes how the organization will account for federal funds and record all costs to avoid audit findings. The application describes how the applicant organization will provide overall program management and ensure that sub-awards and contracts 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.

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2. Review and Selection Process

Subject matter experts provide an impartial evaluation of your application. Then, they pass along the evaluations to us, and we decide who receives awards. See Section 5.3 of the Application Guide for details. When we make award decisions, we consider the following when selecting applications for award:

• How high your application ranks

• Funding availability

• Risk assessments

• Other pre-award activities, as described in Section V.3 of this NOFO

3. Assessment of Risk

If you have management or financial instability that directly relates to your ability to carry out statutory, regulatory, or other requirements, we may decide not to fund your high-risk…