FORHP HRSA-24-119 AR HC Support Final 6-25-24.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

Appalachian Region Healthcare Support Program

Funding Opportunity Number: HRSA-24-119

Funding Opportunity Type(s): New

Assistance Listing Number: 93.912

Application Due Date: July 25, 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 25, 2024

Suzanne Snyder, MSW Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy Call: 301-443-0178 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: Appalachian Region Healthcare Support Program

Funding Opportunity Number: HRSA-24-119

Assistance Listing Number: 93.912

Due Date for Applications: July 25, 2024

Purpose: The Appalachian Region Healthcare Support Program provides technical assistance (TA) to help rural healthcare organizations, including critical access hospitals (CAHs), small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations located in the rural counties served by the Appalachian Regional Commission (ARC) with planning and implementing health care service improvements.

Program Objective(s): Improve health care in rural counties within the area served by the ARC (the Appalachian Region) by working with rural healthcare organizations to:

• Provide objective analysis and assessment of healthcare organizations’ financial status, quality indicators, locally available human services, and gaps in services so organizations can make actionable change;

• Identify clinical areas where expansion of services within a rural healthcare organization would meet local need, keep health care services available locally, and build capacity to improve financial and operational performance as well as quality of care.

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• Support healthcare organizations in implementing best practice recommendations prioritized in TA action plans.

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

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

Anticipated FY 2024 Total Available Funding:

$1,500,000

Estimated Number and Type of Award(s):

Approximately 1 new cooperative agreement

Estimated Annual Award Amount:

Up to $1,500,000 per award, subject to the availability of appropriated funds

Cost Sharing or Matching Required:

No

Period of Performance: September 30, 2024, through September 29, 2027

(3 years)

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Agency Contacts: Business, administrative, or fiscal issues:

Lissette Young Grants Management Specialist Division of Grants Management Operations, OFAM Email: lyoung@hrsa.gov

Program issues or technical assistance:

Suzanne Snyder, MSW Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy Email: RuralHospitals@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:

Thursday, June 27th, 2024 2 – 3p.m. ET Weblink: https://hrsa-gov.zoomgov.com/j/1610615485?pwd=Y0VtaVFVYTRVdFBJdHc3WTkyd0NmZz0

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

Call-In Number: 1-833-568-8864 Meeting ID: 1610615485

We will record the webinar.

mailto:lyoung@hrsa.gov mailto:RuralHospitals@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/1610615485?pwd=Y0VtaVFVYTRVdFBJdHc3WTkyd0NmZz0 https://hrsa-gov.zoomgov.com/j/1610615485?pwd=Y0VtaVFVYTRVdFBJdHc3WTkyd0NmZz0

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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. INCLUDE ANY OTHER DOCUMENTS THAT ARE RELEVANT TO THE APPLICATION. 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

HRSA-24-119 1

I. Program Funding Opportunity Description

1. Purpose

The Appalachian Region Healthcare Support Program provides technical assistance (TA) to help rural healthcare organizations, including critical access hospitals (CAHs), small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations located in the rural counties served by the Appalachian Regional Commission (ARC) with planning and implementing health care service improvements.

The goal of this program is to strengthen healthcare delivery in rural areas of the Appalachian Region by improving financial and operational performance as well as the quality of care in rural healthcare organizations.

The TA provider funded under this cooperative agreement will work with individual healthcare organizations to meet the following program objectives:

• Provide objective analysis and assessment of healthcare organizations’ financial status, market share, quality indicators, locally available human services, and gaps in services so that organizations can make actionable change;

• Identify clinical areas where expansion of services within a rural healthcare organization would meet local need, keep health care services available locally, and build capacity to improve financial and operational performance as well as quality of care.

• Support healthcare organizations in implementing best practice recommendations prioritized in TA action plans.

For purposes of this notice of funding opportunity, “rural healthcare organization” is a health care organization located in a rural area in the Appalachian Region. A “healthcare organization” includes critical access hospitals, small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations. To determine if a health care organization is located in a rural area, visit https://data.hrsa.gov/tools/rural-health. To determine if a county is in the Appalachian Region, visit https://www.arc.gov/appalachian-counties-served-by-arc.For more details, see Program Requirements and Expectations.

2. Background

The Appalachian Region Healthcare Support Program is authorized by 42 U.S.C.

912(b) (§ 711(b) of the Social Security Act).

The Appalachian Regional Commission (ARC) is a federally chartered, regional economic development entity that was established in 1965 to address economic

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distress in the Appalachian region.1 The ARC focuses on 423 counties across Appalachia in 13 states (Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia), and the Appalachian region includes 3 federally recognized and 5 state recognized American Indian Tribal Communities.2, 3 In 2024, 82 (19 percent) of Appalachian counties are designated as distressed (the most economically depressed counties) and 101 (24 percent) as at-risk (at risk of becoming economically distressed).4

Of the 423 counties that make up Appalachia, 107 (25 percent) are rural (non-metropolitan area), and nearly 10 percent (approximately 2.5 million people) of Appalachian residents live in rural counties.5 Rural Appalachian residents experience serious economic and health challenges. Nearly 20 percent of the rural Appalachian population are living in poverty, compared with 15 percent of the residents in non- Appalachian rural counties. In terms of disability, 20 percent of rural Appalachian residents have a disability compared with about 16 percent of the non-Appalachian rural population.6

Rural healthcare organizations, including critical access hospitals (CAHs), small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations located in rural counties provide essential health care to the nearly 60 million people who live in rural areas. However, since 2005 there have been 191 rural hospital closures across the United States, including nine closures in 2023.7 A 2022 HRSA-funded 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.8

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 at the University of North Carolina Rural Health Research Center, 9.2% (196) of rural hospitals

1 Congressional Research Service. (2024). Federal Regional Commissions and Authorities: Structural Features and Function. https://crsreports.congress.gov/product/pdf/R/R45997 (citing P.L. 89-4 and 40 U.S.C. §§14101-14704), pp. 2-3.

2 Congressional Research Service. (2024). Federal Regional Commissions and Authorities: Structural Features and Function. https://crsreports.congress.gov/product/pdf/R/R45997 3 Appalachian Regional Commission. (2024). https://www.arc.gov/about-the-appalachian-region/ 4 Appalachian Regional Commission. (2024). Classifying Economic Distress in Appalachian Counties.

https://www.arc.gov/classifying-economic-distress-in-appalachian-counties/ 5 The Appalachian Region: A Data Overview from the 2017-2021 American Community Survey, Chartbook. (2024). Population Reference Bureau. https://www.arc.gov/about-the-appalachian-region/the-chartbook/rural-appalachia/ 6 Ibid.

7 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.

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

https://www.shepscenter.unc.edu/download/23647/ https://crsreports.congress.gov/product/pdf/R/R45997 https://www.arc.gov/about-the-appalachian-region/ https://www.arc.gov/classifying-economic-distress-in-appalachian-counties/ https://www.arc.gov/about-the-appalachian-region/the-chartbook/rural-appalachia/ https://www.arc.gov/about-the-appalachian-region/the-chartbook/rural-appalachia/ 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/

HRSA-24-119 3

were predicted to be at high risk of financial distress in 2019.9 Hospitals experiencing high financial distress often reduce services, limiting access to care for vulnerable populations and worsening health disparities. Ten of the 13 Appalachian Region states have hospitals at the highest risk of financial distress.10 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.11

The Appalachian Region Healthcare Support Program aims to strengthen healthcare delivery in rural areas in the Appalachian Region through providing technical assistance to help build capacity in rural healthcare organizations, with a focus on improving financial and operational performance as well as quality of care.

II. Award Information

1. Type of Application and Award

Application type(s): New

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 TA, we also get involved in these ways:

• Provide technical assistance to you 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 healthcare organizations;

• Sharing of relevant program data to ensure the greatest impact of TA efforts in rural counties in the Appalachian Region;

• Provide technical assistance, upon request, on processes for the identification and selection of sub-contractors, healthcare organization technical experts, rural healthcare organizations to receive TA, and other key stakeholders involved in the program;

9 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 10 https://www.ruralhealthresearch.org/publications/1658 11 American Hospital Association. Rural Report. (2019). https://www.aha.org/system/files/2019-02/rural-report-2019.pdf 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

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• 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 Offices of Rural Health, state hospital associations, and State Rural Health Associations to market services and identify potential rural healthcare organizations to receive TA;

• Working with the selected rural healthcare organizations to identify clinical areas where expansion of services would meet local medical need, help keep health care services available locally and improve rural healthcare organization finances, operations, and quality of care; and

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

2. Summary of Funding

We estimate $1,500,000 will be available each year to fund approximately 1 recipient.

You may apply for a ceiling amount of up to $1,500,000 annually (reflecting direct and indirect costs).

The period of performance is September 30, 2024, through September 29, 2027 (3 years).

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.

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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*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.

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

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. If you cannot submit electronically, you can request a waiver. See section 3.6 of HRSA’s Application Guide.

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

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 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf

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Select “Subscribe” and enter your email address for HRSA-24-119 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.

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-24-119 workspace application package, it may count toward the page limit.

Applications must be complete and validated by Grants.gov under HRSA-24-119 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

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

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• 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 are expected to select and provide TA to at least five rural healthcare organizations per year that are located in the rural counties in the Appalachian Region. You are expected to work collaboratively with HRSA and ARC on an ongoing basis as you carry out program activities.

2. You must develop and manage a network of nationally known, rural healthcare organization technical experts (which will be heavily focused on finance and quality issues but may also include operational and clinical experts) to provide consultations to rural health care organizations to improve financial and operational performance, and quality. At a minimum, this network of experts must conduct market assessments, quality assessments and financial and operational assessments for each rural healthcare organization selected to receive TA.

3. You must identify and market to rural healthcare organizations who will benefit from TA.

4. You are expected to utilize existing national standards for assessing financial risk, such as but not limited to the University of North Carolina’s Financial Distress Index, as part of the selection of rural healthcare organizations.

5. You must develop a TA plan that meets the objectives of this program that includes a process for identifying community health care needs, market share, operational efficiencies, and other service line expansions in each rural healthcare organization to strengthen healthcare delivery in the Appalachian Region.

6. Based on expert recommendations, you will provide support for software and equipment to implement best practices prioritized in TA action plans. HRSA recommends that you use at least 15 percent of your budget for this purpose.

You must monitor to ensure that the funding is spent in support of program objectives.

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

8. You are expected to provide services only to rural healthcare organizations not already receiving TA from other federal programs.

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

Program-Specific Instructions

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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.

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 assist rural healthcare organizations in the Appalachian Region with building capacity to improve their financial and operational performance as well as the quality of care they provide.

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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 rural healthcare organization technical experts with financial, operational, and clinical expertise and a strong track record of working with rural healthcare organizations. Discuss your plan for governance and decision making as it relates to selecting and managing technical experts.

o As applicable, identify staff and/or consultants who are located in, familiar with, or who have worked with healthcare organizations in the Appalachian Region.

o Include signed Letters of Agreement from all key stakeholders and consultants in Attachment 4.

o Demonstrate your organization’s and your network of rural healthcare organization technical experts’ history providing TA specifically to rural healthcare organizations at a national or regional level. Discuss any past TA provided in the Appalachian region. Include a discussion on the implementation, outcomes and results of the TA provided.

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 healthcare organizations face in building financial sustainability, specifically in the Appalachian Region. 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 healthcare organizations to identify gaps in services that meet local need and

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improve rural healthcare organization finances and operations as well as quality of care.

o Describe the specific challenges rural healthcare organizations 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 organization’s community health care needs, market share, quality indicators and financial and operational performance to inform program recommendations. Discuss your process for identifying areas for expansion that meet local need as well as your methodology for ensuring any recommendations will be cost efficient, financially viable, and able to be implemented.

o Describe the types of TA resources that will be provided to rural healthcare organizations participating in the program that will meet program requirements and expectations.

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

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

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

o Discuss the strategy for determining a rural healthcare organization’s readiness for TA, including commitment from organization’s 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 organization leadership throughout the project and strategy for sustaining activities after the TA services end.

o Describe a plan to track and report on rural healthcare organization 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. Key stakeholders may include, but are not limited to, the Appalachian Regional Commission, state hospital associations, State Offices of Rural Health, and State Rural Health Associations.

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o Describe how you will provide support for software and equipment to implement best practices prioritized in TA action plans, 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 support for software and equipment. HRSA recommends that you use at least 15 percent of your budget for this purpose.

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 healthcare organization 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.

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 healthcare organizations in the Appalachian Region 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 For the purpose of self-assessment, 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.

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o Describe your plan to assess how effective your project is in meeting the program objectives, the specific outcome measures you will use (such as 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 assess the performance of each rural healthcare organization project and the performance of the organization projects 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.

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.

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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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.

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. Include any other documents that are relevant to the application. 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 https://www.gsa.gov/entityid

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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.14

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)

• 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.

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

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

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4. Submission Dates and Times

Application Due Date Your application is due on July 25, 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 Appalachian Region Healthcare Support 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.

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 Appalachian Region Healthcare Support 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 https://www.archives.gov/federal-register/codification/executive-order/12372.html 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 application describes the purpose of the proposed project for providing in-depth TA to rural healthcare organizations in the Appalachian Region to help them build capacity to improve their financial and operational performance as well as quality of care.

• The extent to which the application describes the needs of rural healthcare organizations in the Appalachian Region 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 issues in the rural health environment have on rural healthcare organization financial sustainability, organizational performance, and quality of care.

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.

• 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 organization’s community health care needs, market share, quality indicators and financial and operational performance to inform program recommendations;

o Describes the types of TA resources that will be provided to rural healthcare organizations participating in the program that will meet program requirements and expectations, such as, but not limited to, TA action plans, financial/operational resources, and a final report with recommendations for each hospital.

o Describes the approach to identify and select a minimum of five rural healthcare organizations to receive in-depth TA each year;

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

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

o Discusses the strategy for determining a rural healthcare organization’s readiness for TA, including commitment from an organization’s board/

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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 healthcare organization 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 organization leadership throughout the project and strategy for sustaining activities after the TA services end;

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

o Describes a plan to provide adequate support for software and equipment to implement best practices prioritized in TA action plans. HRSA recommends that at least 15 percent of the budget is reserved for this purpose.

o Describes how the applicant will monitor support for software and equipment to ensure that funds are spent in support of program objectives.

Work Plan (10 points):

• How well the work plan attachment 1 describes the activities or steps to implement a network of rural healthcare organization technical experts to achieve program goals, objectives, and requirements.

• How well the work plan presents a complete and clear timeline that identifies the responsible staff for each activity during the three-year period of performance.

• How well the work plan identifies activities requiring collaboration with key stakeholders (including sub-award recipients) in the planning, designing, and implementation of TA services.

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, rural healthcare organization leadership turnover, challenges with organization board of directors, and recruitment challenges associated with adding new services.

• How well the application describes the specific challenges rural healthcare organizations in the Appalachian Region 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

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• How well the application describes the organization’s profile, budget, key stakeholders/ consultants, and key staffs’ experience, skills, and knowledge, key processes, and expected outcomes of the funded activities.

• 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 performance 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…