HHS-2021-ACL-CIP-NWPG-0065.pdf

Administration for Community Living

Center for Integrated Programs

No Wrong Door Community Infrastructure Grants: Scaling Network Lead Entities

HHS-2021-ACL-CIP-NWPG-0065

06/01/2021

Table of Contents Executive Summary

Additional Overview Content/Executive Summary

I. Funding Opportunity Description

II. Award Information

III. Eligibility Information

1. Eligible Applicants

2. Cost Sharing or Matching

3. Responsiveness and Screening Criteria

IV. Application and Submission Information

1. Address to Request Application Package

2. Content and Form of Application Submission

Letter of Intent

Project Narrative

Project Abstract

Project Relevance and Current Need

Approach

Outcomes and Evaluation

Organizational Capacity

Letters of Commitment from Key Participating Organizations

Budget Narrative/Justification

Work Plan

3. Submission Dates and Times

4. Intergovernmental Review

5. Funding Restrictions

6. Other Submission Requirements

V. Application Review Information

1. Criteria

2. Review and Selection Process

3. Anticipated Announcement Award Date

VI. Award Administration Information

1. Award Notices

2. Administrative and National Policy Requirements

3. Reporting

4. FFATA and FSRS Reporting

VII. Agency Contacts

VIII. Other Information

The Paperwork Reduction Act of 1995 (P.L. 104-13)

Appendix

Instructions for Completing Required Forms

Budget Narrative/Justification- Sample Format

Instructions for Completing the Project Summary/ Abstract

ACL Center:

Center for Integrated Programs Funding Opportunity Title:

No Wrong Door Community Infrastructure Grants: Scaling Network Lead Entities Funding Opportunity Number:

HHS-2021-ACL-CIP-NWPG-0065

Primary CFDA Number:

93.048 Due Date for Letter of Intent:

04/29/2021 Due Date for Applications:

06/01/2021 Date for Informational Conference Call:

04/22/2021 Applications that fail to meet the application due date will not be reviewed and will receive no further consideration. You are strongly encouraged to submit your application a minimum of 3-5 days prior to the application closing date. Do not wait until the last day in the event you encounter technical difficulties, either on your end or, with https://www.grants.gov. Grants.gov can take up to 48 hours to notify you of a successful submission.

Executive Summary Additional Overview Content/Executive Summary Through this funding opportunity, the Administration for Community Living plans to award approximately 10 cooperative agreements to domestic public or private non-profit entities.

The intent of these awards is to provide funding directly to community-based organizations (CBOs) serving as a Network Lead Entity to develop Community Integrated Health Networks that contract with health care sector entities (e.g., accountable care organizations, health plans, managed care organizations, hospitals, health systems, and more) for coordinated access and delivery of services that address social determinant of health.

A Community Integrated Health Network (CIHN) is a coordinated group of visible and trusted https://www.grants.gov/ https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf

CBOs led by a Network Lead Entity (NLE) that have entered a formal partnership with a health care organization. Headed by NLEs, community integrated health networks are scalable and can offer one-stop contracting for multiple proven interventions and services. These networks benefit from using a centralized, coordinated model for service provision, administrative functions, and quality improvement. The NLE, which serves as the hub for coordinating the services of the wider network, provides a unified and consistent approach to program delivery across a geographic area. It can also provide administrative oversight and take the lead in governance responsibilities.

Through a Cooperative Agreement, ACL will support up to 10 NLEs with innovation grants to improve their access functions and support infrastructure costs associated with aligning health care and social services to address social determinants of health for all populations.

Applicants may request a total budget from $250,000 to a maximum of $350,000 for the two-year project period. All awards will be subject to the availability of federal funds.

The awards will be made in the form of Cooperative Agreements to allow for substantial collaboration and involvement with ACL throughout the project period. These cooperative agreements have an anticipated start date of September 1, 2021.

An informational conference call will be held on April 22, 2021 from 3:00 to 4:00pm ET.

Toll Free Number: 877-918-1346 Passcode: 7115063#

A recording will be available approximately one hour after the call concludes at the following number: 866-428-3808

I. Funding Opportunity Description Background

Health care providers and systems are increasingly interested in approaches that address both medical needs and social determinants of health (SDoH). SDoH are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life-risks and outcomes. [1] They have a substantial impact on the health of many Americans and are a key driver to address health inequities.” Health equity is “when everyone has the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance’”. [2] Studies examining the impact of SDoH found that 60 percent of the factors that influence health are non-medical social, behavioral, and environmental factors, while 20 percent are genetic, and the remaining 20 percent are health care factors. [3] Nearly as many deaths are caused by social factors as by behavioral or pathophysiological factors. [4]

Early efforts to address health determinants have occurred within siloed delivery systems, with health care providers addressing individuals’ medical needs and community-based service organizations (CBOs) [5] addressing social, functional, and environmental needs. While these efforts have made significant progress, individuals that interface with both the health care and community service system often experience inefficient, uncoordinated care that can result in higher health care costs, lower satisfaction with care, and poor outcomes. [6] As both systems embrace person-centered approaches to address health determinants, aligning the systems and leveraging the strength of health care and social service providers has been a successful approach to coordinated, holistic, person-centered care. This is further encouraged in the National Strategy for COVID Response and Pandemic Preparedness which highlights the need to facilitate linkages between clinical and social services given the increased need for social services during the COVID-19 pandemic, as well as the need to work with community-based, multi-sector organizations to align health and social interventions.

The need to reduce health care utilization while improving quality of life, as well as promoting the self-management of chronic health conditions, is more important than ever as the health care sector transitions to value-based payment models. Integration of care allows for the provision of services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-clinical risk factors. These essential services are shown to improve health outcomes and reduce the cost of care. This is particularly true for “high-need, high-cost” people who have complex health conditions and social risk factors and who often have significant functional limitations. Moreover, care planning for such individuals needs to go beyond a medical orientation and take into account an individual’s values, preferences, and holistic needs including social, functional, financial, and medical needs.

Launched in 2012, ACL’s business acumen efforts have aimed to strengthen CBO networks from the inside, building their business skills, enhancing their effectiveness, efficiency, and sustainability. Over the course of nearly a decade, these efforts have brought together practical resources, subject matter experts, and technical assistance to promote the successful alignment of health care and social services. The fundamental idea is this: when services from CBOs and health care entities are well aligned, consumers win.

States also have a vested interest to address and reduce health disparities – meeting the unique health and social needs of citizens with variation in culture, economic, and environmental considerations. For several decades, the Administration for Community Living (ACL) and its federal partners have invested in state-level infrastructure and systems change to enhance, streamline access, and align social services in communities for all populations and payers. These investments have been supported by a variety of initiatives, including the Aging and Disability Resource Center (ADRC) program, Real Choice Systems Change grants, the Balancing Incentive Program, Money Follows the Person (MFP), and Veteran Directed Care (VDC). ACL has helped states to streamline processes and implement person-friendly systems that make it easier for persons and their families to learn about and access the services they need.

To align these federal initiatives, ACL, with its federal partners, developed the No Wrong Door (NWD) System vision, which includes national standards, tools, metrics, and best practices that all states can use to develop a single “high performing” access system. In these systems, multiple agencies at the state and local level coordinate to create a simplified process through which individuals of all ages, abilities, and incomes can get unbiased information and one-on-one counseling with community health workers [7] on the options available in their communities.

https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.pdf https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.pdf https://acl.gov/programs/strengthening-aging-and-disability-networks/improving-business-practices

The foundation of NWD Systems are supported by four key functions:

State Governance and Administration;

Public Outreach and Coordination with Key Referral Sources;

Person-Centered Counseling; and Streamlined Eligibility to Public Programs.

The NWD System is designed to serve all populations who may need any long-term services and supports (LTSS), regardless of payer. This includes people who represent a variety of ages, incomes, nationalities, citizenship statuses, cultures, gender identities and expressions, sexual orientations, languages, or disabilities. At its core, a state NWD System is a network of CBOs comprised of community health workers, such as information and assistance specialists, person-centered counselors, etc., that manage access functions and processes to maintain independent living in the community. CBOs have unmatched expertise in understanding local culture and needs, service coordination and delivery, and securing benefits, services, and supports that maximize independence. In addition, the breadth of community health workers residing in a state’s NWD system are best positioned to understand a person’s preferences for community living; these preferences may differ depending on an individual’s age, race, culture, social and family support, as well as which applicable services and supports are important to a person and for a person.

The current literature (see References section of hyperlinked text) shows community-based organizations are more likely to successfully expand their missions to support the diverse needs of individuals and families in the community if they belong to integrated networks with diverse partners. Additionally, the literature suggests that efforts to improve medical outcomes and lower costs by addressing SDoH will be more effective if CBOs, health plans, and health systems develop formalized partnerships within collaborative networks. Through this funding opportunity, applicants will be expected to organize new or enhance existing community integrated health networks (CIHNs) led by a network lead entity (NLE). For the purpose of this funding opportunity, CIHNs are defined as coordinated groups of visible and trusted CBOs lead by a NLE that have entered a formal partnership with health care organizations. These network structures provide a common pathway for private health care entities to contract with multiple community-based service organizations that are supported by the policy, technology development, and resource allocation within a state’s NWD System.

Network Lead Entities offer one-stop contracting for multiple proven interventions and services that maintain independence and can be conducted in an individual’s home, in a person-centered fashion. The NLE serves as the hub for coordinating the services of the wider network, providing a unified and consistent approach to program delivery across a geographic area. It also provides the business operation and administrative oversight of the network and takes the lead in network governance responsibilities.

Establishing CIHNs led by NLEs gives these networks the capacity to:

Deliver a broad scope of SDOH services;

Reach more diverse consumers and traditionally hard-to-reach populations;

https://acl.gov/sites/default/files/common/BA_roundtable_workgroup_paper_2020-03-01-v3.pdf

Build stronger administrative infrastructures;

Capitalize on economies of scale;

Provide expanded geographic coverage at various levels – regional (within a state), statewide (throughout an entire state), and multistate (across state lines in a specific region or statewide in multiple states);

Offer one-stop contracting for multiple services with different payers; and Expand quality improvement initiatives and successes.

States have an opportunity to strengthen and support the evolution of the aging and disability network to deliver high quality, coordinated services in an increasingly value-based, integrated care environment. In addition, with the support and leadership of state NWD Systems, CBOs can continue playing a vital role in facilitating alignment across health care and social services.

There is a time-sensitive window of opportunity to directly address health equity in this country by addressing both 1) equitable access to SDoH-related services through a culturally competent and coordinated statewide access system by leveraging a state’s existing NWD System; and 2) equitable distribution of SDoH by aligning healthcare and social services through the enhancement and expansion of NLEs/CIHNs to increase SDoH availability and delivery.

References

[1] Social Determinants of Health. Centers for Disease Control and Prevention, 9 Mar. 2021, www.cdc.gov/socialdeterminants/index.htm.

[2] Whitehead, Margaret and Göran Dahlgren. WHO Collaborating Centre for Policy Research on Social Determinants of Health University of Liverpool, 2006, Levelling up (Part 1): a Discussion Paper on Concepts and Principles for Tackling Social Inequities in Health.

[3] Blue Cross Blue Shield of Massachusetts Foundation, 2015, Leveraging the Social Determinants of Health: What Works?

[4] American Academy of Family Physicians, 2019, Advancing Health Equity by Addressing the Social Determinants of Health in Family Medicine (Position Paper).

[5] Community Based Organizations (CBO) may include Area Agencies on Aging, Aging and Disability Resources Centers, Centers for Independent Living or other aging and disability network agencies.

[6] Hopson, Chris. “Health and Social Care Integration: How Do We Make It Work?” The Guardian, 18 Sept. 2013.

[7] According to the Centers for Disease Control and Prevention, a community health worker (CHW) is a frontline public health worker who is a trusted member or has a particularly good understanding of the community served. A CHW serves as a liaison between health and social services and the community to facilitate access to services and to improve the quality and cultural competence of service delivery.

Purpose

This funding opportunity aims to support NLEs that are part of ACL’s aging and disability network and are performing access functions as part of a broader NWD System. Please see Appendix A for a list of these access functions. Through a Cooperative Agreement, ACL will support up to 10 NLEs with innovation grants to improve their access functions and support infrastructure costs associated with aligning health care and social services to address SDoH for all populations. A NLE is an organization that helps to create a CIHN at the regional, statewide, or multistate level. The NLE directs the development and design of a network structure and facilitates services, administrative oversight, and governance responsibilities.

Profile of the Leading NLE

In response to the rise in health care financing opportunities, the demand for home- and community-based services to be delivered across larger geographies, and a new frontier of competition, the leading NLEs are evolving to become viable, competitive enterprises that meet and create demand for their services and gain market share in their regions. These leading NLEs are shaped by external market forces and through continuous internal improvements to their processes, infrastructures, and standards of practice. The field of NLEs is established enough today to allow for the core business processes of a network lead entity to be identified, to recognize best practices, and to generate a profile of the leading NLE that demonstrates proficiency across each business process. NLEs and their networks are organized and governed in numerous ways.

While each NLE is unique in how it builds and sustains its network, there are foundational business processes that leading NLEs are performing. Leading NLEs are characterized by their ability to sustain multi-year contracting with multiple health sector partners, follow strategic planning and standard business processes, and employ at least one full-time staff member committed to network management. The aggregation of these NLE business processes have been informed by best practices observed in the field as well as best practices from business and management to generate a profile of the leading NLE. The processes of the leading NLE can be organized into five categories or domains.

1. Leadership: Strategic Planning, Organizing the Network, Controlling Network Performance, Leading Across Organizational Boundaries;

2. Finance: Capitalization, Cost Management, Pricing, Making the Business Case;

3. Business Development: Assessing the Market, Positioning the Network’s Services, Communicating Value Externally, Building a Health Sector Partner Base;

4. Network Development and Support: Communicating Value Internally; Vetting, Onboarding, and Assistance; Monitoring and Managing Performance, Retaining Network Service Providers; and

5. Network Administration: Strengthening Information Systems, Managing Contracts, Meeting Compliance Standards, Billing and Payments.

ACL’s aging and disability network is composed of community-based organizations that offer community living services and supports to advance the health, well-being, independence, and community participation of people with disabilities and older adults. These organizations include Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs), Centers for Independent Living (CILs), developmental disabilities organizations, University Centers for Excellence in Developmental Disabilities Education, Research and Service (UCEDDs), Protection and Advocacy Agencies, behavioral health organizations, aging services organizations, faith-based organizations, Native American tribal organizations (American

Indian/Alaskan Native/Native Hawaiian), nutrition program providers, and other local service providers for persons with disabilities and/or older adults. Additionally, for the purpose of this funding opportunity, as noted in the Purpose section above, CIHNs are comprised of coordinated CBOs lead by a NLE that have formal partnerships with health care organizations. CIHNs reflect collaboration between health care organization and social service networks and are associated with higher performance and reduced health care costs. CIHNs are led by a NLE, an organization that assumes responsibility for directing the development and design of a network structure, facilitates services, and provides administrative oversight and governance. A significant advantage of NLE-led CIHNs is their capacity to provide services at different geographic levels to meet the market demand of health plans’ and systems’ geographic footprint, such as (1) Regional; (2) Statewide; and (3) Multi-state lines. The core set of guiding principles of CIHNs include:

Trust: Networks leverage established relationships in the community and in the home to ensure that individuals feel understood and supported.

Leadership: Social service and health care decision makers share leadership responsibilities in planning and managing social assessments, referrals, service delivery, and team-based, holistic care.

Accountability: Social service leaders implement a system of accountability and quality improvement at all levels using agreed-upon performance benchmarks, frameworks for data sharing and regular reporting, and data-driven strategies for improvement.

Sustainability: Networks finance services that address SDOH through multi-payer arrangements that build community capacity. Over time, they transition from a fee-for-service payment model to value-based/risk-based payment models for delivering social services in comprehensive, coordinated care environments.

Innovation: To maximize efficient delivery of services and health outcomes, networks implement, evaluate, and iterate evidence-based interventions and innovative care models.

Use of Funds

A particularly common and significant challenge experienced by NLEs involves the readiness and willingness of some service providers in the network’s geographic coverage area to join the network and meet the performance standards necessary to fulfil contractual obligations. Many of the service providers require unanticipated levels of personnel time and financial resources of the NLEs to demonstrate the value of joining the network, to help service providers meet the standards for contracting, and to offer guidance on how to manage contracts and services that produce value. Leading NLEs are finding that they need to expand network service provider eligibility criteria to include private for-profit organizations in order to meet the performance and compliance obligations in their health sector contracts. Some are also hiring their own direct service staff to fill gaps in network coverage. These and other challenges experienced by NLEs cause delays in planning and implementation, create gaps in service area coverage and limitations on potential service volume capacities, hinder the NLE’s own growth and advancement, and can ultimately prevent or jeopardize health sector partnerships.

Common Challenges to NLE Success https://www.healthaffairs.org/do/10.1377/hblog20200221.672385/full/ https://www.healthaffairs.org/do/10.1377/hblog20200221.672385/full/

When considering the growth and advancement of NLEs, there are some common challenges to tackle and provide areas that NLEs may wish to utilize grant funding. Challenges include:

Claims management Inadequate capital Difficulties in implementing business development plans Poorly conceived contracting tactics Expensive and complex information technology Non-compliance of network service providers Underdeveloped cost accounting systems Lack of service provider readiness Narrow service provider boundaries Need to expand populations

Develop and Enhance Administration Structure and Functions

The development and enhancement of NLEs provides a unified and consistent approach to program delivery across a geographic area, including management of critical business operations, administrative oversight, and establishment of governance responsibilities. To build and strengthen the operations, infrastructure, and sustainability of NLEs and CIHNs for delivery of home and community-based services and supports in contract with health care entities, funds can be used to:

1. Assess business requirements to operate as a Network Lead Entity (NLE), including insurance liability requirements and gaps in liability coverage that may prevent participation

2. Staffing / Leadership / Governance

a. Assess competencies of key staff performing access functions of NLE

i. Provide relevant trainings in cultural competency, person-centered counseling, social service coordination, etc.

b. Develop mechanisms for managing staff training across CIHN partner organizations to ensure service excellence and a culture of quality improvement.

c. Assess CIHN partner organizations representing underserved populations as defined by Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.

d. Develop mechanisms to curate and evolve CIHN partner organizations to meet the needs of populations over time related to nutrition, housing, transportation, behavioral health, and/or other social determinants of health.

e. Develop mechanisms for managing sub-contractual relationships, develop and implement NLE infrastructure to pay CIHN partner organizations (i.e., subcontractors).

3. Financial Modeling

a. Assess network financial and legal liability for managing risk relevant to participation in contracting.

https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/ https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/

b. Conduct cost benefit assessments to determine the financial costs and risk to the network in contracting.

c. Determine a process for blending and braiding funds from available public resources and health care contracts (enabled by the NLE and supported across the

CIHN).

i. State-level benefits and Medicaid reimbursement (e.g., reimbursement for SDOH assessment, social care coordination, state funded nutrition and transportation assistance, etc.) can be factored into a blending and braiding process.

4. Information Technology (IT) Infrastructure

a. Assess the health IT requirements for contract performance, including hardware, software, business processes, and privacy and security requirements.

b. Assess ability of CIHN partner organizations to file all claims electronically.

c. Assess requirements and opportunities for shared IT services that are needed to function as an NLE but obtained through a collaboration across NLEs.

5. Quality Assurance and Service Delivery Compliance

a. Determine flow of contracting requirements, metrics, and performance evaluation of CIHN partner organizations.

i. Conduct readiness assessments and regular report cards.

ii. Conduct process mapping for service activation and relevant follow up to ascertain service delivery outcome.

Statutory Authority The statutory authority for grants under this funding opportunity is contained in Title IV of the Older Americans Act (OAA) (42U.S.C. 3032), as amended by the Older Americans Act Amendments of 2006, P.L. 109-365. Title II Section 202b of the OAA (Public Law 109-365) specifically authorizes the Assistant Secretary for Aging to work with the Administrator of the Centers for Medicare & Medicaid Services to: “implement in all states Aging and Disability Resource Centers – (A) to serve as visible and trusted sources of information on the full range of long-term care options that are available in the community, including both institutional and home and community-based care;(B) to provide personalized and person friendly assistance to empower people to make informed decisions about their care options; (C) to provide coordinated and streamlined access to all publicly supported long-term care options so that individuals can obtain the care they need through a single intake, assessment and eligibility determination process; (D) to help people to plan ahead for their future long-term care needs; and (E) to assist, in coordination with the State Health Insurance Assistance Program, Medicare beneficiaries in understanding and accessing the Prescription Drug Coverage and prevention health benefits available under the Medicare Modernization Act.”

II. Award Information Funding Instrument Type:

CA (Cooperative Agreement) Estimated Total Funding:

$ 3,491,956 Expected Number of Awards:

Award Ceiling:

$ 350,000 Per Project Period

Award Floor:

$ 250,000 Per Project Period

Length of Project Period:

Other Additional Information on Project Periods and Explanation of 'Other' 24 month project and budget period (fully funded)

Cooperative Agreement Terms These awards will all be new cooperative agreements. ACL will be substantially involved in the project activities. The terms and conditions of the agreement will be included in the Notice of Award (NOA), which is subject to modification by either party as listed below.

The terms and conditions for this cooperative agreement are as follows:

The ACL will carry out the following activities for the cooperative agreement noted above:

1. ACL Project Officer will perform the day-to-day Federal responsibilities of managing a grant initiative and will work with the grantee to ensure that the necessary requirements for the grant are met.

2. Assist the grantee project leadership in understanding the policy concerns and/or priorities of ACL by conducting periodic briefings and by carrying out ongoing consultations.

3. Work cooperatively with the grantee to clarify the programmatic and budgetary issues to be addressed by the project. If issues are identified, work with the grantee to revise the project work plan, detailing expectations for major activities and products during the grant.

4. Provide technical assistance to the grantee on the provision of technical support and associated tasks related to the fulfillment of the goals and objectives of this grant.

5. Review and provide technical assistance on grantee work products.

6. Provide consultation to the grantee in identifying emerging issues as they relate to the goals and objectives of this grant program.

7. Work with the grantee on the development and implementation of evaluation and quality assurance systems to ensure that performance is measured and continuous improvement occurs.

8. Attend and participate in major project events as appropriate.

The Grantee will execute the responsibility of the grant as listed below:

1. Fulfill all of the requirements of the grant initiative as outlined in this program announcement, as well as carry out project activities as reviewed, approved, and awarded.

2. Participate in ACL education and communication activities (including teleconferences and webinars) provided that ACL provides reasonable notice of the subject, date, and time of the teleconference.

3. Complete ACL’s Business Acumen Maturity Model (BAMM) to assess the capacity and readiness of NLEs to identify gaps and needs for becoming a hub (or complete/participate in a readiness assessment).

4. Develop and/or update a business plan, to include a health and social service market assessment, to guide activity and monitor progress.

5. Determine a process for blending and braiding funds from available public resources and health care contracts (enabled by the NLE and supported across the CIHN).

6. For awardees with health care partners, identify a work flow process to ensure efficient, ongoing coordination of services, including clear designations regarding the role and responsibilities of CBO staff and health care partner staff.

7. Comply with all other reporting requirements, as outlined in Section VI of this Funding Opportunity and the Notice of Award.

8. Include the following disclaimer on all products produced using this grant funding:

This project was supported in part by grant number 90XX#### from the Administration for Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

Once a cooperative agreement is in place, requests to modify or amend it or the work plan may be made by ACL or the awardee at any time. Modifications and/or amendments of the Cooperative Agreement or work plan shall be effective upon the mutual agreement of both parties, except where ACL is authorized under the Terms and Conditions of award, 45 CFR Part 75, or other applicable regulation or statute to make unilateral amendments. When an award is issued, the cooperative agreement terms and conditions from the program announcement are incorporated by reference.

III. Eligibility Information

1. Eligible Applicants Domestic public or private non-profit entities including state and local governments, Indian tribal governments and organizations (American Indian/Alaskan Native/Native American), faith-based organizations, community-based organizations, hospitals, and institutions of higher education.

2. Cost Sharing or Matching Cost Sharing / Matching Requirement:

No For awards that require matching or cost sharing by statute, recipients will be held accountable for projected commitments of non-federal resources (at or above the statutory requirement) in their application budgets and budget justifications by budget period, or by project period for fully funded awards. The applicant will be held accountable for all proposed non-federal resources as shown in the Notice of Award (NOA). A recipient's failure to provide the statutorily required matching or cost sharing amount (and any voluntary committed amount in excess) may result in the disallowance of federal funds. Recipients will be required to report these funds in the Federal Financial Reports.

For awards that do not require matching or cost sharing by statute, recipients are not expected to provide cost sharing or matching. However, recipients are allowed to voluntarily propose a commitment of non-federal resources. If an applicant decides to voluntarily contribute non-federal resources towards project costs and the costs are accepted by ACL, the non-federal resources will be included in the approved project budget. The applicant will be held accountable for all proposed non-federal resources as shown in the Notice of Award (NOA). A recipient's failure to meet the voluntary amount of non-federal resources that was accepted by ACL as part of the approved project costs and that was identified in the approved budget in the NOA, may result in the disallowance of federal funds. Recipients will be required to report these funds in the Federal Financial Reports.

3. Responsiveness and Screening Criteria Application Responsiveness Criteria Not applicable.

Application Screening Criteria All applications will be screened to assure a level playing field for all applicants. Applications that fail to meet the three screening criteria described below will not be reviewed and will receive no further consideration.

In order for an application to be reviewed, it must meet the following screening requirements:

1. Applications must be submitted electronically via https://www.grants.gov by 11:59 p.m., Eastern Time, by the due date listed in section IV.3 Submission Dates and Times.

2. The Project Narrative section of the Application must be double-spaced, on 8.5” x 11” plain white paper with 1” margins on both sides, and a standard font size of no less than 11 point, preferably Times New Roman or Arial.

3. The Project Narrative must not exceed 20 pages. Project Narratives that exceed 20 pages will have the additional pages removed and only the first 20 pages of the Project Narrative will be provided to the merit reviewers for funding consideration. NOTE: The Project Work Plan, Letters of Commitment, and Vitae of Key Project Personnel are not counted as part of the Project Narrative for purposes of the 20-page limit.

Unsuccessful submissions will require authenticated verification from https://www.grants.gov indicating system problems existed at the time of your submission.

For example, you will be required to provide an https://www.grants.gov submission error notification and/or tracking number in order to substantiate missing the application deadline.

IV. Application and Submission Information

1. Address to Request Application Package Application materials can be obtained from https://www.grants.gov or https://www.acl.gov/grants/applying-grants.

http://www.grants.gov/ http://www.grants.gov/ http://www.grants.gov/ https://www.acl.gov/grants/applying-grants

Please note, ACL requires applications for all announcements to be submitted electronically through http://www.grants.gov in Workspace. Grants.gov Workspace is the standard way for organizations and individuals to apply for federal grants in Grants.gov. An overview and training on Grants.gov Workspace can be found here at:

https://www.grants.gov/web/grants/applicants/workspace-overview.html

The Grants.gov registration process can take several days. If your organization is not currently registered, please begin this process immediately. For assistance with https://www.grants.gov, please contact them at support@grants.gov or 800-518-4726 between 7:00 a.m. and 9:00 p.m.

Eastern Time.

At the https://www.grants.gov website, you will find information about submitting an application electronically through the site, including the hours of operation. ACL strongly recommends that you do not wait until the application due date to begin the application process because of the time involved to complete the registration process.

All applicants must have a DUNS number (https://fedgov.dnb.com/webform/) and be registered with the System for Award Management (SAM, www.sam.gov) and maintain an active SAM registration until the application process is complete, and should a grant be made, throughout the life of the award. Effective June 11, 2018, when registering or renewing your registration, you must submit a notarized letter appointing the authorized Entity Administrator. Please be sure to read the FAQs located at www.sam.gov to learn more. Applicants should allot sufficient time prior to the application deadline to finalize a new, or renew an existing registration. This action should allow you time to resolve any issues that may arise. Failure to comply with these requirements may result in your inability to submit your application or receive an award. Maintain documentation (with dates) of your efforts to register or renew at least two weeks before the deadline. See the SAM Quick Guide for Grantees at:

https://www.sam.gov/SAM/pages/public/help/samQUserGuides.jsf.

Note: Once your SAM registration is active, allow 24 to 48 hours for the information to be available in Grants.gov before you can submit an application through Grants.gov. This action should allow you time to resolve any issues that may arise. Failure to comply with these requirements may result in your inability to submit your application or receive an award.

Note: Failure to submit the correct EIN Suffix can lead to delays in identifying your organization and access to funding in the Payment Management System.

Effective October 1, 2010, HHS requires all entities that plan to apply for and ultimately receive federal grant funds from any HHS Operating/Staff Division (OPDIV/STAFFDIV) or receive subawards directly from the recipients of those grant funds to:

1. Register in SAM prior to submitting an application or plan;

2. Maintain an active SAM registration with current information at all times during which it has an active award or an application or plan under consideration by an OPDIV; and

3. Provide its DUNS number in each application or plan to submit to the OPDIV.

http://www.grants.gov/ https://www.grants.gov/web/grants/applicants/workspace-overview.html https://www.grants.gov/ mailto:support@grants.gov https://www.grants.gov/ https://fedgov.dnb.com/webform/ http://www.sam.gov/ https://www.sam.gov/SAM/pages/public/help/samQUserGuides.jsf

Additionally, all first-tier subaward recipients must have a DUNS number at the time the subaward is made.

Since October 1, 2003, The Office of Management and Budget has required applicants to provide a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number when applying for federal grants or cooperative agreements. It is entered on the SF-424. It is a unique, nine-digit identification number, which provides unique identifiers of single business entities. The DUNS number is free and easy to obtain.

Organizations can receive a DUNS number at no cost by calling the dedicated toll-free DUNS Number request line at 866-705-5711.

You must submit all documents electronically, including all information included on the SF424 and all necessary assurances and certifications. In accordance with the Federal Government’s efforts to reduce reporting burden for recipients of federal financial assistance, the general certification and representation requirements contained in the Standard Form 424B (SF-424B) – Assurances – Non-Construction Programs, and the Standard Form 424D (SF-424D) – Assurances – Construction Programs, have been standardized federal-wide.

Effective January 1, 2020, the updated common certification and representation requirements will be stored and maintained within SAM. Organizations or individuals applying for federal financial assistance as of January 1, 2020, must validate the federally required common certifications and representations annually through SAM located at SAM.gov.

After you electronically submit your application, you will receive an automatic acknowledgement from https://www.grants.gov that containshttps://www.grants.gov tracking number. The Administration for Community Living will retrieve your application form fromhttps://www.grants.gov.

U.S. Department of Health and Human Services Administration for Community Living

2. Content and Form of Application Submission Letter of Intent Due Date for Letter Of Intent 04/29/2021

04/29/2021 Applicants are requested, but not required, to submit a letter of intent to apply for this funding opportunity to assist ACL in planning for the application independent review process. The purpose of the letter of intent is to allow our staff to estimate the number of independent reviewers needed and to avoid potential conflicts of interest in the review. Letters of intent should be sent to:

U.S. Department of Health and Human Services

Administration for Community Living

Lauren Solkowski https://www.grants.gov/

Office of Network Advancement

Email: Lauren.Solkowski@acl.hhs.gov

Project Narrative The Project Narrative must be double-spaced, on 8.5” x 11” paper with 1” margins on both sides, and a standard font size of no less than 11 point, preferably Times New Roman or Arial. You can use smaller font sizes to fill in the Standard Forms and Sample Formats. The suggested length for the Project Narrative is 15 to 20 pages; 20 pages is the maximum length allowed. Project Narratives that exceed 20 pages will have the additional pages removed and only the first 20 pages of the Project Narrative will be provided to the merit reviewers for funding consideration. The Project Work Plan, Letters of Commitment, and Vitae of Key Personnel are not counted as part of the Project Narrative for purposes of the 20-page limit, but all of the other sections noted below are included in the limit.

The components of the Project Narrative counted as part of the 20 page limit include:

Project Abstract Project Relevance and Current Need Approach Outcomes and Evaluation Organizational Capacity

To assist reviewers in scoring your application, we suggest that applicants organize their proposals using the headings above.

Project Abstract This section should include a brief description of the proposed project, including goal(s), objectives, and outcomes.

Project Relevance and Current Need Briefly describe the current community integrated health network (CIHN) infrastructure within your state or region. Include information on partnerships with state NWD System lead agencies and community-based organizations (CBOs) serving older adults and people with disabilities for outreach and service delivery, as well as partnerships with health plans, health systems, and other payers.

Briefly describe the applicant organization’s role as a network lead entity (NLE) or, if this capacity does not currently exist, indicate why the applicant is well-positioned for this role. Highlight the degree to which your organization is performing access functions as part of a broader NWD System in your state (see Appendix A for list of access functions).

Briefly describe the NLE’s capacity within the following domains Leadership; Finance;

Business Development; Network Development and Support; and Network Administration (reference Purpose section above, Profile of the Leading NLE).

Briefly describe the barriers/challenges that exist with respect to a fully operational/accessible CIHN in your target geography, and how the proposed project would address those barriers/challenges.

Approach Project Description This section should:

State the project’s result-based goals and major objectives.

Describe how the NLE will ensure the delivery of a broad scope of SDOH/social care services for older adults and people with disabilities throughout the CIHN. Specify the services to be delivered.

Describe how your proposed activities will enhance the NLE’s capacity in any/all of the following domains: Leadership; Finance; Business Development; Network Development and Support; and Network Administration (reference Profile of the Leading NLE for more information).

Describe how your proposed activities will address any unmet needs with respect to CIHN infrastructure development and/or expansion (i.e., geographic coverage, populations served, staffing capacity across a variety of roles [access functions, care coordination, community health workers, etc.] to ensure ability of CIHN to fully coordinate and oversee service delivery, information technology, etc.).

If applicable, describe how your proposed project will provide expanded geographic coverage at a regional, statewide, or multi-state level.

Special Target Populations/Organizations

Describe how the NLE will engage network partners to reach diverse consumers and traditionally hard-to-reach populations (as defined by Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government).

Outcomes and Evaluation Outcomes

This section must clearly identify the outcomes that will result from your comprehensive strategy to implement this project. Any proposed outcomes should:

o address the goals of this funding opportunity; and o be quantifiable, measurable, and likely to be achieved during the project period.

List measurable outcomes in the Work Plan grid under “Measurable Outcomes,” in addition to any discussion included in the narrative.

Evaluation This section should describe the method(s), techniques and tools that will be used to: 1) determine whether or not the proposed intervention achieved its anticipated outcome(s), and 2) document the “lessons learned” – both positive and negative – from the project that will be useful to people interested in replicating the intervention, if it proves successful.

Dissemination

This section should describe the method that will be used to disseminate the project’s results and findings in a timely manner and in easily understandable formats, to parties who might be interested in using the results to inform practice, service delivery, program development, and/or policy-making, including and especially those parties who would be interested in replicating the project.

Applicants should also highlight their willingness to participate in conferences, webinars, and other presentation formats to share project-relevant information with interested parties.

Organizational Capacity Describe how the applicant agency is organized, the nature and scope of its work, and the capabilities it possesses.

Describe your experience delivering and/or facilitating streamlined access to services/programs that address the social determinants of health, including for underserved populations. The applicant organization should serve as – and articulate – their role/function as the network lead entity, as well as identify the partners that currently comprise their community integrated health network. It may be helpful to include a network organizational chart as an appendix to your application.

Describe the project management, including the roles and responsibilities of project staff.

You should:

o Provide a description of the qualifications and experience of the key personnel for this proposed project, including for the Project Director. Applicants must include resumes or CVs as an attachment (upload all resumes/CVs as one attachment to your application if possible).

o Specify who will have day-to-day responsibility for key tasks such as: leadership of project, monitoring the project’s on-going progress, preparation of reports, and communications with other partners and ACL.

Letters of Commitment from Key Participating Organizations Include confirmation of the commitments to the project (should it be funded) made by key collaborating organizations and agencies (including community-based organizations and any health care partners) in this part of the application.