hrsa-25-033_final.pdf

Federal Office of Rural Health Policy

Notice of Funding Opportunity

Application due March 18, 2025

Delta Region Community Health Systems Development Program Opportunity number: HRSA-25-033

Modified on 1/28/25 Updated TA Webinar information

Contents Before you begin 3

Step 1: Review the Opportunity 4

Basic information 5

Eligibility 6

Program description 8

Award information 13

Step 2: Get Ready to Apply 16

Get registered 17

Find the application package 17

Application writing help 17

Step 3: Write Your Application 19

Application contents and format 20

Step 4: Learn About Review and Award 29

Application review 30

Selection process 36

Award notices 37

Step 5: Submit Your Application 38

Application submission and deadlines 39

Application checklist 41

Step 6: Learn What Happens After Award 43

Post-award requirements and administration 44

Contacts and Support 48

Endnotes 51

Contents 2

Before you begin If you believe you are a good candidate for this funding opportunity, secure your SAM.gov and Grants.gov registrations now. If you are already registered, make sure your registrations are active and up-to-date.

SAM.gov registration (this can take several weeks)

You must have an active account with SAM.gov. This includes having a Unique Entity Identifier (UEI).

See Step 2: Get Ready to Apply

Grants.gov registration (this can take several days)

You must have an active Grants.gov registration. Doing so requires a Login.gov registration as well.

See Step 2: Get Ready to Apply

Apply by the application due date

Applications are due by 11:59 p.m. Eastern Time on March 18, 2025.

To help you find what you need, this NOFO uses internal links. In Adobe Reader, you can go back to where you were by pressing Alt + Left Arrow (Windows) or Command + Left Arrow (Mac) on your keyboard.

Before you begin 3 https://sam.gov/ https://grants.gov/

Jump to a step

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1:

Review the Opportunity

In this step

Basic information 5

Eligibility 6

Program description 8

Award information 13

Basic information Health Resources and Services Administration (HRSA)

Federal Office of Rural Health Policy

Hospital State Division

Strengthening healthcare delivery in rural areas of the Delta region.

Have questions?

Go to Contacts and Support.

Key facts Opportunity name:

Delta Region Community Health Systems Development Program

Opportunity number:

HRSA-25-033

Announcement version:

Modification #1

Federal assistance listing:

93.912

Statutory authority: 42 U.S.C. 912(b) (§ 711(b) of the Social Security Act)

Key dates

NOFO issue date:

January 17, 2025

Informational webinar:

See Webinar Section.

Application deadline: March 18, 2025

Expected award date is by:

August 1, 2025

Expected start date:

September 1, 2025

See other submissions for other time frames that may apply to this NOFO.

Summary This program seeks to strengthen healthcare delivery in rural areas of the Delta region.

This will be done through comprehensive, multi-year technical assistance to improve financial and operational performance as well as the quality of care in rural healthcare organizations.

Funding detail Application type: New, Competing continuation

Expected total available funding in FY 2025: $10,000,000

Expected number and type of awards: 1 cooperative agreement

Funding range per award: Up to $10,000,000 per year

We plan to fund awards in five 12-month budget periods for a total 5-year period of performance of September 1, 2025 to August 31, 2030.

The program and awards depend on the appropriation of funds and are subject to change based on the availability and amount of appropriations.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 5 https://www.govinfo.gov/content/pkg/USCODE-2023-title42/html/USCODE-2023-title42-chap7-subchapVII-sec912.htm https://www.govinfo.gov/content/pkg/USCODE-2023-title42/html/USCODE-2023-title42-chap7-subchapVII-sec912.htm https://www.govinfo.gov/content/pkg/USCODE-2023-title42/html/USCODE-2023-title42-chap7-subchapVII-sec912.htm

Eligibility Who can apply You can apply if you are a domestic public or private, non-profit or for-profit, entity.

Types of eligible organizations These types of domestic* organizations may apply:

• Public institutions of higher education

• Private institutions of higher education

• Non-profits with or without a 501(c)(3) IRS status

• For-profit organizations, including small businesses

• State, county, city, township, and special district governments, including the District of Columbia, domestic territories, and freely associated states

• Independent school districts

• Native American tribal governments

• Native American tribal organizations

* “Domestic” means the 50 states, the District of Columbia, 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, and the Republic of Palau.

Individuals are not eligible applicants under this NOFO.

Other eligibility criteria Successful applications must target rural healthcare organizations located in the Delta region. For the purposes of this notice of funding opportunity, a “rural healthcare organization” is a healthcare organization located in a rural county or parish in the Delta region. “Healthcare organizations” include:

• Critical access hospitals.

• Small rural hospitals.

• Certified rural health clinics.

• Tribal healthcare facilities.

• Other healthcare organizations.

Step 1: Review the Opportunity 6

You can view maps of the counties and parishes in the Delta region on the Delta Regional Authority’s website. To determine if a county or parish in the Delta region is rural, visit HRSA’s Rural Health Grants Eligibility Analyzer.

Completeness and responsiveness criteria We will review your application to make sure it meets these basic requirements to move forward in the competition.

We will not consider an application that:

• Is from an organization that does not meet all eligibility criteria.

• Requests funding above the award ceiling shown in the funding range.

• Is submitted after the deadline.

Application limits You may not submit more than one application. If you submit more than one application, we will only accept the last on-time submission.

Cost sharing This program has no cost-sharing requirement. If you choose to share in the costs of the project, we will not consider it during merit review. We will hold you accountable for any funds you add, including through reporting.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 7 https://dra.gov/map-room/ https://data.hrsa.gov/tools/rural-health

Program description Purpose The Delta Region Community Health Systems Development Program provides comprehensive, multi-year technical assistance (TA) to help rural healthcare organizations in the rural counties and parishes of the Delta region improve healthcare services. The goal of this program is to strengthen healthcare delivery in rural areas of the Delta region. This will be done by improving financial and operational performance as well as the quality of care in rural healthcare organizations.

Service improvements in healthcare organizations could include the following.

• Financial and operational improvements:

◦ Developing new service lines.

◦ Increasing inpatient and swing bed volume.

◦ Increasing outpatient services.

◦ Implementing revenue cycle best practices to increase point-of-service collections.

◦ Optimizing emergency department operations.

• Quality improvement:

◦ Reducing readmissions.

◦ Improving transitions of care and discharge planning.

◦ Implementing performance measurement systems.

◦ Training on clinical documentation integrity.

◦ Utilizing data analytics.

• Telehealth and technology:

◦ Expanding telehealth services.

◦ Enhancing cybersecurity.

• Workforce and leadership development:

◦ Strengthening workforce recruitment initiatives.

◦ Implementing new technology to increase clinical efficiency.

◦ Providing simulation training for clinicians.

◦ Providing leadership training such as rounding to improve patient and employee satisfaction.

• Emergency medical services:

Step 1: Review the Opportunity 8

◦ Enhancing current emergency medical services through innovative and economical best practices.

• Care coordination:

◦ Enhancing the coordination of care and the rural healthcare organization’s visibility within the community to reduce avoidable bypass.

Objectives If you are funded under this cooperative agreement, you will work with individual healthcare organizations to meet the following program objectives.

• Provide objective analysis and assessment of the following aspects of healthcare organizations, so they can make actionable change:

◦ Financial status.

◦ Market share.

◦ Quality indicators.

◦ Locally available human services.

◦ Gaps in services.

• Identify clinical areas where expansion of services would:

◦ Meet local need.

◦ Keep healthcare services available locally.

◦ Build capacity to improve financial and operational performance as well as quality of care.

• Help healthcare organizations develop TA action plans and implement the best practice recommendations prioritized in these plans.

Step 1: Review the Opportunity 9

Background The Delta region includes parts of eight states—Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. The Delta Region has a population of almost 10 million people living in 252 counties and parishes. Approximately 212 of the counties and parishes (84 percent) are rural (nonmetropolitan area), and 41 percent of the total population of the Delta resides in these rural counties.[1]

The Delta Regional Authority (DRA), established in 2000 by Congress, invests in Delta communities’ human and physical infrastructure. The counties and parishes served by DRA are among the most distressed areas of the country. There is extensive documentation regarding the distress of the counties and parishes in the Delta region in terms of both health and economic conditions. 20 percent of the region’s population has incomes below the poverty rate, compared with the national rate of 14 percent.

Poverty is more persistent in the Delta region than nationally.[2] Rural counties with a high incidence of poverty are largely concentrated in the South, and the most severe poverty is found in historically under resourced areas such as the Delta region.[3]

Research indicates that Delta residents tend to have more complex health issues and chronic conditions. One study found that Delta residents are 1.16 times more likely to die of cancer and 1.45 times more likely to die of injury than the nationwide rate. Blood pressure, diabetes rates, body mass index, and likelihood of smoking are higher in the Delta.[4] Research by the Centers for Disease Control and Prevention assessed factors contributing to health outcomes and found that factors such as tobacco use, diet and exercise, and access to care in Delta counties and parishes were on average 22 percent worse than in the rest of the United States.[5]

A high proportion of the rural hospitals that closed between 2010 and 2023 were located in the Delta region. Recent analysis found that multiple Delta states are among those with the highest number of rural hospitals at risk of financial distress.[6] Hospitals experiencing high financial distress often reduce services, which limits access to care for vulnerable populations and worsens health disparities. Rural hospitals serve small populations, which also impacts their financial sustainability. Rural hospitals have low patient volume and may not have enough patients to cover high fixed operating costs.[7]

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 10 http://www.dra.gov/

Program requirements and expectations Selecting healthcare organizations

• You must identify and market to rural healthcare organizations that will benefit from TA.

• You are expected to assess financial risk using existing national standards, for example, University of North Carolina’s Financial Distress Index, as part of the selection of rural healthcare organizations.

Providing TA

• Each year, you will select approximately ten rural healthcare organizations in the rural counties and parishes in the Delta region and provide multiyear TA to them.

You will work collaboratively with HRSA and DRA as you carry out program activities.

• You must develop a comprehensive TA plan that meets the purpose and objectives of this program. This includes a process for identifying community healthcare needs, market share, operational efficiencies, and other service line expansions in each rural healthcare organization to strengthen healthcare delivery in the Delta region.

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

• You will develop and manage a network of nationally known rural healthcare organization technical experts with financial, operational, quality, and clinical expertise to provide consultations to rural healthcare 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 multiyear TA.

• Based on expert recommendations, you will purchase software and equipment for organizations to implement best practices prioritized in their TA action plans.

HRSA recommends that you use at least 20 percent of your budget for this purpose. You must ensure that you spend this funding in support of program objectives.

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

• You are expected to share data collected during the program with HRSA.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 11 https://www.shepscenter.unc.edu/product/prediction-of-financial-distress-among-rural-hospitals/

Additional TA

• You will respond to requests for additional TA initiatives that meet administration priorities for innovation, adaptability, and sustainability in rural healthcare organizations located in the Delta region.

• You are expected to provide limited TA (e.g., recommendations, resources) to HRSA’s Delta Health Systems Implementation Program award recipients to support successful implementation of projects focused on previous TA consultations.

Step 1: Review the Opportunity 12

Award information Cooperative agreement terms Our responsibilities Aside from monitoring and technical assistance, we also get involved in these ways:

• Providing TA to you to prioritize program activities and assess your progress in achieving the goals of this project.

• Making introductions to other HRSA programs, federal agencies, and HRSA award recipients since their work may be relevant to your project.

• Sharing relevant program data to ensure the greatest impact of your TA efforts.

• Upon request, providing TA on the process for selecting contractors, healthcare organization technical experts, rural healthcare organizations to receive TA, and other key stakeholders involved in the program.

• Reviewing and providing feedback on TA products and proposed outcome measures related to the TA provided.

• Participating, as appropriate, in planning and implementing meetings, webinars, advisory committees, or working groups.

Your responsibilities You must follow all relevant laws and policies. Your other responsibilities will include:

• Collaborating with HRSA and DRA on the process of selecting rural healthcare organizations in the rural counties and parishes in the Delta region to receive TA services and review your activities.

• Applying your knowledge of FORHP and other HRSA programs to link program participants to appropriate resources.

• Consulting with HRSA when marketing program services, showing the benefits of participating in the program and implementing recommendations.

• Engaging with key stakeholders such as State Offices of Rural Health, State Hospital Associations, and State Rural Health Associations to market services and identify rural healthcare organizations to receive multiyear TA.

• Working with the selected rural healthcare organizations to identify clinical areas where expansion of services would:

◦ Meet local medical need.

Step 1: Review the Opportunity 13

◦ Help keep healthcare services available locally.

◦ Improve rural healthcare organizations’ finances, operations, and quality of care.

• Ensuring interventions are appropriate to the needs of the rural healthcare organization community, to gain both community buy-in and commitment from key organization and community leaders to actively participate in the project and sustain activities after TA is provided.

• Developing a process for entities receiving TA to commit to making the recommended improvement activities, as a condition of receiving the TA.

• Building and maintaining a strong understanding of the identified communities and an ability to identify rural healthcare organizations in those communities that want to improve and could benefit most from technical assistance.

Funding policies and limitations Policies

• We will only make awards if this program receives funding. If Congress appropriates funds for this purpose, we will move forward with the review and award process.

• Support beyond the first budget year will depend on:

◦ Appropriation of funds.

◦ Your satisfactory progress in meeting the project’s objectives.

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

• If we receive more funding for this program, we may:

◦ Fund more applicants from the rank order list.

◦ Extend the period of performance.

◦ Award supplemental funding.

General limitations

• For guidance on some types of costs we do not allow or restrict, see Project

Budget Information in Section 3.1.4 of the Application Guide. You can also see 45 CFR part 75, or any superseding regulation, General Provisions for Selected Items of Cost.

• You cannot earn profit from the federal award. See 45 CFR 75.400(g).

• Congress’s current appropriations act includes a salary limitation, which applies to this program. As of January 2025, the salary rate limitation is $225,700. This limitation may be updated.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 14 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=13 https://www.ecfr.gov/current/title-45/part-75/subject-group-ECFR5d90ba314caea08 https://www.ecfr.gov/current/title-45/part-75/subject-group-ECFR5d90ba314caea08 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75#75.400

Indirect costs Indirect costs are costs you charge across more than one project that cannot be easily separated by project. For example, this could include utilities for a building that supports multiple projects).

To charge indirect costs you can select one of two methods:

Method 1 – Approved rate. You currently have an indirect cost rate approved by your cognizant federal agency at the time of award.

Method 2 – De minimis rate. Per 2 CFR 200.414 (f), if you have never received a negotiated indirect cost rate, you may elect to charge a de minimis rate. If you choose this method, costs included in the indirect cost pool must not be charged as direct costs.

This rate is 15% of modified total direct costs (MTDC). See 2 CFR 200.1 for the definition of MTDC. You can use this rate indefinitely.

Program income Program income is money earned as a result of your award-supported project activities. You must use any program income you generate from awarded funds for approved project-related activities. Find more about program income at 45 CFR 75.307.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 1: Review the Opportunity 15 https://www.ecfr.gov/current/title-2/section-200.414 https://www.ecfr.gov/current/title-2/part-200#p-200.1(Modified%20Total%20Direct%20Cost%20(MTDC)) https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.307

Step 2:

Get Ready to Apply

In this step

Get registered 17

Find the application package 17

Application writing help 17

Get registered SAM.gov You must have an active account with SAM.gov to apply. This includes having a Unique Entity Identifier (UEI). SAM.gov registration can take several weeks. Begin that process today.

To register, go to SAM.gov Entity Registration and select Get Started. From the same page, you can also select the Entity Registration Checklist to find out what you’ll need to register.

When you register or update your SAM.gov registration, you must agree to the financial assistance general certifications and representations. You must agree to those for grants specifically, as opposed to contracts, because the two sets of agreements are different. You will have to maintain your registration throughout the life of any award.

Grants.gov You must also have an active account with Grants.gov. You can see step-by-step instructions at the Grants.gov Quick Start Guide for Applicants.

Find the application package The application package has all the forms you need to apply. You can find it online. Go to Grants Search at Grants.gov and search for opportunity number HRSA-25-033.

After you select the opportunity, we recommend that you click the Subscribe button to get updates.

Application writing help Visit HHS Tips for Preparing Grant Proposals.

Visit HRSA’s How to Prepare Your Application page for more guidance.

See Apply for a Grant for other help and resources.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 2: Get Ready to Apply 17 https://sam.gov/content/entity-registration https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application/assurances-non-construction-programs https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application/assurances-non-construction-programs https://grants.gov/applicants/applicant-registration http://www.grants.gov/quick-start-guide/applicants https://www.grants.gov/search-grants https://www.hhs.gov/grants-contracts/grants/get-ready-for-grants-management/tips-for-preparing-grant-proposals/index.html https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application https://www.hrsa.gov/grants/apply-for-a-grant

Join the webinar More information on this NOFO's webinar will be posted at a later date to the related documents tab here.

We recommend you “Subscribe” to the NOFO on Grants.gov to receive updates when documents are posted.

The Webinar will be recorded.

Have questions? Go to Contacts and Support.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 2: Get Ready to Apply 18 https://grants.gov/search-results-detail/355363

Step 3:

Write Your Application

In this step

Application contents and format 20

Application contents and format Applications include five main components. This section includes guidance on each.

Application page limit: 70 pages

Submit your information in English and express whole number budget figures using U.S. dollars.

Make sure you include each of these:

Components Submission format

Project abstract Use the Project Abstract Summary form.

Project narrative Use the Project Narrative Attachment form.

Budget narrative Use the Budget Narrative Attachment form.

Attachments Insert each in the Attachments form.

Other required forms Upload using each required form.

Required format You must format your narratives and attachments using our required formats for fonts, size, color, format, and margins. See the formatting guidelines in Section 3.2 of the Application Guide.

Project abstract Complete the information in the Project Abstract Summary form. Include a short description of your proposed project. Include the needs you plan to address, the proposed services, and the population groups you plan to serve. For more information, see Section 3.1.2 of the Application Guide.

Project narrative In this section, you will describe all aspects of your project. Project activities must comply with the non-discrimination requirements.

Use the section headers and the order listed.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 3: Write Your Application 20 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=35 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=35

Introduction See merit review criterion 1: Need

Briefly describe the purpose of your project for providing in-depth, multi-year TA to help rural healthcare organizations in the Delta region build capacity to improve their financial and operational performance as well as the quality of care they provide.

Need See merit review criterion 1: Need

• Describe the specific challenges that rural healthcare organizations in the Delta region face in building financial sustainability and keeping healthcare services available locally. Describe how this impacts rural populations. You must use and cite data (local, state, or federal) wherever possible to support the information you provide, including population health outcomes and data on the needs for specific healthcare services in rural communities.

• Discuss the need for in-depth, multi-year TA to help rural healthcare organizations identify gaps in services to better meet local need and improve their finances, operations, and quality of care.

Approach See merit review criterion 2: Response

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

Selecting healthcare organizations

• Discuss how you will market this program and refer rural healthcare organizations to other FORHP hospital TA programs to. Describe how you will ensure your activities complement other FORHP programs.

• Describe how you will identify and select rural healthcare organizations to receive in-depth TA each year.

• Describe how you will use selection criteria to prioritize which rural healthcare organizations you will provide TA to.

• Discuss your strategy for determining a rural healthcare organization’s readiness for TA, including:

◦ Commitment from the organization’s board or leadership.

◦ Adequacy of resources.

◦ Support to participate fully in the program and implement program recommendations.

Step 3: Write Your Application 21

• Discuss your plan to build the capacity of targeted organizations to ensure they are prepared to take on in-depth, multiyear TA. Describe any innovative methods that you will use or resources you will create to build their capacity.

Providing TA

• Discuss your comprehensive, multiyear TA plan that meets the purpose and objectives of this program.

• Discuss your strategy for assessing the following elements of your selected healthcare organizations. You will use these assessments to inform program recommendations:

◦ Community healthcare needs.

◦ Market share.

◦ Quality indicators.

◦ Financial and operational performance.

• Discuss your process for identifying areas for expansion that meet local clinical need. Discuss how you will ensure that your recommendations will be cost efficient, financially viable, and feasible.

◦ Describe the types of TA resources that you will provide to rural healthcare organizations participating in the program.

• Discuss how you will foster engagement among key rural healthcare organization leaders throughout the project.

• Describe how you will continually help rural healthcare organizations implement projects based on the expert recommendations and identified needs in the organization and community.

• Describe how you will work with key stakeholders to plan, design, and implement all activities. Key stakeholders may include:

◦ The Delta Regional Authority.

◦ State Offices of Rural Health.

◦ State Hospital Associations.

◦ State Rural Health Associations.

• Describe how you will purchase software and equipment for organizations so they can implement the best practices recommended in their TA action plans.

◦ Discuss how you will monitor software projects to ensure that the funds are spent in support of program objectives.

◦ Describe approximately what percentage of your budget you will use to provide support for software and equipment. HRSA recommends that you use at least 20 percent of your budget for this purpose.

Step 3: Write Your Application 22

• Describe how you will track and report on organizations’ progress in meeting TA recommendations, including by sharing best practices, reports, products, or project outputs with HRSA and target audiences.

• Describe how you will handle requests for additional TA initiatives—beyond those with the ten targeted organizations—that meet administration priorities for rural healthcare organizations’ innovation, adaptability, and sustainability located in the Delta region.

Community and sustainability

• Discuss how you will promote engagement from the rural healthcare organization’s community.

• Describe how you will help rural healthcare organizations sustain the impacts of the program for their communities after the federal funding ends.

• Describe how you will provide limited TA (e.g., recommendations, resources) to HRSA’s Delta Health Systems Implementation Program award recipients to support successful implementation of projects focused on previous TA consultations.

High-level work plan See merit review criteria 2: Response and 4: Impact

• Provide a work plan in attachment 1 that describes the activities or steps you will use to achieve program goals, objectives, and requirements, including your steps to form a national network of rural healthcare organization technical experts.

• Outline your strategic vision of the project over the five-year period of performance. It should align with the program purpose and identify key milestones to measure success.

• Include a timeline that outlines each activity for the entire period of performance and identifies the responsible staff for each activity. As needed, identify key stakeholders who will help plan, design, and carry out all activities, and identify how they will support the project.

Step 3: Write Your Application 23

Resolving challenges See merit review criterion 2: Response

• 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. These challenges might include:

◦ Changes to the project timeline.

◦ Turnover in leadership at rural healthcare organizations.

◦ Challenges with organizations’ boards of directors.

◦ Challenges recruiting new program participants.

Evaluation and technical support capacity See merit review criteria 3: Evaluation measures and 5: Resources and capabilities

• Describe the systems and processes that you’ll use to track your own performance outcomes. Describe how you’ll collect and manage data to enable accurate and timely reporting of those outcomes. For example, you might assign skilled staff or use data management software.

• Describe:

◦ Your plan to assess how effective your project is in meeting the program objectives.

◦ The specific outcome measures you will use. Measures may include but are not limited to increase in revenue, days of cash on hand, operating margin and patient volume.

◦ How you will use process and outcome measure data to improve your project over the five-year period of performance.

• Describe how your outcome measures will effectively assess the performance of each rural healthcare organization project and the performance of the projects collectively over the five-year period of performance.

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

Organizational information See merit review criterion 5: Resources and capabilities

• Briefly describe your mission, structure, and the scope of your current activities.

Explain how they support your ability to carry out the program requirements and expectations.

Step 3: Write Your Application 24

• Include a project organizational chart in attachment 5. Include a staffing plan and job descriptions as attachment 2, and biographical sketches for all key personnel as attachment 3.

◦ Your organizational chart and staffing plan should demonstrate staff presence in the Delta region.

▪ Describe your key personnel’s experience, skills, and knowledge and how they support your ability to carry out the program requirements and expectations.

▪ Identify staff and/or consultants who are located in, familiar with, or have worked with healthcare organizations in the Delta states.

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

• Discuss your plan for governance and decision making when selecting and managing technical experts. Include signed letters of agreement from all key stakeholders and consultants in attachment 4.

• Demonstrate your organization’s and your experts’ history providing TA specifically to rural healthcare organizations at a national or regional level. Discuss any past TA provided in the Delta region. Discuss the implementation, outcomes and results of the TA provided.

• Demonstrate experience with rural health programs such as:

◦ The Medicare Rural Hospital Flexibility Program.

◦ The Small Rural Hospital Improvement Program.

◦ The State Offices of Rural Health program.

◦ The Rural Healthcare Provider Transition Project.

◦ Demonstrate your established relationships with key stakeholders, such as:

◦ State Offices of Rural Health.

◦ Hospital and rural health associations.

• Discuss how you’ll follow the HRSA-approved plan, account for federal funds, and record all costs to avoid audit findings. If you will subaward funds or make contracts, explain how your organization will manage the overall project and ensure that subawards and contracts are properly used and monitored. Describe your related policies and procedures, which must meet or exceed the requirements in 45 CFR part 75 regarding subrecipient monitoring and management.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 3: Write Your Application 25 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75?toc=1

Budget and budget narrative See merit review criterion 6: Support Requested

Your budget should follow the instructions in Section 3.1.4 Project Budget Information

– Non-Construction Programs (SF-424A) of the Application Guide and the instructions listed in this section. Your budget should show a well-organized plan.

HHS now uses the definitions for equipment and supply in 2 CFR 200.1. The new definitions change the threshold for equipment to the lesser of the recipient’s capitalization level or $10,000 and the threshold for supplies to below that amount.

The total project or program costs are all allowable (direct and indirect) costs used for the HRSA award 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 maintenance of effort, if applicable).

The budget narrative supports the information you provide in Standard Form 424-A.

See other required forms. It includes an itemized breakdown and a clear justification of the costs you request. The merit review committee reviews both.

As you develop your budget, consider:

• If the costs are reasonable and consistent with your project’s purpose and activities.

• The restrictions on spending funds. See Funding policies and limitations.

To create your budget narrative, see detailed instructions in 3.1.5 of the Application Guide.

Specific instructions

• Number of healthcare organizations: Please outline the number of healthcare organizations you plan to provide TA for each year. Your budget should indicate the amount of funding allocated toward the organizations you plan to serve.

• Equipment: HRSA recommends that you use at least 20 percent of your budget to purchase software and equipment for healthcare organizations so they can implement the best practices recommended in their TA action plans. Describe approximately what percentage of your budget you will use for this purpose.

Describe how these software and equipment purchases contribute to meeting the goals of your project.

• Personnel: HRSA recommends allocating funds for a project director with 1.0 full-time equivalence (FTE), and at least three additional FTE to carry out program activities. Ideally, you should have one project director rather than splitting the allotted time among multiple staff members.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 3: Write Your Application 26 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=13 https://www.ecfr.gov/current/title-2/part-200#p-200.1(Equipment) https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200%22%20/l%20%22p-200.1(Supply) https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=18 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=18

• Contractual: You are responsible for ensuring that your organization or institution has an established procurement system with fully developed written procedures for awarding and monitoring contracts. Consistent with 45 CFR part 75, you must clearly explain the purpose of each contract, how the costs were estimated, and the specific contract deliverables.

Attachments Place your attachments in this order in the Attachments Form. See application checklist to determine if they count toward the page limit.

Attachment 1: Work plan Attach the project’s work plan. Make sure it includes everything required in the project narrative section. If you will make subawards or expend funds on contracts, describe how your organization will ensure proper documentation of funds.

Attachment 2: Staffing plan and job descriptions See Section 3.1.7 of the Application Guide.

Include a staffing plan that shows the staff positions that will support the project and key information about each. Justify your staffing choices, including education and experience qualifications and your reasons for the amount of time you request for each staff position. For key personnel, attach a one-page job description. It must include the role, responsibilities, and qualifications.

Attachment 3: Biographical sketches Include biographical sketches for people who will hold the key positions you describe in Attachment 2.

For key personnel, include no more than two-page biographical sketches. Do not include non-public, personally identifiable information. If you include someone you have not hired yet, provide a letter of commitment from that person with the biographical sketch.

Attachment 4: Agreements with other entities Provide any documents that describe working relationships between your organization and others you refer to in the proposal. Documents that confirm actual or pending contracts or agreements should clearly describe the roles of subrecipients and contractors and any deliverable. Make sure you sign and date any letters of agreement.

Letters of support must be dated and specifically indicate a commitment to the project/ program (in-kind services, dollars, staff, space, equipment, etc.).

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 3: Write Your Application 27 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75?toc=1 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=21

Attachment 5: Project organizational chart Provide a one-page diagram that shows the project’s organizational structure.

Attachment 6: For multiyear budgets—fifth-year budget For the fifth budget year, submit a copy of Section B of the SF-424A as an attachment.

We do not count this in the page limit however, any related budget narrative does count. See Section 3.1.4 of the Application Guide.

Attachments 7-15: Other relevant documents You may use attachments 7 through 15 to add other relevant documents.

Other required forms You will need to complete some other forms. Upload the listed forms at Grants.gov. You can find them in the NOFO application package or review them and any available instructions at Grants.gov Forms.

Forms Submission Requirement

Application for Federal Assistance (SF-424) With application

Budget Information for Non-Construction Programs (SF-424A)

With application

Disclosure of Lobbying Activities (SF-LLL) If applicable, with the application or before award

Budget Narrative Attachment Form With application

Project/Performance Site Location(s) With application.

Grants.gov Lobbying Form With application.

Key Contacts With application.

1. Review 2. Get Ready 3. Write 4. Learn 5. Submit 6. Award Contacts

Step 3: Write Your Application 28 https://www.grants.gov/forms

Step 4:

Learn About Review and Award

In this step

Application review 30

Selection process 36

Award notices 37

Application review Initial review We will review your application to make sure that it meets eligibility criteria, including the completeness and responsiveness criteria. If your application does not meet these criteria, it will not be funded.

We will not review any pages that exceed the page limit.

Merit review A panel reviews all applications that pass the initial review. The members use these criteria.

Criterion Total number of points = 100

1. Need 10 points

2. Response 35 points

3. Performance reporting and evaluation 10 points

4. Impact 10 points

5. Resources and capabilities 30 points

6. Support requested 5 points

Criterion 1: Need (10 points) See project narrative Introduction and Need sections.

The panel will review your application for:

• How well you describe the purpose of your proposed project for providing in-depth, multi-year TA to rural healthcare organizations in the Delta region to help them build capacity to improve their financial and operational performance as well as quality of care.

• The extent to which you describe the needs of rural healthcare organizations in the Delta region using local, state, or federal data, including population health outcomes and data on the needs for specific healthcare services in rural communities.

• The extent to which you demonstrate an understanding of the issues affecting the rural health environment in the Delta region, how these issues affect the

Step 4: Learn About Review and Award 30 sustainability of rural healthcare organizations, and how this impacts rural populations.

Criterion 2: Response (35 points) See project narrative Approach, High-level work plan, and Resolving challenges sections.

Approach (20 points)

Selecting healthcare organizations

The panel will review your application to determine the extent to which you:

• Discuss how you will market this program to rural healthcare organizations, informing them of the benefits of participation and the available services.

• Describe your approach to identifying and selecting approximately ten rural healthcare organizations to receive in-depth TA each year.

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

• Discuss your strategy for determining a rural healthcare organization’s readiness for TA, including:

◦ Commitment from the organization’s board or leadership.

◦ Adequacy of resources.

◦ Support to participate fully in the program and implement program recommendations.

• Discuss a plan to build the capacity of rural healthcare organizations in the Delta region to ensure they are prepared to take on in-depth, multiyear TA. Describe innovative approaches you will use to build capacity.

Providing TA

The panel will review your application to determine the extent to which you:

• Demonstrate that the strength and breadth of your comprehensive, multiyear TA plan you propose meets the program’s purpose and objectives, which may include:

◦ Financial and operational performance.

◦ Quality improvement.

◦ Workforce recruitment and retention.

◦ Leadership development.

◦ Emergency medical services (EMS).

Step 4: Learn About Review and Award 31

◦ Telehealth.

◦ Community care coordination.

• Discuss your strategy for assessing your selected rural healthcare organization’s community healthcare needs, market share, quality indicators, and financial and operational performance to inform program recommendations.

• Describe how you will continually help rural healthcare organizations implement projects based on the expert recommendations and identified needs in the organization and community.

• Describe your process for identifying areas for expansion that meet local clinical need and how you will ensure that your recommendations will be cost efficient, financially viable, and feasible.

• Describe the types of TA resources you will provide to rural healthcare organizations participating in the program and how they will meet program requirements and expectations. These resources may include:

◦ TA action plans.

◦ Financial and operational resources.

◦ A final report with recommendations for each hospital.

• Discuss how you will foster engagement among key organization leadership throughout the project.

• Collaborate with key stakeholders to plan, design, and implement all activities.

Key stakeholders may include:

◦ The Delta Regional Authority.

◦ State Offices of Rural Health.

◦ State Hospital Associations.

◦ State Rural Health Associations.

• Describe how you will purchase software and equipment so organizations can implement the best practices prioritized in their TA action plans.

◦ Describe how you will ensure that these funds are spent in support of program objectives.

• Describe how you will track and report on organizations’ progress in meeting TA recommendations, including by sharing best practices, reports, products, or project outputs to HRSA and target audiences.

• Describe how you will handle requests for additional TA initiatives that meet administration priorities for rural healthcare organizations’ innovation, adaptability, and sustainability.

Community and sustainability

Step 4: Learn About Review and Award 32

The panel will review your application to determine the extent to which you:

• Describe how you will promote engagement from the rural healthcare organization’s community.

• Describe how your proposed approach will help rural healthcare organizations sustain the impacts of the program for their communities after the federal funding ends.

• Describe how you will provide limited TA to HRSA’s Delta Health Systems Implementation Program award recipients to support successful implementation of projects focused on previous TA consultations.

Work plan (10 points) The panel will review your application for:

• How well the work plan in attachment 1 describes the activities or steps you will use to form 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 for the five-year period of performance that identifies the responsible staff for each activity.

• How well the work plan identifies activities that require collaboration with key stakeholders (including subaward recipients), such as planning, designing, and implementing TA services.

Resolution of challenges (5 points) The panel will review your application for:

• The extent to which you discuss current and potential challenges that may be barriers to implementing the planned program and approaches to overcome these challenges. These challenges may include:

◦ Changes to the project timeline.

◦ Turnover in leadership at rural healthcare organizations.

◦ Challenges with organizations’ boards of directors.

◦ Challenges recruiting new program participants.

Criterion 3: Evaluation measures (10 points) See project narrative Evaluation and technical support capacity section.

The panel will review your application for:

• The effectiveness of your proposed method to monitor and assess performance outcomes.

Step 4: Learn About Review and Award 33

• The effectiveness of your proposed systems and processes to collect and manage data to enable accurate and timely reporting of outcomes.

• The effectiveness of your plan to use process and outcome measure data to improve your project over the five-year period of performance.

• The effectiveness of the outcome measures in assessing the performance of each rural healthcare organization project and the performance of the projects collectively over the five-year period of performance. Measures may include but are not limited to, increase in revenue, days of cash on hand, operating margin and patient volume.

• The strength of your understanding of the barriers to collecting and using process and outcome measure data and your plan to address those barriers.

Criterion 4: Impact (10 points) See project narrative High-level work plan section.

The panel will review your application for:

• The strength of the high-level strategic vision of the proposed project and how well it supports the program’s purpose.

• The effectiveness of the proposed activities and outcome measures to assess how successful the proposed project will be in meeting program objectives.

Criterion 5: Resources and capabilities (30 points) See project narrative Organizational information and Evaluation and technical support capacity sections.

The panel will review your application for how well you:

• Describe your organization’s mission, structure, and the scope of current activities.

◦ Include knowledge, technical experience, and demonstrated outcomes working with rural healthcare organizations to improve their quality, financial health, population health, EMS sustainability, and transition to value-based care (such as the Medicare Rural Hospital Flexibility Program, the Small Rural Hospital Improvement Program, and the Rural Healthcare Provider Transition Project).

◦ Explain how…