HRSA-25-035_Final.pdf

Notice of Funding Opportunity

Application due Monday, April 14, 2025

Federal Office of Rural Health Policy (FORHP)

Rural Healthcare Provider Transition Project Opportunity number: HRSA-25-035

Contents Before you begin 3

Step 1: Review the Opportunity 4

Basic information 5

Eligibility 6

Program description 8

Award information 11

Step 2: Get Ready to Apply 14

Get registered 15

Find the application package 15

Application writing help 15

Step 3: Write Your Application 17

Application contents and format 18

Step 4: Learn About Review and Award 26

Application review 27

Selection process 32

Award notices 33

Step 5: Submit Your Application 34

Application submission and deadlines 35

Application checklist 36

Step 6: Learn What Happens After Award 37

Post-award requirements and administration 38

Contacts and Support 41

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 Monday, April 14, 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 11

Basic information Health Resources and Services Administration

Federal Office of Rural Health Policy (FORHP)

Help small rural hospitals and rural health clinics build a foundation for participating in value-based healthcare.

Have questions?

Go to Contacts and Support.

Key facts

Opportunity name:

Rural Healthcare Provider Transition Project

Opportunity number:

HRSA-25-035

Announcement version:

New, competing continuation

Federal assistance listing:

93.155

Statutory authority:

Section 711(b)(5) of the Social Security Act (42 U.S.C.

912(b)(5), as amended)

Key dates

NOFO issue date:

Monday, January 13, 2025

Informational webinar:

Thursday, January 30, 2025

Application deadline:

Monday, April 14, 2025

Expected award date:

Friday, August 1, 2025

Expected start date:

Monday, September 1, 2025

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

Summary The purpose of the Rural Healthcare Provider Transition Project is to help small rural hospitals and rural health clinics (RHCs) strengthen their foundation in key elements of value-based care, including, but not limited to:

• Quality

• Efficiency

• Patient experience

• Safety

Funding details Application type: New, competing continuation

Expected total available FY 2025 funding: $800,000

Expected number and type of awards: 1 cooperative agreement

Funding range per award: Up to $800,000 per year

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

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.

Step 1: Review the Opportunity 5

Eligibility Who can apply Types of eligible organizations

• 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” organizations 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 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.

• Targets TA to rural health clinics (RHCs) and small rural hospitals that do not meet program requirements and expectations for rurality and hospital size.

• 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.

Step 1: Review the Opportunity 6

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.

Step 1: Review the Opportunity 7

Program description Purpose The Rural Healthcare Provider Transition Project provides technical assistance (TA) to help small rural hospitals and rural health clinics (RHCs) strengthen their foundations in key elements of value-based care. The Center for Medicare and Medicaid Services (CMS) defines value-based care as focusing on quality, provider performance, and patient experience. Value-based programs encourage hospitals to improve the quality, efficiency, patient experience, and safety of care that Medicare beneficiaries receive during acute care inpatient stays. The TA offered through this cooperative agreement strengthens these key elements of value-based care. TA will give hospitals and RHCs a clear understanding of value-based care and the strategies they can use to effectively participate in a healthcare system focused on value.

The CMS defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” In alignment with the HHS priority to achieve equitable healthcare, TA within this program will advance health equity. Value-based care advances health equity by:

• Focusing and having a measurable impact on the health outcomes of every person, including those from underserved populations.

• Encouraging healthcare providers to screen for social needs and work with individuals to develop personalized treatment plans that address their unique needs, such as connecting them to a local food bank, providing interpreter services, or arranging transportation and other accommodations.

• Requiring healthcare providers to monitor and track outcomes across populations to evaluate health disparities and intervene as necessary to help close gaps in access or care.

• Engaging providers who have historically worked in underserved communities and providing necessary resources to meet this health equity goal.

Background Value-based programs are designed to reward providers with incentive payments for the quality of care they provide, rather than the volume. Broadly, programs focusing on value can provide incentives or penalties tied to performance, either through payment adjustments with incentives or penalties or through payment models focused on

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

Step 1: Review the Opportunity 8 https://www.cms.gov/medicare/quality/value-based-programs/hospital-purchasing https://www.cms.gov/medicare/quality/value-based-programs/hospital-purchasing https://www.cms.gov/priorities/innovation/key-concepts/health-equity https://www.hhs.gov/about/strategic-plan/2022-2026/goal-1/objective-1-2/index.html https://www.hhs.gov/about/strategic-plan/2022-2026/goal-1/objective-1-2/index.html financial risk (sharing rewards or losses). The intended result is better quality of care and a better experience for patients.

Rural healthcare providers face many challenges participating in the value-based care environment, including the concurrent need to better measure and account for quality of care in all settings and improve transitions as patients move from one care setting to another. Rural hospitals and RHCs that want to operate in this environment need targeted TA, as they may have less experience coordinating care across different settings, reporting quality measures, understanding how to use data, and understanding the financial risk in a low-volume environment.

Program requirements and expectations Outreach Plan

• Each year, you are expected to select four to six rural healthcare organizations (RHCs or small rural hospitals) and provide TA to them. You will work with HRSA as you carry out program activities.

• The hospitals that you select for TA must meet the definition of small rural hospital. For purposes of this NOFO, a “small rural hospital” is defined as a non-federal, short-term general acute care hospital that:

◦ Is located in a rural area as defined in 42 U.S.C. 1395ww(d), treated as if located in a rural area pursuant to 42 U.S.C. 1395ww(d)(8)(C), or located in a FORHP rural area.

◦ Has 49 available beds or less, as reported on the hospital’s most recently filed Medicare Cost Report.

◦ Small rural hospitals may be for-profit or not-for-profit, including faith-based.

Small rural hospitals in U.S. territories as well as tribally operated hospitals under Titles I and V of P.L 93-638 [PDF]tribally operated hospitals under Titles I and V of P.L. 93-638 [PDF] may receive TA if they meet the other criteria in this section.

• The rural healthcare organizations you select for TA must not be actively receiving similar TA from other federal programs.

• HRSA expects you to verify rural eligibility for all small rural hospitals and RHCs using HRSA’s Rural Health Grants Eligibility Analyzer.

• HRSA expects you to develop an outreach plan to market TA offerings and the benefits of participating to small rural hospitals, RHCs, rural stakeholders, and to share best practice resources, tools, and lessons learned based on the TA to guide other small rural hospitals and RHCs in transitioning to value.

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

Step 1: Review the Opportunity 9 https://uscode.house.gov/view.xhtml?req=(title:42%20section:1395ww%20edition:prelim) https://uscode.house.gov/view.xhtml?req=(title:42%20section:1395ww%20edition:prelim) https://www.bia.gov/sites/default/files/dup/assets/bia/ois/ois/pdf/idc2-057851.pdf https://www.bia.gov/sites/default/files/dup/assets/bia/ois/ois/pdf/idc2-057851.pdf https://data.hrsa.gov/tools/rural-health

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

Direct Technical Assistance

• You must develop and implement a TA plan to help small rural hospitals and RHCs implement key operational components of value-based care. HRSA expects you to align TA with HHS’s priority of advancing health equity. The key components you must address are:

◦ Quality

◦ Efficiency

◦ Patient experience

◦ Safety

• You must develop and manage a network of nationally known rural healthcare organization technical experts with financial, quality, operational, and clinical expertise, and a strong track record of working nationally with small rural hospitals and RHCs. They will provide onsite and virtual consultations on a national level to rural hospitals and RHCs to improve their financial and operational performance and quality.

• For each rural healthcare organization selected to receive TA, this network of experts must conduct the following types of assessments at a minimum:

◦ Market assessments

◦ Quality assessments

◦ Financial and operational assessments

• HRSA expects you to work with each selected rural healthcare organization to gain their commitment to participate and implement the activities that the experts recommend in their TA consultations.

• You must track the number of TA recipients that go on to participate in a payment incentive program or model, in the public or private sector.

• You are expected to monitor ongoing processes, goals, and objectives so you can continuously improve program quality.

• You are expected to share the data you collect through the program with HRSA.

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

Step 1: Review the Opportunity 10 https://www.shepscenter.unc.edu/product/prediction-of-financial-distress-among-rural-hospitals/ https://www.hhs.gov/equity/index.html#eap

Award information Cooperative agreement terms Our responsibilities Aside from monitoring and providing technical assistance (TA) to you, we also get involved in these ways:

• Helping prioritize your program activities and assess progress in achieving the goals of this cooperative agreement.

• Facilitating introductions to other HRSA programs, federal agencies, and other HRSA award recipients whose work is relevant to this cooperative agreement.

• Upon request, providing TA on processes for identifying and selecting subcontractors, healthcare organization technical experts, rural healthcare organizations to receive TA from you, and other key stakeholders involved in the program.

• Reviewing and providing feedback on your TA products and proposed outcome measures.

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

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

• Ensuring hospitals selected for TA meet the definition of “small rural hospital.”

• Verifying rural eligibility for all small rural hospitals and RHCs selected for TA using HRSA’s Rural Health Grants Eligibility Analyzer.

• Ensuring small rural hospitals and RHCs are prepared to assume financial risk in payment models, as applicable.

• Ensuring interventions are appropriate to the needs of the hospital community to gain community buy-in.

• Ensuring that key hospital and community leaders commit to working actively during the project and sustaining activities after TA is provided.

• Engaging with key stakeholders such as State Hospital Associations, State Offices of Rural Health, and State Rural Health Associations to market services and identify potential small rural hospitals and RHCs to receive TA.

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

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

Step 1: Review the Opportunity 11 https://data.hrsa.gov/tools/rural-health

Funding policies and limitations Policies

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

• Support beyond the first budget year will depend on:

◦ Annual appropriation of funds.

◦ Satisfactory progress in meeting the project’s objectives.

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

• If we receive additional funding for this program, we consider options such as:

◦ 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).

• The salary rate limitation imposed by the current appropriations act applies to this program. As of January 2025, the salary rate limitation is $225,700. Note this limitation may apply in future years and will be updated.

See Manage Your Grant for other information on costs and financial management.

Indirect costs Indirect costs are those incurred for a common or joint purpose across more than one project and that cannot be easily separated by project (like utilities for a building that supports multiple projects).

Indirect costs are determined using one of two methods:

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

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

Step 1: Review the Opportunity 12 https://www.ecfr.gov/current/title-45/part-75#p-75.216(b) https://www.hrsa.gov/grants/manage-your-grant https://www.ecfr.gov/current/title-2/section-200.414 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. Program income must be added to the total project costs. 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 13 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 15

Find the application package 15

Application writing help 15

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-25-035.

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 15 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 For more information about this opportunity, join the webinar.

• Thursday, January 30, 2025

• 2 to 3 p.m. ET.

If you are not able to join through your computer, you can call in:

• Phone number: 1-833-568-8864

• Meeting ID: 161 168 2307

• Passcode: 10162276

We will record the webinar. If you are not able to join live, you can contact RuralHospitals@hrsa.gov.

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 16 https://hrsa-gov.zoomgov.com/j/1611682307?pwd=gyafqDu4BGpRKFAhGPNLzQJb005sFQ.1#success mailto:RuralHospitals@hrsa.gov

Step 3:

Write Your Application

In this step

Application contents and format 18

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

Application page limit: 50 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 Other 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 nondiscrimination 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 18 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=25 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=13

Introduction See merit review criterion 1: Need

Briefly describe your proposed project to provide comprehensive, targeted TA to prepare small rural hospitals and RHCs to transition to value-based care.

Need See merit review criterion 1: Need

• Demonstrate your understanding of specific challenges that small rural hospitals and RHCs face when attempting to adapt their operations to align with value-based care.

• Describe the unmet need of small rural hospitals and RHCs in building the foundation for value-based care.

• Use and cite demographic data whenever possible.

Approach See merit review criterion 2: Response

Outreach plan

• Discuss the communication and messaging strategies you will use to target and promote the project to small rural hospitals, RHCs, and rural stakeholders.

• Discuss your plan for marketing the benefits of participation and the availability of services through this program to small rural hospitals and RHCs.

• Describe an effective online application process to identify and select RHCs and small rural hospitals for participation.

• Describe proven methods of marketing programs nationally using online applications, webinars, and interviews to gauge readiness for TA and identify and select small rural hospitals and RHCs for participation in this program.

• Describe how you will disseminate best practices, reports, products, or project outputs to HRSA and rural stakeholders.

Direct technical assistance

• Explain your approach to identifying and selecting small rural hospitals and RHCs for TA and how you will prioritize them based on your selection criteria.

• Describe how your selection criteria will balance need and readiness for TA.

• Demonstrate that your selection criteria will advance health equity.

• Address the foundational needs of small rural hospitals and RHCs, including quality, efficiency, patient experience, and safety of care.

Step 3: Write Your Application 19

• Describe the types of TA resources you will provide to participating small rural hospitals and RHCs.

• Describe how you will determine small rural hospital and RHC readiness to implement your recommendations based on the targeted TA.

• Discuss your methods for building small rural hospitals’ and RHCs’ use of data to:

◦ Measure and improve quality.

◦ Understand costs and build operational efficiencies.

◦ Understand and meet their communities’ health needs.

• Discuss how you will prepare small rural hospitals and RHCs to assume financial risk in payment models, as applicable.

• Describe your plan for ensuring that the hospital board or leadership fully commits to and supports the project. This includes support at the system level for system-affiliated small rural hospitals and RHCs.

• Describe how you will ensure that key hospital and community leaders commit to working actively during the project and sustaining the impact of TA after federal funding ends.

• Describe how you will track and report on participants’ progress in implementing TA recommendations.

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

• Describe how you’ll achieve each objective during the entire period of performance and meet program requirements.

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

• Present a complete and clear timeline that identifies the responsible staff for each activity during the five-year period of performance. As needed, identify activities that require collaboration with key stakeholders—including award subrecipients—and explain how they will help plan, design, and carry out activities.

Resolving challenges See merit review criterion 2: Response

Discuss current and future challenges that may be barriers to implementing your work plan and explain approaches that you’ll use to resolve them.

Step 3: Write Your Application 20

Performance reporting and evaluation See merit review criteria 3: Performance reporting and evaluation section.

• Describe your plan for evaluating the program performance, including how you will monitor and analyze performance data to continuously improve program quality. The program performance evaluation should monitor ongoing processes and the progress toward the goals and objectives of the project.

• Describe the systems and processes that you will use to track performance outcomes.

• Describe how you will collect and manage data to enable accurate and timely reporting of performance outcomes. This could include assigned skilled staff and/ or data management software.

• Explain the specific outcome measures you will use and how you will use process and outcome measures data to improve your project over the five-year period of performance. Measures may include:

◦ Increase in revenue.

◦ Days of cash on hand.

◦ Operating margins.

• Describe how you will collect and report performance data accurately and on time.

• Describe how you will manage and securely store data.

• Describe how you will assess small rural hospital, RHC, and stakeholder satisfaction with the program.

See Reporting for more information.

Organizational information See merit review criterion 5: Resources and capabilities and 6: Support Requested

• Describe your organization’s mission, structure, and the scope of your current activities. Explain how they support your ability to carry out the program requirements and expectations.

• Include your project organization chart in attachment 6 and a staffing plan and job descriptions in attachment 2.

◦ Your organizational chart and staffing plan should demonstrate nationwide staff presence in at least 20 states and experience providing TA to rural communities.

• Demonstrate your organization’s capacity to develop and manage a network of nationally known rural hospital technical experts with at least 25 years of financial, Step 3: Write Your Application 21 operational, and clinical expertise and a strong track record of working nationally with small rural hospitals and RHCs.

• Discuss your plan for governance and decision making when selecting and managing technical experts. Include signed letters of agreement from organizations you will partner with to carry out the TA in attachment 4.

• Present outcome measures that demonstrate your experience improving financial and operational performance in small rural hospitals and RHCs through other programs. The rural health programs you have experience with could include, but are not limited to:

◦ The Medicare Rural Hospital Flexibility Program.

◦ The Small Rural Hospital Improvement Program.

◦ The Delta Region Community Health Systems Development Program.

• Demonstrate knowledge and technical experience with rural health programs that assess and support:

◦ Quality

◦ Financial and operational performance

◦ Population health

◦ Transition to value-based care

• Demonstrate your organization’s and your network of experts’ experience developing and providing TA to small rural hospitals and RHCs on a national level, including experience educating small rural hospitals and RHCs on value-based programs and models.

• Discuss the planned implementation and results of the TA, including outcomes related to quality, efficiency, patient experience, and safety of care.

• Demonstrate your organization’s ability to analyze the return on the community and federal investment.

• Discuss how you’ll follow the approved project 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 22 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 Section 3.1.5 of the Application Guide.

Attachments Place your attachments in order in the Other Attachments form.

Attachment 1: Work plan Counts toward page limit.

Attach the project’s work plan. Make sure it includes everything required in the project narrative section.

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

Step 3: Write Your Application 23 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#p-200.1(Supply) https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=18

Attachment 2: Staffing plan and job descriptions Counts toward page limit.

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 including their role, responsibilities, and qualifications.

Attachment 3: Biographical sketches Does not count toward the page limit.

Include biographical sketches for people who will hold the key positions you describe in attachment 2. They should be two pages or less. Do not include 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 Counts toward page limit.

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 deliverables. Make sure you sign and date any letters of agreement. Letters of support must be dated and show a commitment to the project (such as in-kind services, dollars, staff, space, or equipment).

Attachment 5: For multiyear budgets—fifth-year budget Counts toward page limit.

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.

Attachment 6: Project organizational chart Counts toward page limit.

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

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

Step 3: Write Your Application 24 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=21 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=13

Attachment 7-15: Other relevant documents Counts toward page limit.

Include any other documents that are relevant to the application, such as proof of nonprofit status and indirect cost rate agreements.

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.

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 25 https://www.grants.gov/forms

Step 4:

Learn About Review and Award

In this step

Application review 27

Selection process 32

Award notices 33

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 the following criteria.

Criterion Total number of points = 100

1. Need 10 points

2. Response 40 points

3. Performance reporting and evaluation 15 points

4. Impact 10 points

5. Resources and capabilities 20 points

6. Support requested 5 points

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

The panel will review your application to determine:

• How well you describe the purpose of the proposed project to provide comprehensive, targeted TA to prepare small rural hospitals and RHCs to transition to value-based care.

• How well you demonstrate understanding of specific challenges that small rural hospitals and RHCs face when attempting to adapt their operations to align with value-based care.

• How well you describe the unmet need of small rural hospitals and RHCs in building the foundation for value-based care.

• How well you include and cite supporting demographic data.

Step 4: Learn About Review and Award 27

Criterion 2: Response (40 points) See project narrative Approach, High-level work plan, and Resolving challenges sections.

The panel will review your application to determine how well you do the following.

Approach (20 points) Outreach plan

• Discuss the communication and messaging strategies you will use to target and promote the project to small rural hospitals, RHCs, and rural stakeholders.

• Discuss your plan for marketing the benefits of participation and the availability of services through this program to hospitals and RHCs.

• Describe an effective online application process to identify and select RHCs and small rural hospitals for participation.

• Describe proven methods of marketing programs nationally using online applications, webinars, and interviews to gauge readiness for TA and identify and select small rural hospitals and RHCs for participation in this program.

• Describe how you will disseminate best practices, reports, products, or project outputs to HRSA and rural stakeholders.

Direct technical assistance

• Explain your approach to identifying and selecting small rural hospitals and RHCs for TA and how you will prioritize them based on selection criteria.

• Describe how your selection criteria will balance need and readiness for TA.

• Demonstrate that your selection criteria will advance health equity.

• Address the foundational needs of small rural hospitals and RHCs, including quality, efficiency, patient experience, and safety of care.

• Describe the types of TA resources you will provide to participating small rural hospitals and RHCs.

• Explain how you will ensure interventions are appropriate to the needs of the hospital community to gain community buy-in.

• Describe how you will determine small rural hospital and RHC readiness to implement your recommendations based on the targeted TA you provide.

• Discuss your methods for building small rural hospitals’ and RHCs’ use of data to:

◦ Measure and improve quality.

◦ Understand costs and build operational efficiencies.

◦ Understand and meet their communities’ health needs.

Step 4: Learn About Review and Award 28

• Discuss how you will prepare small rural hospitals and clinics to assume financial risk in payment models, as applicable.

• Describe your plan for ensuring that the hospital board or leadership fully commits to and supports the project. This includes support at the system level for system-affiliated small rural hospitals and RHCs.

• Describe how you will ensure that key hospital and community leaders commit to working actively during the project and sustaining the impact of TA after federal funding ends.

• Describe how you will track and report on participants’ progress in implementing TA recommendations.

High-level work plan (15 points)

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

• How well the work plan presents a complete and clear timeline that identifies the responsible staff for each activity during the five-year period of performance. As needed, identify activities that require collaboration with key stakeholders (including award subrecipients) and explain how they will help plan, design, and carry out activities.

• How well the work plan identifies activities that require collaboration with key stakeholders (including subrecipients) to plan, design, and implement TA services.

Resolving challenges (5 points) The extent to which you discuss current and future challenges that may be barriers to implementing your work plan and explain approaches that you’ll use to resolve them.

Criterion 3: Performance reporting and evaluation (15 points) See project narrative Performance reporting and evaluation section.

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

• Describe your plan for evaluating the program performance, including how you will monitor and analyze performance data to continuously improve program quality. The program performance evaluation should monitor ongoing processes and the progress toward the goals and objectives of the project.

• Describe the systems and processes you will use to track performance outcomes.

Step 4: Learn About Review and Award 29

• Describe how the organization will collect and manage data to enable accurate and timely reporting of performance outcomes. This could include assigned skilled staff or data management software.

• Explain the specific outcome measures you will use and how you will use process and outcome measures data to improve your project over the five-year period of performance. Measures may include:

◦ Increase in revenue.

◦ Days of cash on hand.

◦ Operating margins.

• Describe how you will manage and securely store data.

Criterion 4: Impact (10 points) See project narrative High-level work plan and Evaluation and technical support capacity section.

The panel will review your application to determine how well you:

• Propose activities and evaluative measures that can effectively assess the success of your project in meeting program goals and objectives.

• Describe how process and outcome measures data will contribute to continuous quality improvement.

• Provide evidence that your proposed measures can assess the extent to which results can be attributed to the project.

Criterion 5: Resources and capabilities (20 points) See project narrative Organizational information.

The panel will review your application to determine how well you:

• Describe your organization’s mission, structure, and the scope of current activities, and explain how they support your ability to carry out the program requirements.

• Include a project organization chart in attachment 6 and a staffing plan and job descriptions in attachment 2 that demonstrate nationwide staff presence in at least 20 states and experience providing TA to rural communities.

• Discuss your plan for governance and decision making when selecting and managing technical experts. Include signed letters of agreement from the organizations you will partner with to carry out the TA in attachment 4.

• Demonstrate capacity to develop and manage a network of nationally known rural hospital technical experts with at least 25 years of financial, operational, and clinical expertise and a strong track record of working nationally with small rural hospitals and RHCs.

Step 4: Learn About Review and Award 30

• Present outcome measures that demonstrate your experience improving financial and operational performance in small rural hospitals and RHCs through multiple other programs. The rural health programs you have experience with could include:

◦ The Medicare Rural Hospital Flexibility Program.

◦ The Small Rural Hospital Improvement Program.

◦ The Delta Region Community Health Systems Development Program.

• Demonstrate knowledge and technical experience with rural health programs that assess and support:

◦ Quality

◦ Financial and operational performance

◦ Population health

◦ Transition to value-based care

• Demonstrate your organization’s and your network of experts’ experience developing and providing TA to small rural hospitals and RHCs at a national level, including experience educating small rural hospitals and RHCs on value-based programs and models. Discuss the planned implementation and results of the TA, including outcomes related to quality, efficiency, patient experience, and safety of care.

• Demonstrate your organization’s ability to analyze the return on the community and federal investment.

Criterion 6: Support requested (5 points) See Budget and budget narrative section and Organizational information.

The panel will review your application to determine:

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

• How reasonable costs are and how well they align with the project’s scope.

• How sufficient the time is for key staff to spend on the project to achieve project objectives.

• How you will account for federal funds and record all costs to avoid audit findings and follow the approved project plan and ensure that subawards and contracts are properly used and monitored. This includes having policies and procedures in place that 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 4: Learn About Review and Award 31 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75?toc=1

Risk review Before making an award, we review the risk that you will not manage federal funds in prudent ways. We need to make sure you’ve handled any past federal awards well and demonstrated sound business practices. We:

• Review any applicable past performance.

• Review audit reports and findings.

• Analyze the budget.

• Assess your management systems.

• Ensure you continue to be eligible.

• Make sure you comply with any public policies.

We may ask you to submit additional information.

As part of this review, we use SAM.gov Entity Information Responsibility / Qualification to check your history for all awards likely to be more than $250,000 over the period of performance. You can comment on your organization’s information in SAM.gov. We’ll consider your comments before making a decision about your level of risk.

If we find a significant risk, we may choose not to fund your application or to place specific conditions on the award.

For more details, see 45 CFR 75.205.

Selection process When making funding decisions, we consider:

• Merit review results. These are key in making decisions but are not the only factor.

• The amount of available funds.

• Assessed risk.

• The larger portfolio of HRSA-funded projects, including the diversity of project types and geographic distribution.

We may:

• Fund out of rank order.

• Fund applications in whole or in part.

• Fund applications at a lower amount than requested.

• Decide not to allow a recipient to subaward if they may not be able to monitor and manage subrecipients properly.

• Choose to fund no applications under this NOFO.

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

Step 4: Learn About Review and Award 32 https://sam.gov/content/entity-information https://www.ecfr.gov/current/title-45/section-75.205

Award notices We issue Notices of Award (NOA) on or around the start date listed in the NOFO. See Section 4 of the Application Guide for more information.

By drawing down funds, you accept the terms and conditions of the award.

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

Step 4: Learn About Review and Award 33 https://www.hrsa.gov/sites/default/files/hrsa/grants/application-guide.pdf#page=31

Step 5:

Submit Your Application

In this step

Application submission and deadlines 35

Application checklist 36

Application submission and deadlines Your organization’s authorized official must certify your application. See the section on finding the application package to make sure you have everything you need.

Make sure you are current with SAM.gov and UEI requirements. When you register or update your SAM.gov registration, you must agree to the financial assistance general certifications and representations, and specifically with regard to grants.

Make sure that your SAM.gov registration is accurate for both contracts and grants, as these registrations differ. See information on getting registered. You will have to maintain your registration throughout the life of any award.

Deadlines You must submit your application by April 14, 2025, at 11:59 p.m. ET.

Grants.gov creates a date and time record when it receives the application.

Submission method Grants.gov You must submit your application through Grants.gov. See Get registered.

For instructions on how to submit in Grants.gov, see the Quick Start Guide for Applicants. Make sure that your application passes the Grants.gov validation checks, or we may not get it. Do not encrypt, zip, or password protect any files.

Have questions? Go to Contacts and Support.

Other submissions Intergovernmental review This NOFO is not subject to Executive Order 12372, Intergovernmental Review of Federal Programs. No action is needed.

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

Step 5: Submit Your Application 35 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 http://www.grants.gov/quick-start-guide/applicants http://www.grants.gov/quick-start-guide/applicants https://www.archives.gov/federal-register/codification/executive-order/12372.html

Application checklist Make sure that you have everything you need to apply:

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