MCHB HRSA-23-130 (H49) HSE Final.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2023

Maternal and Child Health Bureau

Division of Healthy Start and Perinatal Services

Healthy Start Initiative – Enhanced Funding Opportunity Number: HRSA-23-130

Funding Opportunity Type(s): New

Assistance Listings Number: 93.926

Application Due Date: July 17, 2023 Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

HRSA will not approve deadline extensions for lack of registration.

Registration in all systems may take up to 1 month to complete.

Issuance Date: May 17, 2023

Mia Morrison, MPH Supervisory Public Health Analyst Division of Healthy Start and Perinatal Services Phone: (301) 443-2521 Email: MCHBHealthyStart@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 U.S.C. § 254c-8 (Title III, § 330H of the Public Health Service Act) mailto:MCHBHealthyStart@hrsa.gov

HRSA-23-130 i

508 COMPLIANCE DISCLAIMER

Note: Persons using assistive technology may not be able to fully access information in this file. For assistance, email or call one of the HRSA staff listed in Section VII. Agency Contacts.

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for the fiscal year (FY) 2023 Healthy Start Initiative – Enhanced (HSE). The purpose of HSE is to improve health outcomes before, during, and after pregnancy and reduce the well-documented racial/ethnic differences in rates of infant death and adverse perinatal outcomes. HSE has two focus areas: 1) providing direct and enabling services (e.g., screening and referrals, case management, care coordination, health and parenting education, and linkage to clinical care) to enrolled HSE participants; and 2) convening Community Consortia (formerly known as Community Action Networks or “CANs”) comprised of diverse-multi-sector partners that advise and inform HSE activities, as well as to develop and implement action plans to improve perinatal outcomes within the project area. HSE has an increased emphasis on addressing social determinants of health in order to improve disparities in maternal and infant health outcomes. The program provides recipients with increased flexibility to customize interventions to meet the unique needs of their community.

Funding Opportunity Title: Healthy Start Initiative - Enhanced (HSE)

Funding Opportunity Number: HRSA-23-130

Due Date for Applications: July 17, 2023

Anticipated FY 2023 Total Available Funding:

$11,000,000

Estimated Number and Type of Award(s): Up to 10 grants

Estimated Annual Award Amount: Up to $1,100,000 per award per year

Cost Sharing/Match Required: No

Period of Performance: September 30, 2023 through September 29, 2028 (5 years)

Eligible Applicants: Eligible applicants include any domestic public or private entity. Domestic faith-based and community-based http://www.hrsa.gov/

HRSA-23-130 ii organizations, tribes, and tribal organizations are also eligible to apply.

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

Application Guide

You (the applicant organization/agency) are responsible for reading and complying with the instructions included in this NOFO and in HRSA’s SF-424 Application Guide. Visit HRSA’s How to Prepare Your Application page for more information.

Technical Assistance

HRSA has scheduled the following technical assistance:

Webinar

Day and Date: Wednesday, June 7, 2023

Time: 1:00 p.m. ET

Weblink: https://hrsa-gov.zoomgov.com/j/1603699813?pwd=S25SUFUvWitIdmNmVFRZK09aNmJlQT09

Attendees without computer access or computer audio can use the dial-in information below.

Dial-in Toll-Free #: 1-833 568 8864 Meeting ID: 160 369 9813 Passcode: 85581825

HRSA will record the webinar and make it available at:

https://mchb.hrsa.gov/fundingopportunities/default.aspx http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application https://hrsa-gov.zoomgov.com/j/1603699813?pwd=S25SUFUvWitIdmNmVFRZK09aNmJlQT09 https://hrsa-gov.zoomgov.com/j/1603699813?pwd=S25SUFUvWitIdmNmVFRZK09aNmJlQT09 https://mchb.hrsa.gov/fundingopportunities/default.aspx

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING/MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

3. SUBMISSION DATES AND TIMES

4. INTERGOVERNMENTAL REVIEW

5. FUNDING RESTRICTIONS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. REVIEW AND SELECTION PROCESS

3. ASSESSMENT OF RISK

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

APPENDIX A: PAGE LIMIT WORKSHEET

APPENDIX B: GLOSSARY

APPENDIX C: HEALTH PROMOTION TOPICS

APPENDIX D: HEALTHY START BENCHMARKS

APPENDIX E: HEALTHY START PROJECT SITE COUNTIES AND ZIP CODES

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Healthy Start Initiative - Enhanced (HSE) Program. The purpose of HSE is to improve health outcomes before, during, and after pregnancy and reduce the well-documented racial/ethnic differences in rates of infant death and adverse perinatal outcomes.1,2,3 HSE is intended to support projects in diverse communities and populations (e.g., rural, urban, non-Hispanic Black, American Indian/Alaskan Native [AI/AN]) experiencing the greatest disparities in maternal and infant health outcomes.

HSE has two focus areas: 1) providing direct and enabling services (e.g., screening and referrals, case management and care coordination, health and parenting education, and linkage to clinical care to enrolled HSE participants; and 2) convening Community Consortia comprised of diverse multi-sector partners that advise and inform HSE activities and develop and implement plans to improve perinatal outcomes within the selected project area. HSE has an increased emphasis on addressing social determinants of health in order to improve disparities in maternal and infant health outcomes. The program also provides recipients with increased flexibility to customize interventions to meet the unique needs of their target population.

The goals of HSE are to:

1. Continue reducing infant mortality rates (IMR) in the U.S., and

2. Decrease disparities in infant mortality (IM) across racial/ethnic groups by achieving steeper declines for groups with the highest infant mortality rates (e.g., non-Hispanic Black and AI/AN infants).

HSE projects should be implemented in communities experiencing high rates of maternal and infant mortality and morbidity that do not already have access to Healthy Start Services. Successful HSE projects will implement program activities in new4

1 https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf 2 https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm 3 https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfant health%2Fpregnancy-mortality-surveillance-system.htm 4 The proposed project area for an HSE project cannot already be served by a recipient of the Healthy Start Initiative: Eliminating Disparities in Perinatal Health (HRSA-19-049). A list of zip codes served by recipients of HRSA-19-049 can be found in Appendix E.

https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm

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project areas and accomplish the following objectives during the 5-year period of performance:

Direct and Enabling Services for HSE Participants

• Increase receipt of case management and care coordination to facilitate access to medical care and community-based resources.

• Increase uptake of healthy behaviors before, during, and after pregnancy.

• Increase use of safe infant care practices.

Community Consortium

• Convene diverse, multi-sector state, local, and community level partners, including

HSE participants and other community members, that will:

• Advise and inform strategies for providing direct and enabling services to HSE participants.

• Develop cross-sector partnerships to ensure access for HSE participants to coordinated, comprehensive maternal, child, and family medical care; health and parenting education; and community-based resources that address social determinants of health within the project area.

• Participate in Communities of Practice with other HSE projects to develop and implement a strategic plan for the community that focuses on at least one social determinant of health.

For more details, see Program Requirements and Expectations.

2. Background

Authority

The Healthy Start - Enhanced program is authorized by 42 U.S.C. § 254c-8 (Title III, § 330H of the Public Health Service Act).5 The purpose of the Healthy Start program is to reduce the rate of infant mortality and improve perinatal outcomes. In FY 2023, the Joint Explanatory Statement accompanying the Consolidated Appropriations Act of 2023 (P.L. 117-328) identified Healthy Start funding “to support a new targeted expansion of an enhanced Healthy Start program model” that, as described in the President’s Budget, aims to reduce racial disparities in maternal and infant health outcomes, such as maternal and infant mortality, low birthweight, preterm birth, and other perinatal health risks. In addition, Healthy Start - Enhanced will address the unique social and environmental factors that contribute to disparities in outcomes for mothers and infants.

5 42 USC 254c-8: Healthy start for infants (house.gov) https://uscode.house.gov/view.xhtml?req=(title:42%20section:254c-8%20edition:prelim)%20OR%20(granuleid:USC-prelim-title42-section254c-8)&f=treesort&edition=prelim&num=0&jumpTo=true

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Infant Mortality, Perinatal Health and Social Determinants of Health

Approximately four million births occur each year in the U.S.6 While most women have a safe pregnancy and deliver a healthy infant, there are persistently higher rates of infant mortality and maternal morbidity among Black and American Indian/Alaska Native populations. The highest infant mortality rates in the country are among Black infants and AI/AN infants (10.38 and 7.68 infant deaths per 1,000 live births in 2020, respectively) with rates that are significantly higher that of Whites (4.40 infant deaths per 1,000 live births in 2020).7

Excess non-Hispanic Black and non-Hispanic AI/AN infant deaths are those that occur due to higher mortality rates relative to non-Hispanic White infants, and can be referred to as deaths attributable to disparity or deaths that need to be prevented to achieve equity. Each year, approximately 3,500 more infant deaths occur due to higher mortality rates among non-Hispanic Black and non-Hispanic AI/AN infants than White infants8.

Inequities in access to health promoting resources such as education, employment and health care contribute to racial/ethnic disparities in perinatal health and infant death.

Research suggests a correlation between individual outcomes and health disparities across racial groups, indicating that they are shaped by interpersonal, institutional, community and policy factors such as racism, providers’ cultural competence, access to quality health care, neighborhood quality, and economic and housing opportunities.9 Several social determinants of health frameworks (e.g., National Birth Equity Framework,10 Vital Conditions for Well-Being,11 and Healthy People 203012) have been developed to help communities, medical and public health professionals, and others better understand and address the multiple factors that contribute to disparate health outcomes.

6 https://www.cdc.gov/nchs/fastats/births.htm 7 https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71- 05.pdfhttps://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf 8 Excess Infant Deaths is a statistical term used in public health to refer to infant deaths that occur due to higher mortality rates than non-Hispanic White infants and can be referred to as deaths attributable to disparity or deaths that need to be prevented to achieve equity in infant mortality rates. Excess deaths are calculated by multiplying excess death rates by the number of births (e.g., [Black IM rate – White IM rate] X Black births).

9 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action:

Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 3, The Root Causes of Health Inequity. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425845 10 https://www.marchofdimes.org/professionals/mom-and-baby-action-network.aspx 11 https://winnetwork.org/vital-conditions 12https://health.gov/healthypeople/priority-areas/social-determinants-health https://www.cdc.gov/nchs/fastats/births.htm https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf https://www.marchofdimes.org/professionals/mom-and-baby-action-network.aspx https://winnetwork.org/vital-conditions https://health.gov/healthypeople/priority-areas/social-determinants-health

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The Healthy Start Initiative

Since its start as a demonstration project in 1991, the Healthy Start program has provided grants to communities with infant mortality rates at 1.5 times the U.S. national average and high rates of other adverse perinatal outcomes (e.g., low birthweight, preterm birth, maternal morbidity and mortality). The purpose of Healthy Start is to reduce infant mortality rates and improve perinatal outcomes by focusing on project areas with high or growing above the national average annual rates of infant mortality.

Healthy Start uses a community-based approach to delivering direct and enabling services that facilitate access to health care and community services. By statute, the program focuses on addressing factors that contribute to infant mortality – such as low birthweight, preterm birth, and social determinants of health -- as well as communities with high rates of infant mortality or high rates of other adverse infant health outcomes in specific subpopulations within the community. As such, Healthy Start works to eliminate the disparity in health status between the general population and individuals who are members of racial or ethnic minority groups.

In the most recent program evaluation, Healthy Start participants were shown to have positive outcomes related to several program goals, including earlier and more frequent prenatal care, greater engagement in infant safe sleep practices, and lower rates of low birthweight infants. Healthy Start participants also met or exceeded targets with respect to having a usual source of health care and having been screened for depression. For more information, see: https://mchb.hrsa.gov/programs-impact/healthy-start.

In FY 2022, the Healthy Start program launched the Catalyst for Infant Health Equity program to implement interventions to accelerate the reduction of infant mortality disparities and excess infant deaths. Nine awards were made to entities with existing action plans addressing social determinants of health that contribute to disparities in infant mortality, with the majority of award recipients focusing on non-Hispanic Black infants and the Healthy People 2030 goal related to Health Care Access and Quality.

For a list of award recipients, see: Catalyst for Infant Health Equity Program Fiscal Year 2022 Awards | MCHB (hrsa.gov)

About HRSA’s Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB) administers programs with focus areas in maternal and women’s health, adolescent and young adult health, perinatal and infant health, child health, and children with special health care needs. To achieve its mission of improving the health and well-being of America’s mothers, children, and families, MCHB has established a strategic plan that includes the following four goals:

Goal 1: Assure access to high quality and equitable health services to optimize health and well-being for all MCH populations

Goal 2: Achieve health equity for MCH populations https://mchb.hrsa.gov/programs-impact/healthy-start https://www.grants.gov/web/grants/search-grants.html?keywords=Catalyst%20for%20Infant%20Health%20Equity https://mchb.hrsa.gov/programs-impact/programs/catalyst-infant-health-equity-fy-2022-awards https://mchb.hrsa.gov/programs-impact/programs/catalyst-infant-health-equity-fy-2022-awards

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Goal 3: Strengthen public health capacity and workforce for MCH

Goal 4: Maximize impact through leadership, partnership, and stewardship

This program addresses MCHB’s goals to assure access to high quality and equitable health services to optimize health and well-being for all MCH populations. To learn more visit Mission, Vision, and Work | MCHBhttps://mchb.hrsa.gov/about-us/mission-vision-work.

II. Award Information

1. Type of Application and Award

Type(s) of applications sought: New

HRSA will provide funding in the form of a grant.

2. Summary of Funding

HRSA estimates approximately $11,000,000 to be available annually to fund up to 10 recipients. You may apply for a ceiling amount of up to $1,100,000 (reflecting direct and indirect costs) per year.

The period of performance is September 30, 2023, through September 29, 2028 (5 years). Funding beyond the first year is subject to the availability of appropriated funds for the HSE program in subsequent fiscal years, satisfactory progress, and a decision that continued funding is in the best interest of the Federal Government.

All HRSA awards are subject to the Uniform Administrative Requirements, Cost Principles, and Audit Requirements at 45 CFR part 75.

III. Eligibility Information

1. Eligible Applicants

Eligible applicants include any domestic public or private entity. Domestic faith-based and community-based organizations, tribes, and tribal organizations are also eligible to apply.

Recipients of Healthy Start Initiative: Eliminating Disparities in Perinatal Health (HRSA- 19-049)13 are only eligible to apply for this grant if a new project area, not currently funded by your existing grant, is proposed. If overlapping areas are proposed, your application will be deemed ineligible and not considered. This provision ensures that new communities with the highest rates of maternal and infant mortality and morbidity

13 For a complete list of current grantees please see Appendix E.

https://mchb.hrsa.gov/about-us/mission-vision-work https://mchb.hrsa.gov/about-us/mission-vision-work https://mchb.hrsa.gov/about-us/mission-vision-work https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75

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that do not already have access to Healthy Start services are reached by this program.

2. Cost Sharing/Matching

Cost sharing/matching is not required for this program.

3. Other

HRSA may not consider an application for funding if it contains any of the non-responsive criteria below:

• Exceeds the funding ceiling amount

• Fails to satisfy the deadline requirements referenced in Section IV.4

Multiple Applications

Multiple applications from an organization are not allowed. HRSA will only accept and review your last validated electronic submission before the Grants.gov application due date.

IV. Application and Submission Information

1. Address to Request Application Package

HRSA requires you to apply electronically. HRSA encourages you to apply through Grants.gov using the SF-424 workspace application package associated with this notice of funding opportunity (NOFO) following the directions provided at Grants.gov: HOW TO APPLY FOR GRANTS. If you use an alternative electronic submission, see Grants.gov:

APPLICANT SYSTEM-TO-SYSTEM.

The NOFO is also known as “Instructions” on Grants.gov. You must select “Subscribe” and provide your email address for HRSA-23-130 in order to receive notifications including modifications, clarifications, and/or republications of the NOFO on Grants.gov.

You will also receive notifications of documents placed in the RELATED DOCUMENTS tab on Grants.gov that may affect the NOFO and your application. You are ultimately responsible for reviewing the For Applicants page for all information relevant to this

NOFO.

2. Content and Form of Application Submission

Application Format Requirements Section 4 of HRSA’s SF-424 Application Guide provides general instructions for the budget, budget narrative, staffing plan and personnel requirements, assurances, and certifications. You must submit the information outlined in HRSA SF-424 Application Guide in addition to the program-specific information below. You are responsible for reading and complying with the instructions included in this NOFO and HRSA’s SF-424 https://www.grants.gov/ http://www.grants.gov/applicants/apply-for-grants.html http://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/web/grants/s2s/applicant-system-to-system.html https://www.grants.gov/web/grants/s2s/applicant-system-to-system.html https://www.grants.gov/web/grants/applicants.html http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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Application Guide. You must submit the application in the English language and budget figures expressed in U.S. dollars (45 CFR § 75.111(a)).

See Section 8.5 of the HRSA SF-424 Application Guide for the Application Completeness Checklist to assist you in completing your application.

Application Page Limit The total of uploaded attachment pages that count against the page limit shall be no more than the equivalent of 60 pages when printed by HRSA. HRSA will not review any pages that exceed the page limit. Using the pages within the page limit, HRSA will determine eligibility using Section III. Eligibility Information of the NOFO.

These items don’t count in the page limit

• Standard OMB-approved forms included in the workspace application package

• Abstract (standard form (SF) "Project_Abstract Summary”)

• Indirect Cost Rate Agreement

• Proof of non-profit status (if it applies)

• The 5th year budget does not count in the page limit.

If there are other items that do not count against the page limit, we’ll make this clear in Section IV.2.vi Attachments.

If you use an OMB-approved form that is not included in the workspace application package for HRSA-23-130 it may count against the page limit. We recommend you only use Grants.gov workspace forms related with this NOFO to avoid exceeding the page limit.

Applications must be complete, within the maximum specified page limit, and validated by Grants.gov under HRSA-23-130 before the deadline.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

1) You certify on behalf of the applicant organization, by submission of your proposal, that neither you nor your principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

2) Failure to make required disclosures can result in any of the remedies described in 45 CFR § 75.371, including suspension or debarment. (See also 2 CFR parts 180 and 376, and 31 U.S.C. § 3354).

3) If you are unable to attest to the statements in this certification, you must include an explanation in Attachment 9-15: Other Relevant Documents.

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1371

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See Section 4.1 viii of HRSA’s SF-424 Application Guide for additional information on all certifications.

Program Requirements and Expectations

Project Area and Target Population

Healthy Start – Enhanced (HSE) applicants are expected to define their project area and target population using the criteria outlined below. You are expected to include information requested under “Project Area Proposed to be Funded” and “Factors Demonstrating Need for the Target Population” in Attachment 1 – (Project Area, Map of the Project Area with a List of Zip Codes, and Target Population).

Project Area Proposed to be Funded

• A project area is defined as a geographic area where the proposed HSE services will be implemented. HSE project areas are expected to be communities experiencing rates of infant mortality that are 1.5 times the national average or greater and that do not already have access to Healthy Start Services.

• You should identify your organization as serving an urban14 or rural15 project area.

Use the Rural Health Grants Eligibility Analyzer to determine whether your project is urban or rural https://data.hrsa.gov/tools/rural-health. Note that this calculation is made based upon the population density of your project area.

• A map of the proposed project area and a list of zip codes within the project area should be included in the application (Attachment 1). If you are proposing to serve a portion of a county or zip code, you are expected to define the borders of your project area using street names or census tracts.

o A project area (i.e., your catchment area) might consist of a group of zip codes or portions of zip codes if it is an urban project. For a rural project, a project area might be a combination of counties (or portions of counties or zip codes). The counties or zip codes in your project area do not need to be contiguous and cannot be served by another Healthy Start-funded project.

Overlapping Project Areas

• If two applications receiving a fundable score propose to serve the same project area in full, HRSA will only consider the highest scoring application. If part of your

14 Urban – Territory, population, and housing units located within an urbanized area (UA) or an urban cluster (UC), which has: a population density of at least 1,000 people per square mile; and surrounding census blocks with an overall density of at least 500 people per square mile.

15 Rural – To determine whether the Census tract or County for your proposed project area is defined as a rural area, visit the webpage Rural Health Grants Eligibility Analyzer and enter the project area address.

Link: https://data.hrsa.gov/tools/rural-health https://data.hrsa.gov/tools/rural-health http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://data.hrsa.gov/tools/rural-health

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project area overlaps with a project area proposed by another applicant, you must establish that there will be no overlap of population served or duplication in services provided as detailed below.

• This includes recipients funded through HRSA-19-049 (a list of HRSA-19-049 recipients’ project areas by zip code can be found in Appendix E) and/or this funding opportunity (HRSA-23-130). Please note the following exceptions:

• AI/AN Primary Target Population - Two applicants/recipients can propose to serve the same project area if the AI/AN population is the primary target population for one but not both of the two projects (a list of HRSA-19-049 recipients whose primary target population is AI/AN is available in Appendix E). If two applicants propose the same project and the AI/AN population is the primary target for both, then only the highest scoring application will be considered.

• Part of Your Project Area Overlaps with a Project Area Proposed by Another Applicant of HRSA-23-130.16 If you and the other applicant receive fundable scores, HRSA will notify you and ask you to develop a Memorandum of Agreement (MOA)/Memorandum of Understanding (MOU) with the other recipient. The MOA/MOU should elaborate what areas/roles each entity will take up to ensure there is no overlap of population served or duplication in services by:

a. Describing the need for multiple HSE/HS recipients within the project area, including the distinct populations served and services provided by multiple HSE/HS recipients.

b. Defining each applicant’s boundaries within the proposed project area using zip codes, street names, and/or or census tracts, demonstrating that there will be no overlap in populations served and services provided.

c. Outlining partnership responsibilities for outreach, recruitment, and referrals demonstrating that there will be no overlap in populations served and services provided.

Factors Demonstrating Need for the Target Population

The target population is the population that you will serve within your project area. It should be the population with the highest rate of infant deaths (i.e., IMR).

Your proposed project area should meet the following criteria:

16 HRSA will use zip codes, street names, and/or census tracts provided by the applicant to determine project area overlaps.

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• Use verifiable, vital statistics17 data for your project area.

• You may not use state level data.

1. The 2018 through 2020 combined 3-year IMR18 should be equal to or more than 8.3 deaths per 1,000 live births (1.5 times the national average) AND there should be 30 or more infant deaths in the target population during the 3-year period, 2018 through 2020.

2. If the combined 2018 through 2020 number of infant deaths are less than (<)30, then to be eligible one of the following should be met:

a. The 2018 through 2020 3-year low birth weight rate is equal to or more than 12.5 percent (1.5 times the national average) AND there should be 90 or more low birth weight births in the target population during the 3-year period, 2018 through 2020.

OR

b. The 2018 through 2020 preterm birth rate is equal to or more than 15.2 percent (1.5 times the national average) AND there should be 90 or more preterm births in the target population during the 3-year period, 2018 through 2020.

• HSE projects are expected to have the necessary partnerships (e.g., Title V, health centers, community non-profits), curricula, evidence-based/evidence-informed, and/or scientific information to implement high quality direct and enabling services addressing the main drivers of infant mortality and disparities in perinatal outcomes within the project area.

• In addition to leading Community Consortium activities, HSE projects are expected to take on a leadership role at the local, state, or regional level by participating in committees, projects or initiatives aimed at improving maternal, infant and child health outcomes. Recipients are encouraged to participate in Fetal Infant Mortality Reviews, Maternal Morbidity and Mortality Reviews or Perinatal Periods of Risk analysis.

• HSE staff (at all levels of the program) should be reflective of the communities they serve and have the training and supervision necessary to address the unique needs of individuals and communities. HSE projects are also expected to have processes in place to support staff retention. Please see

17 Vital statistics include records of births, deaths and fetal deaths. They also record information about the cause of death, or details of the birth. There are 57 vital registration jurisdictions in the U.S.: 50 states, 5 territories (Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, Northern Mariana Islands), the District of Columbia, and New York City.

18 Infant deaths per 1,000 live births over 3 years https://www.hrsa.gov/library/national-fetal-infant-and-child-death-review-program https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/index.html https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/index.html https://www.citymatch.org/perinatal-periods-of-risk-ppor/

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Strengthening the Maternal Infant Early Childhood Home Visiting Workforce:

A Checklist for Staff Recruitment and Staff Retention as a resource.

Direct and Enabling Services for HSE Participants

HSE direct and enabling services should be customized to meet the needs of the project area. Program activities should focus on the target population, which is the group with the highest IMR within the project area. Strategies should be culturally responsive and linguistically appropriate.

Types and Intensity of Services

The following activities are expected of all HSE projects:

1. Conduct outreach, recruitment, and retention efforts to engage and retain residents of the project area in services that focus on identifying and providing HSE services to mothers/women19 of reproductive age, fathers/partners,20 and families experiencing the highest rates of infant mortality and other adverse maternal and infant health outcomes within the project area. It is expected that you will use varied outreach and recruitment strategies to target HSE services to the following groups within the project area:

• Pregnant, preconception and interconception women.

• Fathers/partners who have a pregnant partner, infant(s), and/or child(ren) less than 18 months old.

HSE projects are also expected to implement strategies and activities to retain enrolled participants for up to 18 months postpartum. This can include using incentives (e.g., diapers, gift cards, etc.).

2. Implement a continuum of services that meet the unique needs of HSE participants and communities. It is expected that HSE projects have processes for identifying which services and intensity of support best meet the needs and interests of participants. At a minimum all HSE sites should offer the following types of services:

• Health promotion and education

19 For the purposes of brevity this NOFO will primarily use the term women to describe preconception, pregnant and interconception HSE program participants. The intent is to be inclusive of individuals who are transgender, non-binary or gender-expansive.

20 Partners who are caregivers to infants and children up to 18 months old.

https://mchb.hrsa.gov/sites/default/files/mchb/programs-impact/strengthening-miechv-workforce.pdf https://mchb.hrsa.gov/sites/default/files/mchb/programs-impact/strengthening-miechv-workforce.pdf

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• Preventative screening services and prenatal care (e.g., providing and/or contracting for wellness visits, prenatal/postpartum care and screening for maternal depression, intimate partner violence, sexually transmitted infections, diabetes, hypertension etc.)

• Referrals and linkages to clinical care and support services addressing social determinants of health (SDOH) using high touch support and warm hand-offs

• Navigation support to retain participants in clinical care and maintain connection to services addressing SDOH (this can include case management and/or care coordination described in more detail below).

No single organization can meet the clinical and/or support needs of all participants.

Therefore, it is essential that HSE sites develop and maintain a robust network of culturally responsive referral partnerships that include but are not limited to Title V programs, health care providers, mental health services, doulas, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), education and vocational training programs and organizations addressing housing and food insecurity.

3. Provide case management/care coordination services for women of reproductive age and fathers/partners. HSE projects should provide family-centered, strength-based case management/care coordination for enrolled participants. Case management is a process of developing and executing a plan for an individual to access medical care, community-resources and education by advocating, guiding and coordinating services and supports. Care coordination organizes and aligns participant care by sharing information and individual family preferences to eliminate duplication and increase efficiency and effectiveness. For additional guidance on the essential components of case management/care coordination, please review the Healthy Start Case Management/Care Coordination guidance available online.

All HSE participants enrolled in case management/care coordination services should also receive health/parenting education.

Number Served Through Case Management/Care Coordination:

• HSE projects are expected to provide case management/care coordination to a minimum of 450 participants annually. A minimum of 225 participants should be pregnant women. The remaining 225 participants may be any combination of:

• Pregnant women;

• Preconception women;

• Interconception women of reproductive age;

https://healthystartepic.org/wp-content/uploads/2019/05/HealthyStartCoIINFinalPackageCMCC.pdf

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• Fathers/partners with a pregnant partner or who have an infant or child younger than 18 months of age or who are a current or former partner of an enrolled participant;

• Infants/children from birth to 18 months of age.

• Out of the 450 participants who receive case management/care coordination, a minimum of 50 percent should be from your proposed target population, which is the population with the highest IMR in your project area.

Note that HSE projects are expected to complete Healthy Start data collection forms and collect benchmark data for HSE participants enrolled in case management/care coordination.

4. Provide group-based health and parenting education classes.21 In addition to providing case management/care coordination to 450 enrolled participants, HSE projects must provide group-education to a minimum of 200 individuals (e.g., mothers/women of reproductive age and/or fathers/partners) annually. HSE programs are encouraged to implement strategies that reduce barriers to attending group-based education sessions (e.g., providing child care and transportation) and create opportunities for participants to develop peer-to-peer social support.

Group-based education classes should be facilitated by a knowledgeable HSE staff member, contractor or subject matter expert. Classes should be interactive with opportunities for participants to ask questions, discuss topics and share experiences. HSE projects are encouraged to organize group education classes in cohorts with multiple, successive sessions so that participants have the ability to develop social connects and have a reliable, ongoing source of support and information.

5. Provide health promotion, education, and prevention activities aimed at increasing family health and wellness and promoting optimal perinatal health outcomes. It is expected that:

• HSE projects must offer individual and group-based health and parenting education to all 450 HSE participants enrolled in case management/care coordination and the 200 participants attending group-based education annually.

Health promotion and educational information is delivered through multiple modalities to best meet the unique needs of participants and families. HSE projects should consider strategies that reduce barriers to accessing health promotion and

21 Group-Based Education- HSE projects report a non-duplicated count of numbers served through group-based education. Healthy Start data collection forms are not required for group-based participants.

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educational information. For example, meeting with participants in the home and virtually or providing child care at group-based educational sessions.

6. Ensure HSE participants have access to preventive health services, behavioral health care, and other specialty services.22

• HSE projects must deliver prenatal care and other preventive health services and/or have partnerships and referral procedures for ensuring participants receive clinical and behavioral health services from other entities within the project area. If services are unavailable within the project area, HSE awardees must have plans for transportation and other supports to ensure services are delivered. Prenatal and preventive health services must be operational within 90 days of grant award.

• It is expected that all grantees provide clinical services to HSE participants.23 Successful applicants will be expected to dedicate 10 percent of their award to support nurse practitioners, certified nurse midwives, physician assistants, behavioral health specialists, and other maternal-child advance practice health professionals dedicated to HSE projects. As a part of the 10 percent, funds may also be used to support health educators by having clinical staff conduct trainings on associated topics, such as Maternal Early Warning Signs.

• Applicants are strongly encouraged to consider community-based doulas as members of HSE participant care teams.

Health Promotion Topics

It is expected that HSE projects address the following health promotion topics:

preventive health services, behavioral health and wellness, infant care and parenting, and access to community-based resources and benefits. More details on these four topics and what should be covered can be found in Appendix C.

Community Consortia

Community Consortia (formerly known as Community Action Networks or “CANs”) are intended to bring together various representatives across the community to address pressing issues and needs that may lead to poor perinatal health outcomes.

• Establish a Community Consortium within 3 months of the start of the HSE project period. It is expected that post-award a minimum of 25 percent of

22 Examples of preventive health services, behavioral health care and other specialty services include:

well-woman health visits, prenatal/postpartum care, primary care, nutrition counseling, mental health services and tobacco cessation.

23 Note that $15 million of the total FY23 HS funding is intended to support clinical services within all grants funded through this program, including HSE projects.

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Community Consortium members are enrolled HSE participants and women of reproductive age, mothers, fathers or partners and other people with lived experience living in the project area. It is expected that the Community Consortium will have representation from Title V, public health departments, hospitals, health centers under section 254b, State substance abuse agencies, and other significant sources of health care services. Other categories of partners can include:

community leaders, representatives from service agencies, community-based organizations; state/non-profit organizations/faith-based organizations addressing housing, employment, education, transportation, and health care.24

• The HSE project is expected to hire or contract with a Community Consortium Coordinator from, and representative of, the community being served. The Community Consortium Coordinator will oversee the development and implementation of the plan described below.

• As a best practice, the Community Consortia chair or co-chair should be a current or former Healthy Start participant.

• Advise and inform the planning and implementation of HSE direct and enabling services.

• Develop and submit a Community Consortium plan to address SDOH by June 30, 2024. Plans should go beyond solely addressing barriers to clinical care and improving the local system of care. They should address the environmental, social, and economic conditions that contribute to disparities in perinatal outcomes. Plans are expected to be based upon the results of a community needs assessment and environmental scan that identifies and prioritizes SDOH causes of disparities in perinatal outcomes in the project area. The plan is expected to:

• Describe strategic partnerships and strategies to address the “upstream factors” and unique SDOH contributing to disparities in perinatal outcomes within the project area.

• Include a minimum of five performance measures corresponding to plan activities. Examples of performance measures include:

Increase access to nutritious foods by ensuring X percent of eligible residents of the project area are enrolled in WIC;

24 In making grants under subsection (a), the Secretary shall require that applicants (in addition to meeting all eligibility criteria established by the Secretary) establish, for project areas under such subsection, community-based consortia of individuals and organizations (including agencies responsible for administering block grant programs under title V of the Social Security Act [42 U.S.C. 701 et seq.], participants and former participants of project services, public health departments, hospitals, health centers under section 254b of this title, State substance abuse agencies, and other significant sources of health care services) that are appropriate for participation in projects under subsection (a).

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Increase access to prenatal care by coordinating X centering groups within less than a X minute walk from public transportation;

Increase access to employment opportunities by increasing the General Educational Development test completion rate in project area by X percent.

• The Community Consortium should regularly report out/disseminate information to community members and partners on the implementation of the HSE project overall, the plan and progress made towards achieving goals/objectives of the plan.

NOTE: No appropriated funds may be expended by the recipient of a Federal contract, grant, loan, or cooperative agreement to pay any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with any of the following covered Federal actions: the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

• Begin implementation of the plan to address SDOH by September 29, 2024.

• Participate in HSE Community Consortia Community of Practice activities through the Healthy Start Technical Assistance and Support Center. These activities may focus on peer support across HSE projects, sharing of best practices in partnership engagement, plan implementation, and creation of new knowledge.

HSE Community Consortium Coordinators are expected to participate in focused learning communities such as community of practice, peer support, webinars and in-person meetings on SDOH topics such as housing, food insecurity, and transportation, and racism or discrimination. Examples of performance metrics include:

Number of promising practices identified addressing SDOH topics

Number of Community Consortium participants engaged in focused learning opportunities.

• The Community Consortium Coordinator may invite community partners to engage in select Community of Practice activities.

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Performance Monitoring and Evaluation

1. Data Collection and Performance Monitoring of Direct and Enabling Services

Healthy Start Benchmarks

Awardees will report annually on progress toward achieving the 10 HS benchmark goals and final year outcomes (please see Appendix D for the complete list of HS benchmarks). Failure to ensure compliance with reporting requirements once an award is made may result in further actions or conditions during post-award monitoring (see 45 CFR § 75.371 Remedies for noncompliance).

Objectives and Performance Measures

The application should include baselines for all HS benchmarks in the work plan. When utilizing baseline data, you should document the date of the source. If baseline data sources are older than 2019, please explain why more current estimates are not available. If percentages are used, the relevant numerators and denominators should be provided.

Standardized Healthy Start Data Collection Forms

Your program is expected to use the standardized HS data collection forms for collection of universal participant-level data elements. Your program should ensure organizational approvals are in place (e.g., Institutional Review Board) in order to be ready and able to report on data collected through the forms on a quarterly basis via the Healthy Start Monitoring and Evaluation Data System (HSMED).

2. Quality Improvement

Your program is expected to engage in quality improvement (QI) efforts informed by participant-level, program-level, and community-level data. QI is a process of systematic and continuous actions that lead to measurable improvement, particularly around health care services and the health status of the targeted population

You are encouraged to access technical assistance on QI from the Healthy Start Technical Assistance and Support Center. It is expected that your program will identify opportunities for QI related to your activities, services, and supports, as well as for the overall program. After your program reports its first year of HS benchmark data you are expected to work with HRSA staff and the Supporting Healthy Start Performance Project to develop a QI plan to improve performance on specific HS benchmarks and/or address data collection challenges.

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