MCHB HRSA-24-033 (H49) Healthy Start Initiative _Final.pdf

U.S. Department of Health and Human Services

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2024

Maternal and Child Health Bureau

Division of Healthy Start and Perinatal Services

Healthy Start Initiative: Eliminating Disparities in Perinatal Health

Funding Opportunity Number: HRSA-24-033

Funding Opportunity Type(s): Competing Continuation, New

Assistance Listing Number: 93.926

Application Due Date: December 15, 2023 Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

We will not approve deadline extensions for lack of registration.

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

Issuance Date: September 22, 2023

Mia Morrison, MPH Supervisory Public Health Analyst, Division of Healthy Start and Perinatal Services Call: 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-24-033 HS i

508 COMPLIANCE DISCLAIMER

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

SUMMARY

Funding Opportunity Title: Healthy Start Initiative: Eliminating Disparities in Perinatal Health

Funding Opportunity Number: HRSA-24-033

Assistance Listing Number: 93.926

Due Date for Applications: December 15, 2023

Purpose:

The purpose of the Healthy Start Initiative:

Eliminating Disparities in Perinatal Health (HS) 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.

Program Objective(s): Successful HS projects will accomplish the following objectives during the 5-year period of performance:

Direct and Enabling Services for HS Participants

• Increase receipt of case management/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 healthy and safe infant and toddler care practices.

https://www.cdc.gov/parents/infants/index.html

HRSA-24-033 HS ii

Community Consortium

Convene diverse, multi-sector state, local, and community level partners, including HS participants and other community members.

Eligible Applicants: You can apply if your organization is in the United States and is:

• Public or private

• Community-based

• Tribal (governments, organizations)

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

Anticipated FY 2024 Total Available Funding:

$113,645,000

We’re issuing this notice to ensure that, should funds become available for this purpose, we can process applications and award funds appropriately. You should note that we may cancel this program notice before award if funds are not appropriated.

Estimated Number and Type of Award(s):

Up to 103 grants

Estimated Annual Award Amount:

Up to $1,100,000 per award, subject to the availability of appropriated funds

Cost Sharing or Matching Required:

No

Period of Performance: April 1, 2024 through March 31, 2029 (5 years)

Agency Contacts:

Business, administrative, or fiscal issues:

Tya Renwick Grants Management Specialist Division of Grants Management Operations, OFAM Email: Trenwick@hrsa.gov

Program issues or technical assistance:

Mia Morrison, MPH Supervisory Public Health Analyst mailto:Trenwick@hrsa.gov

HRSA-24-033 HS iii

MCHB Division of Healthy Start and Perinatal Services Email: MCHBHealthyStart@hrsa.gov

Application Guide

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

Technical Assistance

We have scheduled the following webinar:

Thursday, October 12, 2023 1 p.m. – 3 p.m. ET Weblink: https://hrsa-gov.zoomgov.com/j/1615431506?pwd=SnArVTdtTzNFeGVoVWY1MzhjN2loZz09

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

Call-In Number: 1-833-568-8864 Meeting ID: 161 543 1506 Passcode: 89972057

We will record the webinar.

mailto:MCHBHealthyStart@hrsa.gov http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/grants/apply-for-a-grant/prepare-your-application https://hrsa-gov.zoomgov.com/j/1615431506?pwd=SnArVTdtTzNFeGVoVWY1MzhjN2loZz09 https://hrsa-gov.zoomgov.com/j/1615431506?pwd=SnArVTdtTzNFeGVoVWY1MzhjN2loZz09

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING OR MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

3. UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD MANAGEMENT (SAM)

4. SUBMISSION DATES AND TIMES

5. INTERGOVERNMENTAL REVIEW

6. FUNDING RESTRICTIONS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. REVIEW AND SELECTION PROCESS

3. ASSESSMENT OF RISK

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

APPENDIX A: PAGE LIMIT WORKSHEET

APPENDIX B: GLOSSARY

APPENDIX C: HEALTH PROMOTION TOPICS

APPENDIX D: HEALTHY START BENCHMARKS

APPENDIX E: ATTACHMENT 1 CHECKLIST

APPENDIX F: SAMPLE TEMPLATE FOR ATTACHMENT 1

APPENDIX G: COUNTIES ELIGIBLE FOR PRIORITY POINTS FOR OTHER PERINATAL

INDICATORS

APPENDIX H: HEALTHY START – ENHANCED (HSE) PROJECT SITE COUNTIES AND ZIP

CODESTM

HRSA-24-033 HS 1

I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Healthy Start Initiative: Eliminating Disparities in Perinatal Health (Healthy Start or HS) Program. The purpose of HS 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 HS is intended to support projects in communities and populations experiencing the greatest disparities in maternal and infant health outcomes.

HS has two focus areas: 1) providing direct and enabling services (for example, screening and referrals, case management and care coordination, health and parenting education, and linkage to clinical care) to enrolled HS participants; and 2) convening Community Consortia (formerly known as Community Action Networks or “CANs”) comprised of diverse, multi-sector partners to advise and inform HS activities as well as to develop and implement plans to improve perinatal outcomes within the selected project area. HS continues to have an increased emphasis on addressing social determinants of health, such as access to adequate food, housing, and transportation, to improve disparities in maternal and infant health outcomes. Based on stakeholder feedback, this FY 2024 HS competition also provides recipients with increased flexibility to tailor interventions to the unique needs of their community and/or target population.

The goals of HS are to:

1) Continue reducing infant mortality rates in the United States, and

2) Decrease disparities in infant mortality and poor perinatal health outcomes in areas where those rates are high.

HS projects should be implemented in communities experiencing high rates of maternal and infant mortality and morbidity. Successful HS projects will accomplish the following objectives during the 5-year period of performance:

Direct and Enabling Services for HS Participants

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

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

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 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

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• Increase use of healthy and safe infant and toddler care practices.

Community Consortium

Convene diverse, multi-sector state, local, and community level partners, including HS participants and other community members, that will:

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

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

• Participate in Communities of Practice with other HS/Healthy Start Initiative - Enhanced (HSE) projects to develop and implement a plan for the community that focuses on at least one social determinant of health (SDOH), such as access to adequate housing, transportation, or food.

For more details, see Program Requirements and Expectations.

2. Background

Authority

The Healthy Start Initiative: Eliminating Disparities in Perinatal Health (Healthy Start or HS) program is authorized by 42 U.S.C. § 254c-8 (Title III, § 330H of the Public Health Service Act).4

Infant Mortality, Perinatal Health, and Social Determinants of Health

Approximately four million births occur each year in the U.S.5 While most women have a safe pregnancy and deliver a healthy infant, there are persistently higher rates of infant mortality and maternal morbidity among some groups, in particular Black and indigenous populations. The highest infant mortality rates in the country are among Black, American Indian/Alaskan Native (AI/AN), and Native Hawaiian/Other Pacific Islander infants (10.38, 7.68, and 7.17 infant deaths per 1,000 live births in 2020, respectively). These rates are significantly higher than that of White infants (4.40 infant deaths per 1,000 live births in 2020).6 Each year, approximately 3,500 infant deaths occur due to higher mortality rates among non-Hispanic Black and non-Hispanic indigenous, infants.7 Inequities in access to health promoting resources such as education, employment, and health care contribute to disparities in perinatal health and

4 42 USC 254c-8: Healthy start for infants (house.gov) 5 https://www.cdc.gov/nchs/fastats/births.htm 6 https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf 7 https://healthystartepic.org/technical-assistance-activities/catalyst-for-infant-health-equity/ 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 https://www.cdc.gov/nchs/fastats/births.htm https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-05.pdf https://healthystartepic.org/technical-assistance-activities/catalyst-for-infant-health-equity/

HRSA-24-033 HS 3

infant death. For example, in many rural tribal communities, pregnant women and families face barriers accessing medical care due to geographic barriers and insufficiencies in the health care infrastructure and workforce.

The Healthy Start Initiative

Since its start as a demonstration project in 1991, the Healthy Start program has provided awards to communities with infant mortality rates at 1.5 times the U.S. national average and high rates of other adverse perinatal outcomes (for example, low birthweight, preterm birth, maternal morbidity, and mortality).8 The purpose of Healthy Start is to reduce infant mortality rates and improve perinatal outcomes by focusing on project areas with high or above the national average annual rates of infant mortality.

Healthy Start uses a community-based approach to delivering direct and enabling services that facilitates access to health care and community services. In alignment with the statute, the program focuses on addressing factors that contribute to infant mortality, such as low birthweight, preterm birth, and social determinants of health in 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 in communities.

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 (all of which are factors associated with improved infant morbidity and mortality outcomes). 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.

About MCHB and Strategic Plan

The HRSA 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

8 For reference visit https://mchb.hrsa.gov/programs-impact/healthy-start/2019-grantees to see a list of the 101 HRSA-19-049 Healthy Start recipients (project period April 1, 2019 - March 31, 2024). We are including this link for your awareness/background information only. Many of the HRSA-19-049 awardees may re-apply for the same or similar project areas; you may wish to contact them for coordination purposes to avoid overlap in proposed project areas.

https://mchb.hrsa.gov/programs-impact/healthy-start https://mchb.hrsa.gov/programs-impact/healthy-start

HRSA-24-033 HS 4

Goal 2: Achieve health equity for MCH populations

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 lean more visit Mission, Vision, and Work | MCHB: https://mchb.hrsa.gov/about-us/mission-vision-work.

II. Award Information

1. Type of Application and Award

Application type(s): Competing Continuation, New

We will fund you via a grant.

2. Summary of Funding

We estimate $113,645,000 will be available each year to fund 103 recipients. You may apply for a ceiling amount of up to $1,100,000 annually (reflecting direct and indirect costs).

The period of performance is April 1, 2024, through March 31, 2029 (5 years).

This program notice depends on the appropriation of funds. If funds are appropriated for this purpose, we will proceed with the application and award process.

Support beyond the first budget year will depend on:

• Appropriation

• Satisfactory progress in meeting the project’s objectives

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

45 CFR part 75 - Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards applies to all HRSA awards.

If you’ve never received a negotiated indirect cost rate, you may elect to charge a de minimis rate of 10 percent of modified total direct costs (MTDC)*. You may use this for the life of the award. If you choose this method, you must use it for all federal awards until you choose to negotiate for a rate. You may apply to do so at any time. See Section 4.1.v. Budget Narrative in the Application Guide.

*Note: One exception is a governmental department or agency unit that receives more than $35 million in direct federal funding.

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

HRSA-24-033 HS 5

III. Eligibility Information

1. Eligible Applicants

You can apply if your organization is in the United States and is:

• Public or private

• Community-based

• Tribal (governments, organizations)

Additional Notes:

If you are a recipient of the Healthy Start Initiative – Enhanced (HRSA-23-130) (HSE) you are still eligible to apply for this grant if you are proposing a new project area, that is, an area not currently served by your or an existing HSE award. HSE grant project areas have been settled and it is not HRSA’s intent to alter or reset existing HSE project areas. Therefore, if you propose to serve a project area that fully overlaps with your own award or another HSE award, your application will be deemed ineligible and will not be considered. Please see Appendix H for a list of Healthy Start Initiative – Enhanced project areas.

For all other applicants, if your proposed project area is the same as a Healthy Start Initiative – Enhanced (HSE) recipient, your application will be deemed ineligible.

These provisions ensures that new communities with the highest rates of infant mortality and other adverse perinatal health outcomes that do not already have access to Healthy Start services are reached by this program.

2. Cost Sharing or Matching

Cost sharing or matching is not required for this program.

3. Other

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

• Exceeds the funding ceiling amount

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

Multiple Applications

We will only review your last validated application before the Grants.gov due date.

HRSA-24-033 HS 6

IV. Application and Submission Information

1. Address to Request Application Package

We require you to apply online through Grants.gov. Use the SF-424 workspace application package associated with this notice of funding opportunity (NOFO). Follow these directions: How to Apply for Grants. If you choose to submit using an alternative online method, see Applicant System-to-System.

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

Select “Subscribe” and enter your email address for HRSA-24-033 to receive emails about changes, clarifications, or instances where we republish the NOFO. You will also be notified by email of documents we place in the RELATED DOCUMENTS tab that may affect the NOFO and your application. You’re responsible for reviewing all information that relates to this NOFO.

2. Content and Form of Application Submission

Application Format Requirements Submit your information as the Application Guide and this program-specific NOFO state. Do so in English and budget figures expressed in U.S. dollars. There’s an Application Completeness Checklist in the Application Guide to help you.

Application Page Limit The total number of pages that count toward the page limit shall be no more than 60 pages when we print them. We will not review any pages that exceed the page limit.

Using the pages within the page limit, HRSA will determine eligibility using Section III.

Eligibility Information of the NOFO.

These items do not count toward the page limit:

• Standard OMB-approved forms you find in the NOFO’s workspace application package

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

• Indirect Cost Rate Agreement

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

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

If you use an OMB-approved form that isn’t in the HRSA-24-033 workspace application package, it may count toward the page limit.

Applications must be complete and validated by Grants.gov under HRSA-24-033 before the deadline.

https://www.grants.gov/ http://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/web/grants/s2s/applicant-system-to-system.html

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Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

• When you submit your application, you certify that you and your principals9 (for example, program director, principal investigator) can participate in receiving award funds to carry out a proposed project. That is, no federal department or agency has debarred, suspended, proposed for debarment, claimed you ineligible, or you have voluntarily excluded yourself from participating.

• If you fail to make mandatory disclosures, we may take an action like those in 45 CFR § 75.371. This includes suspending or debarring you.10

• If you cannot certify this, you must include an explanation in Attachment 9-15:

Other Relevant Documents.

(See Section 4.1 viii “Certifications” of the Application Guide)

Program Requirements and Expectations The Program Requirements and Expectations for the FY 2024 Healthy Start Program fall into the following categories:

i. Project Area and Target Population

ii. Direct and Enabling Services for HS Participants.

iii. Community Consortium

iv. Leadership at the Local State and/or Regional Level

v. Performance Monitoring and Evaluation

i. Project Area and Target Population

You are expected to define your project area and target population using the criteria outlined below. Include information requested under “Project Area Proposed to be Funded” and “Factors Demonstrating Need for the Target Population” in Attachment 1.

Please note that you are encouraged to use the template located in Appendix F to organize the information requested in Attachment 1.

Project Area Proposed to be Funded

• A project area is defined as a geographic area where the proposed HS services will be implemented. HS project areas are expected to be communities experiencing rates of infant mortality that are 1.5 times the national average or greater.

• Project areas should be distinct and not overlap with another Healthy Start/Healthy Start Initiative - Enhanced project area.

9 See definitions at eCFR :: 2 CFR 180.995 -- Principal. and eCFR :: 2 CFR 376.995 -- Principal (HHS supplement to government-wide definition at 2 CFR 180.995).

10 See also 2 CFR parts 180 and 376, 31 U.S.C. § 3354, and 45 CFR § 75.113.

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1371 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#se45.1.75_1371 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-I/part-180/subpart-I/section-180.995 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376/subpart-I/section-376.995 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376/subpart-I/section-376.995 https://www.ecfr.gov/current/title-2/subtitle-A/chapter-I/part-180 https://www.ecfr.gov/current/title-2/subtitle-B/chapter-III/part-376 https://uscode.house.gov/view.xhtml?req=granuleid%3AUSC-prelim-title31-chapter33&edition=prelim https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-B/section-75.113

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• Applicants are encouraged to be specific in delineating the boundaries of their proposed project area, including existing or future service agreements.

• Identify your organization as serving an urban11 or rural12 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.

• Define your project area by county, Zip CodeTM, or Census Tract. Include a map of the proposed project area and a list of Zip CodesTM within the project area (Attachment 1). If you are proposing to serve a portion of a county or Zip CodeTM, you are expected to define the borders of your project area (for example, use street names, Census Tracts or for portions of a Zip CodeTM you may use county lines).

o A project area (that is, your catchment area) might consist of a group of Zip CodesTM or portions of Zip CodesTM 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 CodesTM). The counties or Zip CodesTM in your project area do not need to be contiguous and cannot be served by another HS/HSE-funded project.

Overlapping Project Areas

To ensure that communities with the highest rates of infant mortality and other adverse perinatal health outcomes have access to HS services, HRSA intends to fund projects serving distinct project areas that do not overlap with one another.

I. If two or more applicants propose the same project area and receive fundable scores, HRSA will award the grant to the highest scoring applicant.

II. If two or more applicants propose project areas that partially overlap and they receive fundable scores, HRSA will notify the applicant(s) of the overlap and request that, within a specified period of time, they establish an agreement outlining amended project areas that do not overlap. The agreement should:

o describe the need for multiple HS recipients within the project area, including the distinct target population served;

o provide a map of each project area. Define each applicant’s boundaries within the proposed project area using Zip CodesTM, street names, and/or or Census

11 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.

12 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

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Tracts, demonstrating the specific population(s) that will be served (HRSA will use this information to check for potential overlaps);

o outline partnership responsibilities for outreach, recruitment, and referrals demonstrating that there will be no overlap in populations served;

o include the number of births in the target population within the project area in order to demonstrate that both/all applicants will each be able to serve 700 participants annually.

Please note: Your revised project area will not be approved if it overlaps with other fundable applicants or Healthy Start Initiative – Enhanced (HSE) recipients.

III. If one or more applicant(s) inadvertently propose project areas that partially overlap with an existing Healthy Start Initiative – Enhanced (HRSA-23-130) grantee’s project area13 and are in the fundable range, it is incumbent upon the applicant(s) to amend their project area, removing the overlap, while continuing to meet the program requirements described in the NOFO. HRSA will contact you before awards are made, ask you to revise your project area and submit the following information:

o Revised project area including a list of counties, Zip CodesTM and/or Census Tracts and an updated map.

o Number of births in the target population for the revised project area.

IV. Tribes, Tribal Organizations and Health Organizations Serving Tribes – Because many tribes and tribal populations access health care services and other social supports through the Indian Health Service and other organizations that are specific to tribal nations, rather than through Medicaid or private health insurance programs, overlaps in project area with applicants proposing to serve non-tribal populations generally does not imply a duplication of services. Therefore, two applicants in the fundable range may propose to serve the same project area if one, but not both of the applicants is a tribe, tribal organization or health organization serving tribes. HRSA will notify you before an award is made and will ask you to develop an agreement with the other applicant(s) to either:

o amend your project area(s); and/or o define your unique target populations within the same project area;

13 Please note: you are highly encouraged to review Appendix H to confirm that your proposed project area has no overlap with an HSE recipient’s project area. There is no expectation that HSE recipients will revise their project areas. It is the responsibility of the applicant to revise their project area and ensure there is not overlap. Your revised project area will not be approved if it overlaps with other fundable applicants or other HSE recipients.

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o establish that both applicants are able to meet all program requirements and expectations, including serving 700 participants annually.14

The following applies to all scenarios involving project area overlap described above:

• Program activities implemented in amended project areas are expected to continue to meet the program requirements.

• If HRSA determines that the changes to your project area potentially impact the information provided under “Factors Demonstrating Need for the Target Population” (below), you will be asked to provide revised data for IMR, low birthweight and preterm births for the target population in the project area. HRSA may also ask for other documentation including a revised budget and work plan.

HRSA will evaluate the information to ensure the proposed activities in the revised project area continue to meet the Program Requirements and Expectations of this NOFO.

• If an agreement is submitted by the deadline and approved by HRSA, you will be required to develop a formal Memorandum of Agreement (MOA)/Memorandum of Understanding (MOU) with the other recipient(s) after the award is made.

• If an agreement cannot be reached in the specified period of time or HRSA determines that the information provided was incomplete or insufficiently demonstrates your ability to meet all of the Program Requirements and Expectations outlined in this NOFO, HRSA intends to fund only the highest scoring applicant.

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, low birthweight, or preterm birth.

Your target population within your proposed project area should meet the following criteria using verifiable, vital statistics data:15,16

14 Please Note: If two applicants propose services in the same project area, with the same primary target population, for example, they propose to serve the same tribe, then only the highest scoring application will be considered.

15 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.

16 Do not use the Maternal and Infant Health Mapping Tool for need-based eligibility criteria. IMR, low birth weight, and preterm birth data are not available for the period requested (2019-2021) and the number of events is not provided.

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1. If the combined 2019 through 2021 number of infant deaths in the target population are 30 or more, the 2019 through 2021 combined 3-year IMR in the target population should be equal to or more than 8.2 deaths per 1,000 live births (1.5 times the national average).17

2. If the combined 2019 through 2021 number of infant deaths in the target population are less than (<)30, one of the following should be met:18

a. The 2019 through 2021 3-year low birthweight rate in the target population 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, 2019 through 2021.

OR

b. The 2019 through 2021 preterm birth rate in the target population is equal to or more than 15.4 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, 2019 through 2021.

ii. Direct and Enabling Services for HS Participants

HS projects are expected to have the necessary partnerships, curricula, evidence-based/evidence-informed, and/or scientific information to implement high quality direct and enabling services.

HS 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 in their target populations. HS projects are also expected to have processes in place to support staff retention (for example, adequate supervision, competitive salaries, manageable caseloads). Please see Strengthening the Maternal Infant Early Childhood Home Visiting Workforce: A Checklist for Staff Recruitment and Staff Retention as a resource.

HS direct and enabling services should be customized to meet the needs of the project area. These services should focus on your target population (which is the group with the highest IMR within the project area or, if there were less than 30 infant deaths from 2019 through 2021, then the group with the highest rate of low birthweight or preterm birth) and the geographic area(s) as described above. Strategies should be culturally responsive and linguistically appropriate.

17 For project areas that include whole counties, CDC Wonder may be used to obtain infant mortality statistics (250,000+ population only): https://wonder.cdc.gov/lbd.html. Otherwise, please contact your state or local vital statistics department.

18 For project areas that include whole counties, CDC Wonder may be used to obtain preterm birth/low birthweight statistics (100,000+ population only): https://wonder.cdc.gov/natality.html. Otherwise, please contact your state or local vital statistics department.

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 https://mchb.hrsa.gov/sites/default/files/mchb/programs-impact/strengthening-miechv-workforce.pdf https://wonder.cdc.gov/lbd.html https://wonder.cdc.gov/natality.html

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HS recipients are expected to provide two broad categories of services: case management19/care coordination20 and group-based health and parenting education.

HS projects will be expected to enroll participants in case management/care coordination and/or group-based health and parenting education depending on each participant’s interest and which types of services meet their needs. A HS participant may participate in both types of services. For example, a participant enrolled in case management/care coordination can also attend, and should be encouraged to attend, group-based education sessions, and vice-versa.

Further expectations for direct and enabling services fall into the following categories:

• Numbers Served Through Direct and Enabling Services

• Case Management/Care Coordination Services

• Provide Group-based Prenatal/Postpartum and Parenting Education

• Numbers Served through Group-Based Health and Parenting Education

• Conduct Outreach, Recruitment, and Retention Efforts for HS Participants

• Implement a Continuum of Services That Meet the Unique Needs of HS Participants

• Ensure HS Participants Have Access to Preventive Health Services, Behavioral Health Care, and Other Specialty Services

• Health Promotion

Numbers Served Through Direct and Enabling Services

HS projects are expected to serve 700 unduplicated participants annually through direct and enabling services within the following categories:

• At least 450 participants through case management/care coordination.21

• At least 250 participants through group-based health and parenting education.22

Out of the 700 participants served, a minimum of 50 percent should be from the target population (group with the highest IMR in your project area or, if there were less than 30

19 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.

20 Care coordination organizes and aligns participant care by sharing information and individual family preferences to eliminate duplication and increase efficiency and effectiveness.

21 For additional details on numbers served through case management/care coordination please see “Case Management/Care Coordination Services for Women of Reproductive Age and Fathers/Partners.”

22 For additional details on numbers served through group-based health and parenting education please see “Group-based Health and Parenting Education”

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infant deaths in your target population from 2019 through 2021, the group with the highest low birthweight rate or preterm birth rate).

The above targets are based on expectations of, numbers served by, and overall performance of Healthy Start recipients through previous Healthy Start Initiative programs.

Case Management/Care Coordination Services

HS projects should provide family-centered, strengths-based case management/care coordination, which is a method of case management/care coordination that focuses on an individual’s strengths, rather than on their challenges and deficits, for enrolled participants. It is expected that participants enrolled in case management/care coordination receive both health and parenting education (either one-on-one or in a group setting) and information on community-based resources. Information will be delivered through multiple modalities to best meet the unique needs of participants and families. These modalities may include meeting with participants in their homes, at the HS site, and/or virtually.

HS projects should encourage participants enrolled in case management/care coordination to attend group-based health education sessions (discussed below).

For additional guidance on the essential components of case management/care coordination, please review the Healthy Start Case Management/Care Coordination guidance available online.

• Numbers Served Though Case Management/Care Coordination:

o HS projects are expected to provide case management/care coordination to a minimum of 450 participants annually. You should plan to serve:

o A minimum of 250 pregnant women;

o A minimum of 25 fathers/partners who have an infant or child from newborn to 18 months of age and/or are the current or former partner of an enrolled participant.

o The remaining 175 participants may be any combination of the following five categories:

Pregnant women;

Preconception women;

Interconception women of reproductive age;

Infants/children from birth to 18 months of 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 and/or are the current or former partner of an enrolled participant.

Provide Group-based Prenatal/Postpartum and Parenting Education

• HS projects are expected to provide group-based health and parenting education which includes prenatal health, parenting, and child development education. HS projects can provide group-based education through a Group Prenatal Care model or a Community-based Group Prenatal and Parenting Education model.

The group education sessions are expected to provide participants with a forum to: 1) learn and obtain information about critical health promotion and education topics, the knowledge of which can lead to positive perinatal outcomes; and 2) form connections and receive support from other pregnant women/parents in their community, which has also been found to lead to positive perinatal outcomes. Tailor models and strategies to meet the needs of the target population.

HS projects are expected to:

• Implement group-based health and parenting education in groups or cohorts so that participants are able to form supportive connections with other group members.

• Implement group-based health and parenting education programs to ensure learning and robust interaction among participants over time in accordance with the design of the group educational model.

• Implement strategies that reduce participants’ barriers to attending group-based health and parenting education sessions, such as providing transportation, meals, child care, etc.

For a list of suggested health promotion and parenting education topics for group-based health and parenting education please see Appendix B. Please note activities such as health fairs do not constitute group-based education.

Numbers Served through Group-Based Health and Parenting Education

As noted above, participants receiving group-based education may be enrolled in case management/care coordination. However, it is expected that HS projects provide group-based education to a minimum of 250 unduplicated participants who are not also enrolled in case management/care coordination (for example, mothers/women of reproductive age and/or fathers/partners) annually.

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Conduct Outreach, Recruitment, and Retention Efforts for HS Participants

Outreach and recruitment efforts to engage and retain residents of the project area in services that focus on identifying and providing HS services to mothers/women23 of reproductive age, fathers/partners24, 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 such as developing referral partnerships with other community-based organizations, hospitals and clinics and conducting direct community-based outreach within the project area.

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

Implement a Continuum of Services That Meet the Unique Needs of HS Participants

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

• Health promotion and education

• Preventive screening services and prenatal care. This may include:

o Providing and/or contracting for well women 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, which is support that delivers care through high frequency patient/participant-provider encounters to deliver preventative services, and warm hand-offs, which are transfers of care between members of a care team that occur in front of the participant and/or family.

o Navigation support to retain participants in clinical care and to maintain connection to services addressing SDOH (which can include case management and/or care coordination).

It is essential that HS sites develop and maintain a robust network of referral partnerships. These partnerships should include, but are not limited to: Title V programs, Maternal Infant Early Childhood Home Visiting (MIECHV) funded home visiting programs, health care providers, mental health services, doulas, Special

23 For the purposes of brevity this NOFO will primarily use the term women to describe preconception, pregnant, and interconception HS program participants.

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

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Supplemental Nutrition Program for Women, Infants and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Ryan White HIV/AIDS Program Part D, education, and vocational training programs and organizations addressing housing and food insecurity.

Ensure HS Participants Have Access to Preventive Health Services, Behavioral Health Care, and Other Specialty Services25

HS projects are expected to 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, HS recipients should have plans for transportation and other supports to ensure services are delivered. Prenatal and preventive health services should be operational within 90 days of award.

It is expected that all recipients provide clinical services to HS participants.26 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 advanced practice health professionals dedicated to HS projects. As 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 Urgent Maternal Early Warning Signs.

HRSA understands the vital role doulas play in reducing disparities in infant mortality, maternal mortality, and other adverse perinatal outcomes. You are strongly encouraged to consider community-based doulas as members of HS participant care teams and to connect participants to doula services during pregnancy, birth, and for at least 3 months post-partum.27

Health Promotion

It is expected that HS projects have a protocol in place for providing health education to all HS participants receiving case management/care coordination and group-based education. Information should be from a scientific or evidence-based curriculum.

Projects should 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.

25 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.

26 From FY 2019 – FY 2024, Congressional Report language accompanying Fiscal Year appropriations indicated that approximately $15 million of Healthy Start funding should be used to support access to clinical services. HRSA expects recipients of funds under this NOFO to support clinical services within HS projects for consistency with this language.

27 Note that doulas should not be included in the 10 percent of funds used to support clinical services.

https://www.cdc.gov/hearher/maternal-warning-signs/index.html https://www.cdc.gov/hearher/maternal-warning-signs/index.html

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HS projects should customize education to meet the unique needs of program participants by partnering with participants and a multi-disciplinary team of knowledgeable HS staff to develop an individualized approach to delivering health education.

Note: Each HS project is expected to submit an annual Health Education Plan (in your Non-Competing Continuation Report) identifying the curriculum, topics and methods of delivery for health promotion topics that will be offered by the program. The plan should also include continuing education for HS staff and a list of the community partners and contractors who you will partner with to provide education to HS participants. Please note that recipients will have 30 days after award to submit their Health Education Plan for the first year of the program.

Community Consortium

Community Consortia are intended to bring together various representatives across the community to address pressing issues and needs that may lead to poor perinatal health outcomes. Community Consortia are expected to implement plans aimed at reducing disparities in perinatal health outcomes by improving the quality of and access to clinical, support, and education services within the project area. Community Consortia may provide training and serve as a forum for organizational updates if and when those activities align with the community-driven approach to implement the plan.

Successful applicants will demonstrate how they meet the following expectations for their community consortium:

• Convene your Community Consortium within 90 days of the start of the HS period of performance.

o Post-award, it is expected that a minimum of 25 percent of Community Consortium members are enrolled HS 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 have representation from Title V, public health departments, hospitals, health centers under section 254b,28 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. The HS project is expected to

28 “Health centers under section 254b” is a reference to health centers receiving funding or designation…