MODIFIED 12.20.21_FORHP HRSA-22-094 (P13) RRPD_FINAL.pdf

U.S. Department of Health and Human Services

Federal Office of Rural Health Policy

Policy Research Division

Rural Residency Planning and Development Program Funding Opportunity Number: HRSA-22-094

Funding Opportunity Types: New

Assistance Listings (AL/CFDA) Number: 93.155

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2022

MODIFIED on December 20, 2021 to extend the Application Due Date.

Program Sustainability requirements will be updated and a revised NOFO posted to Grants.gov on Wednesday, December 22, 2021.

Application Due Date: January 11, 2022 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: October 20, 2021

Sheena Johnson, MPH Health Insurance Specialist Federal Office of Rural Health Policy Telephone: (301) 945-9639 Email: ruralresidency@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 U.S.C. 912(b)(5).

mailto:ruralresidency@hrsa.gov

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508 COMPLIANCE DISCLAIMER

Note: Persons using assistive technology may not be able to fully access information in this file. For assistance, please 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) 2022 Rural Residency Planning and Development (RRPD) Program.

The purpose of this program is to improve health care in rural areas by developing new, accredited, and sustainable rural residency programs in family medicine, internal medicine, preventive medicine, psychiatry, general surgery, and obstetrics and gynecology, to support expansion of the physician workforce in rural communities. For the purposes of this notice of funding opportunity, rural residencies are allopathic and osteopathic physician residency programs that primarily train residents in rural clinical settings for greater than 50 percent of their total time in residency, and focus on producing physicians who will practice in rural communities.

The new rural residency programs will: (1) achieve accreditation through the Accreditation Council for Graduate Medical Education (ACGME) for the eligible specialties, (2) ensure program sustainability through public or private funding beyond the RRPD period of performance, and (3) track residents’ career outcomes post-graduation, including but not limited to retention in rural communities.

This grant program and the RRPD-Technical Assistance Program are complementary and seek to expand the number of new rural residency training programs and subsequently increase the number of physicians choosing to practice in rural areas.

Funding will support planning and development costs accrued while achieving program accreditation.

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Funding Opportunity Title: Rural Residency Planning and Development (RRPD) Program

Funding Opportunity Number: HRSA-22-094 Due Date for Applications: January 11, 2022 Anticipated Total Annual Available FY 2022 Funding:

$10,500,000

Estimated Number and Type of Awards: Up to 14 grants Estimated Award Amount: Up to $750,000 over the 3-year period of performance, subject to the availability of appropriated funds. Award recipient will receive the full award amount in the first year of the period of performance and is required to allocate it across all three years.

Cost Sharing/Match Required: No Period of Performance: August 1, 2022 through July 31, 2025

(3 years) Eligible Applicants: Eligible applicants* are domestic public, nonprofit, or private organizations, including faith-based and community-based organizations, tribes, and tribal organizations. Specifically, these organizations may include, but are not limited to:

1) rural hospitals;

2) rural community-based ambulatory patient care centers, including rural health clinics;

3) health centers operated by a tribe or tribal organization, or an urban Indian organization;

4) graduate medical education consortiums, including schools of allopathic medicine or osteopathic medicine; and

5) faith-based and community-based organizations.

*Either the applicant organization or a consortium’s primary training partner must be located in a rural area.

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

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Application Guide

You (the applicant organization/agency) are responsible for reading and complying with the instructions included in HRSA’s SF-424 Application Guide, available online at http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf, except where instructed in this NOFO to do otherwise.

Technical Assistance

HRSA has scheduled the following technical assistance:

Webinar

Day and Date: Thursday, November 4, 2021 Time: 2 – 3:30 p.m. ET Meeting ID: 160 729 9636 Participant Code: 41475430 Weblink: https://hrsa-gov.zoomgov.com/j/1607299636?pwd=WlRLYXBqYzN0SUYyK0ZadGpja1UwZz09 http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://hrsa-gov.zoomgov.com/j/1607299636?pwd=WlRLYXBqYzN0SUYyK0ZadGpja1UwZz09 https://hrsa-gov.zoomgov.com/j/1607299636?pwd=WlRLYXBqYzN0SUYyK0ZadGpja1UwZz09

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AW ARD

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. DUN AND BRADSTREET DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER

TRANSITION TO THE 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. AW ARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

APPENDIX: RESOURCES

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Health Resources and Services Administration (HRSA) Rural Residency Planning and Development (RRPD) Program. The purpose of this grant program is to improve health care in rural areas by supporting the development of new, accredited, and sustainable rural residency programs in family medicine, internal medicine, preventive medicine1, psychiatry, general surgery, and obstetrics and gynecology, to address the physician workforce shortages and challenges faced by rural communities. This program provides start-up funding to RRPD award recipients to create new rural residency programs that will ultimately be sustainable long-term through viable and stable funding mechanisms, such as, Medicare, Medicaid, and other public or private funding sources.

For the purposes of this notice of funding opportunity, rural residencies are accredited allopathic and osteopathic physician residency programs that primarily train residents in rural training sites for greater than 50 percent of their total time in residency, and focus on producing physicians who will practice in rural communities. Rural residencies may be entirely rurally located or integrated within a larger, often urban residency program, also known as a rural training track (RTT). One common model is the 1-2 RTT format, where the first year of training occurs in an urban hospital or academic medical center, and the final two years in a rural health facility.

This program aims to expand the number of physician training opportunities in rural settings and subsequently increase the number of physicians choosing to practice in rural areas. As such, RRPD funding will only support the development of new rural residency programs or RTTs and applications from existing programs will not be considered.

Program Goals

The goal for the RRPD program is for each recipient to establish a new rural residency program that is accredited by the Accreditation Council on Graduate Medical Education (ACGME) and has a strong sustainability plan for a stable future financial outlook by the end of the period of performance. All RRPD program recipients must be capable of effectively training physicians to practice in and meet the clinical needs of rural populations. As a result, we expect that the proportion of graduates from these programs entering careers in practices primarily serving rural populations will markedly exceed that seen in other programs across the nation.

In addition, programs should: 1) provide interprofessional training specific to the needs of their rural community which may include training with allied health professionals (e.g., nurses, nutrition specialists, and pharmacists); 2) describe any special populations

1 For the purposes of this NOFO, eligible preventive medicine specialties include Public Health and General Preventive Medicine and Occupational Medicine. Refer to program definitions for more information.

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served by the training program and that trainees are immersed in the care of, such as members of tribal communities, veterans, people living with HIV, under- and uninsured patients, patients with substance use disorder, or other groups served by HRSA programs; and 3) address other known challenges specific to rural residency programs such as having sufficient specialty and subspecialty preceptors and ensuring residents will encounter a high enough volume of patients.

Program Objectives

Objective 1: Residency Program Development

1.1 Appoint a residency program director or identify a residency program director in development by the start of year 2 of the grant (August 1, 2023).

1.2 Submit ACGME application for the new rural residency program by the start of year 3 of the grant (August 1, 2024).

1.3 Establish a new rural residency program in family medicine, internal medicine, preventive medicine, psychiatry, general surgery, or obstetrics and gynecology that is ACGME accredited by the end of the period of performance (July 31, 2025).

1.4 Matriculate first class of residents no later than the academic year (AY) immediately following the end of the RRPD period of performance (AY 2026).

Objective 2: Program Sustainability

2.1 Solidify a clearly defined, factual, and validated sustainability plan that includes ongoing funding stream(s) to sustain long-term resident training once the program is established through the following options:

• Qualifying under current regulatory authority for Medicare graduate medical education (GME) payments in rural hospitals starting a new residency training program.2 Specifically, the applicants:

Either have a viable direct GME Per Resident Amount or are eligible to establish one after training residents for the first time; and Are eligible for a viable indirect GME and direct GME resident cap adjustment.

• Creating a new RTT program in accordance with Medicare regulations;

• Establishing state or other public and/or private support; or

• Combining multiple funding streams (e.g., a hospital may have a mix of

Medicare and other public funding).

2.2 Finalize a detailed pro forma for program sustainability by the start of year 2 of the grant (August 1, 2023).

Note: The Consolidated Appropriations Act of 2021 authorized changes to Medicare GME regulations. As of this funding opportunity, the FY22 Inpatient Prospective Payment System (IPPS) Proposed Rule includes the proposed regulations for the GME provisions.

2CMS’s criteria for determining if a program is new are in the August 27, 2009 Federal Register, page 43908:

http://www.gpo.gov/fdsys/pkg/FR-2009-08-27/html/E9-18663.htm https://www.federalregister.gov/documents/2021/05/10/2021-08888/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the https://www.federalregister.gov/documents/2021/05/10/2021-08888/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

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Objective 3: Graduate Tracking Plan

3.1 Develop a structured plan to track and publicly report on resident career outcomes after graduation for a period of at least 5 years after the first graduating class to determine retention in rural communities.

3.2 Identify and establish data collection elements for the graduate tracking plan.

Examples of information collected may include, but are not limited to, practice specialty/sub-specialty and location, patient population served, service time committed to the care of safety net patients, part/full-time clinical practice status, services offered, proportion of clinical time in inpatient and outpatient settings, and any additional training opportunities pursued after residency completion.

2. Background

RRPD is authorized by 42 U.S.C. § 912(b)(5), and will be administered by the Health Resources and Services Administration’s (HRSA’s) Federal Office for Rural Health Policy (FORHP), in consultation with the Bureau of Health Workforce (BHW).

Approximately 20 percent of the population, roughly 61 million individuals, live in rural communities.3 Residents of rural communities experience higher rates of poverty and chronic disease and generally have poorer health outcomes than their urban counterparts. A recent study found that rural areas considerably lagged behind urban areas in achieving Healthy People 2020 mortality goals and experienced higher mortality rates for the leading causes of death.4 Compounding the rural-urban health disparities is the lack of health care infrastructure and a health workforce ready to adequately address rural communities’ needs.

According to the most current data, nearly 68 percent of areas designated as primary care health professional shortage areas (HPSA) are located in wholly or partially rural areas.5 Studies show that higher primary care physician densities and access to high-quality primary care correlate with better health outcomes, increased life expectancy, and reduced rates of hospitalization.6 However, rural primary care physicians often lack clinical support from specialty care providers to treat patients with more complex conditions, despite having a broader scope of practice than their urban counterparts.

Recent studies clearly demonstrate the scarcity of specialty care providers in rural

3 HRSA Federal Office of Rural Health Policy: https://www.hrsa.gov/rural-health/about-us/definition/index.html 4 Callaghan, T. H., Ferdinand, A. O., Akinlotan, M., Primm, K., Lee, J. S., Macareno, B., Bolin, J. N. (2020).

Healthy People 2020 Progress for Leading Causes of Death in Rural and Urban America: A Chartbook. Policy Brief.

Southwest Rural Health Research Center. Available at: https://srhrc.tamhsc.edu 5 HRSA Designated Health Professional Shortage Areas Statistics, Third Quarter of FY2021 Designated HPSA Quarterly Summary, June 30, 2021. Retrieved from https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport 6 Streeter RA, Snyder JE, Kepley H, Stahl AL, Li T, et al. The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health. PLOS ONE 24 April 2020 15(4):

e0231443. https://doi.org/10.1371/journal.pone.0231443 https://www.hrsa.gov/rural-health/index.html https://www.hrsa.gov/rural-health/index.html https://bhw.hrsa.gov/ https://www.hrsa.gov/rural-health/about-us/definition/index.html https://srhrc.tamhsc.edu/ https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport https://doi.org/10.1371/journal.pone.0231443

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communities: 80 percent of rural counties did not have a psychiatrist7, 77 percent lacked an obstetrician8, and 60 percent had no active general surgeon.9 As a result of these shortages, rural family physicians often have a broader scope of practice, such as obstetrics and prenatal care.10

Studies have shown that both enrolling trainees with rural backgrounds and training residents in rural settings are successful strategies for encouraging graduates to practice in rural settings.11 Nevertheless, the bulk of physician residency training has been academic health center-focused with limited opportunities for physician exposure to residency training in rural areas. According to a 2021 GAO Report, the distribution of physician residency programs is highly concentrated in urban areas, particularly in the southern and northeastern regions, while only two percent of training occur in rural settings.12

Rural programs often face financial, human resource and organizational capacity constraints, such as lack of sustainable financing, faculty support and recruiting residents. In order to secure institutional recognition and support, rural residency programs need both academic partnerships as well as rural community faculty champions. There are also specific accreditation challenges, such as lacking sufficient specialty and subspecialty preceptors willing to sponsor residents for clinical rotations or meeting the appropriate level of scholarly activity required for busy community faculty.

The urgent need to address these challenges in developing new rural training opportunities resulted in the conception of the HRSA RRPD program. In FY18 (HRSA- 18-117) and again in FY21 (HRSA-21-102), HRSA funded the RRPD-Technical Assistance Program, a cooperative agreement to establish the RRPD-TA Center to identify and share resources with RRPD applicants and support RRPD Program award recipients.

7 Larson EH, Patterson DG, Garberson LA, Andrilla CHA. Supply and Distribution of the Behavioral Health Workforce in Rural America. Data Brief #160. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, Sep 2016.

8 Patterson DG, Andrilla CHA, Garberson LA. The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S. Policy Brief #168. WWAMI Rural Health Research Center, University of Washington, June 2020.

9 Larson EH, Andrilla CHA, Kearny J, Garberson LA, Patterson DG. The Distribution of the General Surgery Workforce in Rural and Urban America in 2019. Policy Brief. WWAMI Rural Health Research Center, University of Washington, March 2021.

10 Peterson, Lars E. and Fang, Bo, "Rural Family Physicians Have a Broader Scope of Practice than Urban Family Physicians". Rural & Underserved Health Research Center Publications, February 2018.

11 Davis G. Patterson, C. Holly A. Andrilla, Lisa A. Garberson; Preparing Physicians for Rural Practice: Availability of Rural Training in Rural-Centric Residency Programs. J Grad Med Educ 1 October 2019; 11 (5): 550–557. doi:

https://doi.org/10.4300/JGME-D-18-01079.1 12 United States Government Accountability Office. Graduate Medical Education: Programs and Residents Increased during Transition to Single Accreditor; Distribution Largely Unchanged. GAO-21-329. April 2021. Retrieved from https://www.gao.gov/products/gao-21-329 https://www.hrsa.gov/grants/find-funding/hrsa-18-117 https://www.hrsa.gov/grants/find-funding/hrsa-18-117 https://www.hrsa.gov/grants/find-funding/hrsa-21-102 https://www.hrsa.gov/library/rural-residency-planning-development https://doi.org/10.4300/JGME-D-18-01079.1 https://www.gao.gov/products/gao-21-329

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Thereafter, HRSA funded its inaugural RRPD cohort (HRSA- 19-088) in FY19 and additional cohorts in FY20 and FY21 (HRSA-20-107). Currently, HRSA funds 46 RRPD Program award recipients across 26 states developing rural residencies or RTTs in family medicine (35), internal medicine (4), psychiatry (6), and general surgery (1). They consist of rural hospitals, including critical access hospitals and sole community hospitals, tribal entities, federally qualified health centers, and graduate medical education consortiums.

As of August 1, 2021, 20 RRPD Programs have achieved ACGME accreditation and been approved for 283 residency positions at full complement. To navigate the complex and intensive process of accreditation and developing a new rural residency program, all RRPD Program award recipients are required to collaborate with the RRPD-TA center and attend a 2-day Annual RRPD meeting throughout the duration of their award.

To learn more about the RRPD-TA center, visit www.ruralgme.org.

Program Definitions

The following definitions apply to the RRPD Program for the Fiscal Year 2022.

1. Centers for Medicare & Medicaid (CMS) Rural – CMS defines rural in accordance with Medicare regulations at 42 CFR 412.64(b)(ii)(C); that is, a rural area is an area outside of an urban Metropolitan Statistical Area. This excludes hospitals that are physically located in an urban area, but reclassify to a rural area under 42 CFR 412.103. To determine if a hospital is located in a county that is rural for CMS inpatient prospective payment system (IPPS) wage index purposes, refer to the “FY 2022 County to CBSA Crosswalk File and Urban CBSAs and Constituent Counties for Acute Care Hospitals File” that is available on the FY 2022 IPPS Final Rule Homepage. Counties without a CBSA or CBSA Name listed in Columns D and E are considered rural for CMS purposes.

Applicants must contact their Medicare Administrative Contractor (MAC) to confirm rural status and eligibility for Medicare GME payment.

Note: Applications proposing a sustainability plan that includes Medicare GME funding must meet CMS requirements and FORHP’s definition of rural.

2. HRSA Federal Office of Rural Health Policy (FORHP) Rural – FORHP accepts all non-metropolitan counties as rural and uses an additional method called the Rural-Urban Commuting Area (RUCA) codes to determine rurality.

https://www.hrsa.gov/grants/find-funding/hrsa-19-088 https://www.hrsa.gov/grants/find-funding/hrsa-19-088 https://www.hrsa.gov/grants/find-funding/hrsa-20-107 http://www.ruralgme.org/ https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page

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FORHP considers census tracts inside Metropolitan counties with the RUCA codes 4-10 to be rural and makes additional adjustments for very large tracts with low population density and for counties with no population living in Census-defined Urbanized Areas.13 Please use the Rural Health Grants Eligibility Analyzer to determine whether FORHP considers a geographical area to be rural. HRSA’s definition of rural may differ from CMS, which is an important distinction to understand if developing a financial sustainability plan based on Medicare GME funding.

3. Graduate Medical Education Consortium – An association between two or more organizations (e.g., academic medical centers, rural hospitals, universities and/or medical schools) to form an entity that serves as the institutional sponsor and operator of an accredited residency program. At least one consortium member must be a rural primary clinical training partner. The relationship between the consortium members must be legally binding and the agreement establishing the relationship must describe the roles and responsibilities of each entity.

4. National Provider Identifier (NPI) – The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The NPI is a unique identification number for covered health care providers. You can find additional information about NPIs at the following site: https://nppes.cms.hhs.gov/#/.

5. New Medical Residency Training Program – per 42 CFR 413.79(l), CMS defines a new medical residency program as one that is, “a medical residency that receives initial accreditation by the appropriate accrediting body or begins training residents on or after January 1, 1995”.14

6. Preventive Medicine – ACGME defines Preventive Medicine as the medical specialty in which physicians focus on health promotion and the prevention of disease, disability and premature death of individuals in defined populations.15 Preventive medicine focus areas include aerospace medicine, occupational medicine, and public health and general preventive medicine. For the purpose of this NOFO, only occupational medicine and public health and general preventive medicine are eligible focus areas.

13 HRSA Federal Office of Rural Health Policy: https://www.hrsa.gov/rural-health/about-us/definition/index.html Note that FORHP implemented new modifications to the rural definitions for FY 22. We have incorporated these revisions in the Rural Health Grants Eligibility Analyzer.

14 CMS’s criteria for determining if a program is new are in the August 27, 2009 Federal Register, page 43908:

http://www.gpo.gov/fdsys/pkg/FR-2009-08-27/html/E9-18663.htm. In determining whether a program is new, CMS will consider the accrediting body’s characterization of the program as new and whether the program existed previously at another hospital, as well as factors such as (but not limited to) whether there are new program directors, new teaching staff, and whether there are only new residents training in the program.

15 https://www.acgme.org/Specialties/Overview/pfcatid/20/ https://data.hrsa.gov/tools/rural-health https://data.hrsa.gov/tools/rural-health https://nppes.cms.hhs.gov/#/ https://www.hrsa.gov/rural-health/about-us/definition/index.html https://www.acgme.org/Specialties/Overview/pfcatid/20/

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7. Rural Residency Programs – Rural residency programs are ACGME-accredited physician residency training programs that place residents in rural training sites for greater than 50 percent of their total time in residency training and focus on producing physicians who will practice in rural communities.

8. Rural Training Tracks (RTT) – a rural residency program model that consists of partnerships between urban and rural clinical settings where typically the first year of training occurs within a larger urban program, and the final two years occur in a rural clinical facility.

Note: The Consolidated Appropriations Act of 2021 authorized three major GME provisions to close the health equity gap in rural and/or underserved communities, including promoting rural hospital GME opportunities and revising RTT requirements. As of this funding opportunity, the FY22 Inpatient Prospective Payment System (IPPS) Proposed Rule includes the proposed regulations for the GME provisions.

9. Target Area – A target area is the specific rural geographic location(s) and communities you plan to serve with the proposed rural residency program.

II. Award Information

1. Type of Application and Award

Type of applications sought: New

HRSA will provide funding in the form of a grant.

2. Summary of Funding

HRSA estimates approximately $10,500,000 to be available to fund approximately 14 recipients for the 3-year period of performance. The actual amount available will not be determined until enactment of the final FY 2022 federal appropriation. You may apply for a ceiling amount of up to $750,000 total cost (includes both direct and indirect, facilities and administrative costs) for the entire 3-year period of performance. This program notice is subject to the appropriation of funds, and is a contingency action taken to ensure that, should funds become available for this purpose, HRSA can process applications and award funds appropriately.

The period of performance is August 1, 2022 through July 31, 2025 (3 years).

Award recipients will receive the full award amount in the first year of the three-year period of performance, and must allocate the award funding across each of the three years. Additionally, recipients must submit a budget and budget narrative for each of the three years of the period of performance. While you must distribute the funding across each of the three years, the budget does not need to be evenly split across the three-year period of performance, and can vary based on your community’s needs.

https://www.federalregister.gov/documents/2021/05/10/2021-08888/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the https://www.federalregister.gov/documents/2021/05/10/2021-08888/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

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

Indirect costs under this program have a maximum rate of 10 percent, if you have not established a negotiated cost rate.

III. Eligibility Information

1. Eligible Applicants

Applicants must meet all of the following criteria in order to be considered eligible for RRPD funding. HRSA will not consider applicants that fail to meet any eligibility criteria for funding under this notice.

Eligible Entities Eligible entities are domestic public, nonprofit, or private organizations, including faith-based and community-based organizations, tribes, and tribal organizations. Specifically, these organizations may include, but are not limited to:

1) rural hospitals;

2) rural community-based ambulatory patient care centers, including rural health clinics;

3) health centers operated by a tribe or tribal organization, or an urban Indian organization;

4) graduate medical education consortiums, including schools of allopathic medicine or osteopathic medicine; and

5) faith-based and community-based organizations.

Rural Status The applicant organization or the primary rural training partner(s) where greater than 50 percent of rural training will occur must be located in a rural location as defined by CMS and/or FORHP:

• For applications proposing a sustainability plan that relies on Medicare GME funding, the applicant organization or primary rural training partner(s) must meet both CMS and FORHP definitions of rural.

• For applicants proposing sustainability plans with no Medicare GME funding, the applicant organization or primary rural training partner(s) must meet FORHP's definition of rural.

In the case of a RTT, where the applicant organization is located in an urban area, the GME consortium must include at least one rural primary clinical training partner. The relationship between the consortium members must be legally binding and the agreement establishing the relationship must describe the roles and responsibilities of each entity. Applicants must submit Letters of Agreement in Attachment 4.

Refer to Section I.2. Program Definitions for more information on rural eligibility. You must attach proof of rural designation in Attachment 6.

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

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New Rural Program & Eligible Specialties Applications must propose to develop a new, accredited rural residency program in family medicine, internal medicine, preventive medicine, psychiatry, general surgery, or obstetrics and gynecology. Applications requesting funding to expand an existing rural residency program or RTT (e.g., that is already training residents) are not eligible.

Entities who have already achieved ACGME accreditation for the proposed rural residency program in the above specialties by the application closing date are not eligible.

Recipients of awards under the RRPD-TA Program (HRSA-18-117 and HRSA-21-102) or the previous RRPD Program opportunities (HRSA-19-088 and HRSA-20-107) are not eligible to receive funding under this notice. Eligible applicants may apply to both the FY22 RRPD Program (HRSA-22-094) and FY22 Teaching Health Center Planning and Development Program (HRSA-22-107), however HRSA will only fund one award.

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 ceiling amount of $750,000 total costs (includes direct, indirect, facilities and administrative costs)

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

Multiple Applications Multiple applications from an organization are not allowable. You may apply for funding to support developing multiple rural residency programs under one award, but you must clearly demonstrate in the application your ability to establish more than one. We anticipate that most awards will be for one rural residency program.

HRSA will only accept your last validated electronic submission, under the correct funding opportunity number, before the Grants.gov application due date as the final and only acceptable application.

Incomplete Application Failure to include all required documents as part of the application may result in HRSA considering an application incomplete or non-responsive.

Program Sustainability Applications must have a clearly defined, factual, and validated sustainability plan that includes ongoing funding stream(s) to sustain resident training once the program is established. Eligible applicants with a sustainability plan that includes Medicare GME

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payments must meet both CMS requirements (e.g., rural status and Medicare GME eligibility payment rules) and FORHP’s definition of rural. Failure to include a clearly defined, factual, and validated sustainability plan will result in HRSA considering an application incomplete or non-responsive. Refer to Section IV.2.ii. Program Sustainability for more information.

Notifying your State Office of Rural Health You are required to notify the State Office of Rural Health (SORH) of your intent to apply to this program. A list of the SORHs can be accessed at https://nosorh.org/ nosorhmembers/nosorh-members-browse-by-state/. You must include in Attachment 8 a copy of the letter or email sent to the SORH and any response received to the letter you sent to the SORH describing your project.

Each state has a SORH, and HRSA recommends making every effort to contact the SORH entity early in the application process to advise them of your intent to apply. The SORH may be able to provide some consultation to you regarding model programs, data resources, and technical assistance for consortiums, evaluation, partner organizations, or support of information dissemination activities. If you do not receive a response, please include the original letter of intent requesting the support.

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 http://www.grants.gov/applicants/apply-for-grants.html.

The NOFO is also known as “Instructions” on Grants.gov. You must select “Subscribe” and provide your email address for HRSA-22-094 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, certifications, etc. You must submit the information outlined in the 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 HRSA’s SF-424 Application Guide except where instructed in the NOFO to do otherwise. You must https://nosorh.org/%20nosorhmembers/nosorh-members-browse-by-state https://nosorh.org/%20nosorhmembers/nosorh-members-browse-by-state https://www.grants.gov/ http://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/web/grants/applicants.html http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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submit the application in the English language and in the terms of U.S. dollars (45 CFR § 75.111(a)).

See Section 8.5 of the HRSA SF-424 Application Guide for the Application Completeness Checklist.

Application Page Limitation The total size of all uploaded files included in the page limit shall be no more than the equivalent of 80 pages when printed by HRSA. The page limit includes the project and budget narratives, and attachments required in the Application Guide and this NOFO.

Please note: Effective April 22, 2021, the abstract is no longer an attachment that counts in the page limit. The abstract is the standard form (SF) "Project Abstract Summary.” Standard OMB-approved forms included in the workspace application package do not count in the page limit. If you use an OMB-approved form that is not included in the workspace application package for HRSA-22-094, it may count against the page limit. Therefore, we strongly recommend you only use Grants.gov workspace forms associated with this NOFO to avoid exceeding the page limit. Indirect Cost Rate Agreement and proof of non-profit status (if applicable) do not count in the page limit. It is therefore important to take appropriate measures to ensure your application does not exceed the specified page limit. Any application exceeding the page limit of 80 will not be read, evaluated, or considered for funding.

Applications must be complete, within the maximum specified page limit, and validated by Grants.gov under HRSA-22-094 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. § 3321).

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

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

Program-Specific Instructions In addition to application requirements and instructions in Section 4 of HRSA’s SF-424 Application Guide (including the budget, budget narrative, staffing plan and personnel requirements, assurances, certifications, and abstract), include the following:

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 http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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i. Project Abstract Use the Standard OMB-approved Project Abstract Summary Form 2.0 that is included in the workspace application package. Do not upload the abstract as an attachment or it will count toward the page limitation. In addition to the SF-424 Application Guide requirements, the project abstract must include the following information below. The project abstract must be single-spaced and 4000 characters or less. For information required in the Project Abstract Summary Form, see Section 4.1.ix of HRSA’s SF-424 Application Guide.

Abstract Heading Content:

Eligible Entity Type (refer to Section III.1 Eligible Entities) Project Director Contact Information Residency Program Director Contact Information Residency Specialty & Type (e.g., family medicine 1-2 RTT) Sponsoring Institution Rural Target Area(s) Funding Amount Requested Program Sustainability Option (refer to Section IV.2.ii. Program Sustainability for further details) Projected Number of Residents; and Expected ACGME Accreditation and Residency Matriculation Dates

Abstract Body Content:

Brief overview of the project including description of geographic area (e.g., rural counties served), target patient population and needs, consortium partners (if applicable) and clinical partnerships (e.g., training partners and types of clinical facilities); and

Specific measurable objectives and expected outcomes of the project, how the proposed project for which funding is requested will be accomplished (i.e., the "who, what, when, where, why and how" of a project). Please also include a listing of recent HRSA awards received relevant to the project (e.g., health workforce, rural, or training awards).

NARRATIVE GUIDANCE

To ensure that you fully address the review criteria, this table provides a crosswalk between the narrative language and where each section falls within the review criteria. Any attachments referenced in a narrative section may be considered during the objective review.

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Narrative Section Review Criteria

Introduction (1) Purpose and Need

Needs Assessment (1) Purpose and Need

Methodology (2a) Response

Work Plan (2b) Response

Resolution of Challenges (2c) Response

Evaluation and Technical Support Capacity (3a) Impact

Program Sustainability (3b) Impact Organizational Information (4) Organization Resources/Capabilities

Budget and Budget Narrative (5) Support Requested

ii. Project Narrative This section provides a comprehensive description of all aspects of the proposed project. It should be succinct, self-explanatory, consistent with forms and attachments, and organized in alignment with the sections and format below so that reviewers can understand the proposed project.

Use the following section headers for the narrative:

INTRODUCTION -- Corresponds to Section V’s Review Criterion #1 “Purpose and

Need”

Briefly describe the purpose of the proposed project and clearly identify specific project goals, objectives, and expected outcomes. Summarize how the proposed project will address the population health needs and expansion of family medicine, internal medicine, preventive medicine, psychiatry, general surgery, or obstetrics and gynecology care and access for the proposed target area(s).

NEEDS ASSESSMENT -- Corresponds to Section V’s Review Criterion 1

“Purpose and Need”

Provide an overview of the health workforce and health care needs of the target area(s) served by the proposed project. This section should primarily focus on describing the needs of the community, the organization and facility(s) needs to develop a new rural residency program, and an assessment of the current health care infrastructure, including the graduate medical education landscape and other residency programs serving the community. You must use and cite demographic data (e.g., local, state, federal) whenever possible to support the information provided.

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Specifically, this section must include the following information:

1. Description of the geographic area where the residency program will be located, the justification for selecting this area, and the problem that your residency program is working to solve. To the extent possible, include data and describe the population demographics, social determinants of health, health disparities faced by, and health care needs of the population served, barriers to access and care, and any other unmet needs. Indicate the presence of Medically Underserved Communities (MUC) and/or Health Professional Shortage Areas (HPSA).

2. Description of health workforce shortages and need for additional physicians in the specialty for which you are applying for funding, including current (within 3 years) information and data demonstrating needs for the proposed specialty in the target area(s) and identify specific reasons for this shortage.

3. Description of the rural health care delivery system and the specific needs of the facility(s) hosting the rural residency program. Include information on the organization’s structure and the clinical and faculty capacity needed to support a new rural residency program.

4. Description of any residency programs (existing or in development) in the specialty area for which you are applying for funding, that serve the target area(s) where the proposed new rural residency program will be located.

5. Description of any progress that has already been made towards developing a rural residency program.

6. Characteristics of existing residency program partners that align with the purposes of this project and assessment of the need for strengthening of academic and community linkages/partnerships with private sector or safety net providers for development of clinical training sites for residents, preceptor development and retention, and well-trained, culturally competent health care providers.

7. Description of any consultations with the State Office of Rural Health related to the planning and development of the new rural residency program.

The following section below corresponds to Section V’s Review Criterion #2 “Response” which includes three sub-sections – (a) Methodology, (b) Work Plan, and (c) Resolution of Challenges.

METHODOLOGY -- Corresponds to Section V’s Review Criterion #2(a)

“Response”

Propose methods that you will use to address the stated needs and meet each of the previously described program goals and objectives in Section I.1 Purpose of this NOFO. Clearly specify how the proposed methods will overcome challenges and barriers in developing the new rural residency program and bridge any gaps identified in the “Needs Assessment” section above. Specifically, this section must include how you plan to achieve:

1. ACGME accreditation for the new rural residency program no later than the end of the program performance period (i.e., July 31, 2025). Applicants must describe:

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a. Clinical capacity to meet ACGME accreditation requirements including sufficient numbers of dedicated, supervisory faculty, adequate patient care volume, and appropriate resident training time in relevant medical specialties and subspecialties (e.g., adequate obstetrics training). You may achieve this through clinical training partnerships. In this case, you must submit Letters of Agreement in Attachment 4.

b. Current organizational structure and plan to meet ACGME requirements, including governance structure and the capacity of the organization to meet ACGME sponsoring institution requirements. This may also include acquiring access to electronic health records, library services, learning management systems, etc.

c. Plan to appoint a residency program director by the start of year 2 of the grant (if not already hired) and a faculty recruitment and development plan to support the new rural residency program, including recruiting specialty faculty to meet ACGME requirements for the proposed specialty.

d. Curriculum and training plan, including incorporation of interprofessional training and development, culturally and linguistically appropriate care and training to address the health needs and disparities of patients from the proposed target areas(s). The curriculum plan should be high quality, leading to successful board certification of graduates and readiness for clinical practice following completion of training.

2. Resident matriculation no later than the AY immediately following the end of the program period of performance (i.e., AY 2026). Applicants must describe a plan to:

a. Recruit and support a diverse cohort of high quality residents, including outreach to medical students with a rural background.

b. Recruit and train at least the minimum number of residents required to achieve and maintain accreditation for the proposed specialty.

c. Promote retention of resident graduates to practice in rural communities.

3. Tracking residents’ career outcomes for a period of at least 5 years post-graduation from the rural residency program. Applicants must describe a plan to:

a. Develop a tracking tool/mechanism or leverage an existing graduate tracking system to track and publicly report on graduates career outcomes and retention in rural and underserved areas. At a minimum, the graduate tracking plan should be equipped with the ability to accurately collect the following graduate outcomes:

i. National Provider Identifier (NPI)

ii. Practice location(s)

iii. Medical Specialty/Sub-specialty

iv. Employment Status (i.e., Part-time or full-time)

b. Track other practice characteristics and graduate demographics.

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Note: Award recipients should consider adding the performance measures related to accredited positions, admissions, and residents by year of training, by age, gender, race, ethnicity, location of training, new curriculum development, and faculty development, to the plan for tracking characteristics of graduates, practice locations, and intent to be employed in rural areas. HRSA may request award recipients to report on selected characteristics of residents and graduates during the period of performance. Refer to https://bhw.hrsa.gov/grants/reportonyourgrant for examples of performance data.

Additionally, applicants should include any innovative approaches or unique program characteristics that would enhance the quality of rural residency training and address the stated needs of the targeted rural area(s), such as:

Emerging patient care or health care delivery strategies (e.g., patient centered medical homes, telehealth, etc.)

Integration of interprofessional education and practice Integration of oral health and/or mental health and substance use disorder treatment Enhancing obstetrics and gynecology training in family medicine, internal medicine, preventive medicine, psychiatry, and general surgery residencies Incorporation of public health emergency preparedness and response training

WORK PLAN -- Corresponds to Section V’s Review Criterion #2(b) “Response”

Provide a clear and detailed work plan in Attachment 1 that describes activities or steps you will use to achieve each of the program goals and objectives listed under Section I.1 Purpose.