PKG00246563-instructions.pdf

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Administered by the Federal Office of Rural Health Policy and Bureau of Health Workforce

Rural Residency Planning and Development Program

Funding Opportunity Number: HRSA-19-088 Funding Opportunity Type: Initial: New

Catalog of Federal Domestic Assistance (CFDA) Number 93.155

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2019

Letter of Intent Requested by: January 17, 2019

Application Due Date: March 4, 2019

Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

Deadline extensions are not granted for lack of registration.

Registration in all systems, including SAM.gov and Grants.gov, may take up to 1 month to complete.

Issuance Date: November 29, 2018

Points of Contact:

Tracey Smith, MSc, MPH Jemima Drake, MPH, RN Public Health Analyst Health Insurance Specialist Division of Medicine & Dentistry Federal Office of Rural Health Policy Email: TSmith@hrsa.gov Email: jdrake@hrsa.gov Telephone: (301) 443-3612 Telephone: (301) 443-4499

Authority: Section 711(b)(5) of the Social Security Act (42 U.S.C. 912(b)(5)), as amended, and the Economy Act, 31 U.S.C. § 1535.

mailto:TSmith@hrsa.gov mailto:jdrake@hrsa.gov

HRSA-19-088 i

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for fiscal year (FY) 2019 Rural Residency Planning and Development (RRPD) Program.

The purpose of this grant program is to develop new rural residency programs or Rural Training Tracks (RTT) in family medicine, internal medicine, and psychiatry, to support expansion of the physician workforce in rural areas. The new rural residency programs or RTTs are intended to be sustainable through separate public or private funding beyond the RRPD grant period of performance. The funds will support planning and development costs accrued while achieving program accreditation through the Accreditation Council for Graduate Medical Education (ACGME). Hospitals, medical schools and community-based ambulatory settings that have a rural designation along with consortia of urban and rural partnerships are eligible to apply for a grant award.

The applicant organization must demonstrate it has the capacity to acquire accreditation and provide ongoing support for resident training, including financially, by the end of the period of performance.

Funding Opportunity Title: Rural Residency Planning and Development Program

Funding Opportunity Number: HRSA-19-088

Due Date for Applications: March 4, 2019

Anticipated Total Available FY19 Funding:

$21,000,000

Estimated Number and Type of Award(s):

Approximately 28 grants

Estimated Award Amount: Up to $750,000 (fully funded at the outset for use over the period of performance)

Cost Sharing/Match Required: No

Period of Performance: August 1, 2019 through July 31, 2022 (3 years) ii

Eligible Applicants: Eligible applicants are: 1) rural hospitals, 2) rural community-based ambulatory patient care centers including federally qualified health centers, community mental health centers or rural health clinics, 3) health centers operated by the Indian Health service, an Indian tribe or tribal organization, or an urban Indian organization, 4) schools of allopathic medicine or osteopathic medicine, 5) public or private non-profit graduate medical education consortiums, 6) entities such as faith-based and community-based organizations, capable of carrying out the grant activities.

Either the applicant 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.

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 https://www.hrsa.gov/sites/default/files/hrsa/grants/apply/applicationguide/sf-424-guide.pdf, except where instructed in this NOFO to do otherwise.

Technical Assistance

HRSA has scheduled the following technical assistance webinar to help you understand, prepare, and submit an application for this NOFO. The webinar will provide an overview of pertinent information in the NOFO and an opportunity for applicants to ask questions.

WebinarDay and Date: Monday, December 17, 2018 Time: 2 – 3.30 p.m. ET Call-In Number: 1-888-603-7090 Participant Code: 4023556 Web link: https://hrsa.connectsolutions.com/ruralplanning_development_ta/

Playback Number: 1-800-839-2204 Passcode: 5678 http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://www.hrsa.gov/sites/default/files/hrsa/grants/apply/applicationguide/sf-424-guide.pdf https://www.hrsa.gov/sites/default/files/hrsa/grants/apply/applicationguide/sf-424-guide.pdf https://hrsa.connectsolutions.com/ruralplanning_development_ta/

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING/MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Justification Narrative

vi. Attachments

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

SYSTEM FOR AWARD MANAGEMENT

4. SUBMISSION DATES AND TIMES

5. INTERGOVERNMENTAL REVIEW

6. FUNDING RESTRICTIONS

7. OTHER SUBMISSION REQUIREMENTS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. REVIEW AND SELECTION PROCESS

3. ASSESSMENT OF RISK AND OTHER PRE-AWARD ACTIVITIES

4. ANTICIPATED ANNOUNCEMENT AND AWARD DATES

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

IX. TIPS FOR WRITING A STRONG APPLICATION

HRSA-19-088 1

I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Rural Residency Planning and Development (RRPD) Program. This program is authorized by Section 711(b)(5) of the Social Security Act (42 U.S.C. 912(b)(5), as amended, and will be administered by the Health Resources and Services Administration’s (HRSA’s) Federal Office for Rural Health Policy and Bureau of Health Workforce.

Program Purpose The purpose of this grant program is to develop new rural residency programs or Rural Training Tracks (RTT) in family medicine, internal medicine, and psychiatry, to support expansion of the physician workforce in rural areas. The new rural residency programs or RTTs are intended to be sustainable through separate public or private funding beyond the RRPD grant period of performance.

Rural residency programs are allopathic and osteopathic physician residency training programs that primarily train in rural communities, place residents in rural locations for greater than 50 percent of their training, and focus on producing physicians who will practice in rural communities. A common model is the RTT, where the first year of training occurs within a larger program in an urban academic medical center and the final two years occur in a rural facility.

Program Goal By the end of the period of performance, each awardee is required to have established a rural residency program(s) or RTT(s) that is ACGME- accredited and has a stable future financial outlook. The rural residency program or RTT should be capable of effectively training physicians to practice in and meet the clinical needs of rural populations. As such, the number of graduates entering careers in outpatient practices serving rural populations from these programs is expected to be higher than the primary care residency national average.

Program Objectives

1. Develop a newly accredited, rural family medicine, internal medicine, or psychiatry residency program or RTT based in a rural area that is sustainable after the period of performance ends. The rural residency program or RTT should be ready to begin training its first class of residents no later than the academic year immediately following the end of the RRPD period of performance.

2. Have a sustainability plan that includes ongoing funding to sustain resident training once the program has been established. For example, through:

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A. Qualifying under current regulatory authority for Medicare graduate medical education (GME) payments in rural hospitals starting a new residency training program.1 Specifically, the applicants:

i. Either have a viable direct GME Per Resident Amount or are eligible to establish one after training residents for the first time, and

ii. Are eligible for a viable indirect GME and direct GME resident cap adjustment;

B. Creating an RTT program in accordance with Medicare law and regulations2; and/or

C. State or other public and/or private support.

Please see Section IV.2 (ii) Project Sustainability for further details.

3. Have the ability and a structured plan to track residents’ career outcomes after graduation to determine retention in rural communities. Examples of information collected may include practice location, patient population served, service time committed to the care of safety net patients, part/full-time practice status and services offered. Tracking should continue for a period of at least 5 years after the first graduating class.

In addition, programs should: 1) provide interprofessional training specific to the needs of their rural health community which may include training with behavioral health professionals, nutrition specialists and pharmacists; and 2) address other known challenges specific to rural residency programs or RTTs such as having sufficient specialty and subspecialty preceptors and ensuring residents will encounter a high enough volume of patients.

2. Background

This program is authorized by Section 711(b)(5) of the Social Security Act (42 U.S.C.

912(b)(5), as amended.

Approximately 14 percent of the population - around 46.1 million individuals - live in rural communities.3 Residents of rural communities typically are older than their urban counterparts and generally experience higher frequency of chronic disease. Coupled with these demographic characteristics, rural Americans often have poorer health status than urban counterparts4, likely due in part to challenges in accessing health care such as limited transportation options, geographic isolation, and lack of infrastructure. In particular, rural communities are much less likely to have the health professionals necessary to adequately care for their communities’ needs. Of the nearly 2,000 rural

1 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 2 CMS’s rules and regulations for RTT programs are available at 42 CFR 413.79(k)

(https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/xml/CFR-2011-title42-vol2-sec413-79.xml) 3 USDA Economic Research Service Population & Migration Overview: https://www.ers.usda.gov/topics/rural-economy-population/population-migration/.

4 ASPE Issue Brief, https://aspe.hhs.gov/system/files/pdf/211061/RuralHospitalsDSR.pdf http://www.gpo.gov/fdsys/pkg/FR-2009-08-27/html/E9-18663.htm https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/xml/CFR-2011-title42-vol2-sec413-79.xml https://www.ers.usda.gov/topics/rural-economy-population/population-migration/ https://www.ers.usda.gov/topics/rural-economy-population/population-migration/

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counties in the United States (U.S.), 1,550 (78 percent) are primary care health professional shortage areas (HPSAs).5

However, higher primary care physician densities in rural areas correlate with increased quality of care and reduced rates of hospitalization for certain conditions.6 Enrolling trainees with rural backgrounds, and training residents in rural settings, are strategies shown to successfully encourage graduates to practice in rural settings.7 As such, increasing the opportunities for residents to train in rural communities is one approach to addressing physician shortages in rural communities.

To support potential RRPD program applicants, HRSA has funded a RRPD Technical Assistance (TA) cooperative agreement (HRSA-18-117). The primary purpose of this competitive announcement is the establishment of a rural residency planning and development TA center. The RRPD-TA awardee will identify and work with potential RRPD program applicants to share resources as well as conduct preparatory work in anticipation of supporting the RRPD awardees (see section VIII). All RRPD awardees are required to collaborate with the TA center during this period of performance and attend virtual and in-person annual meetings.

Contingent on the availability of resources, the secondary purpose of the RRPD-TA is to provide TA to other entities that a) would have been eligible for the RRPD program but did not apply, and b) were not selected for a RRPD program award.

Program Definitions The following definitions apply to the RRPD Program for Fiscal Year 2019:

Rural – a geographical area located in a non-metropolitan county.

Note: To determine whether a geographical area is considered rural as determined by the Federal Office of Rural Health Policy (FORHP), please use the Rural Health Grants Eligibility Analyzer. It is important to note that the FORHP’s definition of rural may differ from that of the Centers for Medicare & Medicaid Services (CMS). This is a particularly important distinction to understand if developing a financial sustainability plan for a rural residency program or RTT based on Medicare GME support.

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. Note that 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

5 Department of Health and Human Services, Health Resources and Services Administration Data Warehouse, February 2015.

6 Alex McEllistrem-Evenson. Informing Rural Primary Care Workforce Policy: What Does the Evidence Tell Us?:

A Review of Rural Health Research Center Literature, 2000-2010. April 2011. Available at:

https://www.ruralcenter.org/resource-library/informing-rural-primary-care-workforce-policy-what-does-the-evidence-tell-us-a 7 Rosenthal TC, McGuigan MH, Anderson G. Rural residency tracks in family practice: graduate outcomes. Fam

Med. 2000;32:174 –7.

https://www.hrsa.gov/grants/fundingopportunities/default.aspx?id=b5e66db2-acca-4871-aa2b-e48fa24380b7 https://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx https://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx

HRSA-19-088 4

hospital is located in a county that is rural for CMS inpatient prospective payment system (IPPS) wage index purposes, refer to the FY 2019 “County to CBSA Crosswalk File and Urban CBSAs and Constituent Counties for Acute Care Hospitals File” that is available on the FY 2019 IPPS Final Rule Homepage.

Rural Residency Programs - Rural residency programs are allopathic and osteopathic physician residency training programs that primarily train in rural communities, place residents in rural locations for greater than 50 percent of their training, and focus on producing physicians who will practice in rural communities. A common model is the RTT.

CMS New Medical Residency Training Program - 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.

Rural Training Tracks (RTT) - RTT programs are partnerships between urban and rural clinical settings where the first year of resident training occurs within a larger program in an urban academic medical center and the final two years occur in a rural facility. For Medicare purposes, RTT programs, are separately accredited rural track programs where residents rotate at a rural hospital for more than one-half of the duration of the program. CMS’s rules and regulations for RTT programs are available at 42 CFR 413.79(k) (https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/xml/CFR-2011-title42-vol2-sec413-79.xml).

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.

Additional information about NPIs can be found at the following site:

https://nppes.cms.hhs.gov/#/.

II. Award Information

1. Type of Application and Award

Type of applications sought: New

HRSA will provide funding in the form of a grant.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html http://www.gpo.gov/fdsys/pkg/FR-2009-08-27/html/E9-18663.htm https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/xml/CFR-2011-title42-vol2-sec413-79.xml https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/xml/CFR-2011-title42-vol2-sec413-79.xml https://nppes.cms.hhs.gov/#/

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2. Summary of Funding

HRSA expects approximately $21,000,000 to be available to fund approximately 28 recipients. 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 full period of performance. The budget period and the period of performance are a three-year co-extensive duration, from August 1, 2019 through July 31, 2022. Awards are fully funded at the outset for use over the period of performance.

Only one application will be accepted per organization. You may apply for funding to support developing multiple rural residency programs or RTTs under one award but must demonstrate in the application your ability to do so. It is anticipated that most awards will be for one rural residency program or RTT.

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

III. Eligibility Information

1. Eligible Applicants

Eligible applicants are: 1) rural hospitals, 2) rural community-based ambulatory patient care centers, including federally qualified health centers, community mental health centers or rural health clinics, 3) health centers operated by the Indian Health service, an Indian tribe or tribal organization, or an urban Indian organization; 4) schools of allopathic medicine or osteopathic medicine, 5) public or private non-profit graduate medical education consortiums 6) entities such as faith-based and community-based organizations, capable of carrying out the grant activities.

If the applicant’s sustainability plan is to obtain Medicare graduate medical education payments, the applicant organization must be a rural hospital in accordance with Medicare regulations 42 CFR 412.64(b)(ii)(C). See Section IV(ii) Project Sustainability for more information on sustainability options. For more information about rural eligibility, please see Section I (2) Program Definitions.

Eligible applicants must be located in a rural location. In the case of a consortium, a school of allopathic medicine or osteopathic medicine, or other public or non-profit entity, eligible applicants must have a primary training partner (where resident training will occur primarily or exclusively) located in a rural area. For more information about rural eligibility, please see Section I (2) Program Definitions. Proof of rural designation of facilities and training sites must be submitted in Attachment 5. Letters of agreement for residency partnerships and consortiums must be submitted in Attachment 3.

The RRPD-TA awardee (HRSA-18-117) is not eligible to receive funding under this notice.

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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2. Cost Sharing/Matching

Cost sharing/matching is not required for this program.

3. Other

Ceiling Amount HRSA will consider any application that exceeds the ceiling amount non-responsive and will not consider it for funding under this notice.

Deadline HRSA will consider any application that fails to satisfy the deadline requirements referenced in Section IV.4 non-responsive and will not consider it for funding under this notice.

Multiple Applications NOTE: Multiple applications from an organization are not allowable.

If for any reason (including submitting to the wrong funding opportunity number or making corrections/updates), an application is submitted more than once prior to the application due date, HRSA will only accept your last validated electronic submission, under the correct funding opportunity number, prior to the Grants.gov application due date as the final and only acceptable application.

Failure to include all required documents as part of the application may result in an application being considered incomplete or non-responsive.

IV. Application and Submission Information

1. Address to Request Application Package

HRSA requires you to apply electronically through Grants.gov. HRSA encourages you to apply through Grants.gov using the SF-424 workspace application package associated with this NOFO following the directions provided at https://www.grants.gov/applicants/apply-for-grants.html.

If you’re reading this notice of funding opportunity (NOFO) (also known as “Instructions” on Grants.gov) and reviewing or preparing the workspace application package, you will automatically be notified in the event HRSA changes and/or republishes the NOFO on Grants.gov before its closing date. Responding to an earlier version of a modified notice may result in a less competitive or ineligible application. Please note you are ultimately responsible for reviewing the For Applicants page for all information relevant to desired opportunities.

https://www.grants.gov/ https://www.grants.gov/applicants/apply-for-grants.html https://www.grants.gov/web/grants/applicants.html

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2. Content and Form of Application Submission

Section 4 of HRSA’s SF-424 Application Guide provides instructions for the budget, budget justification, staffing plan and personnel requirements, assurances, certifications, and abstract. You must submit the information outlined in the 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 submit the applications in the English language and in terms of U.S. dollars (45 CFR § 75.111(a)).

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

Application Page Limit The total size of all uploaded files may not exceed the equivalent of 60 pages when printed by HRSA. The page limit includes the abstract, project and budget narratives, attachments including biographical sketches (biosketches), and letters of commitment and support required in HRSA’s SF-424 Application Guide and this NOFO. Standard OMB-approved forms that are included in the workspace application package do NOT count in the page limitation. Biographical Sketches do count in the page limitation.

Indirect Cost Rate Agreement and proof of non-profit status (if applicable) do not count in the page limit. We strongly urge you to take appropriate measures to ensure your application does not exceed the specified page limit.

Applications must be complete, within the specified page limit, and validated by Grants.gov under the correct funding opportunity number prior to the deadline to be considered under this notice.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification

1) The prospective recipient certifies, by submission of this proposal, that neither it nor its principals is 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) Where the prospective recipient is unable to attest to any of the statements in this certification, an explanation shall be included in Attachment 8: 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 justification, staffing plan and personnel requirements, assurances, certifications, and abstract), include the following:

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

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i. Project Abstract See Section 4.1.ix of HRSA’s SF-424 Application Guide.

The Abstract must include:

1. A brief overview of the project as a whole;

2. Specific, measurable objectives that the project will accomplish; and

3. 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.

ii. Project Narrative

This section provides a comprehensive framework and description of all aspects of the proposed project. It should be succinct, self-explanatory, consistent with forms and attachments, and well organized so that reviewers can understand the proposed project.

Successful applications will contain the information below. Please use the following section headers for the narrative:

PURPOSE AND NEED -- Corresponds to Section V’s Review Criterion #1

You must include a brief statement of the purpose of the proposed project and clearly identify specific goals and objectives.

This section should provide an overview of the health care and health workforce needs of the geographical area/community to be served, but should primarily focus on the needs of the facility(s) in order to develop a successful, new rural residency program or RTT.

This section must include:

A description of the geographic area and demographics of the population(s) who will benefit from the proposed rural residency program or RTT. Include information on social determinants of health, health disparities, barriers to access and care, and any other unmet needs. Indicate the presence of Medically Underserved Communities (MUC) and/or HPSAs;

A description of the rural health care delivery system and a detailed description of what the specific needs of facility(s) are to host the rural residency program or RTT.

Current (within 3 years) information and data demonstrating primary care or mental health physician shortages in your service area and identify specific reasons for this shortage; and

A description of how the rural residency program or RTT will help address the needs of the community.

A description of any progress that has already been made towards developing a rural residency program or RTT.

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RESPONSE TO PROGRAM PURPOSE -- This section includes three sub-sections

— (a) Work Plan; (b) Methodology/Approach; and (c) Resolution of Challenges—all of which correspond to Section V’s Review Criteria #2 (a), (b), and (c).

(a) WORK PLAN -- Corresponds to Section V’s Review Criterion #2 (a).

You must provide a detailed work plan that demonstrates your experience implementing a project of the proposed scope (a sample work plan can be found here:

http://bhw.hrsa.gov/grants/technicalassistance/workplantemplate.docx). You must:

Describe the activities or steps you will use to achieve each of the objectives proposed during the entire period of performance identified in the Methodology section;

Describe the timeframes, deliverables, and key partners required during the grant period of performance to address each of the needs described in the Purpose and Need section;

Explain how the work plan is appropriate for the program design and how the targets fit into the overall timeline of grant implementation;

Identify meaningful support and collaboration with key stakeholders in planning, designing and implementing all activities, including development of the application and, further, the extent to which these contributors reflect the cultural, racial, linguistic and/or geographic diversity of the populations and communities served; and

If funds will be sub-awarded or expended on contracts, describe how your organization will ensure these fund distributions are properly documented.

(b) METHODOLOGY/APPROACH -- Corresponds to Section V’s Review Criterion #2 (b).

Propose methods that will be used to address the stated needs and how these will achieve identified goals and objectives. Clearly specify how the proposed methods will overcome each of the needs and any challenges and barriers identified in the ‘Purpose and Need’ section.

This section must include how you will achieve:

1) Program accreditation as per ACGME requirements. Applicants must describe:

Clinical capacity to meet ACGME requirements – including sufficient numbers of dedicated, supervisory faculty, adequate patient care volume, and appropriate resident training time in relevant medical specialties and subspecialties. This capacity may be achieved through work with partner organizations. In this case, letters of agreement should be provided in Attachment 3;

The capacity of the organization to meet the sponsoring institution requirements;

A plan to recruit and develop faculty, including required specialty faculty for the residency specialty, to meet ACGME requirements;

http://bhw.hrsa.gov/grants/technicalassistance/workplantemplate.docx

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Current organizational structures and a plan to meet ACGME requirements. This can include acquiring access to electronic health records, library services, learning management systems, etc.; and

The planned training curriculum, including any plans to:

o incorporate inter-professional training and development;

o ensure a high quality educational program, leading to successful board certification of graduates and readiness for clinical practice following completion of training; and o address topics such as provision of culturally and linguistically-appropriate care, and addressing the health care needs (and health disparities) of the safety net and patients from rural and remote areas.

2) Recruitment of a cohort of residents by the end of the period of performance and in line with the academic year. The new rural residency program or RTT developed through the support of this grant must begin training its first class of residents no later than the academic year immediately following the end of the RRPD period of performance. Applicants must describe:

A plan to recruit and support a diverse cohort of high quality residents;

A plan to recruit and train at least the minimum number of residents required to achieve and maintain accreditation.

A plan to promote retention of rural residency program or RTT graduates in practice within rural communities.

3) A plan to track residents’ career outcomes after graduation from the rural residency program or RTT for a period of at least 5 years. Applicants must describe a plan for tracking the career outcomes of their rural residency program or RTT graduates, including retention in primary care and practice in rural and other underserved areas and other key career outcomes (e.g., practice location, patient population served, service time committed to the care of safety net patients, part-/full-time practice status, services offered).

This graduate tracking plan should be equipped with the ability to accurately collect NPI and report data relative to the practice location, specialty area, and other descriptive information about the practice characteristics of residency graduates. While developing or leveraging a previously existing graduate tracking system may be required, the actual tracking of graduate practice characteristics is not funded under this funding opportunity, as the period of performance ends prior to the expected graduation of any residents.

In addition, applicants must:

Describe innovative approaches and include any emerging patient care or health care delivery strategies such as implementation of patient centered medical homes that would improve the quality of residency training; and

Include any unique characteristics of the program being proposed and experiences these will provide to residents, particularly ways the proposed program would integrate interprofessional education and practice, oral health, and/or mental health and substance use disorders training and care delivery.

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(c) RESOLUTION OF CHALLENGES -- Corresponds to Section V’s Review Criterion #2 (c)

Describe barriers and challenges to developing a rural residency program or RTT in the area of service and how your proposal will address these. Rural residency programs and RTTs face unique challenges and barriers not experienced by urban programs. Common challenges often include having sufficient community-based specialty and subspecialty preceptors willing to sponsor residents for educational/clinical rotations, or ensuring residents will encounter a high enough volume of patients as is required for accreditation.

Discuss any additional challenges both internal and external to your organization that may directly or indirectly affect development of the program. Provide details of how these will be resolved. Also, discuss challenges and resolutions to incorporating inter-professional health care approaches and developing a diverse cohort of high quality residents.

Applicants are encouraged to utilize the resources and support of the RRPD-TA center to address barriers and challenges during the application phase. Awardees are required to work with the RRPD-TA center to achieve the goals of the RRPD award.

IMPACT -- This section includes two sub-sections— (a) Evaluation and Technical Support Capacity; and (b) Project Sustainability—both of which correspond to Section V’s Review Criteria #3 (a) and (b).

(a) EVALUATION AND TECHNICAL SUPPORT CAPACITY -- Corresponds to Section V’s Review Criterion #3 (a)

Prior to the end of the period of performance, awardees must report on the following outputs. Please provide anticipated values for these outputs in your application:

Number of newly established rural residency programs or RTTs;

Number of residents each rural residency program or RTT can support at the onset, and the longer-term goal for rural residency program or RTT size;

Number and type of newly established or existing clinical training sites for residents;

Number of faculty and staff trained to teach, support and administer the curriculum at each rural residency program or RTT site; and

Number and type of newly established or existing partnerships that support the rural residency program or RTT at each site.

By the end of the period of performance, awardees must also submit:

Documentation of ACGME accreditation status and plans for future accreditation review and status maintenance; and

Detailed professional certification, training profile, and planned time dedicated to residency supervision and training of rural residency program or RTT leadership (Program Directors/Associate and Assistant Program Directors)

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and Key Clinical Faculty, in line with the current ACGME accreditation requirements for these positions.

You must describe the plan for program performance evaluation to meet these requirements. The program performance evaluation must monitor ongoing processes and progress toward meeting goals and objectives of the project. Include descriptions of the inputs (e.g., key evaluation staff and organizational support, collaborative partners, budget, and other resources); key processes; variables to be measured; expected outcomes of the funded activities; and a description of how all key evaluative measures will be reported. (In Attachment 2, you must submit a complete staffing plan and job descriptions for key personnel. Bio sketches of Key Personnel should be uploaded in the SF-424 R&R Senior/Key Person Profile form).

You must demonstrate evidence that the evaluative measures selected will be able to assess: 1) the extent to which the program objectives have been met, and 2) the extent to which these can be attributed to the project.

(b) PROJECT SUSTAINABILITY -- Corresponds to Section V’s Review Criterion

#3 (b)

Applicants must propose a plan for rural residency program or RTT sustainability beyond the RRPD period of performance covered by this funding opportunity.

Awardees will be expected to arrange for a sustainable funding mechanism to support the costs of training new residents following the development of an accredited rural residency program or RTT. Health care sites sponsoring new rural residency programs or RTTs through this grant program must additionally have a strong, long-term outlook in regard to their financial stability. The application must speak at least broadly to this institutional financial outlook.

You must clearly describe a plan for supporting the costs of your rural residency program or RTT, any foreseeable challenges and barriers to your proposed sustainability plan, and how you will address these challenge and barriers. Several options that residency programs and RTTs currently employ for ongoing funding are delineated below. You must include all required documentation, as described below, to demonstrate the feasibility of your sustainability plan.

To propose any option that relies on Medicare GME payments (Options 1, 2, or 3), you must be a rural hospital in accordance with CMS’s definition of “rural” and plan to train residents in a program that is new for Medicare payment purposes. Medicare does not allow costs borne by non-hospital entities (medical schools, clinics, and grants, local governments) to then be shifted to a hospital that, in turn, would seek to receive reimbursement from Medicare for those costs originally not supported by Medicare. For example, if a medical school receives a grant, the medical school cannot pass the cost of resident training onto the hospital, with the hospital then claiming those costs on the Medicare cost report. However, Medicare does provide that if a grant goes directly to a hospital, it is considered hospital costs, and there is no concern of replacing community support. Therefore, to ensure applicants are able to receive Medicare GME payments, only rural hospitals are eligible if proposing Medicare GME payments for a new residency training program as their sustainability plan. For more information about rural and

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new medical residency training program eligibility, please see Section I (2) Program Definitions.

For Options 1, 2, and 3, you must provide documentation in Attachment 5 that the area in which the hospital is physically located is considered a rural hospital in accordance with CMS’s definition of “rural” for the purposes of the IPPS wage index.

To determine if a hospital is located in a county that is rural for CMS IPPS wage index purposes, refer to the FY 2019 “County to CBSA Crosswalk File and Urban CBSAs and Constituent Counties for Acute Care Hospitals File” that is available on the FY 2019 IPPS Final Rule Homepage.8 It is important to note that for hospitals that have been reclassified as rural, they are rural for indirect medical education (IME) but not direct graduate medical education (DGME).

Option 1: Establishing a Medicare Resident FTE Cap. Medicare provides payments to hospitals to support the IME and DGME costs of residency training programs. Both IME and DGME payments are calculated based in part on the number of full time equivalent (FTE) residents a hospital trains. The Balanced Budget Act (BBA) of 1997 established a limit on the number of allopathic and osteopathic FTE residents for which each hospital can receive IME and DGME payment. This limitation, one for IME and one for DGME, is based on the number of such FTE residents the hospital trained in its most recent cost report ending on or before December 31, 1996. It is referred to as the “1996 Base Year Resident Cap.”

Hospitals that have not established a Medicare resident FTE cap, may establish caps by training residents in a new allopathic or osteopathic residency training program(s).

In addition, applicants should consider that the DGME payment is based in part on a hospital-specific Per Resident Amount (PRA). Establishment of a hospital’s PRA is triggered when the hospital trains a resident or residents in an approved GME program for the first time, regardless of whether those residents are part of a new approved program or an existing approved program, regardless of whether or not the hospital is the sponsor of the approved program, and regardless of whether or not the hospital incurs costs for the resident(s). This option is focused on supporting new residency programs associated with rural hospitals that have not yet triggered their PRA and do not yet have FTE resident caps set. To demonstrate that the PRA has not yet been triggered, rural hospitals must demonstrate that no prior residency training has taken place in their hospital.

No Prior Training: If planning to establish a new Medicare resident FTE cap at your hospital, you must provide a letter from the hospital’s Chief Executive Officer or other responsible leadership stating that the hospital has not hosted pre-planned and scheduled residency training in past cost reporting periods that have been settled, but are still within the 3-year reopening period, and that the hospital does not have a previously set Medicare resident FTE caps. Applicants should be able to determine that no previous caps have been set and no prior residents have been

8 For other facilities not seeking Medicare GME funding, more information about the definition of rural for the eligibility of this grant can be found at: ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf. To determine if a specific geographical area is considered rural according to HRSA’s definition, go to http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvisor.aspx) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page-Items/FY2018-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvisor.aspx

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trained through a careful examination of past cost reports since 1996. This information should be included in Attachment 6.

An online Rural GME Analyzer tool examining publicly available CMS cost reports for prior resident training is available. This tool is provided as a starting point for potential applicants. Applicants should review their own CMS cost reports from 1996 and onward.

Option 2: Rural Hospital “New” Residency Program. Rural hospitals that already have IME and DGME FTE resident caps from a previous accredited program may also receive an increase to their resident caps any time they participate in training allopathic or osteopathic residents in new programs. A rural hospital may be eligible to receive an increase in their resident cap if they start a new medical residency training program in a specialty that has not previously trained in the rural hospital.

For example, a rural hospital with an established Family Medicine residency program may be eligible for an increase in their resident cap if they start training residents in a new psychiatry program.

CMS defines a new medical residency program as “a medical residency that receives initial accreditation by the appropriate accrediting body or begins training residents on or after January 1, 1995.” In evaluating whether a program is truly new, CMS will consider whether the program existed previously at another hospital and other supporting factors such as whether there are new program directors, new teaching staff, and whether there are new program year one residents training in the program without previous training experience in the residency program specialty.

(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.) No cap increases are provided when a rural hospital expands the number of FTE residents it is training in an existing program or if an existing residency program is transferred to a new training site.

Option 3: Rural Training Tracks. There exists some flexibility for urban hospitals to expand their existing Medicare resident FTE caps through the creation of a separately accredited RTT, as specified in the 1999 Balanced Budget Refinement Act. Under this flexibility, urban hospitals may expand their FTE Resident Cap to accommodate additional residents designated to train in an RTT. Rural hospitals are not eligible for this cap expansion and are only able to receive additional FTE resident cap slots if the RTT is a brand new program in their hospital as described in Options 1 and 2, above.

Rural hospitals looking to apply as a new RTT site must include letters of agreement in Attachment 7 from the hospitals with whom they will partner in establishing their proposed RTT.9 Urban hospitals with existing or previous RTT programs in a

9 Section (k) of 42 CFR, §413.79 indicates that urban hospitals may expand their FTE residency cap to accommodate their rural training tracks. Residents training in rural track programs: Subject to the provisions of

413.81, an urban hospital that establishes a new residency program, or has an existing residency program with rural track (or an integrated rural track) may include in its FTE count residents in those rural tracks, in addition to the residents subject to its FTE cap specified under paragraph (c) of this section. An urban hospital with a rural track https://datawarehouse.hrsa.gov/tools/hdwreports/Filters.aspx?id=462

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specialty will not qualify for expanded Medicare resident FTE caps when starting a new RTT in the same residency specialty. Therefore, if you pursue this option, you must provide documentation in Attachment 7 from the current accrediting body of any previously existing or current physician residency training programs indicating that the urban hospital did not or does not have an RTT in the specialty proposed in the project narrative. More information on RTTs is available at:

https://rttcollaborative.net/rural-programs.

Option 4: Other public or private funding. Rural residency programs or RTTs may be supported by funds from sources other than Medicare. Examples include funding from the Department of Veterans Affairs, Indian Health Service, Medicaid, state, or other public and private funding. Eligible applicants for Option 4 include schools of allopathic medicine or osteopathic medicine and community-based ambulatory settings, in addition to hospitals. If you propose this option, you must clearly describe the funding mechanism; application process (competitive vs.

noncompetitive), how your program qualifies for the funding; the anticipated award date and the expected duration and availability of the funding. If you propose private funding for ongoing support of your residency program, you must provide a letter of agreement from the funder in Attachment 7.

Sustainability Options and Required Documents

Required Document

Eligible Entities Attachment 6 Attachment 7

Option 1: Rural Hospital Establishing New Medicare Resident FTE Cap

Rural Hospital Letter from the Hospital CEO stating: a) the hospital has not hosted pre-planned and scheduled residents training in past cost reports that are settled but within the 3-year reopening periods;

and b) the hospital does not have previously set Medicare resident FTE caps or previously triggered

DGME PRA

Option 2: Rural Hospital “New” Residency Program

Rural Hospital residency program may count residents in those rural tracks up to rural track FTE limitation if the hospital complies with the conditions specified in paragraphs (k) (2) through (k) (7) of this section.

https://rttcollaborative.net/rural-programs

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Option 3: Rural Training Track

Rural Hospital Letter from the Hospital CEO stating: a) the hospital has not hosted pre-planned and…