PKG00247771-instructions.pdf

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Federal Office of Rural Health Policy Hospital State Division

Medicare Rural Hospital Flexibility Program –

Emergency Medical Services Supplement

Funding Opportunity Number: HRSA-19-095 Funding Opportunity Type: Competing Supplement

Catalog of Federal Domestic Assistance (CFDA) Number: 93.241

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2019

Letter of Intent Requested By: March 1, 2019

Application Due Date: April 5, 2019

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, including SAM.gov and Grants.gov, may take up to 1 month to complete.

Issuance Date: January 24, 2019

Sarah Young Flex Program Coordinator, Hospital State Division, Federal Office of Rural Health Policy Telephone: (301) 443-5905 Email: syoung2@hrsa.gov

Authority: Title XVIII, §1820(g)(2) of the Social Security Act (42 U.S.C. 1395i-4(g)(2)), as amended.

mailto:SYoung2@hrsa.gov

HRSA-19-095 i

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for the fiscal year (FY) 2019 Medicare Rural Hospital Flexibility Program (Flex Program) Emergency Medical Services (EMS) Supplement. The purpose of this award is to build an evidence base for rural EMS activities in the Flex Program by funding the implementation of demonstration projects of sustainable rural EMS models and quality metrics, and by sharing the results of those projects with rural EMS stakeholders.

Funding Opportunity Title: Medicare Rural Hospital Flexibility Program EMS Supplement

Funding Opportunity Number: HRSA-19-095

Due Date for Applications: April 5, 2019

Anticipated Total Annual Available FY 2019 Funding:

Approximately $2,000,000

Estimated Number and Type of Awards: Up to 8 supplement awards

Estimated Award Amount: Approximately $250,000

Cost Sharing/Match Required: No

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

Eligible Applicants: States with certified Critical Access Hospitals

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 http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf, except where instructed in this NOFO to do otherwise.

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

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Technical Assistance

HRSA has scheduled the following technical assistance:

Webinar

Day and Date: Thursday, January 31, 2019 Time: 4:30 – 5:30 p.m. ET Call-In Number: 1-800-779-4364 Participant Code: 7221124 Web link: https://hrsa.connectsolutions.com/flex_ta_19_095/ Playback Number: 1-800-945-9394 Passcode: 8855 https://hrsa.connectsolutions.com/flex_ta_19_095/

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING/MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

3. 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

HRSA-19-095 1

I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Medicare Rural Hospital Flexibility Program (Flex Program) Emergency Medical Services (EMS) Supplement. Throughout this NOFO, the term Flex Program will refer to the larger, primary program while Flex EMS Supplement will refer to the supplemental projects that are the focus of this NOFO.

The goal of this supplemental funding is to improve access to quality emergency medical care in rural communities. These projects will develop an evidence base for Flex Program EMS activities, by funding projects in the following two focus areas:

Focus Area 1: To implement demonstration projects on sustainable models of rural EMS care. Projects will facilitate the development and implementation of promising solutions for the problems faced by vulnerable EMS agencies and contribute to an evidence base for appropriate interventions.

Focus Area 2: To implement demonstration projects on data collection and reporting for a set of rural-relevant EMS quality measures. Projects will facilitate the development of a core set of validated, rural-relevant EMS quality measures.

The state Flex programs who choose to apply for this supplement should propose a project that addresses one of the two focus areas (see Section IV.2, Program-Specific Instructions).

2. Background

This program is authorized by Title XVIII, §1820(g)(2), of the Social Security Act (42 U.S.C. 1395i-4(g)(2)), as amended. Among other provisions, this section of the act authorizes Flex funding “for the establishment or expansion of a program for the provision of rural emergency medical services.”

With declining numbers of volunteers to staff ambulances, declining financial support from local governments, and increased educational standards for emergency medical technicians and paramedics, access to emergency care is at risk in many rural communities. Flex Program stakeholders have identified addressing the needs of struggling EMS agencies as a key issue to maintaining access to emergency care in rural communities. Stakeholders have also identified EMS quality improvement as a key challenge for both EMS sustainability and EMS participation in value-based care.

The Flex Program provides a platform and resources for states to strengthen rural health care by supporting improvement initiatives with critical access hospitals and rural EMS agencies. State Flex programs have supported EMS improvement activities in the past, but have faced challenges with limited capacity to address EMS needs given other rural health care priorities. This supplemental funding opportunity enables up to eight state Flex programs to implement focused EMS improvement projects that address the challenges faced by rural EMS agencies, while contributing to the rural EMS evidence base.

https://www.govinfo.gov/content/pkg/USCODE-2017-title42/html/USCODE-2017-title42-chap7-subchapXVIII-partA-sec1395i-4.htm https://www.govinfo.gov/content/pkg/USCODE-2017-title42/html/USCODE-2017-title42-chap7-subchapXVIII-partA-sec1395i-4.htm

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The Rural and Frontier Emergency Medical Services Agenda for the Future, published in 2004, describes national challenges and opportunities for rural EMS and lists some important barriers to the provision of EMS in rural communities including long distances, challenging geography, low call volumes, high cost per call to maintain the system, fewer monetary and other resources, and a dependence on volunteerism. The Agenda for the Future made more than 120 recommendations for improving rural EMS systems.

Although fourteen years old, rural EMS stakeholders report that the Agenda for the Future remains relevant and that they are developing new resources to address its recommendations.

The Flex EMS Supplement addresses two of the areas identified in the Rural and Frontier Emergency Medical Services Agenda for the Future:

Encourage EMS-based community health service program development through the funding of pilots, cataloguing of existing successful practices, exploration of opportunities for expanded EMS scopes of practice, and on-going reimbursement for the provision of such services; and

Encourage multi-system data collection for specific research and performance improvement purposes.

II. Award Information

1. Type of Application and Award

Type of applications sought: Competing Supplement

HRSA will provide funding in the form of a supplement award to a subset of recipients under the Flex Program announced under notice HRSA-19-024.

HRSA Program involvement will include:

Collaborating with award recipients to review and provide input on the Work Plans in alignment with HRSA priorities, state needs, and changes in the rural EMS environment through such activities as identifying and prioritizing needs to be addressed using federal funds;

Monitoring and supporting implementation of the Work Plan through progress report reviews; and

Collaborating with technical assistance providers that are developing tools and resources for state Flex program use.

The recipient’s responsibilities will include:

Collaborating with HRSA on refining and implementing the Work Plan according to HRSA priorities, state needs, and changes in the rural EMS environment

Negotiating with HRSA to update Work Plans at least annually, or more frequently as needed (e.g., in response to identified challenges);

Developing and implementing a state Flex EMS Supplement as described in this notice;

https://www.ruralcenter.org/sites/default/files/rfemsagenda.pdf

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Participating in information sharing and program improvement activities coordinated by HRSA’s designated Flex EMS Supplement technical assistance providers; and

Participating in the national evaluation of the Flex EMS Supplement.

2. Summary of Funding

HRSA expects approximately $2,000,000 to be available to fund eight recipients. HRSA expects to award funding to the highest scoring applications in each focus area.

HRSA’s intent is to fund four projects in Focus Area 1 and four projects in Focus Area 2.

You may apply for a ceiling amount of up to $250,000 total cost (includes both direct and indirect, facilities and administrative costs) per year for the Flex EMS Supplement.

The period of performance for the Flex EMS Supplement is September 1, 2019, through August 31, 2022 (3 years). Funding of the Flex EMS Supplement beyond the first year is subject to the availability of appropriated funds for the Medicare Rural Hospital Flexibility Program in subsequent fiscal years, satisfactory recipient performance, and a decision that continued funding is in the best interest of the Federal Government.

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

Limitation on indirect cost rates

Authorizing legislation (Title XVIII, §1820(g)(4) of the Social Security Act (42 U.S.C.

1395i-4(g)(4)), as amended) limits indirect costs under the Flex Program. Indirect costs will be budgeted and reimbursed at the lesser of 15 percent of total direct costs or the applicant’s negotiated Indirect Cost Rate Agreement (ICRA). The 15 percent limit comes to approximately 13.04 percent of the Total Project Costs, inclusive of direct and indirect costs. This limitation on indirect cost rates is a requirement of this federal award and, as required in 45 CFR § 75.351-353, the limitation includes subrecipients.

III. Eligibility Information

1. Eligible Applicants

This competitive supplemental funding opportunity is only open to applicants for the Medicare Rural Hospital Flexibility Program cooperative agreement. As described in the Flex Program funding opportunity (NOFO HRSA-19-024), only states (current Medicare Rural Hospital Flexibility Program award recipients in states with certified critical access hospitals) are eligible to apply for funding under this notice. The Governor designates the eligible applicant from each state. HRSA will accept only one application for the Medicare Rural Hospital Flexibility Program cooperative agreement (responding to NOFO HRSA-19-024) and only one application for the Flex EMS Supplement (responding to this NOFO, HRSA-19-095) from the same applicant in each state.

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#sg45.1.75_1344_675_1350.sg4

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2. Cost Sharing/Matching

Cost sharing/matching is not required for this program.

3. Other

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

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.

NOTE: Multiple applications to this NOFO 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.

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 NOFO following the directions provided at http://www.grants.gov/applicants/apply-for-grants.html.

If you are 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.

2. Content and Form of Application Submission

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

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

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See Section 8.5 of the Application Guide for the Application Completeness Checklist.

Application Page Limit The total size of all uploaded files may not exceed the equivalent of 40 pages, when printed by HRSA. The page limit includes the abstract, project and budget narratives, attachments, and letters of commitment and support required in the Application Guide and this NOFO. Standard OMB-approved forms that are included in the workspace application package do not count in the page limit. Indirect Cost Rate Agreement and proof of non-profit status (if applicable) do not count in the page limit. You are not required to submit a 40-page application. 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 the statements in this certification, an explanation shall be included in Attachment 7: 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:

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

The project abstract must be single-spaced and limited to one page in length.

Please include the following information at the top of the abstract:

Project Title

Applicant Organization Name

Applicant Organization Address

Applicant Organization Web Site Address, if applicable

Project Director Name (if applicable, state that the Project Director is also the State Flex Coordinator)

State Flex Coordinator Name (if different from Project Director) http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf

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State Flex Coordinator Contact Phone Number(s)

State Flex Coordinator E-Mail Address(es)

In addition, please include the following:

A brief description of the project including the needs to be addressed, the proposed services, and the population to be served.

A statement to identify which of the EMS improvement focus areas the project will address, either:

1. Demonstration projects on sustainable models of rural EMS care, or

2. Testing rural-relevant EMS quality measures, data collection, and reporting.

Goals and specific measurable objectives of the proposed 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.

You must select one of the two focus areas outlined below and all proposed activities must be aligned to the intent of the focus area. Proposals for projects in both focus areas or proposals for unrelated projects will not be considered.

Focus Area 1: To implement demonstration projects on sustainable models of rural EMS care

The purpose of this focus area is to provide funding for activities that address the issue of sustainability—the ability to maintain or expand access to EMS in rural communities for the long term. Proposed projects must address an important problem or critical barrier to the provision of rural emergency care. As recommended in the Rural and Frontier Emergency Medical Services Agenda for the Future, this may include approaches to encourage EMS-based community health service program development. You may also propose a project that tests a solution to a process issue, for example implementing and testing financial measures and a financial data collection system that could be adopted by the broader Flex Program.

Projects should test:

Sustainable financial models;

Sustainable service delivery models;

Models to improve coordination and collaboration between EMS and other healthcare entities; and/or

Methods to measure financial and other risk factors and identify vulnerable EMS agencies.

A model is an intervention that leads to substantial changes in how emergency medical services are funded at a local, regional or state level; an intervention that substantially changes the organization of EMS care delivery at a local or regional

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level; or an intervention that substantially improves the coordination of emergency care. Examples include but are not limited to working with:

State partners, payers, and other stakeholders to broaden the role of EMS personnel and create additional revenue sources for EMS agencies;

Local communities to restructure EMS care delivery in a way that addresses financial or staffing issues or fills in gaps in the local healthcare system; or

Partners, stakeholders, and EMS agencies to test a set of EMS financial measures and a data collection system.

The completion of your project should add to the knowledge base regarding effective provision of rural EMS and in some way change the concepts, methods, services, or preventive interventions of rural emergency medical services. The Flex Program may adopt successful projects as recommended activities and incorporate them into future Flex EMS Improvement program area guidance.

Focus Area 2: To implement demonstration projects on data collection and reporting for a set of rural-relevant EMS quality measures

The purpose of this focus area is to identify EMS quality measures and evaluate the suitability of the proposed measures for use in rural EMS quality improvement and in the Flex Program. States will seek stakeholder consensus during the measures selection process, then test processes for collection and reporting of those measures. This is a project to evaluate the measures and not the care provided. Measures recommended by states based on the results of their demonstration projects will be considered for inclusion in future Flex EMS Improvement program area guidance.

You may choose measures from the National Emergency Medical Services Information System (NEMSIS), the EMS Compass project measures identified by the Flex Monitoring Team (FMT), or from a state-level measure set. The measures sets are available at https://www.ruralcenter.org/resource-library/ems-data-sets. Award recipients will work with rural EMS agencies to implement data collection and evaluate measures based on:

Relevance: The measure is related to a condition or patient population rural EMS agencies are likely to encounter;

Feasibility: The data can be realistically collected and accessed;

Actionability: There are specific actions that can be taken to improve EMS performance and capacity using the measure; and

Impact: The focus of the measure is important to improving EMS system performance, patient care and/or outcomes.

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

http://www.flexmonitoring.org/ https://www.ruralcenter.org/resource-library/ems-data-sets https://www.ruralcenter.org/resource-library/ems-data-sets

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INTRODUCTION -- Corresponds to Section V’s Review Criteria 1 (Need), 2 (Response) and 4 (Impact) Provide a brief overview of the purpose of the proposed project, the overall strategy and reasoning, and your projected outcomes and goals for the 3-year period of performance. Explain the importance of the project. Describe how rural EMS technical capability or practices will be improved if the project achieves its aims. Indicate which one of the two EMS improvement focus areas your project will address.

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

Describe the collective needs of rural EMS agencies and rural communities in the state. This section identifies and describes the problem your project seeks to address, with appropriate supporting data. This section should help reviewers understand the state context, environment, rural EMS agencies, and rural communities that will be served by the proposed Flex EMS Supplement.

Clearly identify data sources and data timeframes to show that this assessment is based on the most recent information available.

The assessment should:

Provide an environmental scan assessing rural EMS in the state focused on the problem your project will address;

Clearly define the problem(s) that the project aims to address;

Provide data in support of your assessment of the problem;

Identify potential partners that you can engage; and

Describe how the proposed project advances the overall goal of improving access to quality emergency medical care in rural communities.

Focus Area 1 projects should also identify and describe other ongoing projects in the state or in the country that attempt to address a similar problem.

Focus Area 2 projects should also describe any current EMS data collection or quality improvement requirements, any voluntary reporting or quality improvement projects engaging EMS agencies, the extent of current EMS agency participation in such projects, and current barriers to EMS quality reporting and quality improvement.

METHODOLOGY -- Corresponds to Section V’s Review Criteria 2 (Response) and

4 (Impact) Use this section to describe the methods that you will use to address the identified needs of rural EMS agencies and rural communities in the state. Explain how you will meet the Flex EMS Supplement requirements and how you will achieve the program goal of improving access to quality emergency medical care in rural communities. Identify project objectives and explain how program activities will achieve those objectives and the associated outcomes. Use this section to explain how and why the planned activities described in the work plan will be undertaken. Describe and reference the tabular work plan (Attachment 1) and the logic model (Attachment 5) as needed to strengthen the methodology narrative and avoid duplication of information in the application package.

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Describe the interventions to be used to address the rural EMS problem(s) identified in the needs assessment. Describe how proposed activities and interventions were selected to achieve project outcomes and the evidence base (if available) supporting those activities and interventions. Show how proposed activities are linked to expected outcomes for rural EMS agencies, rural communities, and other stakeholders. Explain the conceptual framework that supports the approach to be used for the proposed project. Explain how all of the proposed activities logically connect to and address a clearly defined purpose in the selected focus area. Describe plans to develop or utilize innovative approaches and best practices. Explain how the proposed project will improve access to emergency medical services and provide valid evidence on the effectiveness and the replicability of the rural EMS interventions that you test.

Identify expected participants in activities and interventions. Project participants must include rural EMS agencies or personnel and may include critical access hospitals, Rural Health Clinics, Federally Qualified Health Centers, rural health networks, and community based organizations. Explain your process for engaging key stakeholders in addition to rural EMS agencies in the proposed project and building collaboration and buy-in. HRSA encourages recipients to collaborate within and across states to improve their impact and effectiveness. HRSA also encourages states to work with State Rural Health Associations, State Hospital Associations, State Offices of EMS, regional and state networks, and others concerned with the future of rural EMS. State Flex programs may choose to work with EMS subject matter experts, community partners, including local government, state agencies, non-profit organizations, and other state Flex programs.

HRSA recognizes that state Flex programs use multiple approaches to access appropriate expertise and complete projects including direct implementation by organization staff, engaging contractors and consultants, and providing subawards to subrecipients such as State Offices of EMS and rural EMS agencies. Describe the approaches (including staff, contracts, and subawards) you will use to achieve program objectives and how you will ensure coordination between staff, contractors, and subrecipients, as applicable. Describe how you will organize the projects to use federal funds as effectively and efficiently as possible.

For projects addressing Focus Area 1, demonstration projects on sustainable models of rural EMS care, your narrative should:

Effectively use data to support the premise of the project;

Describe a project which addresses an important problem or a critical barrier to the provision of rural emergency care;

Describe a project that will add to the knowledge base regarding effective provision of rural EMS services; and

Describe how the successful completion of the project will change the concepts, methods, services, or preventative interventions of rural emergency medical services.

For projects addressing Focus Area 2, demonstration projects on data collection and reporting for a set of rural-relevant EMS quality measures, your narrative should:

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Propose a well-reasoned process that will be used to select measures.

Describe an effective process for identifying rural EMS agencies to participate in the project;

Propose a feasible plan for data collection and analysis; and

Describe how the successful completion of the project will support the use of quality measurement for rural emergency medical services.

WORK PLAN -- Corresponds to Section V’s Review Criteria 2 (Response) and 4

(Impact) The work plan is a separate document from the text-based Project Narrative.

Include the work plan as Attachment 1. This section has instructions for the tabular work plan attachment.

The work plan is a succinct overview of the project objectives, goals, activities, and projected outcomes in a table format. The work plan is not a narrative. As noted above, use the methodology section of the narrative to reference and explain the tabular work plan. The written narrative provides space to elaborate on activities listed in the work plan and describe how and why they will be undertaken.

The tabular work plan will have a 3-year period of performance section and an annual section. The period of performance section of the tabular work plan should include:

Defined outcome measures with a clear, time-limited target for each outcome measure; and

A detailed 3-year timeline indicating project milestones for the duration of the supplemental funding.

For the first year of the period of performance, the tabular work plan should include:

Succinct descriptions of activities planned;

Expected outputs (process measures);

Timeline for activities with key milestones to track progress, identifying multi-year activities as appropriate; and

Responsible individuals including program staff and contractors.

In future years, recipients will provide updates to this section of the work plan as part of annual progress reports.

RESOLUTION OF CHALLENGES -- Corresponds to Section V’s Review Criterion 2 (Response) Discuss challenges that you may encounter in designing, implementing, and staffing the activities described in the work plan, and approaches that you will use to resolve such challenges and implement the program as planned. Describe how you will establish a project management plan that will promote accountability and effective execution. You should discuss any challenges that could be encountered with keeping project participants, including EMS agencies and other partners, actively engaged for the duration of the project, including the completion of final reporting. Discuss approaches that you will use to resolve such challenges.

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EVALUATION AND TECHNICAL SUPPORT CAPACITY -- Corresponds to Section V’s Review Criteria 3 (Evaluation Measures) and 5 (Resources/Capabilities) Please use the following sub-headings in responding to this section: Project Monitoring and Evaluation Capability, Logic Model Description, Final Report Plan.

Project Monitoring and Evaluation Capability Describe current experience, skills, and knowledge base that will contribute to monitoring and evaluation of the proposed project, including individuals on staff, materials published, and previous work of a similar nature. Explain how you will monitor ongoing processes and the progress towards the goals and objectives of the project. Identify the data you will collect and analyze to assess your progress and to measure your outputs (program process measures) and outcomes (measures of program impact). Describe the systems and processes that your organization will use to collect and manage data needed for accurate and timely performance reporting. Use this section to demonstrate that you have the resources and capacity to collect data throughout the project and meet the requirements of the final report.

Include a description of your monitoring and assessment processes for subrecipients, subawards, and/or contractors, if applicable. This section should show your capacity and ability to plan for effective program management for the duration of the proposed project.

Logic Model Description Use this section to provide a narrative description of the logic model included in Attachment 5. With reference to the relationships depicted in the logic model chart, explain how the inputs and outputs of the proposed project will lead to the desired short-term and long-term outcomes and impacts. The logic model should clearly identify the goals and objectives of the project and depict how program activities will achieve outcomes. Use this description to show that the proposed activities will advance the stated goals of the project and provide valid evidence about the effectiveness of rural EMS interventions.

Evaluation Plan and Final Report Use this section to explain how you will produce a final report on the Flex EMS Supplement. Describe how you will analyze data, assess outcome measures, and present and interpret findings to increase the evidence base for sustainable rural EMS models. Describe the timeline with key milestones for implementing the evaluation and producing the final report. Explain how the proposed evaluation plan will assess the effectiveness of the project. Describe your approach to disseminating project results.

The final report will include the project need, goal, methods, results, and lessons learned. Describe how you will assess expected sustainability of the tested model or tested quality measures data collection and how you will determine whether further implementation is recommended or not recommended.

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For projects addressing Focus Area 1, explain how you will determine if the intervention achieved the intended outcome and how you will assess the effect of the intervention on EMS sustainability including testing:

Sustainable financial models;

Sustainable service delivery models;

Models to improve coordination and collaboration between EMS and other healthcare entities; and/or

Methods to measure financial and other risk factors and identify vulnerable agencies.

For projects addressing Focus Area 2, explain how you will determine to what degree the tested quality measures meet the following four criteria:

Relevance: The measure serves the data needs of EMS agencies and the state Flex program;

Feasibility: Data can be realistically collected and accessed;

Actionability: There are specific actions that can be taken to improve EMS performance and capacity using the measure; and

Impact: The focus of the measure is important to improving EMS system performance or patient care and/or outcomes.

ORGANIZATIONAL INFORMATION -- Corresponds to Section V’s Review

Criterion 5 (Resources/Capabilities) Succinctly describe your organization’s current mission and structure, scope of current activities, and explain how these elements all contribute to the organization’s ability and capacity to manage the project and meet reporting requirements. Refer to the organizational chart in Attachment 4 and explain (as applicable) how the state Flex program fits within its larger parent organization.

Describe relationships or contracts and subawards that will help the state Flex program successfully implement and evaluate the proposed Flex EMS Supplement.

Explain how the organization will ensure that key personnel have adequate time devoted to the project to achieve project objectives. Refer to the staffing plan (see Attachment 2), as needed.

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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.

Narrative Section Review Criteria

Introduction (1) Need, (2) Response and (4) Impact

Needs Assessment (1) Need

Methodology (2) Response and (4) Impact

Work Plan (2) Response and (4) Impact

Resolution of Challenges (2) Response

Evaluation and Technical Support Capacity

(3) Evaluation Measures and

(5) Resources/Capabilities

Organizational Information (5) Resources/Capabilities

Budget and Budget Narrative (below)

(6) Support Requested – the budget section should include sufficient justification to allow reviewers to determine the reasonableness of the support requested.

iii. Budget

See Section 4.1.iv of HRSA’s SF-424 Application Guide. Please note: the directions offered in the SF-424 Application Guide may differ from those offered by Grants.gov.

Follow the instructions included in the Application Guide and the additional budget instructions provided below. A budget that follows the Application Guide will ensure that, if HRSA selects the application for funding, you will have a well-organized plan and by carefully following the approved plan can avoid audit issues during the implementation phase.

Reminder: The Total Project or Program Costs are the total allowable costs (inclusive of direct and indirect costs) incurred by the recipient to carry out a HRSA-supported project or activity. Total project or program costs include costs charged to the award and costs borne by the recipient to satisfy a matching or cost-sharing requirement, as applicable.

If indirect costs are included in the budget, attach a copy of the indirect cost rate agreement as Attachment 6.

The Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 (P.L. 115-245), Division B, § 202 states, “None of the funds appropriated in this title shall be used to pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of Executive Level II.” See Section 4.1.iv Budget – Salary Limitation of HRSA’s SF-424 Application Guide for additional information. Note that these or other salary limitations may apply in the following Fiscal Year, as required by law.

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Authorizing legislation (Title XVIII, §1820(g)(4) of the Social Security Act (42 U.S.C.

1395i-4(g)(4)), as amended) limits indirect costs under the Flex Program. Indirect costs will be budgeted and reimbursed at the lesser of 15 percent of total direct costs or the applicant’s negotiated Indirect Cost Rate Agreement (ICRA). The 15 percent limit comes to approximately 13.04 percent of the Total Project Costs, inclusive of direct and indirect costs. This limitation on indirect cost rates is a requirement of this federal award and, as required in 45 CFR § 75.351-353, the limitation includes subrecipients.

iv. Budget Narrative

See Section 4.1.v. of HRSA’s SF-424 Application Guide.

This award will have a 3-year period of performance. The budget narrative should describe expected spending for all 3 years of the project and align with the timeline in the work plan. The annual progress reports will include an annual update to the budget narrative.

The budget narrative should justify all requested costs for the supplemental award.

Funds requested for the Flex EMS Supplement may not duplicate costs already provided under the primary Flex Program cooperative agreement award. The corresponding budget narrative must justify only funds to be used to support additional activities derived from the supplemental funds.

Note that supplemental funds can only be used to purchase equipment and supplies necessary to implement the demonstration project and cannot be used to purchase equipment or supplies for general use. As applicable, you must explain in the budget narrative how each equipment item will be used and how sustainability will be assured, including how the equipment will be inventoried, maintained, and used after the end of the supplemental funding. Supply purchases must also be listed and justified in the budget narrative.

Allowable uses of funds under this notice include, but are not limited to, the following purposes:

Salaries for project management personnel;

Training on data collection;

Data collection tools including software and information technology devices such as computers or tablets and telehealth connection services or devices;

and

Reimbursement of EMS agency staff time, for data collection and reporting.

v. Attachments

Provide the following items in the order specified below to complete the content of the application. Unless otherwise noted, attachments count toward the application page limit. Indirect cost rate agreements and proof of non-profit status (if applicable) will not count toward the page limit. You must clearly label each attachment.

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=4d52364ec83fab994c665943dadf9cf7&ty=HTML&h=L&r=PART&n=pt45.1.75#sg45.1.75_1344_675_1350.sg4

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Attachment 1: Work Plan Attach the work plan for the proposed project that includes all information detailed in Section IV. ii. Project Narrative in a concise, tabular format. Include process and outcome measures for the Flex EMS Supplement.

Attachment 2: Staffing Plan (see Section 4.1.vi. of HRSA’s SF-424 Application Guide)

You must present a staffing plan and provide a justification for the plan that includes a rationale for each award-funded staff position. Include position descriptions with the roles, responsibilities, and qualifications of proposed project staff. Keep each position description to one page in length or less.

Include a brief description of your organization’s timekeeping process to ensure that you will comply with the federal standards related to documenting personnel costs.

Attachment 3: Biographical Sketches of Key Personnel Include biographical sketches for Key Personnel, less than one page in length per person. In the event that a biographical sketch is included for an identified individual not yet hired, include a letter of commitment from that person with the biographical sketch. Key Personnel are the Principal Investigator/Project Director (PI/PD) and other individuals who contribute to the programmatic development or execution of a project or program in a substantive, measurable way, whether or not they receive salaries or compensation under the award.

Attachment 4: Project Organizational Chart Provide a one-page figure or diagram that depicts the organizational structure of the project. Include subrecipients and contractors that are integral to the success of the project in the figure.

Attachment 5: Logic Model Include a logic model that illustrates the design of the proposed Flex EMS Supplement. A logic model is a one-page diagram that presents the conceptual framework for a proposed project and explains the links among program elements. It shows the logical relationships among the resources that are invested, the activities that take place and the benefits or changes that result from these activities. While there are many versions of logic models, for the purposes of this notice, the logic model should summarize the connections between the:

Goals of the project (e.g., objectives, reasons for proposing the intervention, if applicable);

Assumptions (e.g., beliefs about how the program will work and support resources. Base assumptions on research, best practices, and experience.);

Inputs (e.g., organizational profile, collaborative partners, key staff, budget, other resources);

Target population (e.g., the individuals or communities to be served);

Activities (e.g., approach, listing key intervention, if applicable);

Outputs (i.e., the direct products or deliverables of program activities);

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Short-term outcomes (i.e., the results of a program, typically describing a change in people or systems at the end of the budget year);

Medium-term outcomes (i.e., the results of a program, typically describing a change in people or systems at the end of the performance period); and

Long-term outcomes and impacts (i.e., the results of a program, typically describing a change in people or systems over the 3 years).

The logic model should be a chart or diagram and may be written using a 10-point font.

Although there are similarities, a logic model is not a work plan. A work plan is an action guide with a timeline to be used during program implementation; the work plan provides the how-to steps. Information on how to develop a logic model can be found at the following website:

https://www.cdc.gov/dhdsp/docs/logic_model.pdf.

Attachment 6: Indirect Cost Rate Agreement (NOT counted in page limit)

If applicable, provide the current federally negotiated indirect cost rate agreement used to substantiate indirect costs in the proposed budget.

Attachment 7-15: Other Relevant Documents Include here any other documents that are relevant to the application, including letters of support. Letters of support must be dated and specifically indicate a commitment to the project/program (in-kind services, dollars, staff, space, equipment, etc.).

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number and System for Award Management

You must obtain a valid DUNS number, also known as the Unique Entity Identifier, for your organization/agency and provide that number in the application. You must also register with the System for Award Management (SAM) and continue to maintain active SAM registration with current information at all times during which you have an active federal award or an application or plan under consideration by an agency (unless the applicant is an individual or federal agency that is exempted from those requirements under 2 CFR § 25.110(b) or (c), or has an exception approved by the agency under 2 CFR § 25.110(d)).

HRSA may not make an award to an applicant until the applicant has complied with all applicable DUNS and SAM requirements and, if an applicant has not fully complied with the requirements by the time HRSA is ready to make an award, HRSA may determine that the applicant is not qualified to receive an award and use that determination as the basis for making an award to another applicant.

If you have already completed Grants.gov registration for HRSA or another federal agency, confirm that the registration is still active and that the Authorized Organization Representative (AOR) has been approved.

https://www.cdc.gov/dhdsp/docs/logic_model.pdf

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The Grants.gov registration process requires information in three separate systems:

Dun and Bradstreet (http://www.dnb.com/duns-number.html)

System for Award Management (SAM) (https://www.sam.gov)

Grants.gov (http://www.grants.gov/)

For further details, see Section 3.1 of HRSA’s SF-424 Application Guide.

UPDATED SAM.GOV ALERT: For your SAM.gov registration, you must submit a notarized letter appointing the authorized Entity Administrator. The review process changed for the Federal Assistance community on June 11, 2018. Read the updated FAQs to learn more.

If you fail to allow ample time to complete registration with SAM or Grants.gov, you will not be eligible for a deadline extension or waiver of the electronic submission requirement.

4. Submission Dates and Times

Application Due Date The due date for applications under this NOFO is April 5, 2019 at 11:59 p.m. Eastern Time. HRSA suggests submitting applications to Grants.gov at least 3 days before the deadline to allow for any unforeseen circumstances.

See Section 8.2.5 – Summary of emails from Grants.gov of HRSA’s SF-424 Application Guide for additional information.

5. Intergovernmental Review

The Medicare Rural Hospital Flexibility Program is not a program subject to the provisions of Executive Order 12372, as implemented by 45 CFR part 100.

See Section 4.1 ii of HRSA’s SF-424 Application Guide for additional information.

6. Funding Restrictions

You may request funding for a period of performance of up to 3 years, at no more than $250,000 per year (inclusive of direct and indirect costs). Awards to support projects beyond the first budget year will be contingent upon Congressional appropriation, satisfactory progress in meeting the project’s objectives, and a determination that continued funding would be in the best interest of the Federal Government.

The General Provisions in Division B of the Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 (P.L. 115-245) apply to this program. Please see Section 4.1 of HRSA’s SF-424 Application Guide for additional information. Note that these or other restrictions will apply in the following Fiscal Year, as required by law.

Program authorizing legislation (Title XVIII, §1820(g)(4) of the Social Security Act (42 U.S.C. 1395i-4(g)(4)), as amended) limits indirect costs under the Flex Program.

http://www.dnb.com/duns-number.html https://www.sam.gov/ http://www.grants.gov/ http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf http://sam.gov/ https://www.fsd.gov/fsd-gov/answer.do?sysparm_kbid=d2e67885db0d5f00b3257d321f96194b&sysparm_search=kb0013183 https://www.gsa.gov/about-us/organization/federal-acquisition-service/office-of-systems-management/integrated-award-environment-iae/sam-update https://www.gsa.gov/about-us/organization/federal-acquisition-service/office-of-systems-management/integrated-award-environment-iae/sam-update http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf…