Rural Regional Planning Application Response Form_Final.docx

State of Maine - Department of Health and Human Services

RFA# 202603044

Rural Regional Planning for Perinatal Care Districts 6 and 7

APPLICATION COVER PAGE

Applicant Name:

Chief Executive - Name/Title:

Tel:

E-mail:

Headquarters Street Address:

Headquarters City/State/Zip:

(Provide information requested below if different from above)

Lead Point of Contact for Application - Name/Title:

Tel:

E-mail:

Street Address:

City/State/Zip:

· This Application and the pricing structure contained herein will remain firm for a period of 180 days from the date and time of the bid opening.

· No personnel currently employed by the Department participated, either directly or indirectly, in any activities relating to the preparation of the Applicant’s Application.

· No attempt has been made, or will be made, by the Applicant to induce any other person or firm to submit or not to submit an Application.

· The above-named organization is the legal entity entering into the resulting contract with the Department should they be awarded the contract.

· The undersigned is authorized to enter contractual obligations on behalf of the above-named organization.

To the best of my knowledge, all information provided in the enclosed application, both programmatic and financial, is complete and accurate at the time of submission.

RESPONSIBLE APPLICANT CERTIFICATION

Applicant Name:

By signing this document, I certify to the best of my knowledge and belief that the aforementioned organization, its principals and any subcontractors named in this application:

a. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from bidding or working on contracts issued by any governmental agency.

b. Have not within three years of submitting the application for this contract been convicted of or had a civil judgment rendered against them for:

i. Fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a federal, state, or local government transaction or contract.

ii. Violating Federal or State antitrust statutes or committing embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or Local) with commission of any of the offenses enumerated in paragraph (b) of this certification.

d. Have not within a three (3) year period preceding this application had one or more federal, state, or local government transactions terminated for cause or default.

e. Have not entered into a prior understanding, agreement, or connection with any corporation, firm, or person submitting a response for the same materials, supplies, equipment, or services and this application is in all respects fair and without collusion or fraud. The above-mentioned entities understand and agree that collusive bidding is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards.

f. Is not a foreign adversary business entity (https://www.maine.gov/oit/prohibited-technologies).

g. Is not on the list of prohibited companies (https://www.maine.gov/oit/prohibited-technologies) or does not obtain or purchase any information or communications technology or services included on the list of prohibited information and communications technology and services https://www.maine.gov/oit/prohibited-technologies (Title 5 §2030-B).

General Instructions

Applicants must use this form to provide a response to their request for funding. Applicants may expand each of the response (white) spaces within this document in order to provide a full response to each requirement. Refer to “Submitting the Application” in the RFA for submission requirements.

Proposed District to be Served with related Counties (Select one) Applicants must submit a separate proposal for each Public Health District they intend to bid on.

Rural Regional Planning may be inclusive of towns/cities or services outside of the selected Public Health District to ensure comprehensive planning for a continuum of needs is addressed.

· The Tribal Health District will be represented within the specific county of the Public Health Districts listed below.

Public Health District (Select only one) Related Counties

REQUESTED AWARD SIZE

Applicants are eligible to receive up to $60,000 to lead regional rural planning efforts focusing on expanding birthing individuals’ access to high-quality perinatal care providers and services delivered across a variety of settings and through culturally responsive approaches.

Organization Qualifications and Experience

Describe the Applicants qualifications and skills to provide the services outlined in the RFA.

Include three (3) examples of projects which demonstrate the Applicant’s experience and expertise in performing these services as well as highlighting the Applicant’s stated qualifications and skills.

Project One

Business Reference Name:

Reference Contact Person:

Telephone:

E-Mail:

Project Start Date

Project End Date

Include a detailed description of the project below:

Project Two

Business Reference Name:

Reference Contact Person:

Telephone:

E-Mail:

Project Start Date

Project End Date

Include a detailed description of the project below:

Project Three

Business Reference Name:

Reference Contact Person:

Telephone:

E-Mail:

Project Start Date

Project End Date

Include a detailed description of the project below:

SUBCONTRACTORS

If subcontractors are to be engaged, Applicants must describe the application and review process the Applicant will use to evaluate the qualifications and experience of potential subcontractors, and how the Applicant will ensure that debarred, suspended, or otherwise ineligible parties are excluded from all subcontract relationships.

Subcontractor 1

Subcontractor Name:

Contact Person:

Telephone:

E-Mail:

Brief Description of Anticipated Role and Qualifications

Subcontractor 2

Subcontractor Name:

Contact Person:

Telephone:

E-Mail:

Brief Description of Anticipated Role and Qualifications

Subcontractor 3

Subcontractor Name:

Contact Person:

Telephone:

E-Mail:

Brief Description of Anticipated Role and Qualifications

ORGANIZATIONAL CHART

Applicants must provide an organizational chart for the project being proposed. Each position must be identified by position title and corresponding to the personnel job descriptions. Include any proposed subcontractors withing the organizational chart.

The organizational chart may be included below or may be attached to the application separately and appropriately labeled.

LITIGATION

Include a list of all current litigation in which the Applicant is named and a list of all closed cases that have closed within the past five (5) years in which the Applicant paid the claimant either as part of a settlement or by decree. For each, list the entity bringing suit, the complaint, the accusation, amount, and outcome. If no litigation has occurred, write “none”.

Case #

Entity Filing Suit:

Complaint/Accusation:

Amount:

Outcome

Case #

Entity Filing Suit:

Complaint/Accusation:

Amount:

Outcome

INSTRUCTIONS: Applicants must complete this form to discuss the Activities and Requirements referenced in Part II of the RFA and what the Applicant will offer, including:

· A description of the methods and resources the Applicant will use and how each task involved will be accomplished.

· A description of how the expectations and/or desired outcomes as a result of these services will be achieved.

· If subcontractors are involved, Applicants must clearly identify the work each will perform.

Proposed Project

A. Build a Rural Planning Group

1. Identify relevant healthcare and community partners, with a primary focus on rural areas within the Public Health District, needed to conduct Regional maternity and perinatal care planning, such as:

a. Birthing and non-birthing hospitals and health system representatives.

b. Tribal health clinics and Tribal nation representatives.

c. Person(s) with lived experience.

d. Doulas, community health workers.

e. Maternity providers, such as Doctor of Medicine; Doctor of Osteopathic; Physician Assistant; Certified Nurse Midwives; Advanced Practice Registered Nurse; Certified Professional Midwives; and Certified Midwives.

f. Family planning providers.

g. Child health providers.

h. Community resource partners, such as Public Health Nursing; the Maine Family Home Visiting Program; the Women, Infants and Children (WIC) Program; and Other applicable entities.

i. Other partners from various sectors including education, business partners, community leaders, local public health (e.g. District Liaisons through Maine CDC, representatives from the Public Health District’s District Coordinating Council), community assistance program agencies, etc.

In the applicant’s response, identify the specific Rural Regions where planning will be focused which will ensure a comprehensive planning for a continuum of needs will be addressed.

2. Provide a detailed workplan of the proposed outreach and efforts that focus on expanding access to birthing and high-quality perinatal care providers and services within the Public Health District to achieve diverse representation of the Regional planning efforts.

a. The awarded Applicants will be required to provide an updated workplan to the Department within seven (7) calendar days if there are any revisions or changes to the timeline or work to be performed throughout the resulting contract period.

B. Department Engagement and State Planning Processes

1. Work closely with the Department’s Transforming Maternal Health (TMaH) Perinatal Rural Regional Planning Liaison (TMaH Liaison) by:

a. Participating in Statewide discussions with TMaH and other Regional partners by attending virtual meetings at least every two (2) months.

b. Selecting a Regional representative to attend at least one (1) annual Statewide in-person meeting.

c. Creating a Statewide perinatal continuum of care model that includes Regional coordination of services.

d. Inviting the TMaH Liaison to attend Rural Planning Group meetings, specifically, at least one (1) in-person meeting per year and all other meetings remotely.

2. Contribute to the development of a Statewide model that provides a continuum of maternity and perinatal services, ensuring coordinated, high-quality care from pregnancy through the first twenty-four (24) months postpartum.

a. Provide quarterly progress reports to the TMaH Liaison which includes:

i. Milestones met.

ii. Activities completed.

iii. Barriers (experienced or expected); and

iv. Updated list of Regional planning partners.

b. Present and discuss Regional findings to the Department, including successes and challenges at least once a year.

c. Actively participate in TMaH-led meetings by providing feedback and collaborating with other partners.

C. Regional Planning

1. Coordinate and facilitate all aspects of Regional meetings, including inviting partners, taking attendance and meeting notes, and sharing meeting summaries with the Rural Planning Group and State leaders within two (2) weeks of the meeting.

a. Facilitate Regional planning sessions on a regular schedule for two (2) years, with a minimum of four (4) in-person sessions.

2. Develop a Regional inventory of services available to support maternity and perinatal care, including but not limited to:

a. Clinical services.

b. Community-based programs.

c. Support services.

d. Levels 1, 2, 3, and 4 birthing hospitals.

e. EMS services.

f. Federally Qualified Health Centers (FQHCs); and

g. Tribal health clinics.

h. Include a general description of workforce capacity across the continuum of maternity and infant care.

3. Identify Regional overarching goals in the first eight (8) months of the start of the contract period (e.g., improving communication between providers and communities related to maternal service access/resources, increasing referral activity and pathways, starting a centering pregnancy model of prenatal care).

4. Conduct at least one (1) in-person on-site visit of the relevant rural sites offering perinatal care/support within the first twelve (12) months of the start of the contract period.

5. Develop a SWOT Analysis of Regional perinatal access with the Rural Planning Group.

6. Provide mapping of a realistic Regional continuum of maternity and perinatal care that supports birthing individuals from pregnancy through twelve (12) months post-delivery, which includes:

a. Prenatal, delivery, and postpartum care.

b. Relevant existing services and/or supports; and

c. Regional services and/or support which the Rural Planning Group believes is reasonable to expand or augment.

i. If recommending augmenting or expanding services/support, include a detailed proposal for the change, as well as how the new/expanded services will be supported by referral pathways and coordination within existing services and support.

d. Documenting a comprehensive understanding of existing connections and barriers within the current services and support.

D. Reporting Requirements

1. Submit all the required reports to the Department in accordance with the timelines established in Table 1:

Table 1 – Required Reports and Timelines

Budget and Narrative

E. Allowable Use of Funds

Funding amounts will be negotiated with the awarded Applicants and subject to CMS approval and availability of funds.

1. Costs for Rural Planning Group participants, when appropriate to ensure participation and to support deliverables.

2. Payment for a facilitator.

3. Access to data or personnel time to analyze and report out on relevant data.

4. Costs for meetings.

5. Staffing cost for Regional lead and administrative support.

6. Support for a Family Leadership Development process to engage person(s) with lived experience to participate in the Rural Planning Group.

F. Non-Allowable Use of Funds

Cost restrictions can be viewed at the CMS-2N2-25-001 TMaH Model Grant Funding Opportunity webpage by selecting Related Documents and downloading the TMaH NOFO Final 6.26.24 file, refer to Section D.7. Cost Restrictions. Note: this list is not all-inclusive and changes and/or additional restrictions may apply.

BUDGET FORM INSTRUCTIONS

Complete the budget form (below) providing a breakdown of expenses for the entire period of performance as described in this RFA.

Request for funding should not exceed sixty thousand dollars ($60,000).

DHHS RFA Application Response Form (Rev. 10/2025)