Appalachian Region Healthcare Support Program

Appalachian Region Healthcare Support Program is sponsored by Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy. This opportunity supports mission-aligned projects and measurable outcomes.

U.S. Department of Health and Human Services # NOTICE OF FUNDING OPPORTUNITY # Federal Office of Rural Health Policy # Hospital State Division # Appalachian Region Healthcare Support Program # Funding Opportunity Number: HRSA-24-119 # Funding Opportunity Type(s): New # Assistance Listing Number: 93. 912 # Application Due Date: July 25, 2024 Ensure your SAM. gov and Grants.

gov registrations and passwords are current immediately! We will not approve deadline extensions for lack of registration. Registration in all systems may take up to 1 month to complete.

Issuance Date: June 25, 2024 Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy Email: RuralHospitals@hrsa. gov See Section VII for a complete list of agency contacts. Authority: 42 U.S.C.

§ 912(b)(5) (§711(b)(5) of the Social Security Act) HRSA-24-119 i # 508 COMPLIANCE DISCLAIMER Persons using assistive technology may not be able to fully access information in this file. For assistance, email or call one of the HRSA staff listed in Section VII Agency Funding Opportunity Title: Appalachian Region Healthcare Support Program Funding Opportunity Number: HRSA-24-119 Assistance Listing Number: 93.

912 Due Date for Applications: July 25, 2024 Purpose: The Appalachian Region Healthcare Support Program provides technical assistance (TA) to help rural healthcare organizations, including critical access hospitals (CAHs), small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations located in the rural counties served by the Appalachian Regional Commission (ARC) with planning and implementing health care service improvements.

Program Objective(s): Improve health care in rural counties within the area served by the ARC (the Appalachian Region) by working with rural healthcare organizations to: • Provide objective analysis and assessment of healthcare organizations’ financial status, quality indicators, locally available human services, and gaps in services so organizations can make actionable change; • Identify clinical areas where expansion of services within a rural healthcare organization would meet local need, keep health care services available locally, and build capacity to improve financial and operational performance as well as quality of care.

HRSA-24-119 ii • Support healthcare organizations in implementing best practice recommendations prioritized in TA action plans.

Eligible Applicants: You can apply if your organization is in the United States, the Commonwealth of Puerto Rico, the Northern Mariana Islands, American Samoa, Guam, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau, and is: • Public or private, non-profit, or for-profit • Native American tribal governments • Native American tribal organizations See Section III.

1 of this notice of funding opportunity (NOFO) for complete eligibility Anticipated FY 2024 Total Available Funding: Estimated Number and Type of Award(s): Approximately 1 new cooperative agreement Estimated Annual Award Amount: Up to $1,500,000 per award, subject to the availability of appropriated funds Cost Sharing or Matching Required: Period of Performance: September 30, 2024, through September 29, 2027 (3 years) HRSA-24-119 iii Agency Contacts: Business, administrative, or fiscal issues: Lissette Young Grants Management Specialist Division of Grants Management Operations, OFAM Program issues or technical assistance: Public Health Analyst, Hospital State Division Federal Office of Rural Health Policy Email: RuralHospitals@hrsa.

gov You (the applicant organization / agency) are responsible for reading and complying with the instructions included in this NOFO and in HRSA Application Guide (Application Guide) . Visit HRSA’s How to Prepare Your Application page for more information. We have scheduled the following webinar: Thursday, June 27th, 2024 gov.zoomgov.

com/j/1610615485? pwd=Y0VtaVFVYTRVdFBJdHc3WTkyd0NmZz0 Attendees without computer access or computer audio can use the following dial-in information: Call-In Number: 1-833-568-8864 We will record the webinar. HRSA-24-119 iv I.

PROGRAM FUNDING OPPORTUNITY DESCRIPTION ............................................ 1 1. PURPOSE ................................................................................................................

1 2. BACKGROUND ......................................................................................................... 1 II.

AWARD INFORMATION ........................................................................................... 3 1. TYPE OF APPLICATION AND AWARD ..........................................................................

3 2. SUMMARY OF FUNDING ............................................................................................ 4 III.

ELIGIBILITY INFORMATION ................................................................................... 5 1. ELIGIBLE APPLICANTS .............................................................................................

5 2. COST SHARING OR MATCHING .................................................................................. 5 3.

OTHER.................................................................................................................... 5 IV. APPLICATION AND SUBMISSION INFORMATION ...............................................

5 1. ADDRESS TO REQUEST APPLICATION PACKAGE ........................................................ 5 2.

CONTENT AND FORM OF APPLICATION SUBMISSION ................................................... 6 i. Project Abstract ...........................................................................................

8 ii. Project Narrative .......................................................................................... 8 iii.

Budget ......................................................................................................... 12 iv. Budget Narrative ........................................................................................

12 v. Attachments ............................................................................................... 12 3.

INCLUDE ANY OTHER DOCUMENTS THAT ARE RELEVANT TO THE APPLICATION. UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD MANAGEMENT (SAM) .................... 13 4.

SUBMISSION DATES AND TIMES .............................................................................. 15 5. INTERGOVERNMENTAL REVIEW ...............................................................................

15 6. FUNDING RESTRICTIONS ........................................................................................ 15 V.

APPLICATION REVIEW INFORMATION ............................................................... 15 1. REVIEW CRITERIA ..................................................................................................

15 2. REVIEW AND SELECTION PROCESS ......................................................................... 20 3.

ASSESSMENT OF RISK ........................................................................................... 20 VI. AWARD ADMINISTRATION INFORMATION ........................................................

20 1. AWARD NOTICES ................................................................................................... 20 2.

ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS ......................................... 21 3. REPORTING ...........................................................................................................

23 VII. AGENCY CONTACTS ........................................................................................... 23 VIII.

OTHER INFORMATION ....................................................................................... 24 APPENDIX: PAGE LIMIT WORKSHEET .................................................................... 26 HRSA-24-119 1 # I.

Program Funding Opportunity Description The Appalachian Region Healthcare Support Program provides technical assistance (TA) to help rural healthcare organizations, including critical access hospitals (CAHs), small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations located in the rural counties served by the Appalachian Regional Commission (ARC) with planning and implementing health care service improvements.

The goal of this program is to strengthen healthcare delivery in rural areas of the Appalachian Region by improving financial and operational performance as well as the quality of care in rural healthcare organizations.

The TA provider funded under this cooperative agreement will work with individual healthcare organizations to meet the following program objectives: • Provide objective analysis and assessment of healthcare organizations’ financial status, market share, quality indicators, locally available human services, and gaps in services so that organizations can make actionable change; • Identify clinical areas where expansion of services within a rural healthcare organization would meet local need, keep health care services available locally, and build capacity to improve financial and operational performance as well as quality of care.

• Support healthcare organizations in implementing best practice recommendations prioritized in TA action plans. For purposes of this notice of funding opportunity, “rural healthcare organization” is a health care organization located in a rural area in the Appalachian Region.

A “healthcare organization” includes critical access hospitals, small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations. To determine if a health care organization is located in a rural area, visit https://data. hrsa.

gov/tools/rural-health. To determine if a county is in the Appalachian Region, visit https://www. arc.

gov/appalachian-counties-served-by-arc. For more details, see Program Requirements and Expectations . The Appalachian Region Healthcare Support Program is authorized by 42 U.S.C.

912(b) (§ 711(b) of the Social Security Act). The Appalachian Regional Commission (ARC) is a federally chartered, regional economic development entity that was established in 1965 to address economic HRSA-24-119 2 distress in the Appalachian region.

1 The ARC focuses on 423 counties across Appalachia in 13 states (Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia), and the Appalachian region includes 3 federally recognized and 5 state recognized American Indian Tribal Communities.

2, 3 In 2024, 82 (19 percent) of Appalachian counties are designated as distressed (the most economically depressed counties) and 101 (24 percent) as at-risk (at risk of becoming economically distressed). 4 Of the 423 counties that make up Appalachia, 107 (25 percent) are rural (non-metropolitan area), and nearly 10 percent (approximately 2. 5 million people) of Appalachian residents live in rural counties.

5 Rural Appalachian residents experience serious economic and health challenges. Nearly 20 percent of the rural Appalachian population are living in poverty, compared with 15 percent of the residents in non-Appalachian rural counties. In terms of disability, 20 percent of rural Appalachian residents have a disability compared with about 16 percent of the non-Appalachian rural population.

6 Rural healthcare organizations, including critical access hospitals (CAHs), small rural hospitals, rural health clinics, tribal healthcare facilities, and other healthcare organizations located in rural counties provide essential health care to the nearly 60 million people who live in rural areas. However, since 2005 there have been 191 rural hospital closures across the United States, including nine closures in 2023.

7 A 2022 HRSA-funded study conducted by the North Carolina Rural Health Research Program found that rural hospitals that closed between 2017 to 2020 were more unprofitable and much less liquid. The study reports that in the year leading up to a closure, most rural hospitals tend to have few days cash on hand, a negative operating margin, and a negative total margin.

8 A related and ongoing concern is the financial sustainability of the remaining facilities. Based on the Federal Office of Rural Health Policy-funded financial distress index at the University of North Carolina Rural Health Research Center, 9. 2% (196) of rural hospitals > 1 Congressional Research Service.

(2024). Federal Regional Commissions and Authorities: Structural Features and Function. https://crsreports.

congress. gov/product/pdf/R/R45997 (citing P. L.

89-4 and 40 > U.S.C. §§14101-14704), pp. 2-3.

> 2 Congressional Research Service. (2024). Federal Regional Commissions and Authorities: Structural Features and Function.

https://crsreports. congress. gov/product/pdf/R/R45997 > 3 Appalachian Regional Commission.

(2024). https://www. arc.

gov/about-the-appalachian-region/ > 4 Appalachian Regional Commission. (2024). Classifying Economic Distress in Appalachian Counties .

> https://www. arc. gov/classifying-economic-distress-in-appalachian-counties/ > 5 The Appalachian Region: A Data Overview from the 2017-2021 American Community Survey, Chartbook.

(2024). Population Reference Bureau. https://www.

arc. gov/about-the-appalachian-region/the- > chartbook/rural-appalachia/ > 7 University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research.

“Rural Hospital Closures” https://www. shepscenter. unc.

edu/programs-projects/rural-health/rural-hospital- > closures/ . Accessed Jan 2024. > 8 Osgood AS, Pink GH.

Rural Hospitals that Closed between 2017-20: Profitability and Liquidity in the Year before Closure. NC Rural Health Research Program, UNC Sheps Center. November 2021.

> https://www. shepscenter. unc.

edu/download/23647/ were predicted to be at high risk of financial distress in 2019. 9 Hospitals experiencing high financial distress often reduce services, limiting access to care for vulnerable populations and worsening health disparities. Ten of the 13 Appalachian Region states have hospitals at the highest risk of financial distress.

10 Another challenge that impacts the financial sustainability of rural hospitals is serving small populations. With smaller patient populations, rural hospitals have low patient volume and may not have enough patients to cover high fixed operating costs.

11 The Appalachian Region Healthcare Support Program aims to strengthen healthcare delivery in rural areas in the Appalachian Region through providing technical assistance to help build capacity in rural healthcare organizations, with a focus on improving financial and operational performance as well as quality of care. 1. Type of Application and Award We will fund you via a cooperative agreement.

A cooperative agreement is like a grant in that we award money, but we are substantially involved with program activities.

Aside from monitoring and TA, we also get involved in these ways: • Provide technical assistance to you to help prioritize program activities and assess progress in achieving the goals of this cooperative agreement; • Facilitating introductions to other HRSA programs, federal agencies and other HRSA award recipients as their work may pertain to assisting rural healthcare organizations; • Sharing of relevant program data to ensure the greatest impact of TA efforts in rural counties in the Appalachian Region; • Provide technical assistance, upon request, on processes for the identification and selection of sub-contractors, healthcare organization technical experts, rural healthcare organizations to receive TA, and other key stakeholders involved in the program; > 9 Thomas SR, Pink GH, Reiter K.

Geographic Variation in the 2019 Risk of Financial Distress among Rural Hospitals. NC Rural Health Research Program, UNC Sheps Center. April 2019.

> https://www. shepscenter. unc.

edu/wp-content/uploads/dlm_uploads/2019/04/FDI-Geo-1. pdf > 10 https://www. ruralhealthresearch.

org/publications/1658 > 11 American Hospital Association. Rural Report. (2019).

https://www. aha. org/system/files/2019-02/rural- • Reviewing and providing feedback and recommendations on TA products and proposed outcome measures specific to TA provided; and • Participating, as appropriate, in the planning and implementation of any meetings, webinars, advisory committees, or work groups.

You must follow all relevant federal regulations and public policy requirements.

Your other responsibilities will include: • Consulting with HRSA in marketing available services, benefits of participation, and ongoing implementation of proposed activities; • Engaging with key stakeholders such as State Offices of Rural Health, state hospital associations, and State Rural Health Associations to market services and identify potential rural healthcare organizations to receive TA; • Working with the selected rural healthcare organizations to identify clinical areas where expansion of services would meet local medical need, help keep health care services available locally and improve rural healthcare organization finances, operations, and quality of care; and • Ensuring interventions are responsive to the needs of the rural healthcare organization community to gain community buy-in, as well as commitment from key organization and community leaders for active engagement during the project and sustaining activities after TA is provided.

We estimate $1,500,000 will be available each year to fund approximately 1 recipient. You may apply for a ceiling amount of up to $1,500,000 annually (reflecting direct and indirect costs). The period of performance is September 30, 2024, through September 29, 2027 (3 years).

Support beyond the first budget year will depend on: • Appropriation of funds for this purpose • Satisfactory progress in meeting the project’s objectives • A decision that continued funding is in the government’s best interest 45 CFR part 75 - Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards applies to all HRSA awards.

If you’ve never received a negotiated indirect cost rate, you may elect to charge a de minimis rate of 10 percent of modified total direct costs (MTDC)*. You may use this for the life of the award. If you choose this method, you must use it for all federal awards until you choose to negotiate for a rate.

You may apply to do so at any time. See Section 4. 1.

v. Budget Narrative in the Application Guide . HRSA-24-119 5 *Note : One exception is a governmental department or agency unit that receives more than $35 million in direct federal funding.

# III. Eligibility Information You can apply if your organization is in the United States, the Commonwealth of Puerto Rico, the Northern Mariana Islands, American Samoa, Guam, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau, and is: • Public or private, non-profit, or for-profit • Native American tribal governments • Native American tribal organizations 2.

Cost Sharing or Matching Cost sharing or matching is not required for this program. We may not consider an application for funding if it contains any of the following non-responsive criteria: • Exceeds the funding ceiling amount • Fails to satisfy the deadline requirements referenced in Section IV. 4 We will only review your last validated application before the Grants.

gov due date . # IV. Application and Submission Information 1.

Address to Request Application Package We require you to apply online through Grants. gov . Use the SF-424 workspace application package associated with this notice of funding opportunity (NOFO).

Follow these directions: How to Apply for Grants . If you choose to submit using an alternative online method, see Applicant System-to-System . If you cannot submit electronically, you can request a waiver.

See section 3. 6 of HRSA’s Application Guide . Note : Grants.

gov calls the NOFO “Instructions. ” HRSA-24-119 6 2. Content and Form of Application Submission Application Format Requirements Submit your information as the Application Guide and this program-specific NOFO state.

Do so in English and budget figures expressed in U.S. dollars. There’s an Application Completeness Checklist in the Application Guide to help you. The total number of pages that count toward the page limit shall be no more than 50 pages when we print them.

We will not review any pages that exceed the page limit. Using the pages within the page limit, HRSA will determine eligibility using Section III. Eligibility Information of the NOFO.

These items do not count toward the page limit: • Standard OMB-approved forms you find in the NOFO’s workspace application package • Abstract (standard form (SF) "Project_Abstract Summary”) • Indirect Cost Rate Agreement • Proof of non-profit status (if it applies) If there are other items that do not count toward the page limit, we’ll make this clear in Section IV. 2. vi Attachments .

If you use an OMB-approved form that is not in the HRSA-24-119 workspace application package, it may count toward the page limit. Applications must be complete and validated by Grants. gov under HRSA-24-119 before the deadline .

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification • When you submit your application, you certify that you and your principals 12 (for example, program director, principal investigator) can participate in receiving award funds to carry out a proposed project.

That is, no federal department or agency has debarred, suspended, proposed for debarment, claimed you ineligible, or you have voluntarily excluded yourself from participating. • If you fail to make mandatory disclosures, we may take an action like those in 45 CFR § 75. 371 .

This includes suspending or debarring you. 13 > 12 See definitions at eCFR :: 2 CFR 180. 995 -- Principal.

and eCFR :: 2 CFR 376. 995 -- Principal (HHS > supplement to government-wide definition at 2 CFR 180. 995).

> 13 See also 2 CFR parts 180 and 376 ,31 U.S.C. § 3354 , and 45 CFR § 75. 113 .

• If you cannot certify this, you must include an explanation in Attachment 6-15: Other Relevant Documents . (See Section 4. 1 viii “Certifications” of the Application Guide ) Program Requirements and Expectations 1.

You are expected to select and provide TA to at least five rural healthcare organizations per year that are located in the rural counties in the Appalachian Region. You are expected to work collaboratively with HRSA and ARC on an ongoing basis as you carry out program activities. 2.

You must develop and manage a network of nationally known, rural healthcare organization technical experts (which will be heavily focused on finance and quality issues but may also include operational and clinical experts) to provide consultations to rural health care organizations to improve financial and operational performance, and quality.

At a minimum, this network of experts must conduct market assessments, quality assessments and financial and operational assessments for each rural healthcare organization selected to receive TA. 3. You must identify and market to rural healthcare organizations who will benefit from TA.

4. You are expected to utilize existing national standards for assessing financial risk, such as but not limited to the University of North Carolina’s Financial Distress Index, as part of the selection of rural healthcare organizations. 5.

You must develop a TA plan that meets the objectives of this program that includes a process for identifying community health care needs, market share, operational efficiencies, and other service line expansions in each rural healthcare organization to strengthen healthcare delivery in the Appalachian Region. 6.

Based on expert recommendations, you will provide support for software and equipment to implement best practices prioritized in TA action plans. HRSA recommends that you use at least 15 percent of your budget for this purpose. You must monitor to ensure that the funding is spent in support of program objectives.

7. HRSA expects you to work with each selected rural healthcare organization to gain commitment for participating and implementing the recommended activities from TA consultations. 8.

You are expected to provide services only to rural healthcare organizations not already receiving TA from other federal programs. 9. You are expected to share data collected as a part of the program with HRSA.

# Program-Specific Instructions HRSA-24-119 8 Include application requirements and instructions from Section 4 of the Application Guide (budget, budget narrative, staffing plan and personnel requirements, assurances, certifications, and abstract). Also include the following: Use the Standard OMB-approved Project Abstract Summary Form that you’ll find in the workspace application package.

Do not upload the abstract as an attachment or it may count toward the page limit. For information you must include in the Project Abstract Summary Form, see Section 4. 1.

ix of the Application Guide. The following table provides a crosswalk between the narrative language and where each section falls within the review criteria. Make sure you’ve addressed everything.

We may consider any forms or attachments you reference in a narrative section during the merit review.

Narrative Section Review Criteria Introduction Criterion 1: NEED Organizational Information Criterion 5: RESOURCES/CAPABILITIES Criterion 6: SUPPORT REQUESTED Approach Criterion 2: RESPONSE Work Plan Criterion 2: RESPONSE Resolution of Challenges Criterion 2: RESPONSE Evaluation and Technical Support Capacity Criterion 3: EVALUATIVE MEASURES Budget Narrative Criterion 6: SUPPORT REQUESTED This section must describe all aspects of the proposed project.

Make it brief and clear. Provide the following information in the following order. Please use the section headers.

This ensures reviewers can understand your proposed project.  Introduction -- Corresponds to Section V’s Review Criterion (1) NEED Briefly describe the purpose of the proposed project for providing in-depth TA to assist rural healthcare organizations in the Appalachian Region with building capacity to improve their financial and operational performance as well as the quality of care they provide.

HRSA-24-119 9  Organizational Information -- Corresponds to Section V’s Review Criterion (5) RESOURCES/CAPABILITIES and Criterion (6) SUPPORT REQUESTED o Briefly describe your organization’s mission, structure, scope of current activities, and key stakeholders/consultants’ abilities to carry out all aspects of the proposed project.

Explain how these elements all contribute to your ability to meet all program requirements and program expectations . Include a project organizational chart in Attachment 5. Include staffing plan and job descriptions as Attachment 2, and biographical sketches for all key personnel as Attachment 3.

o Demonstrate your organization’s capacity to develop and manage a network of nationally known rural healthcare organization technical experts with financial, operational, and clinical expertise and a strong track record of working with rural healthcare organizations. Discuss your plan for governance and decision making as it relates to selecting and managing technical experts.

o As applicable, identify staff and/or consultants who are located in, familiar with, or who have worked with healthcare organizations in the Appalachian Region. o Include signed Letters of Agreement from all key stakeholders and consultants in Attachment 4.

o Demonstrate your organization’s and your network of rural healthcare organization technical experts’ history providing TA specifically to rural healthcare organizations at a national or regional level. Discuss any past TA provided in the Appalachian region. Include a discussion on the implementation, outcomes and results of the TA provided.

o Discuss how you’ll follow the approved plan, account for federal funds, and record all costs to avoid audit findings.

If funds will be sub-awarded or expended on contracts, explain how your organization will provide overall program management and ensure these funds are properly used and monitored, including having policies and procedures in place that meet or exceed the requirements in 45 CFR part 75 regarding sub-recipient monitoring and management.

 Need-- Corresponds to Section V’s Review Criterion (1) NEED The needs assessment should demonstrate a strong understanding of specific challenges rural healthcare organizations face in building financial sustainability, specifically in the Appalachian Region. You must use and cite data (e.g., local, state, federal) whenever possible to support the information provided.

o Discuss the need for in-depth TA to support rural healthcare organizations to identify gaps in services that meet local need and HRSA-24-119 10 improve rural healthcare organization finances and operations as well as quality of care. o Describe the specific challenges rural healthcare organizations face in keeping health care services available locally.

 Approach -- Corresponds to Section V’s Review Criterion (2) RESPONSE Your approach should demonstrate how you will meet the program requirements and expectations described in this NOFO. o Discuss the strategy for assessing a selected organization’s community health care needs, market share, quality indicators and financial and operational performance to inform program recommendations.

Discuss your process for identifying areas for expansion that meet local need as well as your methodology for ensuring any recommendations will be cost efficient, financially viable, and able to be implemented. o Describe the types of TA resources that will be provided to rural healthcare organizations participating in the program that will meet program requirements and expectations .

o Describe the approach you will use to identify and select rural healthcare organizations to receive in-depth TA each year. o Describe how you will prioritize rural healthcare organizations based on selection criteria. o Discuss how you will market the benefits of participation and the availability of services through this program to rural healthcare organizations.

o Discuss the strategy for determining a rural healthcare organization’s readiness for TA, including commitment from organization’s board/ leadership, adequacy of resources and support to participate fully in the program and implement program recommendations. o Discuss how you will continue to foster engagement from key organization leadership throughout the project and strategy for sustaining activities after the TA services end.

o Describe a plan to track and report on rural healthcare organization progress in meeting TA recommendations, including disseminating best practices, reports, products, or project outputs to HRSA and target audiences. o Identify meaningful support from and collaboration with key stakeholders in planning, designing, and implementing all activities.

Key stakeholders may include, but are not limited to, the Appalachian Regional Commission, state hospital associations, State Offices of Rural Health, and State Rural Health Associations. HRSA-24-119 11 Describe how you will provide support for software and equipment to implement best practices prioritized in TA action plans, and how you will monitor those projects to ensure that the funds are spent in support of program objectives.

Describe approximately what percentage of your budget will be used to provide support for software and equipment. HRSA recommends that you use at least 15 percent of your budget for this purpose.

 Work Plan -- Corresponds to Section V’s Review Criterion (2) RESPONSE o Provide a detailed work plan in Attachment 1 that describes the activities or steps you will use to implement a national network of rural healthcare organization technical experts to achieve program goals, objectives, and requirements.

o Include a timeline that outlines each activity for the entire period of performance and identifies the responsible staff for each activity. As needed, identify meaningful support from and collaboration with key stakeholders that will help plan, design, and carry out all activities.

 Resolution of Challenges -- Corresponds to Section V’s Review Criterion (2) o Discuss challenges that you are likely to encounter in designing and carrying out the activities in the work plan. Explain approaches that you will use to resolve them.

o Describe specific, unique challenges that rural healthcare organizations in the Appalachian Region experience in keeping health care services available locally, and the plan you will use to address them.

 Evaluation and Technical Support Capacity -- Corresponds to Section V’s Review Criteria (3) EVALUATIVE MEASURES and (4) IMPACT o For the purpose of self-assessment, briefly describe your organizational profile, budget, key stakeholders/ consultants, and key staffs’ experience, skills, and knowledge, key processes, and expected outcomes of the funded activities.

Discuss how the proposed project will impact the availability of health care services in rural areas. o Describe the systems and processes that you’ll use to track performance outcomes. Describe how you’ll collect and manage data (for example, assigned skilled staff, data management software) in a way that allows for accurate and timely reporting of those outcomes.

o Describe your plan to monitor project implementation and provide the specific process measures you will use to monitor how well you implement your project as planned.

HRSA-24-119 12 o Describe your plan to assess how effective your project is in meeting the program objectives, the specific outcome measures you will use (such as increase in revenue and increase in patient volume), as well as how you will use process and outcome measure data to improve your project over the three-year project period.

o Describe how your outcome measures will effectively assess the performance of each rural healthcare organization project and the performance of the organization projects collectively over the three-year project period. o Describe barriers to collecting and using process and outcome measure data and your plan to address those barriers. The Application Guide directions may differ from those on Grants.

gov. Follow the instructions in Section 4. 1. iv Budget of the Application Guide and any specific instructions listed in this section.

Your budget should show a well-organized plan. Reminder: The total project or program costs are all allowable (direct and indirect) costs used for the HRSA activity or project. This includes costs charged to the award and non-federal funds used to satisfy a matching or cost-sharing requirement (which may include MOE, if applicable).

You must use any program income you generate from awarded funds for approved project-related activities. Use program income under the addition alternative (45 CFR § 75. 307(e)(2)).

Find post-award requirements for program income at 45 CFR § 75. 307 . As required by the Further Consolidated Appropriations Act, 2024 (P.

L. 118-47), Division D, Title II, § 202, “ 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. ” Effective January 2024, the salary rate limitation is $221,900.

As required by law, salary rate limitations may apply in future years and will be updated. See Section 4. 1.

v. of the Application Guide. Provide the following attachments in the order we list them.

Most attachments count toward the application page limit . Indirect cost rate agreement and proof of non-profit status (if it applies) are the only exceptions. They will not count toward the page limit.

HRSA-24-119 13 Clearly label each attachment . Upload attachments into the application. Reviewers will not open any attachments you link to.

Attach the project’s work plan. Make sure it includes everything that Section IV. 2.

ii. Project Narrative details. Attachment 2: Staffing Plan and Job Descriptions for Key Personnel (see Section 4.

1. of the Application Guide) Keep each job description to one page as much as possible. Include the role, responsibilities, and qualifications of proposed project staff.

Describe your organization’s timekeeping process. This demonstrates that you’ll comply with federal standards related to recording personnel costs. Attachment 3: Biographical Sketches of Key Personnel Include biographical sketches for people who will hold the key positions you