The Rural Hospital Innovation Grant is a funding program from the Kansas Department of Health and Environment that assists Kansas counties in transitioning their local hospital model of care to improve sustainability and community health access. Eligible applicants are county governments outside Douglas, Johnson, Sedgwick, Shawnee, or Wyandotte counties in Kansas, applying on behalf of a hospital within the county.

Applicants must be registered with SAM. gov, must demonstrate that all other available federal and state funds have been exhausted or are insufficient, and must provide attestation by the Board of County Commissioners. Award amounts are defined per the official program notice.

# Rural Hospital Innovation Grant Application Information in this section pertains to the County that is applying for the Rural Hospital Innovation Grant (RHIG) for use at a hospital within the county.

County Applying for RHIG funds: County Commissioner Information: Name and Title of Board of County Commissioners applying for grant: County Commissioners Address: Board Designee applying for grant if different from Board members listed above: Secondary County Contact: County Employer or Taxpayer Identification Number (EIN/TIN): Do you attest that the county is registered with SAM.

gov, in good standing, and will maintain registration for the life of this program? Yes ☐ No ☐ Provide a screenshot of your SAM. gov registration.

Do you attest that all other available Federal and/or State funds that could be applied to the proposed project have been exhausted, including but not limited to funds related to COVID-19 relief, State Loan Repayment Program (SLRP), National Health Service Corp (NHSC), Medicare Rural Hospital Flexibility Program (FLEX), Small Hospital Improvement Program (SHIP), SHIP COVID, and SHIP Testing and Mitigation?

Yes ☐ No ☐ Do you attest that no funds from other Federal and/or State programs are being utilized in duplication to fund the proposed project? Yes ☐ No ☐ Has the county received previous American Rescue Plan Act (ARPA) funds such as State and Local Fiscal Recovery Funds (SLFRF) ?

Yes ☐ No ☐ Does your organization have internal controls in place that include written policies and procedures for accounting separation of duties, conflict of interest, and grant program compliance/management? Copies should be available to KDHE upon request as part of routine monitoring activities.

Do you attest that all appropriate and necessary internal controls are being maintained, adhered to, and updated to assure that grant funds are being properly managed and utilized to achieve project objectives? Yes ☐ No ☐ How many State or Federal grant programs are currently being managed by your county?

Do you attest that $2 of outside stakeholder money has been or will be secured to match every $1 of State money provided through RHIG? It is the responsibility of the county to assure matched funds have been secured. What is the source of the matched funds?

Will the matched funds be held privately or will it be deposited in the Kansas State Treasury for use at the designated hospital? If held privately, proof of private stakeholder matched funds deposited into county bank account where RHIG funds will be distributed from will be required prior to state fund disbursement.

Held Privately ☐ Deposited in state treasury ☐4 Information if this section pertains to the Hospital where RHIG funds will be expended. Primary Hospital Contact: Secondary Hospital Contact: Do you attest that the hospital is registered with SAM. gov, in good standing, and will maintain registration for the life of this program?

What is the hospitals ownership type? Other: Briefly describe the ownership structure: What is your county’s or facility’s Primary Care Health Professional Shortage Area (HPSA) score: HPSA Find Is the hospital located in a Frontier, Rural, or Urban county? Select one: Does the hospital currently receive Small Hospital Improvement Program (SHIP) funding?

Select the hospital’s license classification: Describe briefly the geographic area the hospital serves and any underserved or indigent populations served. Include demographics and percentages if available. 6 Provide information to the following questions as it pertains to the proposed use of RHIG funds at the hospital.

Please try to limit responses to 500 words or less. Provide a brief description of the proposed use of RHIG funds including the structure and objectives of the use. How does the proposed use of funds address public health or negative economic impacts experienced in the community being served by the hospital?

Describe briefly how the proposed use of funds is related to and reasonable and proportional to the public health or economic impact being addressed. What are the intended outcomes for the proposed use of funds? If planning to utilize funds for a market study or other strategic analysis, will additional funds be needed to carry out a later project if deemed appropriate or necessary as a result of the study or analysis?

If additional funds will be required for a future project as a result of a market study or strategic analysis, what will be the source of the additional funding? N/A ☐7 How much money is being requested from the state RHIG fund? Do not include the matched portion, only the portion being requested from the state RHIG fund.

What is the anticipated total cost of the project? What is the timeline for the proposed use of funds? Final closeout deadline must be on or before March 31, 2025 .

Will RHIG funds be used to pay outside vendors, contractors, or consultants? Yes ☐ No ☐ If Yes, describe briefly. I certify that the information provided is accurate and complete to the best of my knowledge.

__________________________________________ Signature of Authorized County Representative __________________________________________ Printed Name of Authorized County Representative ________________ Date Submit completed applications to: kdhe. ruralhealth@ks. gov Include the subject line: " RHIG Application" when submitting.