making difference application

							UND 18-2012       Rural Health: Rural Hospital Flexibility (FLEX) Program ‘11 (CAH)      Page 1




      North Dakota Medicare Rural Hospital Flexibility Grant Program
          MAKING A DIFFERENCE FLEX GRANT PROGRAM
                  APPLICATION FORM (RFP 18-2012)
1.    Hospital Name:

      Federal Tax ID Number:


2.    Hospital Address:
      Phone Number:
      FAX Number:

3.    Name of Contact Person:

      E-mail address:


4.    Name of Acute Care Network Partner (referral hospital):


5.    What type of Flex Grant was the original award:

      a.      Critical Access Hospital Program ___

      b.      EMS Network Grant ___
                   List partners:

      c.      Network Enhancement Grant ___
                    List partners:

6.    □ Yes or □ No:    Completed registration with U.S. Federal Contractor site (also called
      Central Contractor Registration of CCR).

7.    _____________________________ Use this line to provide hospital 9-digit Dun &
      Bradstreet number, also called DUN’s number).

8.    Please describe your proposal by completing the following questions/sections.
      Note: Reviewers appreciate applications that are structured according to the outlined
      sections.
UND 18-2012        Rural Health: Rural Hospital Flexibility (FLEX) Program ‘11 (CAH)        Page 2


      A.      BUDGET & BUDGET NARRATIVE

              1.     The budget section could cover such areas as personnel, fringe benefits,
                     equipment, supplies, travel, contractual costs, etc.

              Rural Hospital Flexibility funds cannot be used to purchase or acquire real
              property or to improve existing property. The funds cannot be used for building
              and/or physical structural improvements.

              2.     The budget narrative must follow the order of the budget and is a
                     mechanism to assist the reviewers in understanding the budget. It should
                     help by using detail to elaborate on the dollar figures presented in the
                     budget.

              3.     A sample budget and budget narrative can be found on the Flex Program website:
                     http://ruralhealth.und.edu/projects/flex/grants.php

      B.      PROVIDE A DESCRIPTION OF THE ORIGINAL FUNDED FLEX PROJECT:

              1.     Need:
                     - What was the problem when Flex funds were originally awarded?
                     - How prevalent was the health issue?
                     - Who were the consumers? (demographics)
                     - How many people/communities were being impacted by the problem?
                     - How is/was the project accessed and used by consumers?
                     - Provide statistical information that demonstrates usage.
                     - Where is the program offered and where do consumers come from?

              2.     Project goals/objectives/responsible party:
                     - Describe the program goals and their subsequent objectives. Outline
                       how each is being addressed.
                     - Clearly identify who the responsible party(ies) are in administering the
                       program, identifying partners if there were/are any.

              3.     Accomplishments:
                     - Describe how this program has had a positive impact on consumers, on
                       the hospital, on personnel and the community as a whole?
                     - Support the program’s accomplishments with empirical evidence.
                       (What has been measured?)

              A strong application will include hospital financial information that indicates how
              the hospital has benefited from providing the service, other financial information
              such as consumer financial savings that resulted from having access to this
              program at the local level (travel time and cost savings), how providers and staff
UND 18-2012        Rural Health: Rural Hospital Flexibility (FLEX) Program ‘11 (CAH)        Page 3

              have benefited (morale, training for skill development, etc.), and other areas
              deemed appropriate to report. Include reference to population health if able. Both
              empirical and anecdotal information is favored. An appendix might include
              actual statements from consumers that attest to their satisfaction, use and current
              need for this service.



      C.      PROVIDE A DESCRIPTION OF THE PROPOSED NEW PROJECT:

              1.     Need & Scope:
                     - Describe the need to further this project’s scope of work and identify
                       whether this is program enhancement and/or program expansion (i.e.
                       does the new project improve the original project but target the same
                       population (enhancement)? or does it reach out to other surrounding
                       communities, but offer basically the same service to the same
                       demographic population (expansion)?
                     - Describe how the project will be enhanced and/or expanded.

              2.     Project goals/objectives/responsible party:
                     - Describe the program goals and their subsequent objectives.
                     - Include a timeline related to program activities.
                     - Clearly identify who the responsible party(ies) are, including the
                       identification of partners if applicable..

              3.     Potential Impact:
                     - Include a description of how the program goals will be measured.
                     - Describe the potential impact that this program will have on the target
                       population, the hospital, personnel and the community as a whole? (Be
                       as specific as possible.)


9.    Signature and Title of Application Preparer:

      ____________________________________________                 ___________________
      Print Name and Title                                         Date

      ____________________________________________
      Signature not required due to electronic submission


10.   Signature and Title of Hospital Official authorized to enter into contract:

      ___________________________________________                  __________________
      Print Name and Title                                         Date
UND 18-2012      Rural Health: Rural Hospital Flexibility (FLEX) Program ‘11 (CAH)   Page 4



      ___________________________________________
      Signature not required due to electronic submission