Full Text HS-94-006


NIH GUIDE, Volume 23, Number 7, February 18, 1994

RFA:  HS-94-006



Agency for Health Care Policy and Research

Letter of Intent Receipt Date:  April 15, 1994
Application Receipt Date:  May 17, 1994


The Agency for Health Care Policy and Research (AHCPR) announces the
availability of cooperative agreements to develop and manage AHCPR
Rural Centers (Centers) to plan and carry out demonstrations of rural
managed care systems in HHS Regions which do not currently have an
AHCPR Rural Center:  Regions I, III, VI, VII, and IX.  This
solicitation is part of AHCPR's Rural Health Initiative.  (AHCPR now
supports by contracts Rural Centers in Regions II, IV, V, VIII, and

The Centers are encouraged to form consortia that include appropriate
State health agencies and academic health science centers.  Center
staff should include appropriate multidisciplinary scientific and
administrative experts.

This Request for Applications (RFA) responds to a Fiscal Year (FY)
1994 directive from the Senate Appropriations Committee for AHCPR to
make grants or cooperative agreements to rural States or health
science centers to assist in the development and demonstration of
managed care networks.  The Committee is particularly concerned that
changes in health care systems nationally that incorporate
innovations in the organization, financing, and delivery of health
care services will not be as accessible to rural populations as those
in urban areas where market forces already effect changes.

The Centers, with substantial input from staff and consultants at
AHCPR, will conduct demonstrations of innovations in the delivery of
health care services in rural areas of the Center's respective State
or region.  Priority will be given to demonstrations of organized
networks of health services delivered to underserved populations such
as populations living in a designated health professional shortage
area, those living in isolated areas and/or impoverished areas, and
uninsured and/or unemployed rural people.  AHCPR will arrange for the
conduct of independent evaluations of these demonstrations.


The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas.  This Request
for Applications (RFA), AHCPR Rural Centers, addresses several of
those objectives.  Potential applicants may obtain a copy of "Healthy
People 2000" (Full Report:  Stock No. 017-001-00474-0 or Summary
Report:  Stock No. 017-001-00473-1) through the Superintendent of
Documents, Government Printing Office, Washington, DC 20402-9325
(telephone 202-783-3238).


Applications may be submitted by: (1) domestic, non-profit
organizations, public or private, including universities, clinics,
units of State and local governments, non-profit firms, and
non-profit foundations; or (2) consortia of organizations, if the
application is submitted by a domestic, non-profit, public or private
organization.  For AHCPR Rural Centers demonstration projects, only
non-profit organizations in HHS Regions I, III, VI, VII, and IX are
eligible to apply.  See discussion under "Objectives and Scope."
Applications from minority and women investigators are encouraged.


The administrative and funding instrument to be used for this program
will be the cooperative agreement (U54), an assistance mechanism
(rather than an acquisition mechanism), in which substantial AHCPR
scientific and programmatic involvement with the awardee(s) is
anticipated during the performance of the activity.  These awards
permit core funding in which the recipient organization may be
reimbursed for administrative and staff support for:  the planning,
initiation, and monitoring of the demonstration(s); technical
assistance in the implementation of statewide managed care plans; and
dissemination mechanisms such as Center-sponsored newsletters.  Any
other support for these activities is available to grant-eligible
institutions from AHCPR and other PHS agencies through their
continuing programs of extramural investigator initiated research and
not through this RFA.

Demonstrations may be supported in their initial stages with core
funds, although it is expected that most of the demonstrations will
be sponsored with funds obtained from sources other than the core
award.  As noted below, review criteria include reference to the
proposed Center's plans to attract and retain other funding sources
in support of its demonstration(s).  Details of the responsibilities,
relationships, and governance of the projects to be funded under this
cooperative agreement are listed under SPECIAL REQUIREMENTS.

The total project period for applications submitted in response to
this RFA may not exceed five years.  The anticipated award date is
September 1, 1994.  Award of continuation funding beyond the initial
budget period will depend upon availability of funds, satisfactory
progress, and annual progress reviews according to customary AHCPR
administrative procedures.  This RFA is a one-time solicitation.


The AHCPR expects to award a total of $10 million over five years
under this RFA for up to five applicants.  Up to $2 million will be
available in FY 1994 and an average of $2 million for each of the
next four fiscal years.



The Senate Committee Report on FY 1994 Appropriations (Report
103-143) directed AHCPR to "give grants or cooperative agreements to
rural States or health sciences centers for planning (including an
evaluation plan) and initiating a statewide or regional managed care
system incorporating features of primary care, clinical preventive
care services, and essential information networks to facilitate
information transfer, including information on health care costs,
quality measurement, and overall health care system performance."
The Committee states that "because access to care is a major problem
in rural States, the managed care network will be in a State" that

1.  Limited public transportation infrastructure,
2.  Geographic features that limit transportation,
3.  Significant health status problems in the population,
4.  Limited managed care penetration statewide,
5.  Unemployment rates above the national average,
6.  High percentage of the rural area designated as health
professional shortage areas.

The AHCPR supports and conducts health services research, including
evaluations of health systems.  This request for applications is for
the planning and implementing of demonstration projects aimed at
improving access to quality health care for rural residents, using
managed care principles.  These demonstration projects should be in
States that reflect the six criteria specified in the Senate
Committee report, as listed above.  Through these activities the
Centers, in collaboration with AHCPR and its consultants, will
provide technical expertise to improve the effectiveness of health
care services delivered to rural populations.

Rural populations have been found to be in poorer health than most
groups in urban and suburban communities.  Some rural States with
isolated populations have not provided for the inclusion of these
citizens in managed care networks in spite of the anticipated role of
such networks in health care reform.  In many rural States provider
networks, rural networks, and State managed care networks have not
been formed, or, if formed, they may not be a part of a linked
network of State and regional services.  (A rural health network is a
locally directed or governed organization that provides a set of
defined health related and administrative services needed in the
community served by the network.)

These demonstrations are to be performed in the context of health
care reform and on a statewide or regional basis. Because the
involvement of many organizations, agencies, and individuals is
essential to develop viable managed care systems, the participation
of consortia is strongly encouraged.  Consortia should include the
appropriate public health authorities, health care providers, and
analytic and technical expertise.  The establishment of Centers will
strengthen the effectiveness of consortia and facilitate
collaborative arrangements among State health agencies, academic
health science centers, and other groups necessary to design,
implement, and monitor system changes in the delivery of health
services in rural areas.

Objectives and Scope

The objective of this RFA for AHCPR Rural Centers is to provide
support for planning, implementing, and monitoring health care system
demonstrations.  This solicitation is part of the Rural Health
Initiative of AHCPR.  Awards will be made for up to five Rural
Centers (no more than one in each of the following HHS Regions:  I
(CT, MA, ME, NH, RI, and VT); III (DE, MD, PA, VA, and WV); VI (AR,
LA, NM, OK, and TX); VII (IA, KS, MO, and NE); and IX (AZ, CA, HI,
and NV).  The Rural Centers will engage in the development and
technical assistance required to implement the demonstrations,
supported by substantial input from staff and consultants at AHCPR.
As stated above, priority will be given to the demonstration of
organized networks of health services delivered to underserved rural
populations.  AHCPR will arrange for the conduct of independent
evaluations of these demonstrations.

As an earlier step in its Rural Health Initiative, AHCPR contracted
for five AHCPR Rural Centers in FY 1993, one each in Regions II
(State University of New York at Buffalo), IV (University of North
Carolina at Chapel Hill), V (University of Minnesota), VIII (Center
for Health Policy Research, Denver), and X (University of Washington,
Seattle).  This solicitation is aimed at addressing needs in the
remaining five Regions through cooperative agreements with rural
States themselves, their academic health sciences centers, or other
appropriate organizations.  An application may be submitted jointly
by State authorities with responsibility for rural health care and
academic health centers engaged in rural health research activities.

The awards will enable the designated AHCPR Rural Centers in those
HHS Regions that do not presently have an AHCPR Rural Center to plan
and initiate statewide or regional managed care system demonstration
projects.  As stated in the Senate Committee Report, the managed care
systems shall incorporate features of primary care, clinical
preventive services, and essential information networks.  Most
definitions of managed care characterize it as a system that
integrates the financing and delivery of appropriate medical care by
means of contracts with selected physicians and hospitals that:
furnish a comprehensive set of health care services to enrolled
members, usually for a predetermined monthly premium; utilize quality
controls that providers agree to accept; incorporate financial
incentives for patients to use the providers and facilities
associated with the plan; and include an assumption of some financial
risk by providers.  These awards may be used to establish new centers
and/or expand existing centers that address policy and health
services research issues of special importance to rural populations
(e.g., the effect on the rural population of the health care reform
initiatives of the State).

The Rural Centers demonstration projects should address, as
appropriate, some of the following issues:

o  Arranging for primary care in rural areas, including such aspects
as financing, recruitment, retention, and effective use of primary
care providers and mid-level health care practitioners and the
intended effect of these primary care arrangements on access to care.

o  Monitoring the appropriateness and effectiveness of rural health
care services and procedures, including patient outcomes, and the
effect of rural practice networks on quality of care.

o  Expanding existing networks or developing new managed care system
models that provide access to high quality of care to the diverse
rural populations within a State or region.

o  Linking appropriate rural health care delivery services and
academic health science centers into consortia.

o  Linking providers in underserved areas with each other, and with
responsible health care institutions and academic health centers,
through information systems and telecommunications.

o  Developing internal and external information networks to
facilitate information transfer, including information on health care
costs, quality measurement, and overall health care system

o  Developing community practice networks and community health plans
that integrate health professionals and health care organizations
supported through public funding with other providers.

o  Addressing the issues raised by border-crossing for rural managed
care networks and antitrust concerns for newly forming health care
networks and accountable health plans.

Within the limits of these resources, the proposed Centers will plan,
implement, and monitor the required demonstration projects and
broadly disseminate project information and results.  In addition to
data collection and monitoring activities, including the associated
assessment of processes and progress necessary for sound management
of the projects, Centers must accommodate requirements of independent
evaluations that may be arranged for by AHCPR.  Centers will be
expected to coordinate internal data collection and monitoring
efforts with the independent evaluation to ensure the collection of
data essential for both efforts.

Work carried out by each Center will be multidisciplinary and must
address important health services delivery issues (e.g., managed care
systems; provider health networks; and State health care insurance
reforms with special attention to their effects on access, cost, and
quality for rural populations).  It is expected that successful
applicant organizations will include on their team appropriate
multidisciplinary administrative and scientific personnel (e.g.,
experts in health services research and administration, medicine,
dentistry, nursing, epidemiology, psychology, statistics, geography,
economics, organizational behavior, law, and public health); and
pertinent State official(s) responsible for health care reform and
managed care in the State through cooperative relationships.  Further
priority consideration will be given to those applicants with a
documented plan to coordinate with the overall State-level health
system planning efforts.

Successful applicant organizations must incorporate the scientific,
technical, organizational, and physical resources necessary to carry
out:  (1) health services demonstrations; (2) technical assistance to
health care providers and others; and (3) dissemination of project
information and results.  Many funding agencies in addition to AHCPR
are providing resources for improving parts of the system for
delivery of health care services to rural populations.  These
organizations include other parts of the Department of Health and
Human Services (DHHS), including the Office of Rural Health Policy of
the Health Resources and Services Administration (HRSA), the Health
Care Financing Administration (HCFA), and the National Institutes of
Health (NIH).  They also include private philanthropic organizations
such as the Robert Wood Johnson (RWJ) and Kellogg Foundations.  This
RFA encourages synergy of existing and developing resources in
preparation for health care reform at the State or regional level.
Appropriate and judicious use of these or other funding sources to
complement each other where there are common goals is specifically
endorsed and should be noted in the application under "Other
Support," or sections 2 or 5 of the "Research Plan," as appropriate.

Center Structure

The Center Director must be a manager who can provide strong
administrative leadership and be committed to this activity for at
least 50 percent of his\her time.  The Director will be responsible
for the organization and operation of the Center and liaison with the
research community and key State officials involved in the State's
health care reform.  The Center should be structured to facilitate
appropriate cooperative arrangements among all members of the
consortium such as State health departments; State or regional
academic health centers; and outside entities including professional
societies, subcontractors, rural provider networks and rural health
alliances, and consumer groups.  Personnel and institutional
resources capable of developing and maintaining a substantial
commitment to rural health services demonstrations must be available,
and that availability should be documented by letters of commitment
in the application under "Appendix."  The Center may consist of core
staff with significant time commitments to the demonstration and
affiliate staff with lesser time commitments.  Multidisciplinary
collaboration within the Center is essential.

In addition, the applicant must show a strong commitment to the
Center and its development, including plans to support the
organizational and management structure of the Center. Each Center is
generally expected to share common resources with other components or
departments of the applicant organization including:  technical,
clerical, and administrative personnel; instrumentation; computer
resources; subject populations; and data bases.

The Center may be a consortium of organizations operating within the
State or Region.  It is expected that members of a consortium will
provide collateral or supplemental support to the applicant

It is expected that each funded Center will have an advisory
committee that includes representation of those involved in preparing
or implementing health care reforms for rural areas in the proposed
demonstration State or region.  Core funds may be used to support
costs associated with an advisory committee, including the convening
of periodic committee meetings to advise about management and
programs.  This advisory committee would typically be composed of:
representatives from the Center's collaborating institutions;
appropriate State officials; and senior national and regional
representatives from outside of the consortium including health care
policymakers, health services researchers, health care providers, and

Budget and Related Issues

A maximum of $400,000 first year total costs (direct plus indirect)
may be requested for center support, and a maximum of $2,000,000 in
total costs may be requested per application for the entire project
period, which is not to exceed five years.

In preparing budget requests, applicants are reminded that the
reasonableness of proposed budgets is among the criteria to be used
in the peer review of applications.  Applicants should justify
whether the scope of their applications calls for the full five years
allowable duration and the maximum $2,000,000 (i.e., five years times
$400,000) amount.  If successful completion of the goals is
anticipated within a shorter duration of time and/or at less cost,
the application should reflect this.


The issuance of awards will be contingent on the availability of
funds and on the quality of the applications.  No awards will be made
if, as result of the scientific and technical review, applications
are not judged to be of high merit.  The initial review committee may
recommend support for less than the requested period or amount.

Terms and Conditions of Award

The administrative and funding instrument to be used for this program
will be the cooperative agreement (U54), an assistance mechanism
(rather than an acquisition mechanism), in which substantial AHCPR
scientific and programmatic involvement with the awardee(s) is
anticipated during the performance of the activity.  Under the terms
of these cooperative agreements, the awardee determines the
organization and management of the Center as specified by this
announcement and retains responsibility for all aspects of
performance of the Center.  The AHCPR, however, anticipates
substantial programmatic involvement in the planning, implementation,
and monitoring of demonstrations and in the provision of advice and
technical assistance to the awardee.

1.  Awardee Responsibilities

The awardee(s) will have primary and lead responsibility for all
activities and should describe in the application the plans to:

o  Establish and maintain appropriate collaborative arrangements with
State agencies, academic health science centers, health care
providers, and others appropriate to effect health care system

o  Make available appropriate types of administrative, scientific,
and analytical expertise to design proposed system changes for the

o  Manage the process of implementing demonstration(s);

o  Participate in an independent evaluation arranged for by AHCPR in
executing a rigorous evaluation plan;

o  Develop an information system that can generate the required data
for measuring changes in health care delivery and health status;

o  Provide technical assistance in the planning and implementing of
demonstrations, as appropriate, to collaborative groups and

o  Disseminate project information and results based on system
changes, especially in collaboration with AHCPR; and

o  Collaborate with AHCPR on data analysis, the preparation of
background information, or other analytical activities relating to
the appropriateness and effectiveness of health care for rural

The AHCPR is committed to disseminating the products of the Rural
Centers as rapidly as possible.  In this context, products include
both written reports of project information and results, and the data
themselves.  The AHCPR will have access to the products of the Rural
Centers upon request.  All rights of access to the data will be
consistent with AHCPR regulations 42 CFR 67, Subpart A, as well as
with section 903(c) of the PHS Act.

2.  AHCPR Staff Responsibilities

The AHCPR Project Officer and other AHCPR staff will have substantial
scientific and programmatic involvement during the conduct of this
activity, through technical assistance, advice, and coordination
beyond the normal program stewardship for grants.  Collaboration on
study design, protocol development, and design of an independent
evaluation will occur after the award(s) is (are) made.
Specifically, AHCPR's role during the project period will include
providing technical assistance, advice, and support to the Principal
Investigator in the areas of:

o  Facilitating program development and priority setting;

o  Planning and implementing of the demonstration(s);

o  Monitoring the Center's demonstrations; and

o  Disseminating the Center's project information and results through
AHCPR's publication program and assisting in selecting additional
mechanisms for effective dissemination.

AHCPR may conduct or arrange for the conduct of a rigorous evaluation
of each demonstration project, which could include specific before
and after measurements for evaluating the effect(s) of system changes
on the delivery and outcomes of rural health care.

Each year's continuation award is subject to a progress review by
AHCPR, in addition to the availability of funds. The progress review
may involve a site visit to the Center by AHCPR staff and expert
consultants to AHCPR.  The progress review will address the Center's
productivity, general compliance with the basic review criteria
listed below, and adherence to the provisions of its approved
application.  If such a continuation review indicates that
insufficient progress has been made, AHCPR may decide not to continue
to fund the Center for the full project period.

The substantial AHCPR involvement will apply in addition to and not
in lieu of otherwise applicable PHS policies and Federal regulations.



The AHCPR requires all applicants for research grants to include
minorities and women in study populations so that research findings
can be of benefit to all persons at risk of the disease, disorder, or
condition under study.  Special emphasis must be placed on including
minorities and women in studies of diseases, disorders, and
conditions which disproportionately affect them.  This policy applies
to males and females of all ages.  If women or minorities are
excluded or inadequately represented in research, a clear and
compelling rationale should be provided.  The AHCPR will not make
awards for applications which do not comply.  If the application does
not contain the required information, it will be returned without

The composition of the proposed study population must be described in
terms of gender and racial/ethnic group.  In addition, gender and
racial/ethnic issues should be addressed in developing a research
design and sample size appropriate for the scientific objectives of
the study. This information should be included in the form PHS 398 in
the Research Plan and summarized in the Section on Human Subjects.

Applicants are urged to assess carefully the feasibility of including
the broadest possible representation of minority groups.  However,
AHCPR recognizes that it may not be feasible or appropriate in all
research projects to include representation of the full array of
United States racial/ethnic minority populations (i.e., American
Indians/Alaskan Natives, Asian/Pacific Islanders, African Americans,
Hispanics).  Where appropriate, the applicant must provide the
rationale for studies on single minority population groups.

Peer reviewers will address specifically whether the applicant's
research plan conforms to these policies.  If the representation of
women or minorities in a study design is inadequate to answer the
scientific questions(s) addressed and the justification for the
selected study population is inadequate, it will be considered a
scientific weakness or deficiency in the study design and will be
reflected in assigning the priority score to the application.


Prospective applicants are asked to submit, by April 15, 1994, a
letter of intent that includes the name, address, and telephone
number of the Principal Investigator; states the number and title of
the RFA in response to which the application may be submitted; and
identifies all co-investigators and other key personnel and member
institutions, community-based organizations, and any other
participating organizations or institutions.

Although a letter of intent is not required, is not binding, and does
not enter into the consideration of any subsequent applications, the
information allows AHCPR staff to estimate the potential review
workload and avoid conflict of interest in the review.  The Letter of
Intent is to be sent to Dr. Norman W. Weissman
at the address listed under INQUIRIES.


Applications are to be submitted on the grant application form PHS
398 (rev. 9/91).  State and local government applicants may use form
PHS 5161, Application for Federal Assistance.  These forms are
available at most institutional offices of sponsored research; the
Office of Grants Information, Division of Research Grants, National
Institutes of Health, Westwood Building, Room 449, Bethesda, MD
20892, telephone (301) 710-0267; and from the Scientific Review
Branch, Agency for Health Care Policy and Research, Suite 602, 2101
East Jefferson Street, Rockville, MD 20852, telephone (301) 594-1449.

The RFA label available in the PHS 398 application form must be
affixed to the bottom of the face page of the original copy of the
application.  Failure to use this label could result in delayed
processing of the application such that it may not reach the review
committee in time for review.  In addition, type "RFA HS-94-006" and
"AHCPR RURAL CENTERS" in Section 2a on the face page of the
application form and the YES box must be marked.

Complete information about the proposed Center must be submitted with
the application.  Consortium arrangements typically take the form of
a formal agreement between the grantee and other organization(s).  In
the grant application, a separate budget must be included for each
organization involved in the proposed consortium arrangement.

The application must describe how the proposed Center will meet the
awardee responsibilities described earlier under Terms and Conditions
of Award.  Follow the instructions for form PHS 398 where
appropriate. However, the form PHS 398 was developed primarily for
research project grants rather than Centers.  Therefore, substitute
the following headings for Sections 1 through 9 of Section C of the
application and address the following issues (see Research Plan,
pages 20- 24, of the instructions).  (State and local governments
using form PHS 5161 should address all of these following areas in
the Program Narrative section of their application).

For Sections 1 - 8 below, suggested page lengths are listed in
parentheses.  However, the cumulative length of these sections cannot
exceed 25 pages.

1. Introduction and background; any special emphases of the proposed
Center.  (1 - 2 pages)

2. Currently available organizational resources.  What resources such
as staff and areas of expertise, ongoing rural research,
organizational support and relationships, funds, and equipment, are
available now to develop and implement the proposed Center?  (2 - 3

3. Organizational changes that will be implemented to develop the
proposed AHCPR Rural Center.  What activities and organizational
alignments will be undertaken to institute the proposed Center?  (2 -
4 pages)

4. The nature of proposed and existing organizational relationships
of the Center.  Include, for example, the proposed Center's
relationship with health care providers, State and local governments
and other policy makers, the proposed advisory committee, and the
research community. (2 - 4 pages)

5. The proposed Center's agenda in rural demonstrations, technical
assistance, information system development, dissemination, and
research projects.  What activities and projects are currently in
place with regard to rural health and/or health care reform?  What
problems in care delivery will be addressed by the demonstration
project(s)?  (8 - 12 pages)

6. The process of decisionmaking and lines of authority within the
proposed Center.  (1 - 2 pages)

7. The expected accomplishments of the proposed Center. (2 - 6 pages)

8. Human subjects.  (the same as in '5' in the application
instructions, page 22)

9. Consultants/collaborators.  (the same as in '7' in the application
instructions, page 23)

10. Consortium/contractual arrangements.  (the same as in '8' in the
application instructions, page 23)

11. Literature cited.  (the same as in '9' in the application
instructions, page 24)

The completed original application, including the Checklist, and four
legible copies (two copies when using the PHS 5161) must be sent or
delivered to:

Division of Research Grants
National Institutes of Health
Westwood Building, Room 240
Bethesda, MD  20892**

Applications submitted under this RFA must be received by the
Division of Research Grants, NIH, by May 17, 1994.  If an application
is received after that date, it will be returned to the applicant.

One copy, labeled "Advance Copy," must be submitted simultaneously

Norman W. Weissman, Ph.D.
Center for General Health Services Extramural Research
Agency for Health Care Policy and Research
2101 East Jefferson Street, Room 502
Rockville, MD  20852-4908

Conference for Prospective Applicants

The AHCPR plans to convene a conference for prospective applicants in
Kansas City, Missouri on March 29, 1994, if there is sufficient
interest from prospective applicants.  At this proposed conference,
AHCPR plans to discuss the programmatic and administrative details of
the AHCPR Rural Centers and respond to questions concerning this RFA.
Attendance is not a prerequisite to applying.  Attendees must pay for
their own travel and accommodation costs.  Individuals with questions
concerning this announcement, or unable to attend the conference, may
contact Ms. Jean Carmody at telephone (301) 594-1357, extension 130,
FAX (301) 594-2155.  Those interested in attending the conference
should mail or FAX their names, addresses, and telephone numbers to:

Ms. Jean Carmody
Center for General Health Services Extramural Research
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 502
Rockville, MD  20852-4908


Upon receipt, applications will be reviewed by the Referral Office,
Division of Research Grants, NIH, for completeness, and by AHCPR
staff for responsiveness to the RFA.  Incomplete and/or non-
responsive applications will be returned to the applicant without
further consideration.  The determination of any application as
nonresponsive will be the sole responsibility of the AHCPR.  All
responsive applications will undergo peer review for scientific merit
by a review committee of experts convened by AHCPR.  When an
application is reviewed, the peer review committee may recommend
further consideration for funding or no further consideration.  The
committee also assigns priority scores to the applications for which
further consideration was recommended.  Recommendations of the peer
review committee will be reviewed subsequently by AHCPR's National
Advisory Council for Health Care Policy, Research, and Evaluation.
The peer review process is rigorous, and only those applications
judged to be of greatest merit will be recommended for further
consideration.  The general review criteria for AHCPR grant
applications are:  significance and originality from a scientific and
technical viewpoint; adequacy of the proposed method(s); availability
of data or proposed plan to collect data required for the project;
adequacy of the plan for organizing and carrying out the project;
qualifications and experience of the principal investigator and
proposed staff; reasonableness of the proposed budget; and adequacy
of the facilities and resources available to the applicant.

Special Review Criteria

In addition to the review criteria noted above, the review committee
will independently evaluate each application in response to this RFA
to assess:  the quality of the proposed Center's program and general
approach, including its proposed demonstration agenda, technical
assistance, and dissemination plans; and the degree to which the
Center's agenda reflects a realistic and well-conceived program in
view of available skills, funding resources, and health care issues
pertinent to the particular rural population(s) to be addressed.  The
following special scientific and technical review criteria will

o  The extent to which the planned demonstration site(s) reflects the
extreme challenges to rural health care delivery system reform as
reflected by:

1.  Limited public transportation infrastructure;
2.  Geographic features that limit transportation;
3.  Significant health status problems in the population;
4.  Limited managed care penetration statewide;
5.  Unemployment rates above the national average; and
6.  A high percentage of the rural area designated as health
professional shortage areas.

o  The quality of the organizational and institutional arrangements
to operate the proposed Center, including plans for the use of an
advisory committee by the Center; and links with State-level health
planning efforts.  Also, in the case of consortium applications, the
degree of clarity in the differentiation of activities and a
description of coordination efforts among organizational
participants. Each component's role and responsibilities must be
clearly described.  This description must include the nature and
extent of collateral or supplemental support provided to the
applicant organization by other consortium members.

o  Evidence of the commitment of the applicant organization(s) to the
provision of, and/or study of health care to rural populations,
including plans to attract or retain other funding sources in support
of its demonstration(s).

o  The actual and planned level of commitment of the applicant
institution(s) to the proposed Center, including its specific plans
to support its organizational and management structure.

o  The extent to which the proposed Center's plan reflects
specificity in identifying problems to be addressed, and an awareness
of significant methodological and data problems in designing,
implementing, and monitoring rural health services demonstrations,
such as availability of defined health status baseline information
for the State or region, population based statistics on penetration
of managed care, and available rural health care facility and related
resource information.

o  The coordination of the proposed Center's planning and
demonstration efforts, including the structure for sustaining ongoing
monitoring of the processes for implementing the demonstration and
progress towards its objectives, separate from AHCPR's independent
and time- limited evaluation activity.

o  The degree to which the proposed Center's program includes
representation from multiple appropriate scientific and
administrative disciplines, including analytic and technical
expertise, capable of planning and implementing demonstrations on
rural issues and problems.

o  The qualifications, achievements, commitment, and number of senior
personnel of the proposed Center, including the appropriateness of
their specific time commitments.

o  The appropriateness of the proposed budget and the extent to which
the fiscal plan provides assurance that effective use would be made
of the funds awarded, including delineation of the service area(s)
for which the proposed Center will be providing technical assistance
in developing rural health demonstrations.


Applications will compete for available funds with all other
applications for this RFA.  No awards will be made if, as result of
the scientific and technical review, applications are not judged to
be of high merit.  The following will be considered in making funding
decisions:  quality of the proposed project as determined by peer
review, program balance, and availability of funds.


Written and telephone inquiries concerning this RFA are encouraged.
The opportunity to clarify any issues or questions from potential
applicants is welcome.

Direct inquiries regarding programmatic issues to:

Norman W. Weissman, Ph.D.
Center for General Health Services Extramural Research
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 502
Rockville, MD  20852-4908
Telephone:  (301) 594-1357, ext. 130

Direct inquiries regarding fiscal matters to:

Ralph L. Sloat
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 601
Rockville, MD  20852-4908
Telephone:  (301) 594-1447


This program is described in the Catalog of Federal Domestic
Assistance number 93.226.  Awards are made under authorization of the
Public Health Service Act, Title IX, and administered under the PHS
Grants Policy Statement and Federal Regulations 42 CFR 67, Subpart A.
This program is not subject to the intergovernmental review
requirements of Executive Order 12372.


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