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The latest Service Area Competitions (SAC) from HRSA are here, and the FQHC Shuffle

2020 was a peculiar year for many reasons great and small, one of the small reasons germane to grant writers and Federally Qualified Health Centers (FQHCs) being that HRSA deferred Service Area Competitions (SAC), allowing FQHCs to skip the typical application, or re-application, process. For those of you unfamiliar with FQHCs, they’re the nonprofit healthcare providers that are designed to accept any patient, regardless of ability to pay, and that specialize in Medicaid patients, or helping the uninsured sign up for Medicaid. FQHCs and their counterparts, FQHC Look-Alikes, have significant advantages over typical nonprofit or for-profit primary healthcare providers in that they get higher reimbursement rates from Medicaid, protection from medical malpractice lawsuits, access to the 340B low-cost medication program, and a few other advantages—including eligibility for Section 330 grants via the SAC process, which offer between hundreds of thousands and millions of dollars per year in funding. Every (or almost every) geographical area in the country is supposed to be covered by a SAC and most FQHCs must submit a competitive SAC proposal every three years to keep their Section 330 grants.

Delaying SACs seemed like a reasonable idea during the pandemic, and their return is likely to herald some changes. We talk to lots of FQHCs, and it seems that some of the incumbents are weaker than they were, or discombobulated by the pandemic. Others, however, seem to have been strengthened, particularly those that moved expeditiously to telemedicine, which let them keep up their patient loads, while others have struggled with telemedicine. It’s often not apparent from the outside what’s happening on the inside of FQHCs. Some that may seem weak are likely strong, and vice-versa. That’ll make this SAC season unusual and interesting, and I’d not be surprised to see larger-than-average turnover in SAC grants. Because each SAC covers a specific geography, any new applicant is by definition trying to take over the designation from an existing grantee. We’ve heard the SAC process called “the FQHC shuffle.” Most FQHCs succeed in getting their SAC proposals approved and Section 330 grants renewed, but a significant portion don’t; most of us wouldn’t want to play a game we don’t think we’ll win.

We’ve worked with FQHCs on both sides of the SAC shuffle: incumbents worried about upstarts, and upstarts interested in taking over the incumbents’s service area and Section 330 grants. Losing a Section 330 grant can be an FQHC’s death knell: while SACs typically compose less than 20% of an FQHC’s budget, and often less than 10%, they often function as the glue holding the organization above the water level. Lose the SAC, and the overall revenue decline may be small, but that revenue may also be the revenue that keeps the organization in the black. During uncertain times like the present, an alert organization may be able to make progress that would be more difficult in other times.

Three of the eight planned FY ’22 SAC NOFOs have been issued so far: you can see whether your organization’s service area is up for renewal in HRSA’s massive SAC lookup table. The rest will be issued in the coming weeks or months. Is your FQHC or would-be FQHC ready to act?

Although the pandemic is receding, we’re still living in a strange time: the nonprofit winners have a lot of cash; some nonprofits, however, are gone. The next generation of nonprofit startups haven’t wholly started up yet. This is a propitious time to pursue change. We’ve been talking to a lot of callers about what’s happening in the present and what the future might hold.

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HRSA sort of “Streamlines” FY ’18 Service Area Competition (SAC) NOFOs

As happens every year about this time, HRSA has been issuing Service Area Competition (SAC) Notices of Funding Funding Opportunities (NOFOs). As we’ve written before, HRSA requires Federally Qualified Health Centers (FQHCs—otherwise known as Section 330 grantees) to compete every three years against non-grantees to keep their Section 330 grants. About one-third of the approximately 1,400 FQHCs must submit a technically correct SAC proposal every year.

We’re in the early stages of the FY ’18 SAC derby and, while the process is more or less the same this year, we came across this, on page 3 of this year’s NOFOs:

The Project Narrative has been streamlined to reduce applicant burden, more closely align with Health Center Program requirements as defined by statute and regulation, and simplify the collection of information.

(Emphasis added.)

Sounds great in theory, but let’s take a closer as what passes for streamlining in HRSA-land. The term “NOFO” replaces HRSA’s longstanding practice of calling their RFPs Funding Opportunity Announcements (FOAs). Thus, HRSA has replaced one pointless three-letter acronym with a similarly pointless four-letter acronym. In they had to change the acronym, why not just use the more common acronym “RFP?”

The FY ’17 SAC FOAs were 73 single-spaced pages, while the FY ’18 NOFOs are 67 single-spaced pages (NOFO length does not include the 365 single-spaced Service Area Announcement Table). It also doesn’t include the 66-page, single-spaced HRSA SF-424 Two-Tier Application Guide (love the doc name). The Guide has intricate formatting instructions for all HRSA grant submissions but often conflicts with the instructions with particular NOFOs, like SAC. Then there’s the voluminous underlying regs for the Section 330 program, but counting these pages would like counting grains of sand on Santa Monica beach.

In summary, HRSA has shaved six pages off of the 498 pages of instructions, not counting regs, or a generous 1.2%! We must applaud HRSA for this Herculean streamlining effort!

To be fair to HRSA, some items previously required of all applicants, like floor plans, no longer must be submitted by current grantees. Also, current grantees don’t have to answer a few of the repetitive questions in the Program Narrative. Still, the SAC applications may not exceed 160 pages “when printed by HRSA.” Despite the digital application upload process, HRSA still prints and copies proposals for reviewers to read in hard copy—partying just like it’s 1999. This is a good reason to avoid color graphics in federal proposals, as most will be printed and copied in grayscale for reviewers.

For FY ’18, HRSA also still requires a two-step application process: the first step in a relatively simply application uploaded through, while the second step is the fiendishly complicated online application through HRSA’s Byzantine Electronic Handbooks (EHB) system.

Without doing a deep dive into the SAC NOFOs, a couple of features remaining in the FY ’18 NOFOs illustrate why HRSA using the term “streamlined” might be euphemistic.

There’s a convoluted section of the Project Narrative called “Governance,” where applicants must explain how their governance structure meets complex Section 330 requirements. For current grantees—some of which have received SAC grants for decades—this is odd, since these applicant couldn’t have been funded before if they didn’t meet these requirements. Also, even current grantees must upload copies of their articles of incorporation and bylaws as attachments. One would think that after, say, four SAC grants, HRSA probably doesn’t need another copies of the Owatonna Community Health Center’s articles and bylaws (I made this up, but there probably is a FQHC in Owatonna, MN).

Also, in addition to the application file, Abstract, Project Narrative, and Budget/Budget Narrative, the EHB application includes 13 required forms and 12 required attachments for all applicants, including existing grantees.

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HRSA’s Service Area Competition (SAC) Soaks Up Some Sun in Miami, While Brownfields Grants Are Available in California

This week’s Grant Alert e-mail newsletter has a curious RFP: a single HRSA Service Area Competition (SAC) grant is available to Miami-area nonprofits. You might remember SAC because we wrote “HRSA Service Area Competition (SAC) Grants: How to Defend Your Turf or Deftly Lift a HRSA Grant from an Unsuspecting Grantee” back in June, when the general competition was underway.

The fact that a second competition is being held exclusively for Miami could mean a couple of things:

1. Whoever got the Miami grant screwed it up and had their funding pulled. If so, the local Miami paper should be on this story but probably isn’t.

2. None of the Miami applications were fundable, but for whatever reason HRSA wants to fund Miami.

3. HRSA somehow came up with extra money, perhaps through a Congressional appropriation or earmark, for Miami money.

4. Something even more devious is going on behind the scenes that we’re not aware of.

Of those, number 1 is the most plausible. This also means that Miami-area nonprofits who want to get on the SAC Section 330 bandwagon have an unusual opportunity to do so, because no one is defending that turf at the moment.

The other set of RFPs in this week’s newsletter are three Brownfields programs that should be of special interest to California public agencies and nonprofit affordable housing developers that are interested in developing Brownfields sites. The grants should generate more interest than usual because the California legislature recently eliminated redevelopment agencies, along with tax-increment financing and the 20% set-aside of tax increment funds for affordable housing that was previously required. In this face of this sea change, Brownfields grants have become a much more attractive way of defraying development costs than they were previously.

If you’re part of a city in California, you should be thinking about this RFP.

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Is It Really a Partnership, Or Is It a Convenient Arrangement To Get the Money?

Is it really love if she only comes back for $300 an hour?

Is it really a partnership if one person holds a gun to the other’s head?

Does Microsoft really care about your business when they’ve kept you on hold for an hour, listening to aggravating muzak, only to tell you that they won’t give you the product key you need?

In grant writing, when you can’t get other local agencies to partner with you for a grant application, it’s often time to offer them a subcontract or some other piece of the action that can be measured in dollars. The piece you want or need can vary with the grant or the importance of the agency to the project and the nature of the project, but if you need the partnership badly enough you’ll pay for it.

In some circumstances this isn’t optimal, and if you’re paying for partnerships you might also be moving other local agencies from an economy based on gifts, favors, and reciprocity to one based on straightforward money—which might make accomplishing your actual goals harder. (Lewis Hyde describes gift versus exchange economies in The Gift, and there’s a rich economics literature on the subject too.) Many organizations, like many interpersonal relationships, don’t exist in a solely gift or solely mercantile space; they operate somewhere in between, and whether a relationship primarily involves gifts or fee-for-service depends a myriad of factors that are beyond the scope of this blog post.

But if an organization doesn’t want to help you out of the goodness of their hearts, or out of the promise that you’ll be their nominal partner on some future project, then money might be your only route forward. School districts are notoriously difficult in this regard, largely because they know that they’ll get ADA money regardless of whether they provide Joe’s Nonprofit with a letter.

Sometimes, however, Joe’s Nonprofit can strike back by getting the local newspaper to write an article about how the district’s intransigence might cost the community a $500,000 grant. A couple of years ago, we were writing a HUD Lead-Based Paint Hazard Control (LBPHC) proposal for a city in California. The LBPHC requires specific health metrics and interventions that are the domain of counties in California. The cognizant agency at first refused to cooperate with our client. We suggested that our client call the county rep and tell her that the next call would be to the newsperson, so that a story about why the county wants young low-income children to be poisoned could run. The county immediately agreed to cooperate and provided a strong letter and data. The proposal was funded. And our client didn’t have to offer any money to get it funded.

Given the realities of “partnerships,” why are funding agencies so interested in partnerships? We’ve addressed this question before, in posts like “Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?” and “There Will Be No Fighting in the War Room: An Example of Nonprofit Non-Collaboration in Susan G. Komen for the Cure,” and “What Exactly Is the Point of Collaboration in Grant Proposals? The Department of Labor Community-Based Job Training (CBJT) Program is a Case in Point.” As we’ve said, genuine partnerships might be appropriate and useful in some circumstances, but much of the time they just look cosmetic, as we’ve discovered from talking to clients who are attempting to wrangle partnerships out of recalcitrant agencies.

When partnerships are primarily cosmetic, I suspect the larger issue is, like so much of grant writing, one of signaling.* In grant writing, partnerships are a kind of social proof—if you can get other people to agree to associate with you, their association is a form of implicit approval of your actions. If you’ve ever seen bars where one guy seems to be talking to all the women in the place, you’re in part seeing social proof at work; if you’ve been reluctant to eat an empty restaurant or happy to wait for a table at a full one, you’ve also seen it.

Among grant applicants, partnerships are being used to prove that the applicant and jump through a large number of somewhat arbitrary hoops, in the hopes that those applicants with the fortitude, tenacity, and skill necessary to do so are also the ones most likely to operate programs well.

* Robin Hanson has written extensively about signaling and its pervasiveness in human social life; his recent post “How Social Are Signals?” is a good place to start if you’re curious. Unfortunately, he hasn’t written a book about signaling and other aspects of his blogging life, so there’s no large-scale guide to his thinking on the subject. Yet.

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HRSA Service Area Competition (SAC) Grants: How to Defend Your Turf or Deftly Lift a HRSA Grant from an Unsuspecting Grantee

The Health Resources and Services Administration (HRSA) recently issued a Funding Opportunity Announcement (“FOA,” which is HRSA-speak for RFP) for the Service Area Competition (SAC) program. This program provides extremely valuable (for reasons we’ll explain in this post) five-year grants to operate one or more Federally Qualified Health Centers (FQHCs).

There are three ways to get become an FQHC, which will let an organization access Section 330 funds: (1) apply to have an existing health clinic certified as an FQHC (this is an incredibly complex process because the regulations are a nightmare); (2) wait for HRSA to issue a New Access Points (NAP) FOA and apply for a grant (this can be done in any community that meets Section 330 requirements, and it has a distinct advantage because a grant award is attached); or (3) wait for HRSA to publish a SAC FOA for your service area (which has the same advantage as number two).

The SAC route is probably the easiest because HRSA already knows that the area and residents qualify for Section 330 funds. Each time a FOA appears, existing Section 330 grantees at the end of their five-year grant period have to compete for new money against any other nonprofit or public agency that can (1) meet the eligibility test to become an FQHC and (2) chooses to apply.

This can make for mighty nervous Section 330 grantees, because running an FQHC or three can be a very lucrative undertaking for a nonprofit or public agency. As a result, even nominal collaborators can turn into cutthroat competitors and sack a grantee during a SAC funding cycle.*

Most federal programs require grantees to re-apply for continuation grants, including some (e.g., TRIO grants) that give bonus points to current grantees. Since operating a FQHC requires significant organizational infrastructure (e.g., specialized facilities and equipment, medical staff, HIPAA-compliant records management, and other features that go above and beyond basic nonprofit infrastructure), it is curious that HRSA requires current Section 330 grantees to compete for continuation funding. If a grantee is more or less getting the job done, why not just let them keep on doing what they’re doing? I assume the complicated re-application process is designed to keep the grantees on their toes. It also forces them to be accountable for the objectives stated in their original application (FQHC, NAP or SAC application), as well as the new SAC application.

HRSA Section 330 FOAs also require applicants to state highly specific objectives for required HRSA “Clinical and Financial Performance Measures,” as well for service delivery levels (e.g., number of patients, service encounters, etc.). Many applicants overstate their objectives beyond what is achievable in the real world. While we often differentiate between the Real World and the Proposal World in our approach to grant writing, sometimes the real world is important. HRSA Section 330 proposal writing is a case in point. Because the SAC application includes electronic data forms with highly specific input boxes and the metrics are so easily measured, a grantee can easily get too enthusiastic and wildly overstate the objectives that are likely to be achieved in the real world.

While being grandiose in stating objectives can be okay in many subjective human services proposals, it is a recipe for future unhappiness in HRSA Section 330 proposals. This is because failure to meet stated metrics will likely annoy your Program Officer, assuming you submit reasonably honest reports. An annoyed Program Officer is likely to torpedo your next SAC application or even cut back your current grant.

For example, a few years ago we wrote a number of funded HRSA, CDC, and foundation proposals for a Section 330 client in the midwest. While the client had no big problems in implementing several complex programs, she unfortunately got crosswise with her HRSA Program Officer over the stated objectives. Incredibly, the Program Officer got so annoyed that the client was forced into a SAC FOA three years ahead of schedule. With HRSA grants, don’t make this mistake and lose millions of dollars by overstating what your organization can do.

If your agency decides to try for the funding of an existing Section 330 grantee, it would be a good idea to request copies of their original application and reports. Just call up your competitor and ask them for these documents (note: this is joke, as no one in the real world would make this call). What you really want to do is call the HRSA Program Officer with the request and, if necessary, follow-up with a Freedom of Information Act (FOIA) request. Keep in mind that FOIA requests can take a long time, so it is best to plan your ambush well in advance.

* For more on the “collaborative” aspects of HRSA FOAs, see “Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?.”

** See also The Real World and the Proposal World.

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Project GEESE is Project NUTRIA At a Table Near You. Also, HRSA’s Service Area Competition (SAC) FOA is out

According to the New York Times, “the city’s too fertile and apparently pesky geese will soon face a grim fate, but will not go to waste: They will go to feed hungry Pennsylvanians.” I’m not making this up.

The idea might sound familiar to Grant Writing Confidential readers. Isaac wrote a post called “Project NUTRIA: A Study in Project Concept Development,” which describes how to conceptualize project development while parodying some of the crazy concepts we see bandied about. A nutria, for those who don’t know, is basically a very big rat, and they were apparently terrorizing Seattle not long ago. So Isaac suggested that low-income and/or homeless individuals be trained to capture the nutria and turn them into food.

This was (mostly) a joke.

The New York Times article, however, indicates that something quite similar is actually happening. No word on whether there’s a job training element to the proposed project or an acronym. If whoever runs this program needs an acronym, we’re willing to contribute one gratis: Project GEESE (Geese Expeditiously Evicted and Served to Everyone). You could change “Evicted” to “Eviscerated.” No word yet regarding whether any of the unsuspecting geese will force fed first to produce foie gras, which I’ve eaten once and would not care to eat again.

Furthermore, you may want to take a gander at this article article from a different source, which claims that “Due to strict New York guidelines regulating the processing and distribution of goose meat, local authorities finally decided to send them off to Pennsylvania, which already has an established protocol for distributing slaughtered geese.” Who knew? So there’s a bureaucratic perspective to this feathered tale as well.

In other acronym-related news, the Health Resources and Services Administration’s (HRSA) Service Area Competition (SAC) Funding Opportunity Announcement (FOA) has been announced, which you should celebrate by asking WTF took so long and ordering some BBQ.

EDIT: In “Why Soup Kitchens Serve So Much Venison,” Henry Grabar reports that “a growing percentage of [venison served to the homeless and needy] comes from the suburbs of American cities, at the unlikely but unmistakably American intersection of bow hunting, pest control and hunger relief.” There are too many deer and too many hungry people, and they intersect here.

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Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?

HRSA just issued a Funding Opportunity Announcement (FOA, which is HRSA-speak for RFP) for the Service Area Competition (SAC). SAC FOAs are issued each year for different cities and rural areas in which HRSA has existing section 330 grantees, including Community Health Centers (CHCs), Migrant Health Center (MHCs), Health Care for the Homeless (HCHs), and Public Housing Primary Cares (PHPCs). Without going too far inside baseball, as section 330 grantee contracts expire, HRSA groups them together and forces them to reapply while encouraging other organizations to complete for the contracts. Hence the word “competition” in SAC.

SAC applicants are required to respond to a section of the FOA called “Collaboration” by describing “both formal and informal collaboration and coordination of services with other health care providers, specifically existing section 330 grantees, FQHC Look-Alikes, rural health clinics, critical access hospitals and other federally-supported grantees.” I’m guessing that if your organization is applying to take the contract away from the current Section 330 grantee, that grantee is probably not going to be in much of a mood to collaborate with your application and give you a letter of support.

To put a requirement for “collaboration” in a FOA that uses the term “competition” in its title demonstrates HRSA’s cluelessness. A particularly fun aspect of the SAC FOA is that HRSA pats itself on the back by stating in the Executive Summary that “For FY 2011, the HRSA has revised the SAC application in order to streamline and clarify [emphasis added] the application instructions.” The instructions are 112 single-spaced pages and the response is limited to 150 pages! And there a two-step application process involving an initial application submitted through our old friend, as well as a second application with a second deadline through a HRSA portal called Electronic Handbooks (EHBs). That’s what I call streamlining and clarifying. I would hate to see the results if HRSA tried to complicate and obscure the application process.

HRSA has another FOA process underway for the New Access Points (NAP) program, which I recently wrote about in “The Health Resources and Services Administration (HRSA) Finally Issues a New Access Points (NAP) FOA: $250,000,000 and 350 Grants! (Plus Some Important History).” A quick search of the FOAs reveal that the term “collaboration” is used at least 32 times in the NAP FOA, compared to 8 times in the SAC FOA. I suppose collaboration is four times as important in writing a NAP proposal that in writing a SAC proposal. For those with inquiring minds, the word “competition” is not used at all in the NAP FOA. As far as I can tell, HRSA does not let NAP applicants know that, if they are successful, they will eventually have to compete to keep their contract, while simultaneously committing to collaborating with their competitors. Since I have written many NAP and SAC proposals, I know how to thread this word needle by writing out of both sides of my Mac. But novice grant writers and new HRSA applicants will find this a challenge.

For more of my reasoning on the essential pointlessness of requiring grant applicants to profess their undying commitment to collaboration, see “What Exactly Is the Point of Collaboration in Grant Proposals? The Department of Labor Community-Based Job Training (CBJT) Program is a Case in Point.”

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You know you’re a grant writer if a Health Resources and Services Administration (HRSA) Service Area Competition (SAC) deadline vexes you

You know you’re a grant writer if… You’re reading the Health Resources and Services Administration’s (HRSA) Service Area Competition (SAC) and discover that the deadline is July 6.

You’re frustrated because Monday, July 6 is a holiday for most people: the Fourth of July is Saturday, so the “holiday” part is the Monday after, which means that you won’t get much tech support if you need it on that Monday. You probably won’t get any tech support on Friday, July 3, either, since everyone in the federal government will probably have left—most of the Feds count that Friday as the holiday this year.

The real deadline is probably closer to July 2, chiefly because whatever genius at HRSA picked this deadline probably didn’t realize it was a holiday weekend, or simply decided to play a cruel trick on applicants. There are two possible reasons for this snafu: incompetence or malice. Neither portrays HRSA in a positive light. Oh, and applicants for this program are “Section 330” nonprofit community health centers, which are perhaps not the best targets for a HRSA practical joke, especially given how tremendously complex and difficult the applications are.

You know you’re a grant writer if… the same SAC RFP further irritates you because you have to submit a preliminary application using for a June 23 deadline, then submit the full application using HRSA’s Electronic Hand Books (EHB) system with a deadline of July 6 July 2. In other words, you have to learn yet another esoteric electronic system, although one that’s at least somewhat easier than

You know you’re a grant writer if… you find’s failures and quirks amusing, causing you to write about them with some frequency.

You know you’re a grant writer if… the budget you receive from your client has no relationship to the narrative you’ve written, based on what the client told you in the first place. Actually, the budget has nothing to do with little if anything to do with anything whatsoever.

You know you’re a grant writer if… you’re the only person in America working on a holiday, other than cops and escorts.

You know you’re a grant writer if… you don’t even realize that tomorrow is a holiday—Memorial Day—and have to be told to hold the Seliger Funding Report for another day.

You know you’re a grant writer if… you’re outraged when you find that a deadline is on the holiday you hadn’t realized was there (see: first paragraph, above).

You know you’re a grant writer if… you’re inclined to write lists regarding when you know you’re a grant writer, and you actually think they’re amusing.