Avon Breast Cancer Crusade Safety Net Hospital Funding Initiative 2016 Request for Proposals

Avon Breast Cancer Crusade Safety Net Hospital Funding Initiative 2016 Request for Proposals The Avon Breast Cancer Crusade ( Avon BCC ) Safety Net Initiative supports public, community, and safety net hospitals and health care systems that provide breast care to low-income, at-risk, uninsured and underinsured individuals. The goal of this initiative is to support programs that improve access to quality and timely breast diagnostics and access to treatment for the medically underserved. A demonstrated commitment to providing health care to underserved populations will be considered in the review process. Funding is limited to a maximum of up to $100,000 for one year. Application Due Dates / Times: All Letters-of-Intent (LOI) for All Geographic Regions are due: January 8, 2016* Letters of Intent and Full Applications must be submitted to the online grant submission system by 11:59pm Eastern on the dates listed below. All Letters of intent for all geographic regions are due January 8, 2016. No exceptions will be made to this date. If an applicant misses the due date, they will have to wait until 2017 to submit an application for funding. The schedule for being invited to submit a full application, submitting that application and receiving a determination on that application is determined by your institution s geographic location. Geographic Region is defined as the area within 100 miles of the city listed: Chicago, IL; Houston TX; Washington, DC Letter-of-Intent Due Date: January 8, 2016* Invitations to Submit Full Proposal: January 15, 2016** Invited Full Proposal Due Date: February 12, 2016 Funding Decisions Disseminated by: December 31, 2016 Boston, MA; San Francisco, CA Letter-of-Intent Due Date: January 8, 2016* Invitations to Submit Full Proposal: February 29, 2016** Invited Full Proposal Due Date: March 28, 2016* Funding Decisions Disseminated by: December 31, 2016 Los Angeles-Santa Barbara, CA Letter-of-Intent Due Date: January 8, 2016* Invitations to Submit Full Proposal: May 16, 2016** Invited Full Proposal Due Date: June 13, 2016* Funding Decisions Disseminated by: December 31, 2016 New York, NY Letter-of-Intent Due Date: January 8, 2016* Invitations to Submit Full Proposal: June 13, 2016** Invited Full Proposal Due Date: July 11, 2016* Funding Decisions Disseminated by: December 31, 2016 National Pool (National Pool is defined as all other cities/ regions in U.S. other than those specifically listed in this document) 1

Letter-of-Intent Due Date: January 8, 2016* Invitations to Submit Full Proposal: June 13, 2016** Invited Full Proposal Due Date: July 11, 2016* Funding Decisions Disseminated by: December 31, 2016 *Applications are due by 11:59pm Eastern on the dates indicated **Only a small subset of LOI submissions will be invited to submit a full proposal. The emphasis of this initiative is to provide hospitals and health care centers with patient navigation programs, partial equipment support and other personnel and infrastructure support that will enhance their breast cancer care services to the medically underserved. Avon BCC grant funds cannot be used to pay for or reimburse for direct costs of care. Funding Period: The funding period for these grants one (1) year, beginning either July 1, 2016 or January 1, 2017. Funding Level: The amount of funding allowable for each proposal is up to $100,000 total costs. Each applicant must determine the appropriate amount to be requested, depending upon needs, ability to effectively manage the amount requested, and justification of the amount. Hospitals requesting funds for equipment must demonstrate that they have funds available to cover or provide for costs in excess of our program cap. High-volume/high-impact institutions that screen, diagnose and treat a large number of uninsured or under-insured women facing breast cancer may request up to $150,000 in one year. Application Process: Application to the Safety Net Hospital Initiative is a two-stage process: 1. Letter-of-Intent (open to all); 2. Followed by full applications (by invitation only based on review of your LOI). A tutorial on how to navigate the online system can be found here. (http://www.avonfoundation.org/assets/application-tutorial.pdf) Click here to start a NEW Safety Net Letter of Intent online form. https://www.grantrequest.com/sid_1102?sa=sna&fid=35003 Clicking the link will bring you to the Safety Net Letter of Intent log-in page to start a NEW Letter of Intent Form. Here you will need to create a new account or use your existing log-in credentials. If you are creating a new account, it is imperative that you use a functional, monitored email account as the user-id as it is the email address the system will use to communicate with you about the application. If you have previously started and saved a letter of intent or full application and wish to log back into it, click here to access you Grants Management Account. (https://www.grantrequest.com/sid_1102/default.asp) For those applicants invited to submit full applications: If you are invited to submit a full proposal, you will receive an e-mail with instructions on how to do so after your LOI has been reviewed and approved. The full proposal is also submitted though the online grant submission system and can be accessed by logging into your grants management account (described above). For your convenience, data from your LOI will be pre-populated in the full proposal online fields. However, you should update fields as appropriate. In addition, several attachments are required. Templates for the required attachments can be found on the Safety Net Funding Page. (http://www.avonfoundation.org/grants/breastcancer/safety-net-guidelines/) 2

Applications will be reviewed by a committee of experts in breast cancer care, research, and public health. Final funding decisions will be made by the Avon Breast Cancer Crusade Board of Managers. Please note: 1. All required fields in the online system must be completed before you are able to submit your letter of intent or full proposal. 2. Applicants seeking equipment must provide additional justification for the need for new equipment, demonstrate matching funds from their institution and identify the vendor and equipment they propose to purchase. 3. All applicants who are successful will be required to submit progress reports every 6 months. Please see information on the required bi-annual progress reporting system in the Commonly Asked Questions section below. Please review the entire application packet before you begin to work on your application. If you need further assistance, please email your questions to Avon Grants Staff at: grants@avonbcc.org. 3

APPLICATION INSTRUCTIONS I. Funding Objectives The Safety Net Hospital Funding Initiative provides financial support to public, private, and safety net hospitals to enable these organizations to provide post screening, diagnostic and treatment services to the medically underserved. The Avon Breast Cancer Crusade intends to alleviate disparities in access to quality breast cancer diagnostics and treatment through this initiative. Grants are to be used for programmatic solutions to challenges experienced by low-income, medically underserved individuals and their medical providers and serve as models for the future. Examples of successful programs funded previously include: Employed patient navigators to improve timeliness and quality of care. Greatly reduced the number of women lost to follow-up. Reduced waiting time for diagnostic procedures and treatment. Increased the provider s ability to offer sophisticated, state-of-the-art care that is less invasive (in the case of diagnostic and surgical procedures). Gave the provider the ability to perform more targeted treatment by allowing more sophisticated pathological procedures. Increased the number of women of diverse cultural backgrounds who utilize regular screening techniques. Allowed the provider to provide high-risk counseling and screening to medically underserved populations. II. Funding Guidelines The following items MAY be funded via this RFP process: Salaries for patient navigators, nurses, nurse practitioners, data managers, translators, and administrative personnel essential to supporting care for medically underserved patients who need assistance in following clinical guidelines and treatment plans. Local transportation and other support needs (not more than 5% of funds requested), such as child or elder care for family members for whom a patient undergoing treatment is responsible. Equipment and technology that will help to upgrade the quality of breast care that can be offered. Grant funds MAY NOT BE USED to pay for the cost of medical services, categorically. Examples of these exclusions include direct costs of: mammograms and diagnostic breast imaging, CBEs, biopsies, lumpectomy, mastectomy, and chemotherapy, or fees to health care professionals performing these examinations and procedures and interpreting results. Other non-allowable items include: capital costs, office furniture, rent or other office expenses, program incentive items, hospitality items (food, beverages), support group activities or exercise classes for breast cancer patients. 4

Applicants should describe all sources of other funding for the breast cancer program at their institution. IMPORTANT NOTICE: A grant award in connection with this RFP does not guarantee funding renewals or ongoing operational support beyond the potential initial award period. The financial welfare of an applicant s breast cancer clinical services should not depend upon funding from this initiative or from the Avon Breast Cancer Crusade. III. Eligibility Requirements To be eligible for funding, applicants must have a demonstrated commitment to providing breast cancer care to low-income, at-risk, uninsured, and medically underserved populations, and provide evidence that they are the primary provider of these services to medically underserved populations in their catchment area. Avon BCC anticipates, but does not require, most applicants to be public hospitals and safety net hospitals as defined by the Institute of Medicine and the National Association of Public Hospitals and Health Systems (www.naph.org). Private, non-safety net hospitals should provide a concise description of their commitment and services delivered to the medically underserved. Applicants must be located in and serve vulnerable populations in regions surrounding or nearby the following metropolitan regions: Boston, Chicago, Houston, Los Angeles-Santa Barbara, New York, San Francisco, and Washington D.C. All other cities will compete in a national pool of applicants (All other cities/regions in U.S.). The Safety Net program is a competitive application process with peer review conducted by experts in breast cancer clinical care, health disparities, and community medicine, with final approval determined by the Avon Breast Cancer Crusade Board of Managers. 5

COMMONLY ASKED QUESTIONS This section includes some additional details to assist you in completing your application. It is very important that you read this section prior to completing and submitting your application. 1. How do I submit the application and how do we confirm that it has been received? Submit all Letters-of-Intent and for those invited, Full Applications, through the online grant system. You can find instructions, a tutorial on how to navigate the online system and links to the letter of intent on the bottom of the Safety Net Funding Initiative webpage. For questions, please contact Avon Grants Staff at grants@avonbcc.org. 2. How will grant recipients be selected? Applications will be reviewed by the Avon Breast Cancer Crusade Staff and external Scientific Advisory Board who will make recommendations to the Avon Board of Managers. The Scientific Advisory Board is comprised of a culturally and professionally diverse group of individuals. Its members are drawn from the breast cancer, social service, medical and patient advocacy sectors. The Avon Breast Cancer Crusade Board of Managers makes the final funding decisions. 3. What will the Avon BCC s role be if our application is funded? Avon BCC program staff will be available to direct you to resources and other beneficiaries with experience in caring for medically underserved individuals. You may also be invited to a national conference, the Avon Breast Cancer Forum, sponsored every 18-24 months for current beneficiaries. The content of the conference will include information sharing with other safety net providers, technical assistance and skill building workshops. Special presentations will be made by selected beneficiaries that have implemented highly effective programs. 4. What are allowable budget items? Allowable items include: support for staff (nurses, patient navigators, translators, and fellowship salaries); program-specific supplies (e.g. postcards and postage to mail out reminders, cost of telephone calls, multilingual educational print and visual/audio materials for patients); transportation or childcare to enable patients to obtain services they need (not more than 5% of the total budget requested); and computer, internet service and software for data management where needed. Support for attendance (registration, travel, and lodging) at two meetings each year: the Avon Breast Cancer Forum (if held during grant term) and one additional major breast cancer meeting in the U.S. per year (e.g., San Antonio Breast Cancer Symposium, ASCO, ONS, etc.) for one key staff member. Indirect costs are limited to 10%. Non-allowable items include: the cost of medical services, capital costs, office furniture, rent and other office expenses, program incentive items, hospitality items (food, beverages), support group activities or exercise classes for breast cancer patients. 5. What should be included on the budget assumption page? Your budget request is based on certain cost assumptions, such as personnel hours projected at a specified rate, the purchase of equipment at a given unit cost, the use of postage for an estimated number of mailed pieces, and travel costs for program-specific trips. A well-prepared budget is one where each line item is explained with detailed assumptions. For example, if you request support for personnel-related costs, your assumptions might indicate if the position is full or part time, the annual salary or, if hourly, the number or 6

hours and the hourly rate. Examples: 1.0 FTE Nurse Navigator $30,000 annual salary 0.5 FTE Coordinator $15 per hour X 1,000 contract hours 6. What required letters of commitment should be included with the Full Application? A letter of support from your Chief Hospital Administrator, or equivalent senior leader, is required. If in-kind services are being included, the letter should reference those and their dollar value. If responsibility for your breast cancer clinical service is shared with a medical school or academic center, a letter from the individual who shares such responsibility should be provided. If funds for a fellow are being requested, a letter from the individual who will be responsible for supervising the fellow must be provided. Please combine ALL letters of commitment into one file for upload to the online system. 7. What optional letters of commitment can be included? The success of programs often depends upon active community cooperation and volunteer commitment. If you envision utilizing or expanding such collaborations, you may include letters from community partners, volunteer (individual or groups) and referring agencies, describing their roles in and commitment to the activities that your application describes. Please combine ALL letters of commitment into one file for upload to the online system. 8. When is my application due? The Letter of Intent and invited Full Applications must be submitted through the online system by 11:59PM Eastern on the due dates noted for your geographic region. 9. What reporting will be required? All awardees will be expected to provide progress reports every 6 months on Avon Progress Report Forms. All Safety Net grantees will utilize a standardized progress report form and system. In addition, all awardees will be required to provide an annual financial report. Sample progress report forms are provided at the end of this packet. 7

SAMPLE PROGRAM TIMELINE This sample will guide you as to the level of detail required in a good timeline. However, this timeline is only a guide; please correct dates and activities to reflect your specific program activities, start date, and service dates. May 2016 o Gift awarded. Comply with pre-award formalities such as signing gift agreement, announcement of gift and publicity, etc. o Prepare job descriptions and begin recruitment of personnel and/or fellow o Order equipment o Begin development/upgrade of data collection and reporting system July 2016 o Start Date for Award o New staff hired and data and tracking systems in place o New staff begins training where needed and appropriate o Core team established; begins to meet regularly to assess progress and troubleshoot October 2016 o Bi-weekly team meetings continue; adjustments made where needed o Outreach activities scheduled January 2017 o Submit first 6-month progress report o New program brochures printed March 2017 o Attend Avon national conference o Hold staff training in use of new equipment July 2017 o Submit 12-month progress report o Continue timeline for the duration of program (Progress reports are always due January 31 and July 31). 8

Avon Breast Cancer Crusade Biannual Progress Report Due Every 6 months Avon Safety-Net Biannual Progress Reports are currently submitted using a secure web-based reporting program called Formstack. Reporting Periods: The reporting periods are every six months as in these examples: First Quarter Report (Jan, Feb, Mar) Due July 31, 2016 Second Quarter Report (Apr, May, Jun) Third Quarter Report (Jul, Aug, Sep) Due: January 31, 2017 Fourth Quarter Report (Oct, Nov, Dec) Report Components: I. Contact Information / Updated Agency Profile A sample of the report can be found at the end of this packet. II. Program Summary You will be asked to provide a one-page summary of your program, identifying any major successes or lessons learned that have occurred during the report period. Remember to take this opportunity to explain any unusual outcomes (changes in attitude, skills, or behavior as a result of the program implementation). III. Data Report You will be asked to submit a data report on your activities. The data is only due to Avon every 6 months, but we do prefer it broken down by quarter if possible. A sample of the report can be found at the end of this packet. IV. Financial Reconciliation, if applicable Annually you will be required to submit a financial reconciliation on the expenditure of grant funds. 9

Safety Net Hospital Agency Profile This form is for new grantee organizations AND should be updated annually by existing or returning grantees. Please complete the fields that are relevant to your organization. The purpose of this form is to get a snap-shot of the Breast Cancer Clinic/Programs in your hospital in addition to Avon support activities/equipment/staff positions. Hospital Name: Address: Contact person: Phone: ( ) Fax: ( ) Email: Is your facility funded through the BCCEDP? Please circle Yes No If YES, how much BCCEDP funding do you receive annually? Volume of services at your institution (whether supported by Avon or not): Annual number of screening mammograms performed: Annual number of diagnostic tests performed: Annual number of WOMEN screened: Annual number of patients treated for breast cancer: I. TYPES OF MAMMOGRAPHY EQUIPMENT: Please indicate all mammography equipment used at your institution Unit 1 Analog or Digital CHECK ONE Mobile Mobile Van Unit Stationary Unit Year Purchased Model Manufacturer % supported by Avon Unit 2 Unit 3 Unit 4 Unit 5 10

II. TYPES OF DIAGNOSTIC TECHNOLOGIES: Please indicate all Diagnostic Technologies used in the Breast Cancer Clinic Types of Diagnostic Technologies Computer Assisted Detection (CAD) # of Units Year(s) Purchased Model(s) Manufacturer(s) % supported by Avon Microwave Radiometry Digital Infrared Imaging Diaphanography MRI Ultrasound Computed Tomography Laser Mammography (CTLM) Other (Please Specify) III. STAFFING: Please indicate all that apply. Include the total number of staff positions and their combined % FTE. (See last page for definitions of key staff positions). Breast Cancer Clinic Staff Profile: Staff Position 1. Radiology Technician 2. Mammographer 3. Oncologist 4. Nurse Practitioner 5. Nurse (RN, LPN) 6. Outreach Worker 7. Patient Navigator 7a. Nurse Navigator 7b. Lay/volunteer Navigator 8. Volunteer 9. Other (Please Specify) Total # of Staff in your Breast Care Programs % FTE % supported by Avon TOTAL IV. OTHER: Please indicate any thing not captured in tables above you feel is relevant: 11

V. TARGET POPULATION (most recent program year): Total number of clients served* by your breast program per year: *Includes clients receiving education, referral services, mammography, and treatment. Please calculate percentages below based on total number of program clients per year. If you do not know the exact number, please provide an estimate. f. Primary Language Spoken: % of clients a. Gender: % of clients English Female Spanish Mandarin Male Cantonese Other (Transgender, Intersex) Vietnamese Unknown Korean Total 100% Arabic Portuguese b. Age: % of clients Creole French < 40 years Tagalog 40 49 years Hindi 50 64 years 65 years or greater Gujarati Amharic Total 100% American Sign Language Cape Verdean Hmong c. Ethnicity: % of clients Polish Hispanic or Latino(a) Not Hispanic / not Latino (a) Russian Croatian Other (please specify): d. Race: % of clients Black or African American White or Caucasian Asian Pacific Islander or Native Hawaiian Native American / Native Alaskan Other Total 100% e. Insurance: % of clients Private insurance Medicare Medicaid Other government (e.g., VA, military, Indian health, etc) Uninsured g. Other Special Populations: % of clients Recent Immigrants ( 10 yrs in US) Refugees Migrant or Seasonal Farm Workers Incarcerated women Homeless Persons with Disabilities Other (please specify): 12

SAMPLE DATA REPORT Name of Grantee Agency: State: Date Submitted: Instructions: 1. Enter quarterly data in the green shaded cells only. Other cells contain formulas and cannot be modified. 2. Provide data for all educational, testing, diagnostic and patient navigation activities relevant to your program. 3. Please complete all relevant sections of the data report for the most recent quarter, as well as all quarters year-to-date. 4. For Mammograms, the total for each quarter is equal to the sum of Screening and Diagnostic. 5. Do not modify this form. Activities 1st Qtr Reach 2nd Qtr Reach 3rd Qtr Reach 4th Qtr Reach Total I. Educational Contacts Total: 0 0 0 0 0 A. Individual 0 B. In Groups 0 II. Educational Events Total: 0 III. Mammograms Total: 0 0 0 0 0 A. Screening Total: 0 0 0 0 0 Less than 40 years of age 0 Ages 40-49 years 0 Ages 50-64 years 0 Age 65 years or greater 0 B. Diagnostic Total: 0 0 0 0 0 Less than 40 years of age 0 Ages 40-49 years 0 Ages 50-64 years 0 Age 65 years or greater 0 IV. Diagnostic Images & Biopsy Total: 0 0 0 0 0 A. Additional mam views 0 B. Diagnostic Ultrasound 0 C. Biopsy/Surgical Consultation 0 V. Genetic High Risk Consultation A. Referred for genetic counseling 0 B. Tested for genetic risk factors 0 VI. Breast Cancer Diagnosis Total: 0 0 0 0 0 A. Ductal Carcinoma In Situ 0 B. Invasive Ductal Carcinoma 0 C. Invasive Lobular Carcinoma 0 D. Lobular Carcinoma In Situ 0 E. Atypical Ductal Hyperplasia 0 F. Other Cancers 0 VII. Patient Navigation Total: 0 0 0 0 0 A. Language translation 0 B. Transportation assistance 0 C. Financial assistance referrals 0 D. Second opinion referrals 0 E. Support group/counseling referrals 0 F. Material support (e.g. bras, wigs, prostheses) 0 13