Workforce Retention Funding for Critical Access Hospitals and Their Owned and Operated Clinics

Provide the following background information: 

1. Organization Name and Background – Provide the name of your Critical Access Hospital, noting its location and the owned or operated clinics it includes and the estimated population served.
2. Project Lead and Contact Information – Identify the project lead who will serve as the primary point of contact to receive communications about your application. Provide first and last name, title, phone number and email. 
3. Project title and brief description of why you’re applying. 

The project narrative must clearly address the identified need and the planned strategies, services, tasks or activities. Be as specific and concise as possible, keeping the narrative focused on how the project will strengthen rural health workforce retention.

Identified Need and Proposed Goals

Identified the need for the proposed project

• Discuss the workforce challenges and retention issues your organization aims to address through the proposed project (e.g., staff turnover, vacancy rates, burnout, child care barriers, staffing shortages, gaps in training and professional development). 
• Describe the specific retention issues impacting your Critical Access Hospital and its owned or operated clinics.
• When available, include relevant local data to demonstrate the scope and urgency of the need.

Outline the overarching goals of your proposed project and the workforce groups who will benefit (e.g., medical and nursing staff, allied health professionals such as behavioral health specialist, radiology technician, respiratory therapist, laboratory technician, physical therapist, occupational therapist, dietitians, etc.).

• Goals should describe the broad, high‑level change your organization seeks to achieve (e.g., strengthen workforce stability by improving retention among nursing staff and allied health professionals through initiatives that support long‑term engagement and reduce turnover; enhance workplace well‑being by strengthening support systems for medical staff, nursing teams and allied health professionals, fostering a more resilient and engaged rural health workforce). 

Identify any similar projects being implemented and their funding sources. Explain how your proposed project will enhance, rather than duplicate, existing efforts, including how you plan to coordinate with partners to prevent duplication. If requesting funds for an expansion, describe why the expansion is needed and how the new funds will support additional efforts. RHTP funds cannot be used to duplicate or replace existing funding, known as supplanting. RHTP funds may be used to expand or enhance an existing project. See the Budget section for additional details. 

Strategies, Activities and Measurable Outcomes*

Describe, in outcome‑focused terms, the specific strategies, services, tasks or activities your project will implement to address identified workforce retention needs. Outcomes should be specific, realistic and directly linked to the strategies, services, tasks, or activities described. They should also reflect how the project will support the goals of the Rural Health Transformation Program, including improvements in rural provider retention, reductions in HPSA designations or a decrease in HPSA scores. 

• Please number your strategies, activities and measurable outcomes in order of priority. Approximately $10,000,000 in federal funding is available in year one for Critical Access Hospitals and their owned and operated clinics, to support rural health care workforce retention efforts. An estimated 37 awards of approximately $270,000 each are expected to be made in year one. Applicants may submit a prioritized funding proposal and requested amounts may exceed $270,000. Activities not funded in the initial agreements may be considered later in the year, pending a review of available funds in August 2026.
• Example: Reduce vacancy rates in nursing staff from 25% to 15% by September 30, 2027, by implementing retention bonuses, enhancing child care supports and covering license renewal fees, contributing to improved rural provider retention.
• In addition, each strategy, service, task or activity must include sufficient detail to ensure the scope is measurable and aligned with program goals. Using the example above, the following information also needs to be provided:
• Retention Bonuses: Describe the structure of the retention bonuses, including how bonus amounts will be determined (e.g., by role, tenure or performance). Specify the types of bonuses offered (e.g., milestone‑based, performance‑based) and outline the criteria and process used to select eligible recipients. Clarify whether the bonuses are tied to a five‑year service commitment.
• Enhancing Child Care Supports: Clearly explain what child care supports will be offered and how they will be implemented (e.g., child care provided at no cost or reduced cost to nursing staff, use of vouchers or stipends, minor renovations or equipment purchases for on-site child care). If applicable, describe how ongoing operational costs will be funded. Describe how the enhanced child care supports will be implemented.
• Covering License Renewal Fees: Identify which license types (e.g., RN, LPN, CNA) will be covered, who is eligible and how the fee‑coverage process will work. Additionally, explain how covering license renewal fees is expected to support staff retention and ultimately contribute to reducing vacancy rates.
• Financial incentives must be tied to a minimum five‑year service commitment. On a prorated basis, the employer (grantee) is required to return the corresponding funds to the state for any participant who fails to complete their five‑year service commitment, within 90 days of the default. 

Applicants must have policies, procedures and systems in place to manage these incentives, including a five‑year service‑commitment agreement with participating staff and a process for monitoring compliance. Refer to the Funding Opportunity section of the Funding Overview to determine which incentives are tied to the five-year service commitment. 

• Provide a description of the policies and monitoring procedures your organization has established, or plans to establish, to meet the above-described requirements.
• Copies of these policies, procedures and service commitment agreements must be submitted to the state office for review and approval before any financial incentive can be issued to an employee and before submission of a request for reimbursement. Instructions on how to submit these will be included in the agreement.   

Applicants will be required to attach documentation demonstrating formal approval of the grant application by the hospital’s governing body.

• For privately or nonprofit owned hospitals, this should include either:
  • A copy of the board of trustees/board of directors (or similar governing body) meeting minutes showing approval of the grant application, or
  • A letter of approval signed by the chair of the board of trustees/board of directors (or similar governing body).

*Applicants must propose strategies, activities and measurable outcomes that align with the RHTP evaluation plan and metrics for the Strengthen and Stabilize Rural Health Workforce Initiative, identified on pages 52-53 of the project narrative, and pages 10-11 of the appendices. 

• Increase the rural provider retention rate at 3 and 5 years
• Expand remote monitoring and AI-assisted care to reduce staffing needs
• Reduce Health professional Shortage Area (HPSA counties)
• Increase the rural primary care provider retention rate

Refer to the Funding Opportunity section of the Funding Overview for examples of eligible workforce retention projects.

Explain how the applicant will sustain successful retention strategies after the funding period ends. Describe how effective practices such as incentive programs, child care supports, wellness initiatives, flexible scheduling approaches or professional‑development activities will be integrated into ongoing operations and be maintained beyond RHTP funding. If the proposed project includes the purchase of equipment or technology, outline the plan for maintaining and continuing to use these tools beyond the funding period. Applicants should consider the following questions when assessing sustainability:

• How will the applicant continue supporting the retention activities that prove most effective?
• Are there opportunities to integrate these strategies into existing policy, operational budgets or workforce planning efforts?
• Do any of the proposed strategies reduce costs associated with staff turnover, burnout or vacancy and can those savings be used to sustain the program?
• Is there a long‑term plan or model to ensure ongoing stability of the retention efforts?

As it relates to your strategies, activities and measurable outcomes, please choose all that apply and briefly explain how your project aligns with each selected statutory element of the Rural Health Transformation Program Notice of Funding Opportunity:

• Improving access:
  How will the proposed workforce retention project improve rural residents’ access to care by stabilizing staffing levels?
• Improving outcomes:
  What are the baseline metrics (e.g., turnover rates, vacancy rates, time‑to‑hire)? How will the proposed project improve retention‑related outcomes identified in this application (listed in the Strategies, Activities and Measurable Outcomes section of this guidance)?
• Technology use:
  How will new and emerging technologies support workforce retention, such as reducing administrative burden, expanding telehealth capacity or improving staff efficiency? How will these technologies be sustained long term?
• Partnerships:
  Which partnerships will be leveraged to support retention in your rural care setting?
• Workforce:
  What training, upskilling or professional‑development activities will be provided to address gaps in the current rural workforce and support long‑term retention?
• Data-driven solutions:
  How will data and workforce‑retention strategies guide the project’s activities and decisions?
• Financial solvency strategies:
  How will the proposed project enhance financial stability by reducing turnover‑related costs and supporting a sustainable rural workforce?
• Cause identification:
  How will the proposed project address the root causes of workforce challenges and retention gaps in the rural continuum of care?

Complete a comprehensive Action Plan detailing how the applicant will carry out the proposed strategies, activities and measurable outcomes. As a reminder, the funding period will start upon execution of the agreement, with all required approvals and signatures. The funding period will end on September 30, 2027, and all funds must be expended by this date. Please identify the corresponding priority numbers from the project narrative in the action plan, as applicable. Being as concise as possible, the action plan must include:

Timeline and Milestones:

• Provide the timeline the applicant will follow to successfully implement the proposed project.
• The timeline should identify key milestones and include estimated completion dates for each key strategy and activity.

Metrics:

• For each measurable outcome, identify specific metrics that will be used and describe how progress will be tracked for reporting requirements.
• As a reminder, templates will be provided for reporting requirements. Due dates and additional information will be provided in the agreement.

Key Personnel:

• Identify key personnel, including a project lead. Describe the type of work each person will perform in carrying out the project. Include relevant credentials and experience managing grants and special projects.
• If the applicant plans to use external sources, such as consultants, please identify them, describe their experience and outline their role in the project. These external sources must also be identified in the budget.

Provide an itemized budget with appropriate justification for each cost category (personnel, fringe, travel, supplies, etc.). If applicable, include any indirect cost paid under the subrecipient and the indirect cost rate used.

RHTP funds are governed by applicable provisions of 2 CFR Part 200 and 2 CFR Part 300, with guidance from the federal RHTP Notice of Funding Opportunity and CMS’s Frequently Asked Questions document. The limits and unallowable costs detailed in this section come from federal guidance and are non-negotiable.

Administrative costs are not allowed in this funding opportunity. 

Approximately $10,000,000 in federal funding is available in year one for Critical Access Hospitals and their owned and operated clinics, to support rural health care workforce retention efforts. An estimated 37 awards of approximately $270,000 each are expected to be made in year one. Applicants may submit a tiered or prioritized funding proposal and requested amounts may exceed $270,000. Activities not funded in the initial awards may be considered later in the year, pending a review of available funds in August 2026. Please apply the corresponding priority numbers from the project narrative to the related budget items.

Staff receiving a financial incentive must be employed and on the payroll at the time this funding application was posted.

RHTP funding is designed to support expansion and scale to better serve rural communities, not to replace or duplicate existing funding sources. When using funds to expand an exiting pilot program or initiative or to develop a new training program with existing partners, the funds may only be applied to the costs associated with the new population, new activities, new program milestones, etc.

If retaining a clinical workforce will be supported by ancillary positions (CEO’s, CFO’s, Administrators), using funds to pay them may be allowable. However, all activities must be sustainable, so there mut be a clear plan of maintaining a given position without RHTP funds. 

Additional Unallowable and Limited Costs

• Pre-award costs.
• Meeting matching requirements for any other federal funds or for local entities. 
• Providers currently participating in a state loan repayment program that includes a service commitment are not eligible for financial retention incentives under this funding opportunity.
• Contracted or locum tenens providers are not eligible for retention incentives or projects, as these efforts are intended to focus on developing a long-term provider base.
• Services, equipment or supports that are the legal responsibility of another party under federal, state, tribal or civil rights law.
• Supplanting existing state, local, tribal or private funding of infrastructure or services (ex. staff salaries).
• The cost of independent research and development.
• Funds related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action or executive order.
• Financial assistance to households for installation and monthly broadband internet costs.
• Meals, unless in limited circumstances such as:
  • Subjects and patients under study.
  • Where specifically approved as part of the project or program activity, such as in programs providing children’s services.
  • As part of a per diem or subsistence allowance provided in conjunction with allowable travel in accordance with the U.S. General Services Administration (GSA) established rates. 
• Replacing payment(s) for clinical services that could be reimbursed by insurance.
• Direct health care services may be funded if not currently reimbursable, will fill a gap in care coverage, and/or may transform current care delivery model.
• Provider payments cannot exceed 15% of total funding in a budget period.*
• No more than 5% of total funding in a budget period can support funding the replacement of an Electronic Medical Record (EMR) system if a previous Health Information Technology for Economic and Clinical Health (HITECH) Act certified EMR is in place as of September 1, 2025.* Upgrades, enhancements, added modules, interfaces or functionality to existing EMR systems are allowable and not subject to the 5% limitation.
• Funding toward projects similar to the “Rural Tech Catalyst Fund Initiative” cannot exceed the lesser of 10% of total funding or $20 million of total funding awarded in a budget period.*
• Clinician salaries/wages for facilities that subject clinicians to non-compete clauses.
• Demolition of aged buildings.
• Administrative costs, capital expenditures and vehicle purchases are not allowed under this funding opportunity.

*Limits apply to ND HHS’s spending of RHTP funds. Individual agreements may be considered for costs exceeding the budget limitations.

Applications will be reviewed and scored solely on what is presented within the application materials. The reviewing committee will score applications based on criteria in the Scoring Tool.

ND HHS aims to notify applicants about their award in a timely manner. ND HHS reserves the right to support applicants with changes to their project proposals to ensure HHS’s RHTP commitments are upheld. HHS is in a cooperative agreement with CMS for RHTP and is subject to substantial CMS project involvement. This may impact funding timelines.

The awarded applicant(s) will be sent an agreement to sign and return to HHS. The awarded applicant(s) shall comply with the agreement provisions set out in the “Sample Funding Agreement” document. Due to the limited timeframe associated with the funding source for this funding opportunity, HHS will not entertain any changes to the funding agreement Terms and Conditions.