Alaska Dept. of Health: RHTP Advisory Council (September 23, 2026)

Hello. Good morning to everyone in the room here in Anchorage and online. My name is Emily Ricci. I'm the Deputy Commissioner of the Department of Health, and I would like to call the Rural Health Transformation Advisory Council to order. We are doing our first hybrid meeting, so thank you for bearing with us.

Thank you for joining us this morning, to the advisory council members, and for your willingness to serve in this important role.

The council brings together a broad range of experience, perspectives, and community voices, and your participation is essential to shaping the future of this project. As a reminder, the purpose of this advisory council is to provide structured, informed, and directional recommendations to the commissioner regarding the design, oversight, and continuous improvement of the Rural Health Transformation Program. The Department of Health recognizes that Alaska's rural health system is highly interconnected, and that advisory council members may be applicants to the RHDP or have professional affiliations with organizations that are applicants, partners, or stakeholders. These relationships do not preclude service on the advisory council, but they do require awareness and transparency as we conduct our work. Members are expected to disclose status as an applicant or relevant professional affiliations to the department in a timely manner.

Members are expected to disclose possible direct personal benefit to themselves and/or family members to the department in a timely manner. The department will review potential conflicts on an ongoing basis. Before we begin, a few reminders about how we operate. Our meetings will follow informal Robert's Rules of Order. When the Steering Committee needs to take action, we will use a simple majority vote among members.

And because we are meeting virtually, all votes will be conducted by roll call. So we will begin this morning with roll call, and we will start with the elected officials serving on the committee and in this room this morning. Senator Giesel? Here. Representative Mena?

Online. I believe we have Jared Kosen. Here, and I'll be in person shortly. Thank you, Jared. We do not have Katie Baldwin-Johnson or Mary Johnson or Mary Wilson yet, but I believe they will be joining.

Nils, are you online? Yeah, I'm present. Okay. Monique Martin? Present.

And Terry O'Connor. Here. Okay. All members are present and we have a quorum to conduct business. So next we'll move on to the next, to the agenda and approval of the agenda.

The agenda was provided in advance. It has also been publicly noticed. Are there any requested changes?

Okay. Seeing no requested changes or objections, the agenda will be approved.

Okay, the agenda is approved. Approval of the minutes. The minutes from our last meeting were distributed ahead of time and I think are available as part of the online packet. Does anyone have any corrections or changes to the minutes?

Okay, if there are no corrections or changes, the minutes will be approved barring any objection.

Hearing no objection, the minutes are approved. So now we're going to move into the next item on the agenda, department updates. And we wanted to start with Rural Health Transformation Year 1 updates. I will— we have a PowerPoint just to help guide the conversation. Of course, we can stop at any point during the PowerPoint to— for any discussions, questions, or issues that arise.

And Betsy Wood, the Executive Director of the Office of Health Savings, will start us with a quick look at where we're at overall. And then Eliza Ramsey will walk us through the year 1 award process and where funds are being invested. So if we could move into the PowerPoint presentation. There we go. Betsy.

All right. Thank you very much. So we do have quite a bit to cover today, but we wanted to start with looking at year 1 and, you know, talk through implementation and kind of then we'll move into year 2 and where we are looking ahead. We wanted to start with a reminder of the timeline because it really does give some context for how quickly this program has moved. We're just over a year from when CMS released the notice of funding opportunity for the Rural Health Transformation Program.

September 15th of last year is when that came out, and we've accomplished a lot in that time period. We have stood up the program. We held our statewide convening. We are nearing completion of our first application cycle. And we're moving into year 2.

One thing I want to highlight is that we've continued to hold regional plannings throughout the process. Since the council last met, we've had additional meetings in Ketchikan, Valdez, and then as recently as yesterday, we had the greater Anchorage area, that where we met, in this just next door. We have 3 more regional meetings that are scheduled through the end of this year. We have Utqiagvik in the North Slope on October 27th. We'll be in Kodiak on November 9th and down in Juneau on November 17th.

The other thing that I want to point out with the timeline is that we're hitting the stage where our year 2 implementation and our year 1 implementation and our year 2 development are happening at the same time. So we're doing a lot of concurrent work on a lot of levels and And I think that's some of that is what we'll talk through today to kind of give you a sense of how we're moving through the decisions on year 1 and ramping up for, for another cycle moving into year 2. But with that, I will pass it over to Eliza Ramsey and—.

Before Eliza speaks, this is Emily Ricci, and I would just like to note that Katie Baldwin Johnson has joined us online with the Alaska Mental Health Trust.

Eliza. Thank you. Just want to lay over the award process for year 1. Award announcements have been happening on a rolling basis rather than all at once. The first notices of intent to award were issued August 7th, and we have continued releasing awards on a weekly basis since.

The steps to get to both a notice of intent to award and then a final award packet and signatures by all parties vary by project. They may include follow-up clarification on budget revisions CMS review of select items, and completion of kind of all required documentation. That means that no two projects move to award agreement on the same timeline, and the biggest variable is usually how much budget refinement remains before the award package may be finalized. The important point is that the process is continuing to move forward, and we are moving forward on announcing awards and making sure that applicants have the support that they need. We are working through the remaining projects as quickly as we can, as quickly as we can, while also making sure award agreements are accurate and federally compliant.

As of September 18th, we have announced $239 million in project awards to 244 projects. You can see here that the slides come out in several rounds beginning August 7th with the largest announcement on August 21st. These amounts are still projected rather than totally final as we work through revisions with applicants to ensure that their budgets are appropriate and accurate. We do anticipate some modest movement in the announced numbers. And then we also do still anticipate additional project awards to be announced.

Thanks.

This now—. Oh, yeah. Let me— sorry to interrupt. I wanted to confirm with the project awards continuing, could you clarify when or if there's a final date that CMS requires all the monies to be allocated? I know there's a lot of movement over even since— I always remind people it's just been since July that this bill of 2020 that this bill was signed into law.

So we've gone from legislation to money out the door in an incredibly fast speed. So I think clarifying some of those points, has any timeline shifted from CMS in terms of when do states have to allocate all their dollars?

Thank you for that question. States have to allocate all of their year 1 dollars by the end of the first budget period, which is October 30th of this year. So next month, by the end of next month, we have to have allocated that. Then we have through the end of the following federal fiscal year to finish expending. So to finish pulling money down from our federal partners.

So that's September 30th is the end of that kind of expenditure window. That is from the, really, I think of that as like from the state to, to the federal government. What's the state's obligation window and the state's expenditure window? For all of our subrecipients who are receiving their award announcements and beginning their performance periods. Those performance periods all run through June 30th, 2027.

Getting my dates right. And that's 3 months before the end of that expenditure window to allow us time to do kind of final reporting and wrap up for that performance period. As we, you know, talk about moving into year 2 and we talk about moving into, you'll hear us a little bit later talk about gearing up for the fall cycle. The way that we'll be awarding over the next, you know, handful of years, as long as the program is going, is that there will be a spring cycle of awards and a fall cycle of awards that will be kind of 6 months offset. So anyone who's receiving an award in this round and they come up at the end of their performance period on June 30th, if they have continuation activities that they'd like to continue that project into the next year, they will apply through the spring cycle application process so that their year 2 performance period can start right as their year 1 performance period is ending.

But CMS has been very firm that there are no extensions to the dates. There's no wiggle room. That there's— that is, they're not flexible dates.

If I may, Deputy Commissioner, I think— thank you, that was super helpful. I had a different timeframe in my mind when the state had to allocate all the, all the dollars. So I think that's really helpful. And then that performance period, if I could suggest, based on feedback that I've heard from applicants and awardees, is really highlighting when that performance period ends, because there's so many different moving dates with end of federal fiscal years versus state fiscal years versus calendar years, and that's a question that I hear regularly from awardees is, can you clarify when I have to spend my money? So I think that's something that we could work on really clarifying with folks is that June 30 date that we should all be keeping in mind for 2027.

Thank you. Yeah, thank you. I think that's helpful feedback and it is easy to, I think, to get a little lost in the federal fiscal year, state fiscal year, calendar year budget period mix. And I think we can take that back and put together some resources that make it easier for folks to understand at a glance.

One comment I would have too that I think is important for people listening to just be reminded of is that we have reporting requirements too from the state side that we have to complete. And so part of the reason that the performance period for grantees, you know, has that June 30th date is because we— our team has a report to CMS that has to be filed by the end of August. And so not only do we have to do those closeout and reporting periods, but we also have to put together a compelling report to demonstrate to CMS that we have done the things we said we're going to do, because then they take that into consideration before announcing award amounts for the following year. So there is some grace period that we are building into that award period, particularly because year 1 has happened so fast, right? And we're all moving.

But, but that, I, you know, we recognize that award period is, is shorter than we'd like. But, but I think it's important to understand that the work that the state has to do in order to, to put together, you know, accurate and compelling reporting for year 2, and we do need a little bit of time to do that.

Any other questions on this slide?

Okay, Eliza.

Okay, moving back to an overview of how Year 1 funds have been invested by initiative area. The largest share to date has gone to healthcare access, followed by SPARK technology and innovation. We've seen about $30 million go to pay for value efforts, followed by strength and workforce, healthy communities, and healthy beginnings. This distribution reflects the proposals that were funded in the first cycle, and it's not intended to establish a fixed percentage of where we see future awards being allocated. This gives us a useful baseline though as we move to year 2, thinking about where there are needs in our healthcare system and continuing to shape future funding opportunities.

And we're excited to kick off our year 2 discussion with you all today, because thinking about how do we inform, you know, what we learned in this first cycle and how we are moving forward.

Sorry, I have to turn on my mic. So I think what we're going to do now is transition from year 1 as we start to think about how do we move into learning lessons and preparing for year 2. And we've learned a lot of lessons. We've seen a lot of reflections, both from this group and from members of the public and applicants. And I'll have Allison Miller, one of our program coordinators, kind of talk through how we've been making refinements based off of some of the feedback that we've received so far.

Thanks so much, Betsy. Yeah, our team has been doing a lot of reflecting lately, both as we prepared our first progress report to CMS, but also as we started thinking about what the year 2 application was going to look like. And these are some of the biggest pieces of feedback that we heard, both from applicants, but also from other players and stakeholders. In the healthcare landscape. The first was that the application was too laborious and time-consuming.

There were a lot of components. There were two different application cycles, including the LOI cycle, and it took a lot of time, and we're appreciative of that. The second was that the application, as it was formatted and structured, was not necessarily a good way to capture all of the big creative ideas that people had about how to transform healthcare. And so we've been thinking a lot about how we can support applicants in translating those big creative ideas into actionable proposals that fit within the framework and the parameters of the RHTP. The third was that application clarification took too long.

We have been spending a lot of time going back and forth with applicants on their budget narratives and their materials. And I think that applicants enjoyed that about as much as we did. And so we have been thinking a lot about how we can, how we can streamline that process or avoid it entirely in the year 2 cycle. And then finally, we've heard a lot of feedback about how smaller organizations don't see themselves in the process. They don't feel that this funding is for them and that they want a lot more support.

And that's something that we've taken really seriously. We're thinking a lot about how we can provide more resources, more opportunities to have face time with the team so that they can ask questions about their specific proposals and just how we can support them in moving forward in the year 2 cycle. And go to the next slide. Next slide, please.

I also want to highlight some kind of overall changes that we have made to the program. The— and I'm sorry, to the application cycle this year. The first is that we're getting rid of the letter of interest cycle. So there will be just one single application for every single proposal. The second is that we've developed a lot more targeted questions.

And so in addition to all of the core questions that every applicant will answer, we've developed some questions that are around specific areas like equipment or workforce or provider payments, areas where we now know after going through this process once with CMS that we need more information than we originally asked for. We're also limiting the number of applications per organization to 5, and our intention here is not to restrict organizations, but hopefully to make it easier for them to focus on the things that are most important to them. We're also providing a lot more guidance before this next cycle opens. We talked a lot at the Anchorage convening yesterday. We hope you'll all hang around later today for our first-ever applicant convening where we're going to talk a lot about year 2, and we'll also have open office hours where people can ask questions.

And then we have 2 webinars planned for next week. The first is going to be a walkthrough of the full application so people can see it and hear more about it. And the second where we're going to recap a lot of the things that we talked about today. Moving forward, we are hoping to continue this 2-cycle-a-year application process, and, and we'll try to make that calendar available as far in advance as possible. But our, our goal is that having 2 application cycles in a year will make it easier for applicants to apply on a timeline that works for them rather than having to rush to put together a proposal when maybe they're not quite ready yet.

Allison, this is Emily Ricci. I would like to add to, I think one of the considerations for 2-year cycles is organizations may have capacity 6 months from now that they don't really have right now. And so giving them a chance to think about, again, when can I put forward a project that I can complete within the budget period is really important. Part of the challenge with the Rural Health Transformation Program is like you need to be able to do the projects that you say you can do within the specified time period or there's risk to the state for losing that money during that budget period and in the future. And so we want to provide, again, more guidance and, or more time and more opportunities for organizations to align those applications with organizational capacity.

All right, so slide 8. Put some dates around what Allison has just been describing. You can see, you know, looking at what we're planning for, we're planning to open the application, the fall application cycle, September 30th, and that would be open for 4 weeks through October 28th. And then we're looking at about 4 to 5 weeks for application processing and review, and then about 3 weeks for final clarifications and moving into that award performance period beginning January 1st. That's when we expect that that would happen.

You can see on the right-hand side of the screen, there's kind of a darker colored diamond that shows where we would have landed if we had been moving at the spring cycle's pace. So we are trying to streamline the process. I think with, you know, with any new process, you learn a lot as you move through it and you find a lot of opportunities for building efficiencies and streamlining. And so that's really what we've tried to do with here too.

We also, as Allison alluded to, have heard feedback from, from a number of people that it would be really helpful if the state could provide a little more kind of clarity and focus on what some, some focus areas or areas of priority are. And so what we are introducing for the fall cycle this year is that we are highlighting 3 areas of focus that really came out of what we saw in the first round of letters of interest and applications and kind of the needs that we see and also some of those really foundational activities to be able to move into system transformation. So the 3 planned areas of focus that we are looking at are pay for value readiness. So thinking about what some of the foundational work that providers need to, to have integrated into their organizations to be ready for value-based payment structures. Infrastructures.

So that could be building up your data capabilities, your care coordination, administrative capacity, other infrastructure to help organizations move into a value-based payment system. We are also particularly interested in building out resources to strengthen care coordination and help support patients as they move between settings, particularly patients that are discharging out of hospital settings into, into a different level of care or different organization, trying to help strengthen some of those care coordination pieces. And then also really looking at EMS, emergency medical services, and thinking about how we can build out supports on the data side, both for kind of near real-time data in the moment, as well as, you know, incident data or kind of outcomes data to help people be able to reflect back on what occurred. And then thinking about some of the pieces, you know, workforce capacity or tools that EMS that needs to be successful. So those are the 3 focus areas that we've identified.

But I do want to stress that there still is an open call, is what we're calling this, across all 6 initiatives. So we've heard from people who have said, that's great that you're highlighting some focus areas, but my project that I really would like to put forward doesn't exactly align. What does that mean? Every round there will still be an open call where people can say, you know, I have this great Healthy Beginnings aligned project and I'd really like to put that forward. Alignment with the focus areas doesn't give anybody extra points or extra credit.

What we are intending to do is to identify maybe a target funding amount for each of the focus areas and try to balance towards that when we move through our portfolio review. So we'll talk about that a little bit later in the presentation today. But And just, you know, really, I think the highlight here is that the department is planning to focus in on specific areas every funding round to kind of elevate and encourage people to think about some of the foundational pieces that are really helpful to move through the overall program transformation, as well as maintaining that opportunity for organizations to bring their great ideas forward and to put them in the mix under any of the calls. Another thing that I want to highlight on this slide is, as we think about what does— how does this fall cycle lead into the spring cycle? We know there are a lot of organizations that are awarded in this cycle that say, this is a multi-year project, I need to continue.

What does that look like? I'm just getting awarded, do I need to apply again? The answer is no, that folks that are submitting or that are starting their work now Um, will need to apply again for that continued funding, but that would be in the spring cycle. So they'll have months of work under their belt and they can say, here's how my project has been going. This is what a continuation to year 2 would look like.

So people who are starting their awards now shouldn't be thinking that they need to reapply in the fall cycle. They will reapply in the spring cycle and will work in that continuation.

One thing that I would note too is just as a consideration, we want to ensure that, that entities that have funding streams outside of RHDP for those continuations are using those and leveraging those. And so we will be reviewing those projects as well and making sure that entities that are applying for those continuation grants really have fully leveraged any other funding opportunities before they apply for those continuations. We want to make sure that as much funding as available remains open. Open. And I think in year 1, we saw a lot of entities that had built in maybe multi-year operational fund— not operational funding, but continuation funding into their proposals.

And we asked for that information because some entities may want that. But I just want to make sure those listening, again, I think we reiterated, we said this consistently in the last year, like year 2 funding is not assured. And so the expectation that I think it's really important for entities to have is that you develop sustainable funding outside of RHTP and do not rely on continuations for the future. So I just want to state that again. Senator Giesel.

I wanted to ask about the underdevelopment piece. Have you not gotten to that last item on this? State-directed targeted? Or did I miss it? No, that— so the underdevelopment piece we're looking at, You know, we've talked about different funding pathways, you know, that there's planning, planning grants for organizations that need that implementation grants.

And then we've talked about some of the state-directed targeted innovation projects. And we think about that as, you know, for example, with care coordination, there may be pieces of care coordination readiness that are organizations needing a planning grant in order to figure out what do they do implementation, same for that. But then there may be an element where the state needs to put out an RFP for an organization or a contractor to come and support some of the stateside pieces of that. So we wanted to, to highlight that that's still a pathway that remains available and that you may see some elements of RHTP projects coming out as state-directed RFPs or state-led contracts. And I really, our primary focus has been standing up year 1 and getting money out into community and then preparing for year 2 to continue to get money out into community.

And we're, we're a very small but mighty team. So I would say this is a part of the work that is still under development. You'll see more to come in the next few months. Thank you. Representative Mena.

Thank you. These microphones are different. I wanted to ask how the department picked the plan areas of focus for this fall. Was that based off of awards overlaid on the portfolio framework? And my second question is, what's the anticipated date for that spring cycle?

Thank you for the question. So we, we picked these looking at, you know, when we saw the letters of interest and the applications that came in, I think that we identified areas where we saw a lot of parts and pieces where people identified need and like a lot of asks around EMS, a lot of asks around care coordination that were maybe similar but slightly different. And so what we wanted to do is put forward a focus area where we can, and I mean, I think what you see here with just a few lines, what we'll put in the application process and what we'll share out to applicants going in is more robust examples of when we say an EMS focus area, what do we mean by that? Give examples of types of activities and types of projects and types of services that can be coordinated and integrated together. So we saw opportunity to kind of get people working in the same direction rather than having a number of organizations trying to do similar work, but in silos and slightly askance and kind of not quite coordinated.

So I would say that's where the focus area really came from, was looking at what did we see, where did we see opportunities for alignment in the first year, and then also kind of thinking about, you know, as we think, think about the 5-year cycle that we have under Rural Health Transformation and know that we're in this space of building up capacity and building up foundational pieces that organizations need in order to be able to kind of climb the, you know, the roller coaster up into being ready to build out some of the system transformation pieces that we think are going to be really critical to then kind of glide down into a sustainable and differently shaped healthcare system. We think a lot of these foundational pieces have to happen now, particularly around care coordination. And so saying let's really highlight that and really try to get folks moving in that direction so that we can all work together for system transformation as we move forward. Deputy Commissioner, would you add anything to that? I would just reflect on some of the conversations I heard yesterday in the Anchorage convening at a few of the tables I was at when people were talking about what would be helpful, the care coordination, the better connection.

Actually, the HIE came a lot. Came up a lot, better connection to the HIE, being able to share data, being able to use that data, and then having the staff to do something with that. And so I think that aligns really well with these first two goals. I think emergency medical services is an area that we know needs a lot of support and strengthening, and there's a lot of work happening around the state, but how can we ensure that that work is coordinated and that that is a focus area this fall? So some of these focus areas represents what we've heard through the regional convening.

Some of it represents what we saw in either the LOIs or the applications. Applications, and then thinking strategically. If we wait until year 4 to really focus on like the data build-out, the care coordination, and the administrative support, I think we're gonna, we're not going to achieve some of the goals we have for the program.

Representative Mena. Thank you. I still wanted the clarification on the spring cycle, but a follow-up that I had was on when you say alignment, and, you know, I think about it in two ways. One is alignment to the actual CMS requirements, the portfolio project framework, but also perhaps alignment in terms of organizations better collaborating with each other. And so I'm wondering how that is happening.

Is it just follow-up from different entities that are at regional convenings that those relationships have been established? Is the department perhaps reaching out to rejected LOIs under those buckets and following up? But I'm just wondering how we can help foster more collaboration with, with a lot of those entities that may not have received year 1 awards.

I think that, well, I'll talk about the collaboration first, and then I promise I'll remember your question on the spring cycle. I do think that as we think about what sort of technical assistance we can offer to organizations and to applicants, a huge part of that, and you'll see when we start talking talking about some of the changes we're proposing to the evaluation frameworks too, is a heavy emphasis on thinking about collaboration as not just a who are you formally partnered with, but who are the other people and organizations that are also caring for the patients that are at the center of the work that's happening. And, you know, I think that building out additional opportunities for folks to connect and to learn about what other organizations in your community or in your kind of space are working on and say, hey, we're really aligned. Let's think about how we can do this together. A lot of that is, you know, we're trying not to kind of come in heavy-handed and say you all have to— like we're doing some forced matchmaking, trying to avoid that, but also saying let's build out collaborative communities of practice.

And where we see a lot of people who are working on the same sorts of things in the same sort of area, and you want to, you know, do big things with this funding, saying let's build out places where people can work together and can collaborate and can say, yes, I'm, I'm going after this funding and you're going after this funding and we're going to work together and get on the same page. So I do think we're trying to build out some of those opportunities to, to say that they, you know, here's better places to collaborate. I would point out with EMS, emergency medical services specifically, I know the commissioner and the department has been meeting with some EMS groups statewide to try to make sure that everyone is working together. So it's not necessarily heavy-handed or directive, but it is heavily influenced. I would also say one of the things that's hard to capture with the regional planning meetings, but in my mind has been the most valuable and is is, is not predictable from my perspective either, is when groups within a region come together and they realize that they are working on similar things, or that one project someone has or one idea complements another, and they begin to make those connections.

And then we end up seeing that, um, either through coordinated proposals where you have groups in a community that are saying, we will take this, like, we will submit this, we will not submit that, right? So you have some natural coordination that has occurred within a community in terms of the proposals they're putting forward. And, you know, we didn't have that with the LOI stage, which was a little bit by design, right? It was cast a wide net, see where everybody's at, but we're trying to be more thoughtful.

And then I just wanted to make sure I addressed your question, Representative Mena, about the spring cycle. We don't have firm dates yet, but we are thinking for by spring, I really think of that as like a late winter type of a thing that we that, you know, we've talked a lot about. One of the reflections is people are like, we would love to have a little more time to plan, we'd love to have a little more time to apply, and we really want to have more space. I think what we've been successful with in planning for the fall cycle is building in efficiencies and streamlining. But I mean, if you looked at the timeline, it's still a tight timeline.

It's still, you know, we're opening the application process next week, 4 weeks to apply. 4 To 5 weeks for kind of review and decisions, a few weeks for clarification. That's still moving really rapidly. And so part of that is the carryover of the just the tight timelines we're on for year 1 that it's been. We don't have the luxury of time, but thinking ahead to how do we plan for the spring cycle of year 2, we're hoping to be able to move that application process even earlier and give people a little bit more time and kind of build in the space for people to have time to apply, the department to have time to process through the applications, move through that clarification cycle and award issuance well in advance of that July 1 start date for the spring cycle.

So that will happen, you know, this late January, February is probably when you'll start to see things kick off.

Monique. Thank you. I wanted to talk about pay for value a little bit because that's a big one and that we really haven't touched on today. And that's sort of a big deal. So I'm, I'm curious how we can sort of start to have that conversation a little bit more informed with some of the data the state already has.

I've heard the commissioner mention, um, at the last webinar that this Department of Health is working with MNAT, with GuideHouse, and I think GuideHouse has some— and I think let's not forget the Mesa report because there's a lot of great information in that report. And, um, as we think about pay for value, I think we have to acknowledge where maybe different provider types have been chronically underfunded. And I'm kind of thinking back to a couple years ago when there was the skilled nursing facility acuity-based rate. And we, um, and Jared, correct me if I'm wrong, it's been a little while and I don't work at a skilled nursing facility, but those SNFs, we were, we were taking the the, the budget amount that we were spending on skilled nursing facilities and saying, okay, now for lower acuity, we're going to pay you less, and for higher acuity, we're going to pay you more. And I think, um, what I heard from skilled nursing facility providers is we can barely make it on the rate you're paying us now, State of Alaska.

We need a higher rate so that we can really serve Alaskans with really complex conditions. So as we think about value-based payments, I think, um, we really have to have those conversations about where we are not serving Alaskans now. We see those at the Alaska Native Medical Center, patients that are stuck. The Alaska Hospital and Healthcare Association has done reports on hospital boarding where 1 in 7 or 8 patients are stuck in the hospital because there's no place for them to go. And because of their typically way more chronic conditions, children that are in, involved with the Office of Children's Services that are stuck because there are just not foster services available for children with really complex needs.

We've had patients wait over a year for a placement. I think that the Hospital Association report is a great place to start. They were, gathering data on why are patients stuck. And I think that where we see opportunities to really serve patients, um, that with those complex conditions, I, I just wanna have us in that frame of mind that we might need to spend more to make sure that we are serving patients with complex conditions. Paying differently.

Absolutely. There's lower acuity, higher acuity. Certainly we can look at those opportunities. But when I think about general relief, when I think about these programs that we've built, um, providers really have no choice but to select to serve those patients at the lower acuity end of the typical patients they serve because they still have to be able to pay the provider. Some of those are one-on-one.

Some of those patients are three-to-one based on what we see at the Alaska Native Medical Center. So I think that, um, there's a lot to learn in that space. I would love to hear more from applicants who put forward and were awarded funds by the state of Alaska of why they think this works. Um, what can we learn collectively from efforts people are thinking about undertaking? What did hospitals learn from the DRG, um, effort that rolled out?

What did we learn from the SNF acuity base rate? So that we don't have, um, a lot of time and energy spent on a project that we really can't move forward as envisioned. And I think there's just lots of great synergy and energy we can build from kind of working collaboratively on that. And how do we make sure, um, that we're really building programs? Because I worry about the state's capacity to really roll out, um, 7 different pay for value type concepts.

So those are some of the space when I think about pay for value. I could probably talk about that for a lot longer, but I'll try and stop there. I will make a reminder that there are special protections provisions that providers will have to think about when serving Alaska Native and American Indian people that we really need to remind folks of regularly throughout the application process so that they're remembering those requirements. So, so that's sort of my pay for value soapbox, I guess, as I was thinking about the meeting today. But I might also highlight, and I appreciate the department sending out the minutes ahead of the meeting.

One of the things we've talked a lot about at Advisory Council are the milestones associated with the state's application. And we talked a little bit about this at the last Advisory Council meeting. And I really would like applicants to understand those milestones. And if they are kind of in our rearview mirror now, is there still an opportunity to present those projects to the state for considering consideration of funding? And I know that we were kind of a— that was an ever-evolving process with CMS.

So if you have any insight that you could provide on pay for value and how we can use some of Guidehouse's work on studies at the legislature, we're looking forward, and those milestones in the application, that would be great.

Jared. Just to add, Monique's overview of the acuity rates was totally accurate. And very well done. It was assisted living, not skilled nursing, just for the record. But the other thing I wanted to offer just on top of what Monique said, because I think she said it very well, when we look at sustainability for pay for value, it's gotta be, it can't be a 1, 2, 3-year effort and it's gonna show major returns.

We have to take at a minimum 5, preferably 10-year outlook and project returns, do performance, because if we judge sustainability on early years, it's not going to work. I mean, Monique's right. It's going to take investment upfront, and that investment's going to cost money, and it will take longer than probably 3 years to prove itself out.

The last thing I'd add is to Monique's point. I think I heard when I was listening as I was coming over here, was it $30 million was pay for value in year 1, and that's gone out so far? That's a lot of money in a good way, but that does make me agree with what Monique's saying. I think we would really, if we're going to concentrate on pay for value, it's got to be a consolidated effort. If you do a big scattershot, I think it's going to be really hard to build synergy from that.

I think you really need to concentrate the effort, especially if you are going to believe what I just said and take that longer-term view for returns.

I think we are absolutely aligned with that. I think that's partly why when you see pay for value, it's pay for value readiness, because there are core— I think there are core things that entities can invest in now that are beneficial regardless of what the model is that the state decides to move forward with or regardless of which provider type they are, right? It's the data connections, it's the care coordination, and it's that administrative support. So I really think like this year and next year, the majority of what we can be focusing on while we figure out as a state, not like, again, the big state of Alaska, but like all of us, what do we want to move into, we can still be investing in these foundational issues, in these foundational items for organizations because they will be helpful. They will be needed regardless of what that end model looks like.

You know, one of the other things that came out of the Anchorage convening yesterday is something that I think I was thinking about when we first started this process is our aging population and our system set up in a way to support to support and serve seniors. And I think if we can really focus on that now over the next 5 years, we will do ourselves and our seniors and our younger generations a great service to be more prepared. And I do think there's an element of pay for value that can come into that. We had anticipated to be very kind of candid. We had hoped and had even like put dates on a calendar for a pay for value convening so that we could start to focus on that.

We have just not had the capacity in year 1 to do that in a thoughtful way. I think back to some of the work that happened with SB 74, and I actually think that we have a statutory structure to consider as we think about what pay for value looks like, what some of these larger payment reforms may look like. But they do need a larger conversation than what will occur in any single proposal. Or in any single convening, right? So I think this is an effort that we would do well to undertake over the next year very thoughtfully so that we can begin to leverage our HTP resources in a more focused way in years 3, 4, and 5.

And I think that aligns with what, what you both are saying, right? We don't know what the models are that we need to move to. I've been thinking a lot about pay for value and kind of that need for improving outcomes, both in terms of what we're paying and the value we're getting for that and the the patient outcomes primarily, but also the need for provider stability. And so when we're thinking about alternative payment models or value-based payment, from my perspective, a lot of those conversations is how does risk shift between the organizations, the provider providing the service and the payer, right? How does that risk shift for the overall outcome of payment?

And I think in Alaska, what I hear frequently from different sets of providers is that one of the challenges that we have in thinking about pay for value or alternative payment models is that that risk, that risk kind of shifting creates, can create, can impact stability. And many of our providers are at a point where they can't undertake any sort of risk that impacts their stability. So I think that element of stability really has to be part of that. And I think that's actually core to the RHTP program, right? How do we make our healthcare system more efficient, but how do we create stability particularly for rural healthcare providers.

So I see it tying together. I think we need some more time and space and think about how to shape that conversation at a larger level. And I think that's something that ideally we will have an opportunity to focus on in the next year or two years. Jared. Just to make one closing comment for myself on this.

I hope we all have the philosophy, and I think this is what Monique was getting at, and I know Emily, you totally get it. But for the record, pay for value cannot be pay less. And I say that from the standpoint that value is predicated on a functional system. We can— value, certainly from a hospital perspective, is predicated on the ability to discharge someone out after they're medically cleared. So it's like you can restructure our reimbursement, but essentially it's just more uncompensated care gets swallowed up in the hospital system because even though we can bear the risk on certain patients, if we cannot move them out when it's time, which we can't today, then the system kind of collapses.

So I would just— I really think we're in a position where we have to take meaningful baby steps. And I think you're right about the senior population. And I, you know, in an ideal world, if it were me and we had unlimited resources, I would do a massive cash infusion for early childhood development and things like that. And I would do a massive cash infusion on the senior side and let those things play out over time. But obviously we don't have that luxury, but I'll stop there.

Oh, those are well said comments. And I think a lot of the struggle that I see in the system is how do we build out places for people to go? How do we make sure that those places know that they can accept people, right? Like that connection between the patient and the lower-level care options up and down the continuum is really hard to build out, right? Even using all the tools we have at our disposal with the Medicaid program and others.

And I think that gets a little bit to the system, right? This system is a reflection of where our resources are right now. And so how do we thoughtfully make sure that those resources are creating a different system without— while recognizing that we have to provide stability for providers in the system now because many of them are struggling.

Anything else on this slide? Deputy Commissioner, I'm sorry, I kind of jammed in a lot in my comments. I'm still working on my copy. This morning, but could you highlight the milestones? I think that, that was kind of the report card folks were looking at and thinking about their proposals in terms of the state says we are going to achieve this in quarter 4 of 2026.

So just wanted to highlight, I know, Betsy, you've been talking a lot with CMS about those milestones. So any insight for applicants would be great. Yes, thank you. Don't worry, I was tracking that you wanted to talk about milestones.

So the milestones that we have, that we built into the original application are the milestones that CMS is looking at when we do reporting. They look at a number of things. They look at our financial spend. How are we spending? How are our subrecipients spending?

It does kind of, it's a fairly complicated trickle-down of, they want to know, you know, if we're subawarding, they want to know, are the subawardees actually spending this money? As well. And so we will touch on reporting for subrecipients a little bit towards the end of this presentation, kind of give a, a preview of that. But when we think about the milestones, that's how they're kind of gauging our progress as we move through each of the initiatives. And so the target timelines that we put in our original project narrative are the target timelines that we developed a year ago when we were writing the application.

And I think we've learned a lot since since then. I will say that, you know, our team put together the state's non-compete continuing application to CMS and submitted that in August. CMS has that, as they do with all states, under review right now. So they're looking at any— were there any updates to your project narrative? Are there any updates to your, you know, what does your year 2 kind of planned budget look like?

We haven't heard back from CMS, nor have any other states as to any feedback on that NCC application, though we have been told to expect, you know, any questions or clarifying pieces of that in October. So mid-October is when we've been told to anticipate that CMS will come back to us with questions, and there may be some final adjustments, and then they'll, you know, accept states' NCC applications and issue the year 2 award amounts. So I think that timeline is helpful to think through when you think about, okay, when can I understand, did the state make any updates to the milestones? You know, I'm— we're hesitant to put out any updates right now given that it's still under CMS review and that there will be some back and forth. I would say that the timing on the milestones, we did put forward some adjustments kind of thinking that, okay, not a change to what is it that we would like to do because CMS has also been very clear that they're, they're not open to major shifts from states as to what their project plan was and what their narrative was.

They said, you know, you submitted your application, we approved it, and they're really trying to, they're saying states have to track to that. But as far as the timing on, you know, we thought we were going to, you know, do this thing by quarter 2 of 2024, but really we're looking maybe it's going to be quarter 3 of 2024. 2020, Not 2024, that's way back in time. But, you know, they're open to some minor adjustments there. So I think that a deeper dive on the milestones and kind of looking at what have we put forward, what is kind of that target timeline and what does that mean is probably something I'd like to plan for a future council meeting after we have that NCC back and we're able to say, you know, this is kind of the adjustments that have been made there.

I think too, in that conversation, it would probably be helpful to summarize, and I think we'll be doing this in round 2, but to summarize some of the guidance and clarity that we've received from CMS as we've gone through this process in terms of what is allowable, what is not, where are some of those lines that haven't been totally clear throughout this, but some of those are really emerging, right? And so, I don't want to say that there is necessarily a tie or an impact directly to the milestones, but I think it will be important to have those conversations again and just make sure— we've been through so much so fast over the last 13 months at this point, like, where are we now? Because CMS has been building this out at the same time we are. And so where we're at as we go into year 2, you know, we have a little bit more guidance, we have clearer lines, we have some of that direction. And I think those two things will be important for us to highlight.

Any other questions?

Okay. Well, that I think leads us nice— is that organizations will be asked to complete one organization registration, and that has a lot of kind of the evergreen details that apply to any organization's project, right? So your addresses and who do we need to get in touch with to work out payment, and what's your tax ID, and can you send us your W-9, and all of those items. So organizations organizations will complete one registration, and then for the project applications, they will complete multiple project applications. So last time, organizations had to complete all of their information every time they applied.

And if you were applying multiple times, it's just another step where you're like, I've already given you this information. I don't want to do it again. So that's one piece that we think will be well received by, by our applicants, and we'll make it easier on our end too to kind of gather maintain all of that information in one place. But the project application structure, I think we alluded to it earlier, that there will be one application regardless of kind of what you're proposing, but we'll be using form logic so that we're asking you questions that are more relevant and specific to the type of work that you're proposing to do. So, uh, there's one application portal.

We'll be asking organizations to tell us which initiative they align to. Also be providing information in the portal itself to help people think about, okay, I'm— my project is under strength in workforce or my project is under healthy communities. I think that this will help people really think about their work. I keep using the building block analogy where we're— we told CMS, here's the shape of the tower that we want to build. This is what it looks like.

And then everybody has their own little magnet tile piece where they're saying, here's how my piece fits in there. But I, we're going to, to provide more information for folks that they can understand which tower are they contributing to. There is a lot of overlap. I'm sure people will say I'm working, you know, I have a maternal workforce project in my Healthy Beginnings and my Strengthened Workforce. We know that there's a lot of like cross supports between initiatives.

People really do need to pick one initiative, like what's the core thing of their project and which one does it most fit into. Most closely aligned to. It will also be easier for subrecipients to choose one initiative for reporting purposes because we do have to report under each initiative. So if people really want to make a case and say, I'm under all 6 initiatives, think about there will be 6 reports that you have to do and it, it becomes very complicated. So it's okay for there to be overlap or kind of that cross-cutting support, but think about what's the core of your project with and which of these initiatives does it align to?

So that's something that we'll be asking folks to do. We'll also be asking questions around does this align or match with one of the focus areas? We may have a few additional questions, you know, for example, under care coordination, we may ask like, are you, are you already integrated with the HIE? Do you want to be integrated with the HIE? Just to help us get a sense of the size and shape of the project and kind of where folks are.

But then, They could also say, you know, I'm not aligned, I'm, I'm submitting under the open call. That's okay too. We'll be asking questions to understand, are people looking more for those planning dollars or do they have a full-blown implementation project? The questions may be a little bit different for each, but we will ask for that core project information across all projects. So we need to understand, you know, the work, the work plan, your budget, what are your outcomes really, what are you planning to do?

What is it like succinctly? What is your project? What are you going to do? And what do you expect the impact to be? I think that that's a piece of advice that we would give to all applicants is just be really thoughtful about putting together in a really clear way, this is the core of my project and this is what I'd like to do.

And then the bar that you see at the bottom here, step 5, This is a reflection of a lot of the information that we've learned through the clarification process with our applicants and with CMS that, you know, if you're proposing travel costs, we need to make sure that we are asking some specific questions about the traveler, that you understand some of the pieces that go along with that. If you're putting forward equipment, we want to understand if it's a really large piece of equipment and it's building out a new service line, how does that integrate within your organization? What does that look like for you? If you are proposing a project around workforce, there are some really specific questions that we can ask on the front end that will reduce the, the need for clarifying questions on the back end. But if you don't have a workforce project, we don't want you to have to answer those.

So we will lead people through the application process where we're asking what we need to know if your project contains those elements, and you won't see those questions if your project doesn't contain those elements. Applicants. Another thing that we do plan to do is to put the questions, make them available to applicants to look at ahead of time so you can kind of see the pathways. So you don't have to think that you're on this kind of blind labyrinth, choose your own adventure. Am I missing a question?

You can see what questions are going to be asked if you, if you go down a certain road so that you know, oh, I do want to tell them that I do have a workforce element. Eliza, would you add in anything to any of the elements that we're asking for, any of the kind of reflections that we've gotten from clarification and how we're trying to integrate that into the application.

Thanks, Betsy. I mean, I think you really hit it on the nail on the head that we are learning lessons from the conversations that we've had with CMS and with applicants throughout this clarification period. One point on the last slide that a question didn't get asked about is that we are going to be consider projects with capital infrastructure and equipment asks as part of the spring cycle in recognition that that is a capped category. And as the Department of Health, we need to be able to balance across the portfolio. And so we will be deferring those applications until the spring cycle.

And so I think that was a, you know, a really major, you know, we heard that is a really key ask across the Alaska healthcare system is that we need to be able to invest in infrastructure. We've gotten to do a lot of collaboration with CMS in the renovation space and understand what those projects really look like. That is a place where we will continue to need to, you know, receive prior review from CMS before we can reach funding decisions. And so how can we initiate in the application the details relevant to that? But that will be a part of the spring cycle.

And I would just add part of that is, again, because we have have these caps in terms of how much of the overall budget can go to what's essentially considered capital funds. And those caps also play into some of the continuance that we see from round 1. And so it's really a budget logistical issue on our end. We need to make sure that we're not exceeding those caps.

Representative Mena.

Thank you. I am curious about the caps. I know there's federal funding caps related to renovation, etc. And I was looking back into the original RHDP project narrative, and there is estimated funding towards each of the initiatives, and I'm trying to recall if there's hard caps on our initiatives or if that's reflective in the portfolio framework. And I just ask because if you're an organization and you have overlapping initiatives, you didn't receive year 1 funding, you're trying to get year 2 funding, and you're looking at this map of where year 1 funding is being invested, you see there's a lot in healthcare access, you don't see a lot in Healthy Beginnings in Communities.

Is it more strategic for an organization to put an initiative in for one of those areas that didn't receive a lot of funding in year 1 to increase their likelihood in year 2. And I just also ask this because I know a lot of organizations have so many questions about why they didn't receive funding, and I don't think we talk enough about the, the, the context of one proposal's really, really good idea in relation to all of these other proposals that are being submitted.

Thanks for the question. So the initiatives don't have hard caps. And, you know, looking back to the original project narrative, you'll see in there kind of here's kind of some target or anticipated or planned amounts that we expected to fund in each of those. But I think we also tried to be really clear and have continued to be clear with CMS that a lot of it really does depend on what do we see coming in from from our applicants and from potential subrecipients. I think one thing that Alaska is doing a bit differently than most other states is really taking a community-based approach to the way that we're distributing the funds.

I think that we're, we've talked to a lot of other states that are kind of, you know, taking more of a top-down and setting aside money over here and kind of pushing it out that way. And we really have taken a bottom-up approach because We know that the needs are so varied across the state and in communities depending on what part of the system you touch. So that's been really important to us that we maintain flexibility, that we can be responsive to kind of what do we see coming up through the application cycle and through the application process. We do, when we think about kind of building the portfolio and balancing among all of the, the really good applications that we've seen is making sure that there is distribution across all of the initiatives. So that is an element of it, but there's not a specific cap for each initiative that people should be thinking about.

But those, those kind of really specific capped categories, that's us working within the program requirements. And so I think you actually even see that reflected in the year one awards that the healthcare access awards, a lot of the health facility upgrades or renovations fall under that healthcare access initiative. So you do kind of see a, you know, more of a shift there because there we're really trying to leverage those available dollars for renovations. So that's, that's some of the balancing pieces. You know, I think my advice to applicants when they're thinking about it, well, I have this project or I have this project, really just to think about what's the most critical and pressing what are they, you know, prepared to do within the time period that's ahead and then make that, that case.

One thing I would clarify is when Betsy was talking about caps, so there are caps. I mean, I know this group is aware of it, but just for those listening, there are very, there are strict caps usually presented as a percentage of the overall award that states cannot expend more for any category. And those caps are set caps. I think the one we talk about the most is capital, which can include some equipment costs, which is partly why we need some of these special questions on equipment, as well as some facility or renovation costs or even vehicle costs. Other caps that I don't think people are as aware of, and this gets really nuanced, but again, it's a good example of how complicated this program is to administer, is there is a 5% cap.

So 5% of the overall award the state receives in any given year, no more than 5% can be spent on replacing EMRs that took from organ— that, that were funded using HITECH dollars, right? Now that's replacing, that's not upgrading. So if you're looking to upgrade an EMR and you use HITECH dollars, that doesn't necessarily hit that 5% cap. And so this is part of where, as we've gone through the budget clarification process and even some of the evaluation process, this is where we're trying to build in some of those really nuanced questions so that from the beginning we can get the information we need to, to make that backend process faster. And we just, we learned a lot specifically from the clarification and looking at the budget narratives as we went through the proposal evaluation this year.

But I did want to highlight that. I think the other thing to consider, and again, as we go into Phase 2, we route Year 2, I guess, Cycle 2, I think we're trying to call it. We are, we have learned things from Cycle 1 and we're going to try some new things in Cycle 2. So the thing that, the way that I think about Cycle 2 is everything on the left-hand side, right? The, the choose your initiatives, the open call, the implementation of planning, kind of those are all a reflection of Cycle 1 improved and more efficient.

What's new is matching the DOH focus area. And so that's And that's what we're trying to build out right now. And again, I think the way we've been thinking about it is, you know, are there budgetary targets within the amount that we anticipate awarding in this fall cycle that we do want to make sure we're focusing on that priority area? And Representative Mena, to your point, the way that that would emerge is really through that portfolio review, right? We, if we're trying to hit those budgetary targets within the portfolio review and those distributions, how are we taking that into account?

Into account when we're balancing projects that are focused on those areas. So that's how we see that emerging. We are continuing to kind of refine that concept over the next few weeks. Well, I guess the next week before we move forward, but that's how we're thinking about it now. But I do want to highlight this is new.

This is something new we're doing for Cycle 2. And so like anything, we will, we will learn once we do it what worked and what we might need to tweak in the next cycle. And one thing though, really quick, I think I would highlight too So, you know, as we are trying on things for size, right, and say we think that this could be an improvement for the next cycle, let's give it a shot and let's see how it goes. I think one of those areas too is limiting applications to 5 per organization per cycle. You know, we did see some organizations kind of say, and it's hard because people have asked us, should I bundle my asks together or should I break them apart?

You want to see? And the answer is, you know, it's like the Goldilocks thing. It's kind of somewhere in the middle, that if you put everything and the kitchen sink all together into one massive project, it becomes a little bit unwieldy and a little bit difficult to really pick apart what are you going to do. Also to understand, are you going to be able to accomplish all of that within the performance period that you have there? Are these different— are these really different projects that you have lumped together.

That, I think, is some feedback that we've shared with some organizations that said we shot really big and we put it all together and here's our dream project. And, and that becomes hard to understand how will that realistically occur within the timeframe that you have to work within the first performance period. The flip side of that is if you pull everything apart and you say, you know, I need a toolbox, but I'm going to ask ask for every single tool individually. At that point, some of it becomes, well, you could ask for the whole toolbox and tell us, like, what tools are in there and what it looks like together. So that's some of the feedback we're trying to share for people is find kind of a way to group your like things together.

But also, if you're an organization and you have multiple ideas and projects, think about what could— what really does kind of stand on its own separately. And so the 5 application or 5 project application limit is trying to help kind of corral people into thinking about, okay, what are the 5, you know, if I've got a lot of ideas, what are 5 things I can put forward for this next round that we really can accomplish there? We also do ask organizations if they're submitting multiple applications to prioritize them and to rank them. And that's, I know that that's hard. It's like choosing your favorite child, but at the end of the day, at some point it is helpful for us when we're looking at, you know, trying to kind of balance what is the mix going to look like.

It is helpful to know, is this one really the organization's top priority? Where does it fall within that prioritization? And I say again that we're trying this on for size because if it, if, you know, we go through this round and we find out that the 5 application limit really doesn't work and we hear feedback from folks where they say this was really limiting in this way or really unhelpful in that way, you know, we're always open to feedback. And I think this is going to be an evolving process. So we're happy to evolve.

Now we want to go to a question from Terry, but I want to say the 5 application limit is not— do not feel that you have to put forward 5 applications if you are listening to this, right? That is a limit that is on aspiration. In some ways, some of the best projects I think that we saw were from organizations organizations that probably could have put forward 5 or 10, but really chose 2. And they were focused on what they could achieve, and they were meaningful to the organization's goals for evolution. So again, not an aspiration, really a limit.

I think it's what can your organization do that achieves our HTP goals and is meaningful for that. Terri, did you have a question? I do. And actually, it has to do with the organizational limit and whether there could be a consideration for very large organizations that cover, you know, a variety, you know, multiple communities and have a really broad scope. Because, you know, it's a different, it's a really different exercise, you know, choosing, consolidating into 5 projects for an organization with a narrower scope versus, you know, maybe like, I think of like regional tribal health organizations as like the one example of an organization that could fall into that category where they have lots of things, lots of different types of services they provide.

They cover, you know, many, many communities and whether they could be some consideration for that in terms of the limit. There could be a higher limit for those folks because as you're saying, you don't want them to consolidate, you know, like 15 different types of projects into one project just to get them through.

That's, that's good feedback. You know, I think the other consideration too is they're part of, part of the intent between behind having 2 rounds is so that it, any entity including larger entities don't have to do everything at once in the fall, right? There's also the opportunity to do more in the spring. And so I think that that balance is important. I will say that the 5 application limit was not, it was not random.

I think it reflected what we saw in doing awards for this last year in terms of what organizations overall in the state seem to have the capacity to do within the time period. And I don't think there were many that had the capacity to realistically do more than that, if any. So I think definitely open to feedback, but it does become hard to administer where you have a cap that applies to all all except some. I think that's the balance and the challenge that we have with it. Monique.

Thank you. One, one thing I'm curious if the states receive much feedback on, or could we talk with applicants from our most rural and frontier communities in Alaska, is there's a big need when I've heard from applicants or people considering applying for that capital investment, the equipment investment, but they are particularly challenged because of just the logistical challenges of getting information or supplies, contractors, whoever it might be to their communities. You got one shot on the barge, you've got, you know, summer and that's it. So I know that might be an effort that I will talk to folks about is how, what the timing really looks like for those organizations. And I know the state is somewhat, has your hands tied, right, in terms of the things CMS requires that you do or not do for future awards.

But I think that's something that we can all help with in terms of advocacy with CMS. That rural's right there in the name of this whole program. So when we think about, there's no place more rural or frontier than Alaska. So if we need to do something different or advocate for something differently in terms of, um, I'm not even sure what it is, but if we were working with those ultra rural frontier communities to say, I need like a good 18 months to 24 4 months to really plan to have an MRI. Maybe an MRI is a horrible example, but whatever the equipment is, right?

So I'm curious if you've heard anything from applicants about that or how we might be able to help advocate with our partners at CMS if there's ever an opportunity for an exemption, a caveat for Alaska. I feel like this is it. When we think about the goals of the RHTP, even from Congress's perspective to CMS, et cetera. So any insight you have on that would be really helpful. I would say, I think with awards going out now, if there are, I think it will be really very, very important, you know, across the board, but particularly for rural areas that are trying to get equipment out.

If there are delays or issues with that this year, knowing that very quickly so we can begin to bring those forward, like that in my perspective starts to lay the groundwork for those conversations with CMS. I want to be clear, we have not seen any flexibility at all, just not in the sense that people are trying to be difficult. But, you know, when you're engaging with organizations or different federal groups, sometimes you get a sense that there might be be some sort of opening in the future for flexibility or changes. I just want to be transparent. I have not gotten that sense at all.

So, but Alaska, I mean, we have quite a powerful voice in certain areas. So I think that's important to track. One thing that I think would be helpful is to understand from some of those very rural perspectives, when is, what is a good, what would be an ideal timeline for them, for them when they would have awards, and especially if you're thinking about seasonality and equipment and shipping, from their perspective, what is the time— what is their ideal timeline that we need to be aware of? And then I think we can take that into consideration as we think about future phases. But I've talked about that before, just the barge cycles and planning and being able to get the transportation there.

I know Eliza has some comments as well to think about. I think one of the things we're looking forward to as we continue to continue regional planning is to have these conversations and continue to tell the story of, you know, what did we learn in year 1? And I think to a little bit to some points that were made earlier, some of those smaller and more rural entities and applicants who maybe or were not applicants because they didn't see themselves in the process and highlighting some of those places where where, you know, we did have awards that came out of year 1 and where can there be lessons learned. I also want to recognize that there are things that are not allowable under our HTP that we were asked for and that we could not get to yes on because, you know, we have to be responsible stewards of these funds. Commissioner Hedberg, in collaboration with some other entities, is thinking about how to engage other funders and other partners in this space and saying, you know, we recognize that there's a tremendous ask for infrastructure investments Not only is that a capped category, but we cannot support new construction.

And so, you know, while we have learned a lot about what the bounds of that renovation that are allowed under the project are, where are there projects that we simply cannot support with RHTP, but we can build upon sort of the collaboration and the energy and the focus and both engage with some Alaska funders as well as some national funders to say, how can we, you know, bring together other dollars to these needs? Might be, you know, have more flexible timelines.

Katie.

Sorry, just a quick question. I might have missed it, and if I did, I apologize. For organizations that were awarded that were already submitted in this last round, does that count for 5?

No, right now we're looking at 5 per cycle. So if you have awards kind of moving and projects going, That's great. I also have gotten questions around, well, what if I'm partnered and there's a number of organizations that are collaborating together? Does—. How does that count towards everybody's 5?

How does that work? And, you know, I think it's— there's one organization that has to actually submit the application. So whoever submits it, that will count towards your 5. I mean, we're really not trying to police it. I would say the way that we're going to administer it is that when you move through the portal, you'll have one organizational you know, kind of registration pathway and then the separate project application pathway.

I think it will limit your organization out at 5 of those. So that's how you should be thinking about that.

Any other questions on the slide? Okay. Okay. So moving on, we want to talk about the evaluation frameworks, and I think that this is is the kind of the last significant piece that we want to talk through with this group today. And thinking about what are the evaluation frameworks, how are we, you know, looking at the applications, what does that process look like?

First, before we kind of move into what are some of the changes that we've developed and put forward, I do want to talk through the timeline. I think that, you know, we all recognize we're working on imperfect timelines and that in an ideal ideal world, we would have been able to provide proposed changes weeks ago and provided a lot of opportunity for public comment reflection with this group prior to the fall cycle opening. We're not quite in that space, but we think it's really critical to get feedback from you all here at the table today and really critical to put these frameworks out for public comment before they're used. So you, you do have in your meeting material I, you know, a summary of changes to kind of help orient you to what we've put forward as far as changes to the evaluation frameworks. You have copies of the project evaluation frameworks, and I'll talk through kind of the summary of changes today, and we can have some discussion around this as well.

But looking at the project evaluation framework that's used to review each individual application, there's an implementation pathway and Planning Pathway framework, as well as that portfolio analysis framework that kind of guides how do we look at how all these projects fit together and how do we build kind of a slate across the state. But first, for the timeline, our intent is to put these comments out through the state's online public notice system on Friday, on the 25th, and post that for public comment for 2 weeks. So the comments would come back, um, on October 9th, and that would give, uh, me and my team a few days to take those comments, synthesize them, make any adjustments, and then we would put the final versions of the frameworks out on October 14th. That's halfway through the 4-week application cycle. So going into the cycle, people can look at the proposed changes so they can have a sense of where the state's going.

Um, and then And then halfway through, they'll have kind of— these are the final frameworks that the state will be using to evaluate the projects and to evaluate the slate. And that will be 2 weeks before the portal closes on October 28th. So just wanted to talk through that timeline. I know that the group was provided with these proposed changes yesterday. I'm sure you haven't had time to read them in great detail, or maybe you have, but, you know, if you have comments and reflections based off of your read-through and based off of the conversation we'll have here this morning.

We do have, you know, a small window before we'll be posting these for public comment. We can make any adjustments if the group identifies anything that would really need to be adjusted before the 25th. Otherwise, you know, if you want to sit with it a little bit longer and provide feedback to the department over the next 2 weeks, that would be very welcome as well.

Okay, just to make sure I understand. So So the framework for reviewing the applications is going to be finalized after applications start coming in. Is that logic correct? No. Okay.

The framework for reviewing the applications would be finalized on October 14th, and the applications are due on the 28th. Okay. But the portal opens on— so if I was really ambitious, I could submit my application October 1st? You could submit your application October 1st. You could also wait until October 15th.

Okay. I'm just— I'm going to do this every time I get it. I don't have a problem with this because it's not your fault. But this is just, again, an example of just how terrible these timelines are. And this is not your fault.

But when you— I just have a really hard time when the expectation is we're transferring performing healthcare and we have to edit our framework for reviewing applications and open the window for applications to come in simultaneously. Like, no one in their right mind would ever want to do it that way. But obviously your hands are tied. I get it. So that is not a judgment on you.

But I, I really, it's just frustrating. And I'm sure everyone else, I hope, feels that frustration here too. We very much are trying to keep to that January 1 start date. We have looked at how we can move the portal closure back and, you know, we want to make sure we get 4 weeks. We also want to make sure we put this out for public comment, you know, in some way, shape, or form.

And so this is— we're trying to thread the needle. We're also going into a holiday season as well between November December, and so we want to make sure that we're not putting applicants in the, in the position of having to work over the holidays. Same thing for our staff. Quite frankly, our staff is extremely tired. So that's, that, that is part of what went into this, and I think we're, we're pushing it back as much as we can while still hitting that January 1 cycle start date.

But it's, it's not ideal. To be clear, there's zero judgment on you guys, and and everything you're doing, in my opinion, is, is about what you have to do because you can't delay any longer. I mean, the spend window, you know, I heard when we were going through the dates earlier, you know, people who receive Round 1 funding have to exhaust those funds by, you know, June of next year. That's not that far away. And so everyone's under time pressure, and time pressure is never a good thing when you're trying to do complicated things.

So zero judgment on you guys. I appreciate what you're doing, and I agree you cannot delay this anymore, and I think you're being thoughtful about doing public comment and all those steps you're taking. My judgment is not on you.

Thank you, Jared. Monique? I just want to second what Jared said. I know there's some limitations in, in terms of, we understand that you're working in an incredibly restrictive timeline from our partners at CMS, which is challenging. And the department has so many priorities, right?

You also have a whole department to run besides RHTP. And I would really encourage, I know you're limited right, in terms of administrative dollars. But as, as you're developing this program, I hope you're really considering, um, the, uh, small but mighty team and how you can bring more resources and people power to that team. Um, because we, um, we need you guys. Um, and we, um, we're all counting on you.

No pressure. So, uh, I, I really encourage that. I think that's something when I hear there's sort of 5 people dedicated to this cause, I, I think like, one, major kudos. But also, please don't break the 5 people. And also don't break the department because you also have incredibly important initiatives like each other HR1 provisions, other modernization efforts for the Division of Public Assistance.

Other SNAP requirements, things that the department really just ha— there's so much that you guys are all doing and we appreciate that so much, but please dedicate those resources. I know those administrative dollars are sort of coveted because they're really limited by CMS, but I think that ensuring you guys have the team to be able to do this is really incredibly important. Important for your longevity, but also really for all of us to be able to spend the money. So I hope you're considering that. You guys are amazing, but I think that if we need more people in this area, we simply need more people in this area.

And if I could thank you for thanking me for thanking you. No, I'm also going to emphasize what Monique said. But, you know, even going one step further on a piece, just to clear up some details, you could take this philosophy, forget about trying to be quick, efficient, we need people to have time to spend the money. You need to clear the deck to start implementing HR1 and whether it's the work requirements, unless, you know, the good faith waiver goes through, if that's happening or not. But also, you, no matter what, have more frequent eligibility.

Renewals, and I know there's overlap on this team. So that alone could be a reason, like, hey, realistically, we have to clear the deck to be ready for January 1st. Forget rest, and like, you guys cannot run at this pace. Um, I agree with, uh, Monique, we do not want to break you, um, but I fear, you know, anyone in your position eventually will break. And so I hope, as Monique so eloquently said, you guys can find more resources because you guys need it, not because you're not mighty and incredible, but we want you to be able to do this for a long time.

Thank you very much for those comments and for the acknowledgment of how hard the team has been working. I go back to kind of what I was reflecting on the last few weeks is I think in the very beginning I talked to many of you and said the department can't do it alone. We need help. And everyone has really stepped up and been incredibly helpful, right? This is not about any single administration or even the department.

This is about how the state can use these resources to help ensure Alaskans have access to healthcare now and in the future that they need. We are, we are making progress on building out the team, which feels good. I wish it were 9 months months ago, but we're, you know, it's, it's, as I imagine you find in your positions, finding the right people too with this level of expertise in healthcare systems and administration can be a little bit challenging, but we found some really incredible people, new voices at the table. Every time we have an advisory council meeting, I hope is a little bit of demonstration of that. We have some more people that will be joining our team here soon in the next few weeks, and we've actually built out the grants administration side a little bit more.

But we do, we do, I think we've had a chance in the last 2 weeks to kind of take a look at what we think we need in the future from a team perspective and are having an opportunity to build that out. We are also engaging with Guidehouse and Manat. Those are 2 contractors that we have on board to support us with different efforts, and they are stepping into the space. You'll see them stepping into the space more in the next year to provide some more of that contractual support. So I think that will be helpful.

And then of course, we also had the Alaska Community Foundation that has been incredibly helpful for us in the last year. I don't know that we could have done this without their— I know that we would not have been able to do this without their support and assistance. So I appreciate that. And I think going through year one, we have a better sense of what the level of effort will be to sustain and support the Rural Health Transformation Program. And I think that also leads into maybe what I have been thinking about is, okay, once we get through this first year, things will, we'll have a little bit more time and things will slow down.

I think yes, but not if we're doing two sites cycles, and I think there's an importance to doing those two cycles, but how we staff, how we staff out, and I think what applicants and the healthcare entities in the state need to be prepared for is that this will be a, you know, we're essentially creating a continuous cycle, and there are good reasons for that. But we need to consider what our cadence looks like, I think, over this next year and move into like stabilization and maintenance mode instead of in some ways like startup mode, which is what we've been in for the last 13 months. So thank you for those comments.

Anything else on this? Oh, Senator Giesel. Well, more just to follow up on all of these comments and more broadly, you know, there's a reason that Representative Mena and I are here to really get a big picture there was some feeling at the beginning of this, suspicion, would this money be managed properly, etc. And that's why we were here as watchdogs, so to speak. But honestly, knowing the tremendous workload that you've taken on and listening to people, citizens, etc., we're in a We're in a decision time right now, uh, globally in this state, uh, elections, talking about cutting state government and, um, and that we have too many state employees.

And I know the single audit's going to be coming out. There'll be questions about SNAP. Do—. What's our accuracy level, right? There's huge need in this state for more robust support for state employees, state services, etc.

So this really helps Representative Mena and I as the budget process goes forward. The capital budget, where does that come into play here for capital appropriations to put infrastructure in place? So this has just been super helpful, I think, to Representative Mena and myself. Thank you.

Thank you, Senator Giesel. I know you and Representative Mina are incredibly busy, and we appreciate you taking time to participate in this. Thank you.

Any other comments on this slide?

Okay.

Okay, so this is Betsy Wood again. Being cognizant of time, because I think as Monique mentioned, we do have a hard stop because we're meeting with applicants at 10, which is fantastic. Fantastic. And again, we really do hope that you all will stay with us. What I'd like to do is kind of briefly run through a highlight of the summary of the changes that we've put forward in the, in the project framework so you can kind of understand some of the context and ask some questions.

I'm not going to run through them line by line. You do have them available to you to reflect on. And as I mentioned, if there's any, you know, if you have any reflections you'd like us to consider or to incorporate before we put these out for public comment on Friday. I realize, again, Jared, the timeline's not ideal. It's tight turnaround for, for your review as well.

Please let us know in the next day or so, but otherwise, again, over the next 2 weeks, if you'd like to provide more robust comments, we're very, very open to that.

I think the first one of the major changes that we made was in the past cycle, we had one project evaluation framework and one for saying, here's how we're going to undertake the portfolio analysis. We have heard from people, and as our reviewers looked at the process, we really need two project evaluation frameworks, one for the planning pathway and one for the project evaluation for implementation, because a lot of times people are saying, well, I don't have a sustainability plan yet because I need to plan for that. I need some help to understand what is my sustainability ability plan going to be. So we've built out two project frameworks. We started with the same space, or, you know, the same kind of foundation, which was the prior version, and then have really tried to align them as best we can.

But there are some minor adjustments that you'll see in the planning framework that accounts for the fact that a lot of those are going to be in a planning stage. We've also added some clarity around how the applications are going to be scored. So we've added some narrative around how does that process look like? What is the review process at the Department of Health look like? We have 3 Department of Health reviewers who look at every application.

They score across all of the elements that you see here. There is some information in there around kind of what is that minimum threshold score. I think last time we said there's a minimum threshold of 3 in every category in order to advance into the portfolio. Portfolio review. We've adjusted that a bit where this year it's a 3— we're proposing to put forward that projects need to score kind of a 3 overall on the weighted average, but also in each criteria they need to score a 2.5 or higher.

The reason for that is to account for reasonable differences in the way that any reviewer would review an application. So if you have 2 people who score one element a 3 and scores at a 2, you don't want to give somebody, one person, complete veto power in one category. So we're trying to build in a little bit more space for some of those, those differences.

Another element that we included was some clarification around how impermissible costs are considered during the project evaluation. When you think about someone proposing a project where they say, I would like to to, you know, construct a brand new facility, the core of your project is an impermissible cost. And that's something where we just can't do that. But if you're putting something forward and you say, I want to build out this, you know, more robust remote patient monitoring program, and I would like to buy every, you know, Starlink and pay for internet access for every home in my community, we can't pay for internet access in people's homes. But you still could build out your remote patient monitoring and we can look at connectivity options in other ways.

So we've built in some more nuance so that, you know, having a few impermissible costs are not something that would just kind of knock your project out. We've learned through the budget clarification process that there's a lot of space for us to say, this element of your project is not, is not an allowable cost under the program. We'd like you to remove it, but you can still complete your project. You can still do the core of the work. So building a nuance and space for that.

Um, Betsy, can I— I know it's a very short question, but just curious, what is— but what has your experience been with ask, like, follow-up questions with applicants? Is it pretty challenging? And I'm actually going to let Eliza answer that. I think we have a lot of good reflections, because what you just said kind of suggests, like, there'd be a dialogue, like, your project's not gonna be totally knocked out, but this part, I'm just curious. And you—.

I'll, I'll say overall it's been a really great process, but I'll let Eliza share a little bit more. I mean, I'll echo that it's been a really great process and have appreciated sort of the receptivity and the quickness with which applicants have worked with us or said, I don't quite understand what you're asking of me. And just kind of progressing through that back and forth. And, and I think to some, the, the earlier kind of comments and questions on asking those additional questions in the application. I think those are some of the same questions that we found ourselves asking over and over again of applicants.

And then I will acknowledge that there is a third party in this process, and that is CMS, and working through with them where, you know, those projects that are reviewed by CMS, you know, when they have questions and kind of working together with applicants to ensure that they have the information that they need.

I would add this, this is one of those areas where we're trying to design the application from the beginning differently so that we can reduce the budget clarifications that we experienced in this round. And just make sure that we're getting some of the consistent information that we were running into as part of that back and forth, because even if it's a fast back and forth, it's at least a day. Sometimes it's a week, right? And that really contributed to some of the lengthy timelines that I think we worked through this fall cycle. So we're trying to incorporate that into questions.

And I also want to share that our CMS partners have been incredibly fast and responsive with us. And I think that they— that's been really heartening for our team because, you know, we're kind of in the middle between asking applicants, clarifying questions, trying to understand what CMS needs. And the team that we've been working with at CMS is— they understand too that this is could— this is a place that could be a bottleneck, and they're working really hard to not have it be a bottleneck with some of the clarification on the actual subrecipient applications. They've been really great to work with.

Okay, so moving on to other changes to evaluate, I think the next two are spaces that I really would recommend that the council look at the elements that we've built out here. One is looking at How are coordination and partnerships evaluated and how do we describe what we're looking for? And some of the feedback that we heard from a lot of applicants and a lot of partners was, you know, partnership is a really interesting kind of thing to evaluate and how do you, how do you look at that? And so we've tried to expand the way that we're talking about it in the evaluation framework. So it's not just do you have a partner that is engaged in doing this work with you, but also So like, are you thinking about the community context of your work?

Are you talking to, you know, the people that you're serving to make sure that this, what you're building is going to meet their needs? Are you talking to the other people who serve the people that you're serving? Are you collaborating? And then also building in, we saw a lot of, um, maybe aspirational partnerships that, that were highlighted from some applications. And so giving our reviewers space to kind of evaluate, like, should this be a concrete partnership?

If you're coming with an aspirational partnership, that, that may not be what you need. You do need to build some concrete partnerships. You need to demonstrate to us that the people who should be aware of and/or working with you on what you're doing are aware of and supportive of what you're doing. So there's a lot more information in there. We were very, again, very open to feedback in that space, but we've tried to shift some of the language to provide a little more clarity about what we're broadly looking for there.

Or if you are saying, I am going to partner with this organization to do that, and it is kind of that formal partnership that I think a lot of folks were thinking about last time, we would like to know that that formal partnership is— everybody's participating, everybody's a willing participant there and is aware that they're part of the partnership.

Another, another element that we've added, this is a new criterion that we've added this time, which is cost-effectiveness. And I know this is something that the council talked about last time, thinking about how do we have cost-effectiveness evaluated in the context of, you know, thinking about what the costs, what is an effective or a reasonable cost in remote and rural and frontier Alaska versus what is an effective cost cost closer to a population center. And I hope that we've struck a balance at the language that we've looked at there. We do think that it's important for us to think about, you know, really it's, have you explained where your costs came from? Can we understand what the justification is for the cost that you're asking for?

And so if you're trying to buy a really large piece of equipment for your clinic and you're out in in Alaska and you need to think about what is the shipping cost going to be, what is all of that, like, that's going to be a more costly enterprise than if you were trying to do that in Juneau. And I think there's space for that in the cost-effectiveness criterion. It's thinking about the context of where is the project going to be operating, what setting will it be in, what are some of those other factors. So it's not just did, like, is this one cheaper than that one? So do take a look at that element.

Element, and, and you're very open to feedback there as well. And then the, the final pieces that we added, we're looking at the portfolio framework and the portfolio review. We've added more information around how does that portfolio review look, how is it undertaken, what are some of the balancing pieces that, that we look at through that process. We also have added pathway and department focus area as criteria that are considered during the portfolio review. You know, we're making decisions on the planning applications at the same time as the implementations.

That'll be one element we look at to ensure that we're supporting both organizations that have ideas in the planning stage as well as organizations that are ready to implement. And also, again, looking at those focus areas, like we said earlier, we're not intending to kind of give bonus points to somebody that has a project area that aligned to the focus area, but we do want to, um, probably set some funding targets and make sure that we're supporting, um, buildout along those focus areas. And then I think the last, um, element to look at is that we've adjusted the weighting of the evaluation criteria within the project, um, frameworks, and that's really to account for that new criterion being added, um, of the cost-effectiveness that the, the weights had to come from somewhere. So at this At this point, I think none of the criterion are weighted below 10%, so everything's at least 10%, and there are a few, you know, like alignment, and I don't have it in front of me, but we have a few others that are weighted a little bit heavier.

Monique. Thank you. Betsy, I really appreciate the extra work you guys have focused on that coordination and partnerships. I think you were generous in using the term aspirational partnerships. Some folks were surprised to see their organization named when they never heard of the applicant before.

So I really appreciate the department focusing on that. The other thing that I think folks from rural communities were a little bit surprised by are the, um, the service area or the community or borough that, um, different applicants propose to serve in their applications. Um, and I think as we really think about the intent of the Rural Health Transformation Program and serving people living in our most rural communities, um, Really understanding how an organization, a provider, whoever in a hub community or in Anchorage might be serving rural residents is a really important, um, uh, or concern, I should say, that I heard from people in those rural communities or hub communities. So I hope that's something that we can spend a little bit of time thinking about. Um, I think just because an organization is maybe based in Anchorage and they'll serve anyone who walks in the door, I don't know if that means they can check every box because I, I think we hear regularly that the challenge for people getting healthcare is getting to that hub community or into Anchorage for that really specialized care.

So I think that is something I've heard from rural providers, rural community members. Important for us to really think about is just because somebody checks all the boxes for all the boroughs, are they really serving the, um, people in those communities?

Thanks. That's, that's a consideration that we've had to, uh, really think about and look at as we go through the, both the evaluation process, the portfolio evaluation process, and then also thinking about our data, right? And as we were we report out for projects and as we award, how are we noting what areas are served in that, in that award notice? And we are, we are continuing to build out the dashboard, the interactive dashboard for the award notice. Guidehouse is actually the contracting entity that's helping us with that right now.

And I think that when we, when that goes forward, I think, you know, we're going to do our best to make sure that correct, but it's data. And we're, I think we're going to need to spend a lot of time having conversations about, okay, what does this actually mean? Like, what does this description actually mean? What does this view of the award data really mean? And that might be a really good time for us to have this conversation because we'll have some specific examples that we can talk through.

Eliza has actually been helping coordinate that. So Eliza, I don't know if there's anything you want to add. I think it's complex and it a lot is coming from applicants themselves and wanting to sort of recognize where they say, you know, work is occurring. We've also— there's a statewide, you know, we recognize that there are, there are projects that are meant to sort of, sort of address systems level and sort of have that broader statewide without having that like very specific local impact. And so making sure that the questions we ask, you know, do reflect some of those kind of dynamics.

I think, too, there's, there's some other questions like, sort of on what's the number of people that you anticipate, you know, this project serving. And I think that there have been times in which we have seen some similarly ambitious responses there, um, and really asking applicants to, to be sort of, to be clear and to be thoughtful in the scope of what they're doing. And more is not better, um, and really recognizing that for some of those rural communities, you there is not a huge population there. And so being really thoughtful about sort of both articulating in the narrative and in the materials, the scope of what is being conducted is really important as well as sort of in those data pieces. I think enumerating geography is really challenging.

There's also some regions in Alaska that are immense in thinking about, you know, as we create maps and look at boroughs and census areas, there are projects that are aligned with certain boroughs and census areas that are really focused on one community. And that is going to just be a path that we continue to walk in conversations that we continue to have.

Just to follow up on that, I'll keep it really brief. I think striking the balance is hard. I think there's a lot of value in Anchorage projects because of the statewide, but I also think it's really easy to click the statewide box. We've all done it before, right? But, you know, one way to consider it would be to add a question after you put service area to put estimated percentage of impact or volume by whatever box.

So it's not about the numbers. If, you know, a village has very few people, you know, if 100% of your project's going to go to that borough, village, or area, then you will be able to tease out some more detail. To be, to be candid, we tried to pick it apart and look, and I immediately saw that statewide, and I was like, well, this doesn't really help me. So maybe it, it wouldn't be hard, and you can really quickly decipher, okay, most of this is probably Anchorage, which there's nothing wrong with that, but it's a probably easy data point to give you a little bit judgment.

Thank you for that. That's, that's really helpful. That's something I know that we've struggled with, kind of gone back around in circles, what's the best way to get this information?

And I will say there's clearly some, and, and they tend to not be submitted by entities that have partnerships in Alaska where, um, Department of Health employees are reviewing these. Like, we have some knowledge, maybe not perfect knowledge of everywhere, but we have some general knowledge and it doesn't align with what the boxes that are being checked. So there's there's that human element too.

Okay, well, in the interest of time, I'll move on. We have just a few more slides. This slide 13 highlights some of the next steps that the department is undertaking, and there's a number of things here. You know, I think I alluded to it earlier that CMS is currently reviewing our continued application. We expect to hear back from that in October.

So again, I think that probably the next time this council Council meets, we can, we can talk through some of the milestones in there. I will say there were not significant changes. CMS is not open to significant changes, and we didn't see the need for significant changes either, but maybe some minor tweaks that we can talk through. As we think about kind of where are we, where is our team focused right now? Again, we're really focused on continuing to finalize and issue and administer the Year 1 awards, but we're also looking ahead reporting.

We've gotten a lot of questions from subrecipients around what will their reporting look like. Um, our first subrecipient reports are expected to be due in January, and that would cover work through December. So, um, I've heard people saying, am I going to have to pull my staff, you know, over Thanksgiving and Christmas to get you something by the end of the year? And, and right now, no, um, that— I don't believe that that's what we're working towards. We will put out kind of a reporting template guidance.

We'll have many more webinars. We're also building out, like we've said, opportunities for technical assistance and for people to say, who can I talk to when I don't understand? Like, who can I get my questions asked? So building that up again, we're in this startup phase. So that, that does take time.

But I think that when people are thinking about how am I going to have to report on it, you know, we're going to need financial reporting and CMS wants to understand how are you spending across those allowable uses of funds. That's why we asked you to put your budgets into those allowable uses of funds. You can be thinking about that. I will say that the reporting that we will build will be built in a way, or that we are building, is intended to feed into the way that we have to report to CMS so that we can take information from subrecipients and feed it in nicely. CMS has also been in a startup phase.

You know, I think the reporting template templates that we were meant to use were issued just a few weeks before we had to submit them. So it was, you know, they're also in the same cadence of timing. The other element is that we, there will be some programmatic reporting. A lot of that, you know, we're trying to strike the balance between making sure we get enough information from organizations that are doing the work that we can tell the story, but also not making reporting this incredibly arduous process. But, you know, when we think about the programmatic reporting, a lot of it, we're asked to report to CMS success stories.

So that's a lot of what we'll, we'll be asking for from our organizations as well. And then finally, these are just some of the upcoming dates that I think we've highlighted already and just opportunities for folks to engage. We're putting out multiple webinars to walk through the application and all And also that October 2nd webinar is going to recap what we will all be working through later today in our applicant convening. And we have some regional meetings upcoming, and we're again trying to communicate and partner with communities at every opportunity.

I know we have about 2 minutes left. One thing that I think we should spend some more time on as well in the next meeting is talking about the technical support that we are building out with some of our contractors, not just for applicants that entities that are thinking about applying, but actually technical support for entities that have received a grant award. And, you know, we're thinking about it from a policy perspective and from like a technical perspective as well. And so I think it would be good to talk. I know, again, we have about a minute left before we hit the end of our meeting.

I think I've done a I did a poor job of talking us through formally the agenda, but we made it through the agenda and are now under closing items. Does anyone have any last comments to share?

Okay. Thank you all so much for your time. At 8:00 a.m. on Wednesday morning, we appreciate your time, your expertise, and your commitment Improving Rural Health in Alaska. If there is no objection, we will adjourn the meeting. Are there any objections?

Okay, the meeting is adjourned. Thank you so much, everyone, and we will see you in a minute in the room next door. Bye.