Alaska Dept. of Health: RHTP Advisory Council (August 17, 2026)

I would like to call to order the Rural Health Transformation Advisory Council. My name is Emily Ricci, and I am the Deputy Commissioner in the Department of Health, and I would like to thank the council and all of the members of the council for joining us today and for your willingness to serve in this important role. This 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 the 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 Advisory Council members may be applicants to the Rural Health Transformation Program 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 voting 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 begin with the elected officials serving on the committee.

So I would start with Senator Kathy Giesel. Here. Good morning, Senator. Representative Mena. Here.

Good morning. Good morning. Jared Kosen. Here. Mary Wilson.

Here. Nils Andreassen. Here. Monique Martin. Here.

And Nancy Merriman. Here. Good morning. Good morning. All members are present and we have a quorum to conduct business.

So we'll move on to the next item of the agenda, which is approval of the agenda. And the agenda was provided in advance. It has been publicly noticed. And so I would pause to see if there are any requested changes to the agenda by the council.

Okay, hearing none and no objections, the agenda will be approved.

So we will move on to approval of the minutes. The minutes from our last meeting were distributed ahead of time. Uh, are there any corrections or changes to the minutes?

Hearing no further corrections, the minutes will be approved.

Okay, we got through welcome and call to order. Next, we're going to move on to department updates, and we do have a lot of department updates. Things are moving pretty fast within— on a weekly basis within the department. I'm going to start by going through a PowerPoint presentation, and then, you know, we can do questions at the end of the PowerPoint presentation, or we can answer questions as we go through it. I will leave it up to the advisory council members, it might be easier to have questions as we go through.

So I have a number of individuals from our team who will be presenting and sharing information throughout. This includes Allison Miller and Lauren Hughes along with Betsy Woods. So you will begin to see some new faces presenting information from our Rural Health Advisory Program team, or Rural Health Transformation Program team. Apologies. Allison, we can see the slide.

Thank you.

So moving on to the next slide, I'm going to ask Betsy Wood to present. Sure thing. Good morning, everyone. This is Betsy Wood, Director for the Office of Health Savings. And this is a slide that you've seen before.

This is just kind of an update to the progress that we've been making in year 1. Since we last met, we're really going to be looking at what's occurred in July and August, and we began our evaluation and portfolio review process, moved into that final budget and CMS review, and you'll be hearing a little bit more about what that— what that process looks like from others on the team further on in the presentation. But as we move into August, we're really excited that we are able to begin issuing those rolling awards and continue finalizing our project reviews. So, I think as you all have been receiving the emails and have been seeing our updates weekly on Fridays, we are issuing awards to organizations and letting folks know that they have been selected to advance. So, we're really thrilled to be able to see that continue throughout the month.

Another thing that you'll see that isn't reflected on this slide, but that our team is working on this month as well, is working through our first reporting package to CMS. That's due at the end of this month that reports on progress from December 29th, from the date of the notice of award, all the way through July 31st. So, we're putting together a reporting package. CMS also has been working diligently to finalize items, and I believe they received final approval on the federal side for what that reporting package looks like at the end of last week. So, now we are working through putting that together and we'll submit it at the end of this month, as well as our year 2 non-compete continuing application that will kind of articulate what we're thinking for, for project year 2 under this award.

So our team's working on those items as well as finalizing all of the project awards from this round. So it's going to be— it has been a busy August and will continue to be a busy August.

Any questions before we move to the next slide?

Okay, hearing none, we'll move to slide 3.

So this is a snapshot for the Notice of Intent to Award. I believe there is a version of the PowerPoint that, that is either online or will be online very shortly that reflects Notice of Intent to Award as of August 7th. This includes August 14th, so we will update that in the future. But for anyone who is Following along online, I want to highlight that difference. So I just want to remind everyone where we started.

So we started with 1,800 letters of interest from 864 unique organizations, and that accounted for almost $2.7 billion in, in asks is what our estimate was. So we started really big, and I think especially for year 1, that was helpful in some ways because we got a sense of where everyone was at, kind of at that moment in time. And if they could put projects forward, you know, what would be important to them? What would they put forward? And I highlight that because I think it will be important to go back to those letters of interest, and that's something that we, we want to do and that we are thinking about as we prepare for round 2.

Because of those 1,800 letters of interest, about 403 moved forward into implementation applications, and that included 28 planning projects. Or that was in, in addition to 28 planning projects. And I just want to highlight again that difference from 1,800 to 403. There is a number of letters of interest that had some really strong ideas that we want to continue to pursue and we think would be beneficial, but for a variety of reasons, some of them was timing on the department's part, some of it may have been maturity of ideas or just the need for more time to evolve. Those did not move forward from letters of interest into the implementation round.

But I think it's something that we want to think about as we move into round 2, and I would even say in future years as well, is for those strong ideas that were letters of interest that did not move forward, how do we make sure we are circling up with those entities and/or we are working to help them build out those concepts? But we moved from 1,800 to 403 implementation projects and 28 planning projects. Of those 403, 366 of the letters of interest that moved into the application phase, 366 projects were actually submitted. So there's a little bit of a delta there between the 403 projects that moved into the, that application phase and the number of applications that were actually submitted. And then as of today, we spent, as Betsy noted, we spent July working through kind of the evaluation and portfolio review and beginning that kind of final review with CMS going back and forth on some of the budget items we'll talk about in the next few slides.

But as of today, we've issued notice of intent to award for 43 implementation applications, and so far we're moving into that grant award for 13 planning. So we're seeing kind of a small start the first week of August, and every week I anticipate building into larger and larger award cycles as we work through through the review process. So with that, I want to move on to the next slide and talk a little bit about what that review process is. And I would actually ask Allison Miller— oh, I want to— I see a question from Nancy Merriman. Hi, Nancy.

Hi. Yes, sorry, a question on the previous slide. Do you have an estimate of timeline moving from notice of intent to award to actual award?

Um, by the time we are issuing notice of intent to award, I think we are— we, we have to be confident before we issue notice of intent to award that we generally— I mean, that we have alignment in terms of all of the, the documents and the requirements that we need to issue notice of, uh, to, to actually enter into signing that grant agreement. So the timeline should be fairly quick. I think my pause is just capacity within our team to, uh, to manage that. So I'm hearing that grant agreements should start being issued this week for those entities that receive notice of intent to award, uh, so far, and we are running a concurrent process. So I would invite Allison and others to speak to that when we get into these slides.

They are kind of the members of the team that are managing the back and forth right now between applicants.

Yes. Any other questions?

Yeah, one thing I want to highlight under the notice of intent to award as of August 14th is just that that includes, I think at this point, $30, nearly $35 million in award notices that have gone out. And again, we expect that to increase pretty significantly over the next few weeks.

Next slide. Okay, I would like to ask Allison Miller to just provide a background about kind of the implementation application components because this becomes important as we talk about some of the ongoing review and back and forth with CMS. So just kind of reminding everyone what some of those elements are. Allison?

Oh, can everyone hear me okay? Yes, great. Thanks, DC Ricci. Good morning, everyone. Yeah, so I'll start by giving an overview of some of the application components that we're looking at.

You've all seen this slide before, so I won't spend too much time on it, but this is just a reminder of all of the information that we collected from applicants regarding their work plan, their budget, how they plan to implement their project, how much it's going to cost. And then there's a few items actually that aren't even on here. In order to be able to issue a grant award, we need from every applicants a W-9, proof of their updated SAM.gov registration, a UEI, all of the little administrative stuff. And our partners at ACF have been really helpful in getting all of those little details pulled together. But I do just want to emphasize that there's a lot of moving parts for every single application.

All right.

We've talked about this previously too, but I also just want to mention again that CMS allowability is a big part of this. I know that all of you are aware that there's restrictions on this funding that we need to be mindful of. In particular, things like internet and new construction are things that we keep running up against as areas that we have to navigate and that have featured in some of the applications that we received. There's also a lot of expenses that are allowable but still require case-by-case approval from CMS. In particular, that's anything over $10,000 in equipment costs and also anything involving renovation.

So even if it's not strictly construction, if it's renovation, we need to approve that on a case-by-case basis with CMS, and that is for every single project that we intend to award. There's also a lot of gray areas here, and so the guidance that we're receiving from our federal partners is evolving on a I would say almost daily basis. We meet with our program officer biweekly, and every single time we meet with them, we learn new information about kind of what the nuances are around those allowable costs. I think one thing that comes up again and again is where is the line between construction and renovation? There's a 5-year service commitment for any training stipends or training-related costs that go out to potential providers, and that's something that we need to know that applicants are able to handle and to implement on their side.

So there's again just a lot of moving pieces that we need to be mindful of. Food is another one that has come up a few times. We are not able to buy meals for participants as part of a program. It is allowable though in very specific cases, like for per diem travel, or if it's part of kind of a very time-limited pilot study. So a lot of what we're doing now is following up with applicants who had any of those sort of gray area costs and saying, okay, what exactly are you going to do and how can we work with you to get CMS approval on this and move forward with this project?

Jared, did you want to ask a question? Yeah, my question is, can you describe— and you don't have to go in depth— but what is it like having those conversations with CMS? Because it's so fact-intensive for each individual project, whether it be construction, whether it be anything. Are you talking to the program officer that's assigned to us to get the all clear, or is it elevating above that. I would imagine that's really time-consuming and cumbersome, and there's nothing you can do about it, but I'm just curious.

Yeah, it's, it's both. And, um, well, I would start by saying that we, we often don't know what questions to ask until we are presented with a very specific scenario. So we know that major construction or major renovation even is not allowed. But often we don't know sort of what specific questions to ask about what counts as major versus minor renovation until we see an application where we're like, I don't know, this is really borderline and it involves putting up walls within an existing facility, or it involves redoing HVAC or plumbing systems. And that, I mean, probably depending on who you ask, you could get about 8 different answers on where that falls on the scale from major to minor.

And so a lot of the time when we go to our partners at CMS, we are looking at a very specific problem and saying, where does this fit in terms of allowability? And then they can kind of answer that question and say, well, this is the intention of that rule, and here is maybe some guidance on how to interpret it. It's a little bit of a critical thinking exercise because they are also developing this program at the same time that we are. Implementing this program, as you know, and so often the answer is, "I don't know, let me follow up with you on that." And then if our program officer is not able to provide a direct answer, they usually invite us to submit the questions again in writing, and they will then go to the Office of Administration and Grants Management. I'm, I'm probably butchering that acronym, but we call them OAGM, and they are kind of responsible for the nitty-gritty financial details.

So long story short, our program officer is kind of our first line of defense, and then she often triages us from there. Um, but again, I think the problem is that we don't know the question until we are looking at a specific application, and sometimes then we can extrapolate towards other applications. But there's just so much breadth of the type of applications that we are looking at that we've come across a lot of those little tiny one-off applications, and I think the challenging part too sometimes is that we will look at an application and say, "Okay, program officer, is this allowable?" And the program officer will say, "Maybe in this specific situation, but we would need more information." And so then we have to go back to the applicant and say, "Hey, can you give us more information so that we can go back to CMS?" And then the applicant provides it, and then we have to go back to CMS again. So it's often a very iterative process, and we're doing this with more than 150 applicants that we sent individual feedback letters to saying we need more information on this, or your budget needs more work, or something like that. I'm seeing a couple of other questions.

I don't know, Betsy. I just, I want to close my comments with just say thank you, and, um, man, that's super, super inefficient, but it's obviously not your guys's fault. And, uh, you know, I, again, I, I hope people realize that that gives a glimpse of what I thought was probably happening. But, you know, your team is being asked to go back and forth, back and forth, back and forth. And so as these things drag on, I think it's important to share that so that people understand what you guys are being required to do as you're trying to administer this money.

So I just am going to say I'm sorry, that's rough, but thank you so much for all the effort. And I'm going to provide again, again, just a little bit of context too, in that You know, we are— Alaska has approached RHTP, I think, a little bit differently than other states and how we are approaching awarding the money out, right? And so we are, we are doing substantial subrecipient awards that you don't necessarily see in other states. They're done through more of an RFP process with a smaller number of subrecipient awards. So Alaska is doing something different, and I think that is the right fit for our state.

But it does create additional administrative complexities for us and, quite frankly, for CMS. And one thing I would note is our CMS team is highly responsive. They— I have never seen CMS be quite as responsive as they have been on this project in terms of timing on the back and forth. But it is a lot of volume, and it is a new program for everyone. And so every question we get is almost like precedent-setting for others, and that will help us in the future because we're building this out.

But right now it is time-intensive, and Jared, appreciate the kind comments.

Monique, I saw you had a question. Yeah, I think my comments really relate, um, tacking on to Jared's points and right, like, I think I really appreciate the process that the state built because to, for subrecipients, because I think this will help us get to dollars to the most rural communities, right, and allowing them to identify ideas that they have to better suit the needs of the people they serve. However, I think like as we talk about year 2 funding, this is really an intense process for the state and CMS, I don't doubt. But I think it would be great for the advisory council in the state once you're past the point of distributing dollars in year 1, excuse me, year 1 is how do we work with CMS as well to get faster, faster answers, because as I talk to applicants about this process and the back and forth, and really some of the questions coming back accounting for less than 3% of the money, this is really intense. And this is a pretty hard process, not only for the state and CMS, but for applicants as well.

And this is really— I worry that this level of intense scrutiny and back and forth with CMS is going to mean we see smaller organizations really struggle to decide if, if they can really navigate and manage this level of back and forth. And wondering as we manage this work that we could do with our congressional delegation, I think certainly our senators for Alaska were very involved. In development of the RHTP, and how do we ensure that we are not, um, the level of scrutiny that CMS is sort of requiring of states, especially like you highlighted, DC Ricci, where we have subrecipients, which I still feel like is the best path for Alaska, but how, how can we reduce some of this administrative burden because ANTHC is a large organization and we're struggling with how do we keep up with this. So imagine if you're serving really rural populations. So I think that as we look to future years is how do we partner with CMS to really understand some of these things, um, and that we don't inadvertently discourage rural applicants from trying to pursue some awards.

Thank you, Monique. Those are important comments. I know ones that we've been reflecting on too, and I think we've identified some things to think about for year 2 that, that maybe will be helpful in terms of having some of this information from the beginning so we don't have to go back and forth. But again, I also echo your comments. I know that our senators were very very heavily influential in ensuring that this program was created and would benefit Alaska.

And so that is another avenue for us to consider.

Nancy, I saw—. I thought I saw your hand for a moment. Thank you. My question was answered.

Alison or other RHDP members, do you have anything that you would add to this slide? Before we move to the next.

Okay, let's move to the next slide.

All right, we've touched on this a bit already, but I just wanted to go over briefly kind of what the RHTP team is working on a, on a daily basis. So we sent out clarification letters to over 150 applicants and Those ranged a pretty broad spectrum from some of the things we just talked about, like, hey, you have renovation costs, you need to tell us more about exactly what you intend to do so that we can figure out whether this is in the spectrum of allowability, to things like, your budget narrative total does not match your budget spreadsheet, and so we need to know what the actual total is for your project. So this has been an ongoing process for a couple weeks now, but I think we're getting close to the finish line. Really, really happy to see how responsive applicants have been. Most people have been really willing to work with us and get their stuff back in a timely fashion and have asked really wonderful clarifying questions.

So, it's been a learning experience for everyone. As of right now, we are continuing to work on submitting projects to CMS for review. Those are, again, the projects that require approval because they have more than $10,000 in equipment costs or have some kind of renovation or questionable sort of gray area allowability. I should say too, our program officer has been really wonderful, and we've actually been seeing really fast responses on these from CMS. So they're working as hard as they can and being really great with us to move this process forward.

Well, Allison, one thing I would add to the slide that I think is important for the council and others to be aware of is, you know, again, this is a a little bit of an iterative process in some ways. So if you haven't, if you are a project that you have not had outreach about, that doesn't necessarily mean that you are not being funded. There are, as we work through this process, if there's a project, for example, that costs, I don't know, $1 million or $2 million, and as we go back and forth with CMS, we understand that maybe $800,000 of that million-dollar project can be funded, but $200,000, it does not, is not allowable, right? We need to then go back to the entity and ensure that that project can still move forward with the, with the funding that's available. But then it also means that there's now $200,000 that we can look to fund another project.

And so this is an iterative process that we are going through, and I just wanted to kind of add that context as well. Representative Mina, I see you have a question that says, what does additional information needed? Allison, can you expand on that? Yeah, a lot of it is kind of those administrative details that I mentioned previously, like having a W-9 for their organization, ensuring that their SAM.gov registration is up to date, their organization's UEI, the actual sort of nuts and bolts that we need to think about transferring money or executing a grant agreement before we can even do that. So, um, in an ideal perfect world, we would do all of this sort of clarifying process first, and then we would start collecting those sort of nuts and bolts information We do not live in that perfect world, and so in an effort to speed things along as quickly as possible, we're doing both of those at the same time.

So that's another kind of concurrent processes to manage and multiple things to check for before we can actually even say, okay, is this organization in a place where we can send them a notice of intent to award?

One more editorial comment for me. The more, the more I kind of step back and think about what has been most challenging about this process, it really is that we cannot we don't have our ability to do things sequentially from the beginning has been limited, right? So we are frequently doing things concurrently that would be sequential. And so I think as we move into future years, we will be able to move away from that. But right now, I think that is one of the most challenging aspects of this and has been, I think, since the beginning.

Allison, any other comments on the slide or any other questions from advisory council members?

Nancy. Thank you, Dee Sriruchi.

Despite the questions that you all had for applicants for additional information on their applications, one of the most consistent pieces of feedback that we have received is that the application was substantially more complex and time-intensive than many anticipated. So I'm just wondering if you have ideas about, or if it's possible to refine, clarify, streamline, or simplify the application so that both the applicant can make sure they're providing everything they need to, to you, and you're getting everything you need, but possibly in a more streamlined way.

We are thinking about that, and I think, again, as we think about Round 2, we've learned a lot. I think seeing the applications and what was submitted versus what we ended up needing from CMS, right? There are some gaps, and I think some of those gaps may be just due to the build-out of the program and the time that we have had to understand what CMS needs and to understand How did, how did those words translate into what an applicant hears and where are the differences? So I think there's lots of opportunities for efficiencies in year 2. I think we will still need potentially, you know, I don't anticipate the level of detail changing in year 2, but I think how we solicit that information from the beginning can help make the process more efficient and help applicants know exactly kind of what the target is in terms of the information that they need to provide from the beginning.

And I think, again, just as we are building this out and because Alaska is doing more subrecipient awards than other states, I think that's, that is an area that we learned about as well through the process.

We are also thinking about ways to build out very strong technical support, particularly when it comes to budget and probably objectives, because those were two areas where we saw gaps. But I would probably defer to the team to add more in this topic since they have been closer to it than me.

Sure, this is Lauren, Senior Program Coordinator, and I just wanted to touch on just the sheer enjoyment our team has had on tackling these complexities and just how happy we've been that, as Allison mentioned, everyone has been incredibly eager to work with us and Nancy, we really appreciate all of the feedback. That has been a really— it's just been a gift because as we're working through to try to improve and have kind of a continuous improvement, we've been taking notes as we're creating and as we're doing the work. And I might tap on Eliza just for a quick second to talk just briefly about some of the reflection points that we're looking to launch once we get the announcements for funding out the door. So technical assistance and support is a, is a really important element. We've had a lot of discussions about making sure that's available for everybody in rural locations, and then just kind of making sure that our FAQs are constantly being updated.

But I think we also have some plans for another webinar. Eliza, do you want to touch on that for just a quick moment and just maybe talk a little bit about what you've learned from the back and forth with CMS process we've been moving through? Yeah, happy to, Lauren. Hi, Eliza Ramsey. I'm with the RHDP team and have been doing a lot of sort of these applicant material reviews and as well kind of communication with CMS.

We are in the planning stages of another webinar to really hone in on some key lessons learned and identify some of those places where detail, you know, is really important. I think one of the things that I'm also looking forward to is the opportunity to elevate some of the you know, both the applicants that have been funded and some of the projects. I think speaking to, uh, Monique's point about, you know, how do we help illustrate and invite for some of those smaller communities, smaller entities, like what are projects, you know, that have been able to move forward under this project. And I think that's gonna be a really exciting thing. Um, and then to, to be able to share some example materials of like, this is really the level of detail that we need in a budget narrative related to travel, related to renovation.

For us to get to a yes with CMS on some of those items. And so really thinking about, yeah, how do we provide more illustrative examples to our applicants and to our community partners?

Thank you, Eliza. Thank you, Lauren.

One thing as well that I neglected to say kind of in the beginning, but I think is a kind of a good reminder to frame where we're at, Instead of waiting until we had perfect information from everyone in order to move forward with the notice of intent to award, we made the decision to move forward and to approve projects and issue notice of intent to award as we're able to. So we have moved to that weekly rolling basis. But that also means that what is being approved and what is being rolled out on a weekly basis is not— in each award announcement is not necessarily fully balanced, right? It is the portfolio balance when all of the awards are complete. That demonstrates all of the different characteristics in that portfolio review that, that were under consideration and looked at.

So I do know that there are a number of projects in smaller rural areas, Monique. We are working through that approval process as well. So I just want to make sure again, as these awards roll out on a weekly basis, we want to make sure that we come back to the AC, and I imagine this will be a series of kind of many different conversations, like what does that portfolio balance look like, right? And how have we tried to care for all of the different elements in that? But that, that is not happening on a weekly basis because we really are sensitive to trying to make these awards and keep moving.

Any other questions on this slide?

Okay, next slide.

And I think I will pass this to Lauren.

Sure. This is the regional and community planning slide. So this is kind of sharing with everybody just a reminder of all the regional meetings that we have held across the state to this point. These have been incredibly exciting meetings where every participant has really created its own unique identity based on the regional location and had these amazing discussions and takeaways for us to really have moments of connection within the context of the Rural Health Transformation Program and just in a really awesome kind of grassroots community context, which is these great aha moments. I remember when we were attending the Kenai meeting, I loved sitting at a table where one nonprofit was talking about a food scarcity issue with their program and somebody at their same table said that they had too much food and that it was being basically had to be disposed of because they just couldn't find uses for it.

And so right at the table, these moments where communities are able to have conversations about maybe if they are lacking something and somebody has more. So those, those like aha moments were so exciting to just get to participate in in real time. So you can see the meetings that we've held. And as we've been moving through this process, our contractor, MnAT, has been putting together reports. And so we're, we're starting to get in some of these draft reports.

And our next step is to send these out to the attendees from these meetings, get feedback, make sure that we kind of captured all of the discussion in the appropriate way, and then getting those reports moved forward. So the upcoming regional meetings that we have planned I might just tap Allison for a moment and talk a little bit about what we have on the horizon.

Yeah, thanks, Lauren. We have 4 more regional meetings that are confirmed for this year and, and possibly one more that is not confirmed, but we're trying to make the most out of the year. And I, I think to emphasize something that Lauren said, we, we see these as a little bit separate from the application process, but also not at the same time. They've been a really valuable way for DOH to get clarity on what the needs of specific communities are and to get qualitative feedback, not just quantitative data about what health outcomes and access challenges are, but they're also an opportunity to bring people together and, and to encourage people to participate in the applications a little bit. We as a team have had a lot of conversations, and I know this is a concern that's been brought up before, about how to encourage participation from really small organizations who maybe feel that they are a little pushed out of a process that is this big and this complicated, as folks have also noted.

And I think one of the exercises that we've started doing in these regional meetings is challenging people as a group to come up with a project and giving them sort of a theme to work on and then asking questions to encourage them to develop something on their own that could feasibly be turned into an application. And so to, to the best of our ability, we could spend these whole meetings just, you know, doing Q&A or providing technical support. I don't think that's the best use of that time, but we are really trying to encourage people to engage. And the most recent meeting, Ketchikan, was a really cool example of how the RHDP has fostered collaboration. We heard from two of the major healthcare providers in that region that when the LOI application opened, they started talking to each other and having more discussions about how can we make sure that we're not duplicating our asks.

So what are you asking for and what are you asking for so that we can make sure that together as a whole we're kind of covering the needs of the community, but we're not competing with each other, we're filling different niches. And so it was really encouraging that even outside of any, um, any prodding or encouragement from DOH that they had found a way to work together and it had strengthened ties between their two organizations. DC Ricci, is there anything you would add here?

I would just, I see a question from Representative Mena. Her question is, will the regional reports from ANAAP be made public or is a summary or a summary of the regional meetings? I think we do want to make sure that we're sharing the information out. We also want to, in some ways, respect these reports as being community reports. And we wanna make sure that people who felt like they were sharing information have a chance to review that and that information really reflects that's, you know, what they shared and that they feel comfortable with that.

So we are having that back and forth with the draft reports, but we do want to make sure that we find a way to provide this information publicly while also respecting just kind of the community's ownership of the reports and those meetings.

One thing that I would highlight is the Greater Anchorage area is September 22nd, and that is, that is coming up here very quickly. And I think right now We are not ready to commit to this, but we are considering if there's other activities that we can use to support round 2 or to think about providing technical assistance on September 23rd. Again, anything we do would also be available. We would also make sure that we're providing those opportunities for technical assistance or engagement through online means as well. So it's not, you know, just limited to people that are able to participate in the Anchorage area, but I do just want to kind of flag that.

Again, we have not finalized plans. We are still working through that, but we do want to make sure that we are kind of fully utilizing all, all of our opportunities to address both kind of where we thought we would be and then what, what the needs are now that we've kind of walked down this path a little bit farther.

Anything else the team would add or any other questions from the Advisory Council?

Okay, I think that is the last slide in the presentation. Oh, hi Nancy, I see you have your hand up.

Yes, my sincere apologies for taking the group back one step, but I realize I forgot to ask a practical question about timeline and awards. Since the the awards are coming out later than folks initially thought. Could you talk through a process that will be available to, to project owners to realign timelines and potentially budgets and deliverables based on the new project start dates? Sure, and I will actually pass that question over to Betsy or Lauren and the RHTP team.

Thanks, Nancy. I think that's— I'll pass it off to Lauren or to Allison in just a moment, but I do want to talk a little bit about kind of the performance periods and the timing on that. I think one thing where I'll echo what the team shared earlier around CMS being incredibly responsive and really quick to work with us, on a lot of things. One area where I don't believe they have flexibility is on the timelines for obligation and expenditure of funds. So even though, you know, we're working into August and we had been hoping to be doing a lot of this work prior to August, we're still looking fairly firm at the end timeline for when, when do these funds need to be obligated and when do these funds need to be expended on our end.

So I say that to kind of to set up that, The end of the performance period for these— for this first round of awards is still going to be what we had originally planned, right? You know, we're looking at— let me make sure I get the correct summer month— that the end of June of 2027 is still what we are working towards for the end of this performance period. And I know that does, you know, allow those kind of 3 months of— I think we've called it a grace period in the past, but we really want people to be looking at September— July 3rd— oh my goodness, June 30th of 2027 as the time that they need to be wrapping up all of their activities for this. And if, if individual organizations are identifying, hey, given the timing of the start, I need to readjust, they're going to need to reach out. And Lauren's going to keep me honest here, but I believe that once they've kind of executed their award, they can connect through ACF back to us and we can work with organizations to understand what is it going to look like to work through your project under this performance period.

But I just want to say again, we really don't have any flexibility on the spend timelines on this. I think those are pretty hard and fast program requirements that we've not been able to identify any flexibilities there. Lauren, would you add anything else? I would just say that similarly to how we're moving through the process of getting clarification, that we've had some folks reaching out who, who have very specific questions, and it's been really helpful to us as it's a case-by-case. Certain elements of the budget, you know, there's issues of shipments, you know, there may be only a barge available to ship an item up, and that's a requirement needed to fulfill an element of their grant.

And so as we're working with subrecipients and potential subrecipients, we're sending those questions in and we're getting quick responses from CMS. About the best way to tackle those, you know, those situations. And as we're learning more in there every week, we're getting more and more CMS guidance coming out because this is not an Alaska, unique Alaska problem challenge. This is something that all the states are facing, you know, this challenge with how fast this RHTP program is moving. So we're just being as transparent and quick to respond to these questions as possible.

So those specifics have been really helpful though.

Monique, I see you have a question. Yeah, I'm not sure. You said this was the last slide, I believe, and maybe I'll wait till new business, but I wanted to make sure we got through information that might be helpful for people in the community first.

Okay, so no question now, but question in the future. Exactly. Sorry. No, no, you're good. My brain's the same way right now.

Any other questions for this slide or presentation?

Okay.

Allison, I think we can stop sharing. And in terms of department updates, I don't believe that we have any additional department updates at this time. I know next in the agenda we have both unfinished business and new business. So before I move to those items, I do want to see if there's any other questions regarding department updates from the Advisory Council, anything that we did not share or cover.

Okay, hearing none. Then I will move on to the next item on the agenda, which is unfinished business. And I would see if there's anyone that has unfinished business. I think most of our unfinished business is actually a year 2 planning, which is what is the next item on the agenda.

Yep, Monique. Yeah, I think I have a couple of questions here. You know, I think One of the questions I know that has been asked at a couple of the regional planning meetings relates to some of our milestones, right, that are incorporated into the state's application. And we heard during legislative session how important hitting those milestones were when it is sort of correlated in terms of future awards the state of Alaska might get for RHTP. So some of those milestones we, we did not see any awards made.

And, and in turn, because we heard that people were focused on those milestones, right? So I'm going to propose things that they said they would do in year 1, year 2, quarter, whatever, right? So a couple of those items relate to off-grid sanitation. Which applicants put forward proposals to that effect, but they did not move forward. So people are a little bit confused.

And I guess also, you know, there was another milestone related to identify and prioritize rural facility renovation needs. And as we— and I think a lot of people in rural and frontier communities really felt like here's our chance, right? We, we're off the road system, we're serving people, but how, how are those sort of incorporated when we don't see those really in awards thus far?

Thanks, Monique. Those are good questions. So I think I'll just start by doing a little bit of kind of framing again.

This is a new program that CMS is standing up as well. So what we put in the application and the milestones that we put in the application reflected what we heard from entities and their priorities, right, including sanitation and rural health and facilities.

Clearly, the renovations is an element that we are still working through with CMS to really understand what some of those boundaries are. Same thing a little bit, I think, with some of the water and sanitation, although we did not have projects that move forward this round specifically on those, we were able to make some adjustments to our milestones. And this has been relatively recently that CMS has allowed for some adjustments to those milestones. So I think we feel that we are in a strong position for year 1 to make sure that we are meeting all of our milestones, but those have been slightly adjusted. When we were doing the kind of the review and the evaluation, ensuring that those milestones that were not adjusted, that the projects reflect that was— is part of what some of our consideration is from that portfolio review perspective.

But I would let Betsy speak to some of this. I would say again, regarding the renovation and some of the kind of the hard construction or building terms, one of the reasons that we felt it was appropriate to move some of those milestones or adjust some of those milestones is because we don't have the clarity of guidance this year that I think we need. We are beginning to develop that, and CMS is too, but it's hard to focus on some of those projects that really fall into either an unallowable use area or a very gray area. And so we need to better understand what that means. Betsy, would you add anything?

I would just kind of echo that, that I think, you know, when we looked at— well, first of all, I think, Monique, the two examples that you highlighted are really critical and really important. And They're also in that space of, I think, as we heard Allison speak to earlier, in that space of renovation construction world, like there's a little bit of, I think there's a learning curve for us and for CMS as to where does this project fall on the kind of spectrum of it does, is this allowable, is this not? And I think that we know that we've put this into our application. We believe it was approved, and we think that there is certainly space to say these are projects that we would like to move forward. But recognizing that CMS was going to be looking for a considerable amount of detail on a lot of these projects, and also recognizing that there are limited funds within that kind of Category J renovation category, I guess, that's where we said, let's kind of hone in a focus here for year 1, but recognize we want to support projects throughout the spectrum of the— or throughout the life of the this program, look for more ways that we can kind of put some targeted opportunities or put structure around opportunities out there for year 2, and understand a little bit more from CMS and get them kind of used to the, to the types of projects that are important and impactful in Alaska and say, here we go, this is what we're looking at, this is what we mean, and kind of build that, that shared language and shared understanding of the impact of the projects.

And I think look to year 2, and then as As Emily mentioned, with the milestones, CMS has indicated to states that when we look at how do we tweak and refine our project plan over the years, they recognize that what we all put into our project plans last summer, or I guess last fall, that there may need to be adjustments to that. Or I think, I think of it more as a minor tweak, like, and you say, I had thought this is when we would be doing these types of things and how we would approach and that may shift a bit over time, and that's where CMS has indicated to us that they're open to movement within the milestones, but mainly kind of when do you anticipate achieving this, not so much, you know, replacing one milestone with something else entirely. CMS has also been very clear that the project plan we started with is something that we need to maintain throughout the life of this program, but they are open to minor adjustments to the when and maybe a little bit to the how, but not really to the what. And so that I think is, is really heartening to me too when I look to projects like the water and sanitation and then looking at the renovation needs that we see throughout the state where we say, well, this is what was baked into our initial project application and we'll work with you on the how, but this is also critically important to us. And so let's think about how does that play out with the win.

So, I hope that that's helpful, but, you know, I would say we've also, you know, as we've noted, we're building every element of this program as we go. CMS is also building the elements of this program as they go, and so we've asked about, okay, how— what's the best place and way for us to say, here are some adjustments to the timing of these milestones, and they've directed us to look to that NCC application that the team will be submitting by the end of this month as really the best venue to make some of those adjustments. So I think that's something that once we've submitted and received approval, then we can kind of talk through here's what we're looking, looking at there. Thank you. That, that was super helpful.

If I can just add on to that, as we think about that, right, certainly things I've heard the department say, things the department said, and you know, the convening at the Hilton, presenting to legislators, is I've also directed, because of the comments the department's made, I've directed folks to those milestones, right? Like, this is how CMS is going to grade the state. Therefore, right, the state is looking to check the boxes on these. So I think as we look to future funding year awards, we should really be considering how we highlight those changes because there were a lot of organizations that focused on there, on those, because they felt like it was a quick way to focus on those and be successful and make things happen. And they may have been a little bit— for other priorities may have been further down the line because those milestones sort of dictated, drove, informed, whatever the right word is, people's applications.

So as we look to future funding years and we think those are going to move and shift. I think it's going to be really important that applicants understand those so that as they're— that they're focused on the right thing. Right. So, for example, another one I see that we were really focused on because of feedback from a couple organizations is child care. Child care seemed to, on a completely unscientific analysis of projects that did not move forward, I was sort of surprised at how many childcare proposals did not move forward based on Commissioner Hedberg's comments around childcare being very important for the workforce, being a priority in her arcs of effort for that department.

So that's something that folks were prioritizing and have asked for any sort of insight. So I think as we look to those milestones, helping people understand them in future funding years is going to be really important to understand that timing.

Yeah, Monique, I appreciate that. And I, again, I just kind of want to emphasize what Betsy said, which is like minor tweaks to the milestone on wholesale replacement, right? So those are still our priorities.

I also just want to kind of think back about how far both us and CMS have come from January versus now, right? Things have emerged, they have matured, information has changed, and especially this year one, we've had to be a little bit more flexible and adaptable in terms of we don't have enough money to meet all of the needs. We heard $2.7 billion in LOIs, right? We have $272 million. So what is it that we think is kind of most reasonable and appropriate as we work, as we build out this new program, right?

Based on an application we had 6 weeks to put together back in August. I know we all lived through the pain of that, right? That we hoped we got it right, but we knew there were going to be things that we put in there that, that, you know, we're going to have to change or modify, not because they're not important, but because this is a new program and the timing and the logistics of that are being built out. And I think you see that this year. You see that in looking at the milestones and saying, well, considering we are having a lot of conversations about what renovation means, that may not— and we need to get money out the door quickly and we have $2.7 billion in needs, right?

Like, where do we make sure that we are focusing our time so that we are most effectively, like, building off of the guidance that CMS has provided as that changes? Right, or becomes more developed, and maybe that's a better word, becomes more developed, because nuance is really important when it comes to RHDP. And how are we taking that into consideration so that we can build out what we need to in year 2, right? But everything in the milestones, that is still important, that will remain. It's probably more tweaks about timing.

And childcare is an area that we knew when we submitted it, we were pushing the boundaries. On what could be allowable. And we made a choice to do that because of its importance to us. But again, as the program is built out in year 1 a little bit more and we have more information and understanding, I think those are things that we can consider.

We can think about how to help projects be more successful in being approved for round 2 because we have more information through year 1 that we did not have back in January or February.

Uh, Representative Mena.

Thank you, Emily, and thank you to the department for the presentation and the update. Really, really helpful. Um, I just wanted to build off of Monique's questions. Um, I looked back at those milestones and also the portfolio framework, and this past summer I've been in a lot of different meetings with other state legislators on how their RHDP process is going. So You know, I've learned a lot about different permutations of partnerships with university researchers or utilizing healthcare economists because you do have this wealth of data where, um, you as a department have to balance between implementation but also meeting so many of these milestones and really making sure that we're tracking these healthcare outcomes.

So, uh, I'm, I'm curious, looking at these milestones, um, and also the portfolio framework, and as we move into year 2, how is the department looking at the gaps that we received in the LOI? Region-wise and highlighting where we need more applicants in a particular area? Is that going to be a proactive effort by DOH, or is there an opportunity to utilize our partnerships with ACF or maybe with, you know, another, like, research institute to just figure out, like, where we're— where we are needing more of an effort in applicants? It seems like right now so much of that work is being relegated to stakeholders to anecdotally figure out what those gaps are and wanting to see how we can be successful in these year 2 awards.

That is a great question, and that's something that we are kind of working through right now within the department. What is the best approach? I think the answer would be like, yes to all of those different ideas. I don't think it's just one way. I think maybe the most direct way we have from the department perspective is through, you know, this concept of state-directed, state-directed applications or initiatives.

I feel like I'm losing the word here. That really gives us the ability to maybe focus applications for requests for applications for funding in some of those specific areas or gaps. And we're trying to think through and evaluate right now what some of that would be. I know that's a conversation that we would want to have as well with the Advisory Council and others in terms of kind of what does that framework look like. I would ask if any other RHDP team members want to add to that.

Yeah, this is Lauren again, Hughes, and I just wanted to share— excuse me— that we are, as DC Richie just shared, we're in the active process of taking the ideas that were shared with us and partnering with the Alaska Community Foundation to really have a good overall process for year 2. So this is a great conversation that we have been— there's been a lot of side conversations on based on good feedback that we've received from the public, hearing from other states the way that they either successfully kind of picked a path forward with some of these state-directed projects or some of those pitfalls. And a lot of these have been shared with us through the CMS weekly webinar learning series and just been able to gather a lot of excellent information and just see how other states have also been just kind of going about this and trying to make sure that as we're looking at these initiatives, as we're looking at the milestones, just making sure that we're not missing areas that really need support for Alaska. So that's, that's definitely been a big area to tackle, but we're feeling really positive about that.

Eliza, do you want to add the— do you want to talk a little bit about the report card concept?

Yeah, it's you, DC Ricci. Um, we recognize that as we are in this quickly evolving period of announcing projects with intent to award that we have not been able to develop materials, kind of a report card, a dashboard that more kind of shows the summation of the portfolio. And that's because it's— that information is not ready yet. And so want to communicate and, and, you know, also invite your feedback on how do we keep building, you know, resources so the public can understand kind of what are the awards and, you know, the sum of that portfolio that gets funded and how does it align with our milestones and how does it serve across Alaska. You know, those are all things we are building towards, but right now with, you know, as we are building, you know, and rolling out these projects on a weekly basis, that kind of that view of the whole picture is not ready yet.

And so do want to, like, let you know that it will be coming for us to have opportunities for stakeholders, for partners to be able to look at, you know, how do these projects that, you know, have been invited from across Alaska line up to our milestones? Where might there be opportunities for more, you know, investment in year 2?

Thanks, Eliza. I know one item that Eliza is working on is kind of the development of a concept, almost like a report card weekly to report those out. But I would note we have provided the information in an Excel sheet. That was something people asked for last time versus a very, very large PDF. So that is kind of an interim step as we finalize the kind of the more comprehensive dashboard that we've talked about.

Any other items in unfinished business?

Okay. Next item on the agenda is new business. And I think we started to go into this a little bit talking about year 2 planning. Again, year 2 is coming up pretty fast. We will submit our report, our NCC Betsy, at the end of this month, right?

So that's just, that's less than 2 weeks away at this point. And then CMS will issue year 2 funding announcement by October 31st. So we should know by then kind of what that year 2 funding will look like. Again, year 1 was on a shorter cycle because of just the timing in the bill and the award notice and the application process from CMS. So we're on almost this— we'll be on kind of that maybe not quite a full fall timeline, almost like a summer timeline or spring, but moving into the years 2 and beyond, I think it will be helpful for everyone to have more of like a fall/winter timeline for the process.

I think particularly in areas where, you know, spring and summer are construction periods in Alaska, that can be really important for some of these areas, particularly in rural Alaska for planning. So we don't have a timeline developed right now for this meeting, but that's probably the next item that we want to talk about with the AC, along with kind of the culmination of the award amounts for year 1 and a a description of that. I know for year 2, we are, like I said, we're actively kind of having those conversations, um, in building out some concepts for how we approach the year 2, structuring the year 2 application process. We think there's a lot of value, uh, important value in having, I think, Jared, what you referred to as an open call to a certain degree. So an opportunity for, for projects to submit across a variety of initiatives but we also know that providing some more structure in certain areas can be really important.

And so are there ways that we can also look at what other states have done, how they have approached maybe some of their subgrantee recipient processes? Are there concepts that we can take from them and build into maybe some state-directed initiatives that would be helpful? So we're thinking about that. I think one item for year 2 that we really have identified is wanting to build into the application process some more structured requests around certain elements of projects. And Lauren or Allison, I might kick this to you to describe kind of what we're thinking in terms of like equipment or renovations or kind of stipends or training and salary support.

So Allison or Lauren, I'm not sure who wants to step in there and talk about that briefly. Absolutely. Thank you. I think some of the thought that went into this, I think just tagging along with the feedback from the way we moved through year 1, is to try to assist and make it both easy for the— easier for the subrecipient and easy for the review process to maybe refine and categorize a little bit more specifically areas that we found subrecipients had some bumps or some challenges on just because of the way the program has been structured. And so I think Allison and Eliza both spent a lot of time, and I might tap on one of them to share kind of their experience, but when we were looking at it, there were these questions on equipment, and we were thinking if we worked and partnered with ACF to kind of come through and just refine it so it's easier, so the pathway is clearer, so the guardrails are in place, the, you know, the FAQs regarding these specific types of projects are just a little bit easier for that to move through.

So I might tap on Eliza or Allison to just share briefly about just why we're looking at, you know, like equipment. And I know we kind of went through and identified a couple of categories that we thought this would be a really good idea to kind of work with and flesh this process out. But those are the questions that I think we were looking at really, really closely that subrecipients were having a little bit of a challenge moving through with this the way that it was structured for year 1. So kind of restructuring that. Alison or Eliza, do you guys want to just chat for a moment on that?

I mean, happy to. I think you covered the high level of it, is that the breadth of projects that we are reviewing applications for is really remarkable and reflects the breadth of needs that we have across the Alaska healthcare ecosystem. But the level of detail is also really different. Um, and while our templates can provide, you know, a starting place, there are some really key places where we need additional information and level of detail. I think that has become very apparent, especially in the renovation space, in conversation with CMS.

And we're learning so very much as we, you know, go back and forth with them. And I will again echo, like, I have been astounded by the speed with which they have come back and, you know, both said, you know, these are projects that, like, yep, this works, or this project where we need, you know, extra clarification on. And so how do we ensure that where there are kind of really key pieces of information that we've asked for that upfront, both so that applicants can be thinking about it and can understand like where, you know, where that squishy line is or where that squishy puddle pool is for, you know, that line between what's main, you know, major and minor renovation. So I think that's a place for sure. I think also in the technology space, wanting to ensure that we are supporting applicants as they think think through what are some of the considerations for, you know, making technology investments related to EMRs, related to some of the sort of— we have a lot of requests related to AI.

We've also seen some major sort of clinical technology equipment infrastructure questions that we want to support applicants with thinking through sort of the business case of bringing on board some of these sort of major pieces of equipment so we can understand You know, what is the, like, the service population that they intend to support with that equipment? How does that align with their current practice? And that really leads up to CMS's focus on sustainability. We want to make sure that we can leverage the RHEP funds for some of these kind of major upfront investments that are, you know, really important to modernizing healthcare in Alaska. But then how do we ensure that, you know, these entities in our healthcare system are able to sustain that investment going forward?

I would add one more item that I, that I've seen a little bit is when you're thinking about building out new programs, um, and we've heard this before, like startup funding to support the buildup of staffing for new programs that can then be supported through other types of reimbursement is important. And we, we are absolutely seeing that in the projects and applications that come forward, and I think that makes a lot of sense, particularly when when there are limits on new construction or there are limits on renovation or other areas, right? It's like, okay, how do we think about using this money to start up new programs that we think will improve population health and reduce costs in the short or long term in other areas? So we are seeing those requests for salaries to support staffing salaries for different programs. And, you know, that, that's fine.

The sustainability is going to be something that we look at really critically for those because we don't want to create a scenario where a program is stood up and then it's not sustainable and people have to like let staff go or end the program, right? I think that was a big lesson that we had from CARES Act funding. But one, one item that I think we will be probably asking for input and that we're kicking around is really ensuring that entities are moving off of RHTP for that staff funding when there is an alternative billing option available as soon as possible. And I think in the beginning we have seen some applications where entities want to continue that staff funding for, you know, the entirety of the RHTP program when there are other reimbursement methods that they can be switching to much faster. And so how do we ensure we are building that into the application?

Because we want to make sure these funds are fully available for as many Alaskan projects as possible, and if— and it's not appropriate for the RHTP funding to be used to support some of those programs for half a decade when there is another option available that they can transition to. So as we think about round 2, we're thinking about how we can build that a little bit into the application so that entities are kind of on notice from the beginning if there's— there are— you need to move to sustainability as fast as possible and not rely on this for the entirety of the award period before you move into that. To a certain degree, that was included in the evaluation metrics. But I'm— and we did see that come up in more applications than I thought.

I think I had another thought as well, but it has fled my brain. I guess I would open this up to the council members just for your thoughts. What's worked well? What are you— what do you think is really important for us to be considering for round 2, especially as we are kind of in this phase ways of putting together an outline that we will then share out as far as, you know, how do we approach this effectively. Probably again with a relatively short timeframe, but with more information than we had in this last year.

Nancy. Just one quick question and a longer one. On your NCC, are you being directed by CMS to build a budget around the original award amount, $272 million?

Yes. Yes. Yeah, that's what we've been directed to start with. And I think that this is me speculating. I imagine that if that award amount adjusts, that they would do a similar process that they did in the first year, which is, you know, request that states adjust within a timeframe to align with what it is that they've said everyone should use their first-year award as that baseline.

Okay. And then just given the timing of these year 1 awards, and there won't be any performance data to speak of available from funded projects before the year 2 applications begin. So just thinking about what, what the department will use when considering those funding decisions if you don't have data from year 1.

Projects. Are you thinking considering the funding decisions for what we've built into the year 2, or how are we going to be reporting on progress? I guess both. How are you going to report to CMS on progress, but also if projects have requested multiple years of funding, but funding in future years is dependent on performance in year 1, but you don't have year 1 information or data. How will—.

I think you got muted right at the end, Nancy, but both are great questions. You know, I think what we're doing with the year 1, we've heard, we've been participating in a lot of webinars with other states that are looking at the year 1 reporting and are saying, well, how are we supposed to demonstrate progress when we're in this program buildup? And there's a fairly complicated framework to, to do the reporting, but it's— there are elements that we can report on that demonstrate how we've made progress on program buildup, on governance structures, on kind of establishing a framework to, to manage the program. And then when we look at the elements of implementing the initiatives, while there are components of the subrecipient awards that we will be unable able to report on because of the timing, because we're, you know, into August and it's through July 31st. There are other elements that we are able to report on.

I think community and regional planning is a really great example that we started that early, and that has really kind of kicked off and gotten underway. And CMS is looking for— when we say we've kind of kicked off an initiative, they're looking for, okay, are you doing something? Have you issued a contract? Have you done that? And there are elements of that that pull in for various initiatives.

So, you know, I think I would say, and I and others from the team can chime in if they have a different perspective, but I would say that our progress, we have measurable progress to report, and I think it aligns with where we're seeing a lot of other states kind of based off of the questions that they're asking and the types of things that they're sharing that they may want to report. So I think, you know, we'll report on what we've done, and I think that there's, there's enough elements that we can demonstrate some, some measurable progress in that first reporting period. As far as looking to year 2 and building out the, the NCC application and the associated illustrative budget, I think we'll take a similar approach to kind of how we've approached the first one, which is projecting kind of a general sense of the types of projects. And, and I think that there are some that we can say, you know, there's enough space for us to say, here's what we've started in year 1, here's how we imagine these initiatives continuing and what some of those elements and components are. So, I think, you know, CMS has been with the project narrative, they're looking for us to kind of stick to what we've started with and say we're going to fund these types of organizations to do these types of things, and that language seems to work well worked really well for them.

So I think we'll be able to continue that forward. There's, you know, and I think we, we have a fairly strong sense of, or a better sense than we did going into the initial application of where is everybody across the state situated and what types of projects are they interested in. And that can help us kind of knit that into year 2. The other element that I really wanted to highlight, going back to the reporting, is we made significant progress in the state policy action commitments this year, and that gives us really strong elements to report on. And I will say that when we talk with other states and with CMS, there are eyebrows raised where they say, wow, you really hit the ground running and did a lot of work to move a lot of those policy commitments forward.

And we think that that's really going to be a strong element of our year 1 reporting.

I'll say there are some states, I don't know that they're still trying to find staff in August, but some states had not. They were still working to hire their RHTP team.

I think we have some positions open, so we will still, if you know someone, send them our way. But we are, all of the, how we think about performance in year 1 looks a little bit different than it will in future years. And I think that's across all states. Nancy, any other questions right now? Monique?

I'm kind of glad that I got to follow Nancy's question about performance in year 1 because I, I think what I would be interested in learning more about, and I think we heard lots of questions from individuals as well, are performance in year 1 from the Department of Health in terms of administering a program. I know this has been an all hands on deck situation for the Department of Health, but you are also implementing other components of HR 1, the one big beautiful bill, and really sort of wanting to understand, has the Department of Health, do you feel, built out the infrastructure and people power to really do this work? Or what should we be thinking about building in year 2 for, for the preservation of your team? Because I, you, there's just no way to run a Medicaid program, distribute $300 million and implement the type of changes that are necessary for HR-1 with Medicaid applications, SNAP benefits, etc. So I would really love the opportunity to hear from the state what year 2 looks like so that we don't, you know, run your team right into the ground.

And I realize that your team is, is you are the folks on this webinar, right? And the more you're So really understanding how do we build an infrastructure that truly supports the Department of Health for RHTP distribution, meeting the time, incredibly tough timelines that this legislation set out, but also allows you to be successful in implementation of HR1 and, and managing a state Medicaid program. So I think that is something that I'd really like to understand as a member of an advisory council. And how to help advocate for whatever change that looks like to ensure that the Department of Health has that structure beneath that. I think an important part of that component also is some real clear, um, understanding by community members, policymakers at the state and federal level of how was the decision-making undertaken by the Department of Health.

We sort of understood, I think, from my perspective anyway, that a lot of this work would really truly be led, defined, et cetera, by the Alaska Community Foundation. But where did the final decision— we understood Commissioner Hedberg was the final say, but did that mean that every person at the Department of Health was madly reading 1,800 LOIs 3,366 applications. And how do we ensure that everyone, that there is not a question about the transparency, consistency, accountability, um, that folks would really like to see in this type of project. So I think that a, I would love to see an advisory council meeting where we talk about sort of from the Department of Health, right? Understanding the tight timeline and really trying to do this work while doing the, like, as the, as the direction, the policy is coming forward, how do we really ensure that we are protecting the team that needs to do this, protecting applicants and protecting sort of in terms of just general positive way people are looking at this and they don't feel like I've been left out because of X, Y, or Z, that there's really clear transparency around the decision-making that happened around this.

As part of that, I think what I see as important for year 2 is some real clarity on the state award. To internal state agencies. That's a pretty significant portion. Sorry, this is kind of a laundry list of new business that I see, but there's pretty significant, close to $10 million, I believe, in state awards, um, to other state agencies. Um, and how that might impact other techno— knowing, right, for example, there's some technology to the Department of Corrections.

So how does that impact other technology awards to applicants that have submitted, right? And understanding what's the— what was the application process? What's the real clear, right, the clarity, the transparency, the consistency among state agencies as applicants versus did— was there a budgetary amount that they knew and they got? Got it right. Like lots of organizations had to jump through a lot of hoops to get there.

So have the state agencies had to have that level of transparency with CMS especially? So I think that helps us. And, you know, just to— I want to state the obvious. I'm not suggesting that there's anything that was not done by the book because I— we get to talk to you a lot about this process. But I think there's a lot of people in the community, policymakers, when we're facing a January session, how do we ensure that everybody sees the thoughtful process that you've really developed at the Department of Health?

And I think kudos from CMS really highlights how well the department has done under really tough extenuating circumstances. But also, you know, making sure everyone has that transparency and that we get to see this team a lot around for a lot longer and not completely burned out by a process that's just really unsustainable for the Department of Health. So anything that we can do to advocate for that, I would be all about it because it's so important. And you guys have done just an incredible amount of work in a really short period of time. And how do we make sure that folks see that and we build something that's truly sustainable for everyone involved?

Thank you, Monique. Those are all really important points. I might highlight just a few and then move on to Representative Mena's question. And I think some of these do require just more time for us to sit down and also more time for us to put together the information in a way that is helpful. I think sometimes it's hard to, like, it's, the information about this is so important and we need to make sure that it is shared in a way that people can understand because there's, because I think Alaskans view the Rural Health Transformation Program as their program, as it should, right?

This is not, we've always said from the beginning, this is not about the Department of Health. This is an Alaska-based program. And so we want to make sure that we are able to communicate these points, but to you, but, but to what you've said, our team has been working incredibly hard for well over a year, I think, at this point, and we have a number, I think, to address kind of staffing. We have substantially more people on our team than we did when we started. You heard new voices today.

I hope that you continue to hear more as we move forward. I think we are doing an assessment right now of You know, do we have— now that we have gone through one of these, you know, one of these rounds, do we need, you know, is the, is the support that we have, does that align with the needs that we had and have and anticipate having moving forward? And are there gaps? Are there other areas where maybe we didn't realize that we needed some subject matter expert expertise that was specifically focused on X, Y, or Z, and we think that we do need to bring that in as we move into round 2, right? With the contractual support that we have, kind of where are the unique strengths of those different types of contractual support?

Do those align again with how we're thinking about year 2 and beyond? Do we need to make tweaks there? Same thing with some of our staffing. So I know we, we are looking at our staffing plan and figuring out, you know, how to get into a more sustainable place. I really think a lot of it is is sequencing versus moving concurrently, and that just makes things really difficult.

Ultimately, regarding the decisions, you know, Alaska Community Foundation has been an incredible partner at helping support us with the application process and with that work. But the decisions, the review, the scoring parts of the evaluation, right, there's two elements to the proposals, and these are we discussed these with the Advisory Council and appreciated kind of the public feedback and input, but there's the evaluation and scoring, and then there's a portfolio review. So that evaluation and scoring was— that review was done by state employees. Hats off to many of the directors of our divisions that have specific subject matter expertise about different areas. They stepped in and participated in that, in that kind of proposal review, evaluation, and scoring components, and it was much more time-consuming than we had anticipated.

And it took up a lot of hours and weekends, I think, for everyone to move through it on the schedule that we needed to. But ultimately, that did rest within the Department of Health, and everyone that had kind of senior subject matter expertise was tapped to come in and to review some of these different evaluations and proposals. So So that decision-making authority and review did rest with the Department of Health, and ACF really supported us in that, but that ultimately rested with us. I think it'll be important to have a conversation about the state projects. State projects also went through a vetting process.

The LO, like state projects, including the university, was considered a state entity. And you might have heard this in the webinars. There were questions where the university was like, I, Where am I supposed to, you know, apply? I don't think it's supposed to be through the portal. But also went through the letters of interest process, ultimately into kind of applications, and then were moved forward, really focusing on a combination of the milestones that we need to complete.

Some of those tie directly to the milestones and some of those policy commitments as well that are part of the application. Or to community need that we've heard and/or kind of longstanding well-known issues that impact, I think, our ability to have successful outcomes in some of these different places. So, but happy to spend more time talking about that in the future. I know we're probably running a little short on time now. Yeah, just if I could just write, like, I feel like a lot of us on the the advisory council have good insight into that.

And this is by no means to call into question anything the state's done. I think it's just the opposite, is I want to make sure that you have all that because it's just, I worry, is that a sustainable pace for everyone, right? Like just the sheer, even when there's a smooth process, getting $270 million out the door, is not going to be easy. And how do we ensure that the team at the Department of Health has exactly what they need? And I think that there is a lot as a state agency distributing those monies.

I think you've done a lot to ensure people are aware of everything, but how do we make sure that everybody is aware, right? And I think that that could be an entire kind of session of the advisory council and how we— I'm willing to dedicate some time to helping people understand that. Some of us went down to Juneau and helped people understand, policymakers understand that. So we want to be advocates in this space. And also, you know, I think one of, one of my roles on the advisory council is ensuring that, you know, questions that come up come to you and come to the department.

I try to answer those as best I can, but I also try and make sure that those questions are answered in a venue like this so that there's broad awareness of them.

And we appreciate that. And I, I mean, all of the advisory council members, you, you know, have been part of this for a very long time. And I know one of the things I've been reflecting on, our team has been working incredibly hard and we cannot repeat what we did this last year from a sustainability perspective. It is— I think it is too much for everyone, but I just also want to reflect, I know that that also extends to the applicants, right? I mean, we are all— I feel like as Alaskans, we are all working as hard as we can on a very short time frame.

And I had a chance, I think when we were down in Ketchikan, I was hearing stories from individuals who were talking about working late into the night on their applications, and I kind of wanted to say, and what's funny is we were probably working late into the night on our end at the, like, those same nights too, right? So this is really kind of all of Alaska's, but we do need to move into a different space for year 2 that is more sustainable for everyone. One thing I would note, I've heard this a few times, and I heard it again last week when I was traveling, is I think Alaska has been identified as having one of, if not the most transparent process for Rural Health Transformation Program. Among states. It's hard to say that with 50 states, but I have heard that consistently unprompted from people I do not know from other states.

And, you know, in a meeting last week with a number of legislators from other states, some of them did not know who was managing their rural health transformation program within their state or how the money was being distributed or even how much they had. So there, I always feel like we can do more because this is so complicated and we have so little time. Time in many ways to communicate out, but I do think that we have a strong foundation, particularly in comparison to other states. That's what I hear on unsolicited, but I, you know, I'm sure you have heard similar things as well.

Okay, Representative Mena. Thank you, Emily, and I just want to agree with what you said in terms of the transparency of the department. It has been really enlightening talking to so many other state legislators and listening to their takeaways. And I've met with some state legislators who serve on health committees, and they have no idea what their state is doing with RHDP. So I really commend a lot of the engagement that the department has had with the legislature on this process.

I have two questions just related to performance metrics, going back to that topic. The first is just for my own familiarity, so I understand, you know, the NOFO and the scoring as it relates to the initiatives. So I want to know what the role of the performance metrics are, the performance metrics are in that scoring. And my second question, as it relates to feedback and how the, what the department could do in this, in year 2. I, I definitely agree with Monique and want to support the department on whatever your needs are in that capacity, and just for us to learn more about what those capacity needs are as you do your own internal assessment.

But from hearing different state presentations on their RHDP, I'm really interested in data analysis and metrics. There's one state in particular, it was Iowa's department, where they have a position of data, and it's one person that has access to all the different data of the state as it relates to health. And that person helps with their RHDP, but underneath them they hired a health economist. And so what they were able to do was map out performance metrics with the different types of RHCP projects that they have to dial in on areas of the state or particular counties where they know that there are high health needs and refocusing their year 2 efforts to help make sure that there are more investments in those areas. I love that idea and I, I don't know what the consideration is, or maybe it's happening already in the department.

Is there a position or is there an interest in utilizing healthcare data from your performance metrics? I know there's a lot of different data sources and mapping out where geographically there are high needs. And, you know, some of those performance metrics, infant mortality, adult cancer screenings, behavioral health services. If you're able to look particular areas of the state where you do have those high needs, maybe we can come out more in those performance metrics in the future, and you could also integrate the qualitative conversations from this community convos within identifying that. Those are my questions.

Thank you, Representative Mena, and I, I've looked at, I think, Wyoming's data and Iowa's data, and I have been very jealous I think that is something that we would like to build out and we can use RHTP to support. But I want to start by asking kind of Betsy to take the first part of this question and then Eliza for the second. Sure thing. Thank you, Representative Mena. I think this is a really important part of the conversation to look at, you know, how do we measure success?

How do we look at outcomes? How do we, how do we reflect, you know, how, what the impact and the outcomes are of these projects? And so I'll just note for the metrics that are in our application, which is also what we report on. I'll start with your question around how does that impact scoring. I think the short answer is it doesn't.

You know, CMS is looking for, as far as impacts to scoring, it's progress towards our kind of milestones, progress underneath this kind of program build-up checkpoint framework that CMS has structured the reporting on for all states. And progress on the state policy actions. So, so that our progress on our initiatives and our progress on the policy actions, those are the areas where we may see an impact to future awards. As far as the metrics that we put in there and our reporting on those outcomes, that's more of a kind of programmatic look at how are we progressing, and it doesn't impact the scoring for future, for future years. And, you know, I think it's also important, um, and I'll pass this over to Eliza, who can speak much more eloquently than I on this, um, when we built our metrics, we were looking at what do we, where do we have baselines and what can we report on now?

But we know that there are other areas where we, there's space for improvement. And I think that's something that we're really looking for, um, opportunities to build out underneath the RHTP program too. So, Eliza, I'll pass it over to you if you kind of want to talk about, you know, the various elements of data that we have and how those either marry or don't marry and kind of what we're thinking for the future. Hey, Betsy, right? And Eliza, right before we do that, I just want to go— I'm like flashing back.

I can't believe it's been a year to when we were developing the application. And we knew that we had to identify outcomes. We knew that those would not be scored. We also knew that we needed to identify outcomes that that had consistent data that existed at the time that we could go back and refer to. And I say all of that because the outcomes that we put in the application are important, but I don't know that they are— from my perspective, they are not by any means the only outcomes that I think we should be tracking towards as a state, and perhaps in some ways not even necessarily the most useful from an initial, like, short-term, medium, perspective.

And so I think that's an area that had we had more time in year 1, we would have built out almost an underlying outcomes dashboard for us as Alaska to say, this is where we want to move towards. It may not be directly in the application, but these are our outcomes that complement to or support those. We haven't had a chance to do that yet, but I think that's an important conversation for us to have in the future. And so with that, Eliza, do you want to jump in and maybe share a little bit about your background? Not to put you on the spot.

Yeah, happy to. So Eliza Ramsey, I am new to the RHCP team, but not new to the department. I am trained as an epidemiologist and came up through public health, which the Division of Public Health is a place where a lot of those metrics and outcomes those come from. Those are some really key data sources on understanding the health of our population. So have had the experience to work across public health with many of those teams and understand many of those different data systems.

And then for the past year and a half have been supporting sort of data strategy through the Health Information Exchange as well as doing some Medicaid analytics. And so I've gotten the opportunity to better understand kind of Medicaid and how we think about the data systems that related to that and to our other public benefits. And so joining the RHTP team with that data could sort background and lens and expertise. And so really excited to step into this space a lot more and to support, you know, some of those asks. Representative Mena, really appreciate you elevating some examples from other states on where you think they're doing a really strong job.

And then I think to echo DCVG, you know, what are the metrics that we really care about for Alaska? I think there are metrics that are really important to our application and as we communicate going forward with CMS, but also how is this As this program continues to unfold, do we identify those metrics and those key pieces of data that are critical to understanding how this application is rolling out? Where are there opportunities to highlight additional investment areas or strategies that we can lean into? And I'm always thinking about how do we get more timely data in front of policymakers, in front of decision makers? A lot of our data from the healthcare space takes a really long cycle to mature and be ready to share.

And so how do we move to more real-time data informs decision makers and really, you know, answers questions that people have. Really appreciate kind of the callout of examples. And if you ever have, you know, other examples or other ideas, really welcome that to send our way.

I know one area that we're focusing on very quickly is a gap, provider gap analysis. Again, so that we can think about kind of where are some of our core gaps across the state, particularly with like specialists or subspecialists. I think we know that, but sometimes it's surprising. And so I've seen some demos of what is being developed, and it's pretty cool. It involves almost like a heat map type of approach for looking at this.

And I'm not sure what the timeline is on that. I think it's probably more in the November timeframe. But that is one area that we're starting with, and I think that'll give us a good example of what we can build out. And you know, are there other things that we should be building out to aside from the provider gap analysis? I know the answer to that is yes.

So maybe a better way to frame it is like, what should we prioritize on building out from that data perspective? So Representative Mena, I don't know if that kind of helped answer your question or if there's other detail we could provide right now. No, no, that really helps answer a lot of my questions. It's, I feel like there's a joke here about the performance metrics not being value-based. But no, but it's, it's really good to know, just especially as an appropriator, making sure that we're retaining and supporting you all, um, in the awards for next year.

Um, and really appreciate Eliza, um, you know, your work with the department and your experience on data. So, um, we'll— I'll keep an ear out for other good examples for you all. Thank you.

Thank you so much, Representative Mena. I would go to Mary Wilson next, and then Nancy, I wanna make sure we circle around and pick up the question in the chat. Yeah, thanks. Hi, Mary Wilson from the Alaska Mental Health Trust. I'll try to be quick in terms of the time.

What a— you guys should all be so proud, and I know we're all very proud of the work that you've been doing. It's pretty stunning. I'm just focused in my remarks and questions really about how to make the process more sustainable next year. And I think, Emily, you said early on, as— and I— every— everybody's been talking about it, is how important the decision was for Alaska to make it local and to have things bubble up. So the process is really important, and the transparency that we've been very proud of, it sounds like, as a state compared to others especially.

So those two So retaining those two things are really important in year 2, and yet that's also the reality is part of what's made it difficult to sustain and, and hit targets and timelines and so on is that process which reflects the local bubbling up, the application going through the applications, all of that stuff. So I'm wondering if there's room in year 2 to both respect, respect all of those values, and introduce an element of strategic priority making. And I, and you were calling it state-directed, but, and that may be the right word for it, but that's not sort of how I was thinking of it. But something that says we've, you'll have data now from the regional convenings, so you've got some themes. You'll have basic data from the applications that have been accepted and the themes that you're getting from the bubbling up process.

So basic analytics And to build on what Representative Mina was saying, the more analytics, the better, but they don't have to be perfect. They just need to be directional. So you'll have a lot of information. We will have a lot of information. And can that be used in year 2 to say X amount of dollars in year 2 is gonna go respecting all the local initiatives.

Here's why it's being driven that way, and we're gonna be able to make some decisions that direct money that aren't necessarily bubbling up through an application process for every dollar. And I don't know if that's doable or of interest to anybody, but I feel like you could really respect all of the values that are so deeply important and will make the project successful and still get dollars out efficiently in year 2 in that way. And so I don't know if that's the right idea, but I feel like, Emily, you were leaning into something like that, and I just I feel like there, you could, we could do the very same process and add more people. And that's one possibility, or say, is there a way we can be just as respectful of the process that we love and do it a little bit differently in terms of being adding a strategy and some dollars to that value?

Thank you for those thoughts. I mean, I think that's, that's exactly part of the balance that we have been trying to think through. How do we retain, again, Jared, to your terminology, that open call element for new ideas and new projects while also trying to develop some strategic focus? How do you blend those? I will say the other element that has emerged for me in this process is the, the strength and the value of coordination within communities or regions, particularly regarding applications.

And so when projects emerge that have really strong, very clear support and coordination among other healthcare providers in a region or other entities in a region or even across a region, that demonstrates to us that this really is a project that is valued, that is necessary, and that is worth investing in. And that, that strength and collaboration, I think, is also an area, as I've been reflecting on Alaska's healthcare system, where we, we tend to be very independent in our healthcare system. Right? Many of— when I first started, I heard stories about people who moved to Alaska to avoid the managed care that was down in the lower 48, right? I mean, we have a system of providers that tend to operate relatively independently compared to other states.

And there's a lot of benefit in that. I think that reflects our spirit as Alaskans. It also, though, means that we don't have some of the inherent systems to create more of that coordination and collaboration that I think can really benefit patient care and financial efficiency and sustainability. And so I think part of our challenge in Alaska is how do we create systems that build that out while retaining the independence that's so important to us, right? What does that look like?

And it's maybe one of the reasons we've had a hard time copying what other states have been doing is because we, we operate in that different type of environment. So I share all of that because I think when we see projects that, that have that strong community support and collaboration or regional collaboration, to me that's an indicator of like, what does transformation look like in Alaska? It's the ability of us to be kind of more efficient and effective in coordinating care, right? Like creating scale where we can while retaining that independence and providing the tools and the equipment and the resources that providers need to offer the best services for the patient. So how those merge moving forward is something that we're developing and we look forward to discussing with the Advisory Council.

But I do think you'll see from our perspective that emphasis on regional alignment, coordination, and collaboration is, is important. Ultimately, I think we've tried really hard to defer to communities and regions about what their priorities are while sharing kind of our perspective on what we see in the data or some of the challenges that we see in the healthcare system. So that's a little bit of what is shaping our approach for year 2. What that looks like, again, we'll need to share out and share back kind of what we're thinking very quickly.

I want to make sure that we move to Nancy's question. And so Nancy, your question is, at what point will Department of Health know how much money is available to award for year 2 projects. And for that, I'm going to kick it to the RHDP team. Thank you. And, you know, I think that question really dovetails a lot onto the, to the answer to the last question, which is, you know, how do we plan ahead, right?

We know that we want entry points for new projects. I think we all moved really fast, like everyone in the state moved really fast. To say, okay, let's build the opportunity. Let me give you my frontline ideas or my faster ideas, because there are a lot of groups that said, I have some like longer thought process ideas or something that might need to take a little more time to build. I can't put it together for year 1, but I'd love to tell you about it in year 2.

So we want to make sure that there's an entry point and opportunities for those kind of newer or more developed or ideas that people didn't put forward in the first round, but also recognize that as we, you know, move into this award cycle that we have a lot of projects that are coming in that are saying this is a multi-year effort and I would love to have multiple years of funding in order to complete the investment that you've made in my organization in the first year. And, you know, I think we, we've tried to care for pulling in the information that we would need to help us get a little bit of a sense of what that would look like. And so those of you who went through the application process noticed that there were future year estimates that we asked organizations to kind of build and bake in so that we could have a sense of what you might be looking for in year 2. Now, nobody's going to be held to that amount, right? Because your need may evolve over the course of the year.

We don't know what we're going to be able to support as far as future years of funding for individual projects that come in, but I think we move through this first round of awards and identify, okay, here are the projects we're moving forward with, we can take that information, that kind of initial estimate projection information that organizations provided to us, and that can help us shape, you know, how much money we may be looking at kind of setting aside in, in a, okay, we need, we know we want to be able to support start second-year awards for this first year, or for, you know, for this first cohort, I guess. And then also identify that we, we want to have sooner funding opportunities for new entrants or new projects. So we're balancing those two elements. I don't think I have— I can't say here's the date and we know we're going to have this much money, but do know that our team is very much so thinking about what is that future kind of funding pressure look like for the year 1 group, but also wanting to ensure that we really maintain space for new entrants and new ideas on a shorter timeline.

I see we only have a few minutes left. Any kind of last questions or thoughts before we wrap up?

Okay, I would suggest we will, we will reach out to the council to find times that work. We, given where we're at with round 2 and wrapping out, wrapping up round 1, I'm not sure when that will be, sometime probably in the next 4 weeks, but we will reach out to the council and we will notice in the meantime You know, there are more— there is more information coming out this Friday. And again, we are trying to work through these notices of intent to award as fast as we can. So we will continue to make that public and to share information with the Advisory Council. In the meantime, everyone knows, I think, how to get a hold of each other and me.

And if there's nothing else, I will ask for if there is an objection to adjourn.

Okay, hearing no objection, we will adjourn 2 minutes early. Thank you so much for your time and all your work. Very much appreciated. Happy Monday. Thank you.

Thank you. Thank you.