Open Line Health Access

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Executive Summary

Open Line Health Access is a nonprofit in Missouri that turns trusted local places, such as libraries, churches and community centers, into private telehealth access points where rural residents can see a doctor, nurse practitioner, counselor or specialist by video, with a friendly person to help and good internet that works. We do not provide medical care ourselves. We provide the room, the equipment, the connection and the human help that make telehealth possible for people who would otherwise go without.

Telehealth has made it possible to see a specialist 200 miles away without leaving town. But in many rural places it only works if you have a smartphone, a strong internet connection, a private place to talk and the confidence to use the technology. Many of our neighbors have none of these. Some live where broadband does not reach. Some share one phone with a family. Some are older adults who have never done a video call. Some need a private place because they live in a crowded home, or because the visit is about something personal. The distance to care is still there, only now it is digital.

With this grant we will open six telehealth access points in Year 1, staffed on set days by trained Telehealth Navigators. We expect to support about 1,800 telehealth visits for about 700 different people. Navigators help people schedule visits, get set up, join the call and follow up on prescriptions, labs and referrals. A loaner tablet and hotspot program serves people who need to take part from home, with a Technology Coordinator providing support. Free digital skills sessions help people feel confident.

Our Year 1 budget is about $325,000, growing to about $385,500 by Year 5 as we grow to twelve access points. Each year's budget is planned to balance, with a small surplus each year. We have 5 paid staff in Year 1 and 6 by Year 3. Health systems and clinics pay a partner fee for each site because we bring them patients they could not otherwise reach, and county and regional contracts and local donors add steady support, so grants fall from about 70% of our income in Year 1 to about 46% in Year 5.

We are asking the Heartland Rural Health Fund for $86,000 for one Telehealth Navigator, our telehealth platform and technical support, broadband service at the access points and the loaner tablet and hotspot program. Partner fees, other grants, county contracts and local donors cover the rest, so this grant is one part of a shared funding plan.

I am Dale Peterson, the Executive Director. The numbers in this proposal are estimates based on the assumptions listed at the end, not promises.

Company Description

Open Line Health Access is a nonprofit organization in Missouri. We are a 501(c)(3) public charity (or a program of one, through a fiscal sponsor), governed by a volunteer board of directors. We will provide our IRS determination letter, board list and most recent financial statements with this proposal.

Our mission. To make sure that where a person lives does not decide whether they can see a doctor, a counselor or a specialist.

What we believe. Technology should serve people, not the other way around. Telehealth works best when it is simple, private and supported by someone who knows you. Trusted local places, such as the library and the church, are the best doors into the health system for many rural residents. We work with clinicians, not in place of them, and we protect every person's privacy.

How we started. Open Line began when a county librarian noticed that more and more people were asking to use the library's computers for a video visit with a doctor. Many did not know how to log in. Some tried to take a call in the middle of the reading room. A retired nurse and a technology teacher volunteered to help, and a small meeting room was turned into a private space with a donated computer and a headset. Over two years the library supported about 300 video visits, and four other libraries and two churches asked us to bring the same thing to their towns. This proposal asks for support to build a network of six access points in Year 1 with a trained staff and a permanent plan.

What we offer:
- Telehealth access points. A private room at a trusted local site with a computer, camera, headset, a privacy screen and a white noise machine, simple health check devices (such as a blood pressure cuff, pulse oximeter, thermometer and scale) for use when a partner clinician asks, and reliable internet.
- Telehealth Navigators. Trained staff who are at each access point on set days to help people schedule visits, get set up, join the call and understand what to do next. Navigators wait outside the room during the visit unless the patient asks them to stay.
- A loaner tablet and hotspot program. Devices with a data plan for people who need to take part from home, with a simple setup and a phone number for help.
- Digital skills sessions. Free, small-group sessions on using video calls, patient portals and online prescriptions.
- A partner provider network. Agreements with health systems, community health centers, behavioral health clinics and specialists who agree to see patients at our access points and who confirm what the patient's insurance covers.
- Technical support. A help line, remote support and spare equipment so a broken headset or a dropped connection is fixed quickly.

What we do not do. We are not a medical provider. We do not diagnose, treat or prescribe, and we do not see, store or share anyone's health records. We are not an emergency service. A telehealth visit is not for emergencies, and every access point has a posted emergency plan that tells people to call 911.

How we are run. A seven-member volunteer board of directors oversees the organization and approves the budget each year. The board includes a rural physician, a county librarian, a hospital telehealth director, a pastor, a county commissioner, a retired nurse and a certified public accountant. The Executive Director manages the organization and partnerships, the Technology Coordinator manages equipment and connections, and an outside accountant reviews our books every year.

Where things stand today. We have signed letters from six host sites that have offered a private room, power and a staff contact at no cost. A regional health system and a community health center have agreed in principle to take patients and pay a partner fee, and two counties have invited us to apply for rural health funds. Before we begin, we will sign an agreement with each host site, confirm each partner's requirements and have an attorney review our privacy policies.

Problem & Opportunity

Why this program is needed.

Rural residents often live far from doctors, specialists and counselors. Many rural counties have few primary care providers, little or no specialty care and long drives to the nearest hospital. Telehealth, which is care by video or phone, can close part of this distance, and in recent years more doctors, hospitals and insurers have offered it. But telehealth only helps the people who can actually use it.

The gaps we see:
1. No reliable internet. Large parts of rural Missouri still have slow or no broadband, or service that is too expensive. A video visit needs a steady connection, and a weak one means a dropped call at the worst time.
2. No device or no camera. Some people have only a basic phone, or share one device in a household. Others have a smartphone with a small data plan that runs out.
3. No private place. Many people live in crowded homes, in a car or with family members who do not know about the visit. A sensitive conversation, such as one about mental health, family planning or a new diagnosis, needs privacy.
4. Digital confidence. Older adults and people who have not used much technology may be afraid to try, or give up when a link does not work. A patient who cannot join a call is marked as a no-show.
5. The system is hard to navigate. Patient portals, apps, passwords and forms are confusing, and the rules differ among providers.
6. Specialists are far away. A person who needs a cardiologist, a psychiatrist or a diabetes specialist may face a drive of two hours each way, a day of lost work and gas money. Telehealth could mean no drive at all.
7. Rules and payment change. Telehealth coverage and payment rules have changed several times in recent years and differ among Medicare, Medicaid and private insurers. Providers need a safe, reliable way to reach patients, and patients need help understanding what is covered.

How we know people want this. At the library that began this effort, about 300 video visits were supported in two years, almost always for people who said they would otherwise have skipped the visit. Staff at four other libraries and two churches told us they get similar requests every week.

How we will show the need. Before we submit this proposal, we will add the share of our counties' households without broadband from the Federal Communications Commission's National Broadband Map, the number of primary care providers, mental health providers and specialists per resident from the County Health Rankings and the Missouri Department of Health and Senior Services, the average drive time to the nearest hospital, the share of residents who are 65 and older, and the number of people who asked our host sites for help with a video visit.

Who benefits first. Residents of our rural counties who have no reliable home internet, no private place for a call or little experience with video, including older adults, people with chronic conditions, people who need mental health care, veterans, families without transportation and people who work during clinic hours.

Products & Services

What the grant will pay for and what we will do.

1. Open six telehealth access points. We work with six trusted local hosts, such as public libraries, churches and community centers, to set up a private room. Each room has a computer, HD camera and headset, a privacy screen, a white noise machine to keep conversations from being overheard, a door or partition for privacy, and basic health check devices that a partner clinician may ask a patient to use. Each room is on a reliable business-grade internet connection.

2. Staff each site with a Telehealth Navigator. In Year 1, two Telehealth Navigators are each responsible for three sites and are on site two days a week at each. On other days, a trained host staff member can open the room and help a patient check in, and a Navigator is available by phone.

3. Help people before, during and after the visit.
- Before: schedule the visit with the provider, make sure the patient knows what to bring (such as a medication list), test the equipment and connection, and help with forms and the patient portal.
- During: get the patient into the private room, join the call and then leave. A navigator does not stay in the room unless the patient asks. A patient may bring a family member or an interpreter.
- After: help the patient make a follow-up appointment, get a prescription to a pharmacy, schedule labs and understand the instructions.

4. Run a loaner tablet and hotspot program. A pool of 40 tablets with a case and a mobile hotspot, loaned for a visit or a period of weeks to people who need to take part from home or whose home internet is not enough. Each device is set up by the Technology Coordinator, locked to approved apps and cleaned and reset after each use. The program pays for data plans and replacement.

5. Teach digital skills. Free, small-group sessions on using video calls, patient portals and online prescriptions, held at host sites in the evening and on weekends. About 60 sessions a year reach about 500 people.

6. Work with provider partners. A regional health system, a community health center, a behavioral health clinic and specialist groups agree to see patients at our access points. Each partner is responsible for its own clinical care, privacy and billing. We help partners understand the setup and confirm what applies.

7. Provide technical support. A help line, remote support and a stock of spare headsets, cameras and cables, so a broken piece is replaced quickly.

How we will measure results. For every visit we record, without health details, the site, the date, the type of visit (such as primary care, behavioral health or specialist), whether the visit was completed and whether the patient says they would otherwise have traveled or skipped the visit. We track how long people wait, how many visits are lost to technology problems, how many loaner devices are in use, how many people complete a digital skills session and how patients rate the experience. With the patient's permission, partners tell us whether the patient kept follow-up care.

Our Year 1 goals:
- Six access points open and about 700 different people helped.
- About 1,800 telehealth visits supported.
- At least 95% of scheduled visits completed without a technology failure.
- At least 70% of patients say they would have traveled more than an hour, skipped or delayed the visit without our help.
- About 40 loaner devices in regular use.
- About 500 people complete a digital skills session.
- At least 90% of patients say their privacy was respected.
These are goals, and we will report our real results to the Fund, including where we fall short. We do not promise any health outcome, because the care itself belongs to the patient's clinicians.

Market Analysis

Who we serve and how many.

The people. Residents of our rural counties who need health care and cannot easily reach it in person or online. We welcome every person, whether or not they have insurance. We reach out especially to older adults, people with chronic conditions, people who need mental health or substance use care, veterans, families without transportation, shift and farm workers, and people who live in places with weak internet.

Where we work. Six host sites in four rural counties in Year 1, chosen because they are trusted, in or near the center of a town, open at useful hours and willing to share a private room. We grow to eight sites in Year 2, ten in Year 3 and twelve in Year 4.

How many we will reach:
- Year 1: six sites, about 700 different people and about 1,800 telehealth visits, about 40 loaner devices and about 500 people in digital skills sessions.
- Year 2: eight sites, about 1,000 people and about 2,800 visits.
- Year 3: ten sites, about 1,350 people and about 3,800 visits, with a third Telehealth Navigator.
- Year 4: twelve sites, about 1,600 people and about 4,500 visits.
- Year 5: twelve sites, about 1,700 people and about 4,800 visits.
Over five years we expect to support about 17,700 telehealth visits. Many people use the access points more than once, so we count visits and different people separately.

Who else benefits:
- Providers and health systems. They see more patients who keep their appointments, and they can reach people they could not before.
- Employers and families. A visit that takes 40 minutes in town instead of a half day on the road saves time and wages.
- Host sites. Libraries and churches strengthen their role as trusted community centers.
- Local pharmacies and clinics. They gain patients who follow up on care.
- Counties. Healthier residents and fewer missed appointments and avoidable emergency visits, though we do not promise this.

How we will size the need before we submit. We will add the number of households without broadband in each county, the population, the share age 65 and older, the number of providers per resident and the drive time to the nearest hospital and specialist, and the number of visits our host sites already support informally. These come from the FCC National Broadband Map, the U.S. Census Bureau, the Missouri Department of Health and Senior Services and the County Health Rankings.

Competitive Landscape

Other options people have, and how we fit.

- Telehealth from home. This works for people who have a strong connection, a device and a private space. We serve the people for whom it does not, and we help many of them eventually use it from home through the loaner program and digital skills sessions.
- Clinic-based telehealth rooms. Some hospitals and health centers have telehealth rooms in their own buildings. Those are useful but are usually in the same towns that already have clinics, and are open only during clinic hours. We go to trusted places in smaller towns and are open on evenings and weekends in later years.
- Libraries and community centers on their own. Many librarians help patients informally. They are not set up for privacy, are not trained in telehealth, and are stretched. We provide the room, the equipment and the trained help.
- Pharmacy and retail clinics. Convenient in larger towns. In small towns they may not exist.
- Mobile clinics. Mobile clinics bring in-person care to a town and are valuable. We work with them and share schedules, and our access points can extend care between visits.
- Broadband and digital inclusion programs. State and local efforts expand internet access, and federal programs such as Lifeline offer discounts for qualifying households. Programs change, so our Navigators check what is available and help people apply. Our focus is making health care usable, not building the network.

The gap we fill. In our service area, no other program puts private telehealth rooms, equipment, reliable internet and trained human help in the trusted local places where rural residents already go.

Our partners:
- A regional health system and a community health center, which provide primary care and specialty visits.
- A behavioral health clinic, which provides counseling and psychiatry by video.
- Six host sites: four public libraries, a church and a community center.
- Two county governments and a regional rural health network, which provide planning and funding support.
- A rural broadband provider, which provides discounted service to host sites.
- The University of Missouri Extension, which helps with digital skills sessions in later years.

Marketing & Sales Strategy

How people will find us and how we keep them engaged.

Reaching people who need us:
- Provider referrals. Doctors, nurses and schedulers at partner clinics tell patients who live far away or miss appointments that they can use an Open Line access point.
- Host sites. Librarians and church staff tell patrons and members, and display signs and flyers.
- Navigators. Our Navigators visit senior centers, food pantries, farm and equipment stores and health fairs to talk with people one on one.
- County and community channels, including county health departments, extension offices, local radio, newspapers and church bulletins.
- A simple website and a toll-free phone number with clear information and an easy way to book a visit.
- Veterans service offices, home health agencies and schools share information with the people they serve.

Making it easy to say yes:
- No appointment with us is needed to come in, and a person can call or walk in to schedule a visit with a provider.
- Using the access point is free. We do not charge patients, and we do not bill their insurance. Providers bill for their own care.
- People can bring a family member, a friend or an interpreter.
- We explain privacy in plain words: the room is private, the Navigator waits outside, and we never see or keep health records.

Keeping people engaged:
- The same Navigator works with the same sites, so people see familiar faces.
- Reminder calls or texts, with permission, before a visit, with no health details in the message.
- Digital skills sessions help people become more independent over time.
- We ask patients for feedback after visits and use it to improve.

Reaching supporters. Health systems, clinics, counties and local businesses are invited to sponsor an access point or the loaner program. We share results twice a year with funders and partners, as totals.

Outreach budget. Training, outreach and evaluation together are about $9,000 a year in Year 1, growing about 4% a year. Site signs, brochures and the website are paid for once from startup money ($3,500).

Operations Plan

How the program will be carried out.

Timeline for Year 1:
- Months 1 to 3: Sign host site agreements and provider partner agreements, hire two Telehealth Navigators and a Technology Coordinator, order and test the equipment, upgrade internet service at the sites, build the privacy partitions, and have an attorney review our privacy policies.
- Month 4: Train Navigators and host staff on equipment, privacy, emergency plans and how to help people with disabilities. Practice visits with partner providers at each site.
- Months 5 to 8: Open the six access points and begin the loaner device program. First digital skills sessions.
- Months 9 to 12: Add evening sessions at sites with demand. Review each site's use, patient feedback and technical problems. Report to funders and plan for Year 2.

Space. Each host site provides a private room at no cost under a written agreement. We pay a small host stipend for utilities and for staff time to open and close the room, about $12,000 a year in Year 1 across six sites. We build a privacy partition, a solid door or sound panels where needed, one-time costs of $12,000 across the six rooms.

Equipment. We buy about $46,000 of equipment once at the start: six telehealth stations with a computer, HD camera, headset, privacy screen and white noise machine ($18,000), basic health check devices for each station ($4,200), forty loaner tablets with cases and mobile hotspots ($19,800) and a portable training kit with laptops, a projector and a Wi-Fi tester ($4,000). After Year 1, we set aside about $6,000 to $10,000 a year to add sites and replace equipment. Each station's equipment is cleaned after every patient, and tablets are reset between loans.

Internet. We contract for reliable business-grade internet at each access point, about $18,000 a year in Year 1 for six sites. Where fiber or cable is not available, we use a fixed wireless or satellite connection tested in advance, with a backup hotspot. We check each site's connection speed before we open, and we use the FCC's National Broadband Map and local providers to plan.

Technology and support. A telehealth platform and technical support, which provides scheduling support, secure video for sites that do not already use a partner's platform and remote help, about $14,000 a year in Year 1. Most visits use the provider's own secure platform, and we make sure our equipment works with it.

Staffing. In Year 1: an Executive Director, two Telehealth Navigators, a Technology Coordinator and a part-time Program Coordinator. A third Telehealth Navigator joins in Year 3 as we grow to ten sites.

Privacy. We are not a health care provider, and we do not see, store or share patients' health records. Navigators wait outside the room during a visit unless the patient asks them to stay. We collect only what we need to schedule and support a visit, and we report results to funders as totals. Each provider partner is responsible for its own clinical privacy under HIPAA, the federal health privacy law. Whether any of our activities make us a business associate of a provider is something an attorney reviews, and we sign any agreement required. Computers are locked down, browsers are cleared after each use, nothing is saved on the machine, and loaner tablets are reset to factory settings after each loan.

Emergency plan. Telehealth is not for emergencies. Every room has a posted plan with the site's street address and the 911 number. Navigators and host staff are trained to call 911 if a patient has an emergency, to stay with the patient and to give the dispatcher the exact address. If a patient in a behavioral health visit is in crisis, the provider follows its own safety plan and staff can offer the 988 Suicide and Crisis Lifeline.

Rules and coverage. Telehealth rules, Medicare, Medicaid and private insurance coverage, and the rules about where a patient may be during a visit differ and have changed several times. We do not give billing or coverage advice. Each partner confirms what applies to its own patients, and we update our guidance each year. We confirm with each provider that our room setup meets its needs before opening.

Accessibility. Rooms are at ground level or have an accessible route, with a desk that works for a wheelchair, large-print instructions and a headset with volume control. We offer interpreters through our partners.

Insurance and cybersecurity. We carry general liability, property, cyber liability and workers' compensation insurance, and equipment coverage. Insurance and cybersecurity are about $8,000 a year in Year 1.

Records and reporting. Grant money is tracked separately so we can show each funder how their money was spent, and an outside accountant reviews our books every year.

Management & Organization

Who leads the organization.

Dale Peterson, Executive Director. Dale leads the organization, raises money, manages grants and partnerships with host sites and providers, supervises staff and reports to the board. He worked 10 years as a rural hospital information technology manager and 5 years running a county library system before founding Open Line. Planned salary: $60,000 a year.

Telehealth Navigator. Helps patients schedule, connect to and follow up after a visit, teaches digital skills, and is the face of the program at host sites. This role requires experience in health care support, library or community work and comfort with technology, and a background check. Two in Years 1 and 2 and three from Year 3, at a planned salary of $44,000 each. The Heartland Rural Health Fund grant would support the first Telehealth Navigator.

Technology Coordinator. Sets up and maintains the equipment and internet connections, runs the loaner program, provides remote support and manages security. Planned salary: $48,000 a year.

Program Coordinator (part-time). Handles scheduling, host site communications, data, supplies and loaner device records, about 25 hours a week. Planned pay: $22,000 a year.

Pay figures include payroll taxes and workers' compensation insurance.

Staff in each year: 5 paid staff in Years 1 and 2, and 6 from Year 3 on.

Volunteers. About 20 trained volunteers in Year 1, including retired nurses, librarians and technology teachers who help with digital skills sessions and greeting. Volunteers do not handle health information.

The board. A seven-member volunteer board approves the budget, reviews results twice a year and helps raise money. Board members serve three-year terms. The board's certified public accountant chairs the finance committee. The board's physician and hospital telehealth director advise on clinical partnerships and privacy.

People who help us. An outside accountant who reviews our books every year, an attorney who reviews our host agreements, provider agreements and privacy policies, an insurance agent who understands technology risk, a cybersecurity consultant, and an advisory group of patients, librarians and clinicians who meet each semester to tell us what is working.

Training. All staff and volunteers complete training in privacy, emergency response, accessibility and cultural humility before starting, and Navigators receive training from each provider partner on its telehealth process.

Money management. Grant money is tracked separately for each funder. The Executive Director and a board member must both approve any payment over $2,500.

Milestones Narrative

Our goals for each year and how we will measure them.

- Year 1: Open six telehealth access points and begin the loaner program, helping about 700 people with about 1,800 visits. Complete provider and host agreements. A balanced budget of about $325,000, with a small surplus of about $12,800. 5 paid staff.
- Year 2: Grow to eight sites, helping about 1,000 people with about 2,800 visits, and add evening hours at the busiest sites. A balanced budget of about $328,500, with a small surplus of about $11,500. 5 paid staff.
- Year 3: Grow to ten sites and add a third Telehealth Navigator, helping about 1,350 people with about 3,800 visits. A balanced budget of about $377,000, with a small surplus of about $10,300. 6 paid staff.
- Year 4: Grow to twelve sites, helping about 1,600 people with about 4,500 visits. A balanced budget of about $381,000, with a small surplus of about $9,200. 6 paid staff.
- Year 5: Hold at twelve sites, helping about 1,700 people with about 4,800 visits, with provider partner fees and county contracts covering about 42% of our budget. A balanced budget of about $385,500, with a small surplus of about $8,000. 6 paid staff.

What we measure:
- Access points open and hours they are used.
- People helped and visits supported, by type of visit.
- Visits completed, and visits lost to technology problems.
- Patient reports of distance saved and whether they would have skipped the visit.
- Loaner devices in use and returned, and digital skills sessions completed.
- Patient satisfaction and whether patients felt their privacy was respected.
- Provider partner satisfaction and the share of patients who kept follow-up care, with permission.

How we review results. The Technology Coordinator reviews equipment and connection problems every week. Each quarter, staff review each site's use, patient feedback and safety reports, and change schedules or sites. Twice a year, the board reviews results and we share them with funders and partners as totals. Every number in this plan is a goal, and we will report what really happens.

Funding Request

What we are asking for, and how the money will be used. Our request: $86,000 from the Heartland Rural Health Fund for one Telehealth Navigator, our telehealth platform and technical support, broadband service at the access points and the loaner tablet and hotspot program, for July 2027 through June 2028.

The request is spread across these budget lines:
- Personnel: Telehealth Navigator salary, $44,000.
- Contractual: Telehealth platform and technical support, $14,000.
- Other: Broadband and internet service at the access points, $18,000.
- Other: Loaner tablet and hotspot program (data plans and replacements), $10,000.

Other money in the program. Other grants, provider partner fees, county contracts and local donors pay the rest of the budget, including the Executive Director's salary ($60,000), the second Telehealth Navigator ($44,000), the Technology Coordinator ($48,000), the part-time Program Coordinator ($22,000), host site stipends and utilities ($12,000), training, outreach and evaluation ($9,000), insurance and cybersecurity ($8,000) and administration and accounting ($14,000).

Year 1 budget: about $325,000, planned to balance with a small surplus (about $12,800 after the yearly wear on equipment). Year 1 money coming in: grants $229,000 (this request plus other grants we are applying for), health system and provider partner fees $36,000 (six sites at $6,000 each), county and regional rural health contracts $40,000 and donations and local sponsors $20,000. Year 1 costs: Executive Director $60,000; two Telehealth Navigators $88,000; Technology Coordinator $48,000; Program Coordinator $22,000; broadband and internet service about $18,000; telehealth platform and technical support about $14,000; loaner tablet and hotspot program about $10,000; host site stipends and utilities about $12,000; training, outreach and evaluation about $9,000; insurance and cybersecurity about $8,000; administration and accounting about $14,000; and about $15,200 a year for the wear on equipment, which we set aside so we can replace it.

About partner fees. A health system or clinic pays a yearly fee for each access point that serves its patients, because the access point helps them reach people who otherwise miss care. We plan $6,000 per site in Year 1, growing to $7,500 per site by Year 5. These fees are for our room, equipment and navigation help, not for any patient care or referral, and we never accept payment based on the number of patients sent or the services they receive. An attorney reviews every partner agreement to make sure it follows the federal rules on payments between health care organizations.

One-time startup costs. Startup costs of $73,500 are paid once from startup money, not from the yearly budget: $46,000 of equipment (six telehealth stations, health check devices, forty loaner tablets and hotspots, and a portable training kit), $12,000 for privacy partitions, doors and sound panels, $2,500 for spare cables, headsets and webcams, $5,000 for an attorney's review of host and provider agreements and privacy policies and for accounting setup, $3,500 for site signs, brochures and a website, and $4,500 for background checks, a cybersecurity setup and the first insurance payment.

How we got our startup number. The Funding Need Calculator in this plan adds the startup costs ($73,500) and a cash cushion of about $75,800, which is about three months of Year 1 costs. That comes to $149,500. We start with $30,000 of our own savings and $125,000 in startup support from a regional health system, a rural health foundation and our board, $155,000 in all, which covers that amount.

The next five years. Our budget grows from about $325,000 in Year 1 to about $385,500 in Year 5. Grants are planned at $229,000, $200,500, $215,000, $189,000 and $175,500 in Years 1 to 5. Provider partner fees grow from $36,000 to $90,000 as we grow from six to twelve sites. County and regional contracts grow from $40,000 to $70,000, and donations and local sponsors grow from $20,000 to $50,000. We add a third Telehealth Navigator in Year 3. Grants fall from about 70% of our income in Year 1 to about 46% in Year 5.

Savings. We plan to keep several months of costs in savings. The lowest year-end balance in the plan is about $114,800, at the end of Year 1. Some payments arrive after we bill, so we plan for about $16,250 owed to us at the end of Year 1.

After the grant. Our plan is for provider partners and counties to pay a growing share, because the access points help them reach patients and residents they cannot reach otherwise, and for local businesses and donors to sponsor sites. We will also apply to state and federal rural health and digital inclusion programs. Because the access points use the room and equipment again and again, our cost per visit goes down as use grows.

Risks and how we will handle them:
- Internet at a site is unreliable. We test connections before opening, use a backup hotspot and have a plan to move a site if needed.
- Telehealth rules or payment change. Our partners confirm what applies to their care, and our model does not depend on any one payer's rules.
- A privacy problem. Rooms are private, nothing is stored, staff are trained and an attorney reviews our policies.
- Equipment is lost, damaged or stolen. Equipment is locked, insured and logged, and loaner devices are tracked and reset.
- A host site leaves. Each host signs a written agreement, and we keep a waiting list of other sites.
- A grant or a partner fee ends. We keep savings, diversify partners and grow donors each year.

If you are just starting. A new organization can begin before it has its own 501(c)(3) status through a fiscal sponsor: an established nonprofit that receives grants for you and passes them to your program, usually for a fee (commonly around 5% to 10% of the grant, sometimes more; ask before you agree). Another way is to start smaller: one private room at one library with a donated computer, a headset, a partner clinic and a trained volunteer, tracked carefully. Strong results from a small start make larger grants easier to win.

Appendix Notes

Documents to attach with this proposal:

- Your IRS 501(c)(3) determination letter, or your fiscal sponsor agreement.
- Your most recent financial statements and your current year budget.
- A list of your board members and what each one does.
- Resumes for your Executive Director and Technology Coordinator.
- Signed agreements or letters from each host site.
- Letters of commitment or agreements from provider partners (a health system, a community health center and a behavioral health clinic).
- Letters from the counties about rural health funds, or proof you have applied.
- Internet speed tests and quotes for each site, and a quote for the equipment.
- Your privacy policy, emergency plan, equipment cleaning policy and loaner device agreement.
- Proof of liability and cyber insurance, or quotes.
If you don't have any of this yet, no worries - let's continue.

The assumptions behind our numbers (change them in the Financials section to match your own):
- Grant Revenue: $229,000 in Year 1, then $200,500, $215,000, $189,000 and $175,500.
- Health System and Provider Partner Fees: $6,000 per site in Year 1 (six sites, $36,000), then $52,000 (eight sites), $70,000 (ten sites), $84,000 and $90,000 (twelve sites).
- County and Regional Rural Health Contracts: $40,000 in Year 1, growing to $70,000.
- Donations and Local Sponsors: $20,000 in Year 1, growing to $50,000.
- Pay (a full year, per person, including payroll taxes and workers' compensation): Executive Director $60,000, Telehealth Navigator $44,000 (two in Years 1 and 2, three from Year 3), Technology Coordinator $48,000, Program Coordinator (part-time) $22,000.
- Other yearly costs in Year 1: Broadband and Internet Service $18,000, Telehealth Platform and Technical Support $14,000, Loaner Tablet and Hotspot Program $10,000, Host Site Stipends and Utilities $12,000, Training, Outreach and Evaluation $9,000, Insurance and Cybersecurity $8,000, Administration and Accounting $14,000. These grow between 4% and 5% a year.
- Equipment: $46,000 at the start, then $6,000 to $10,000 a year to add sites and replace equipment.
- Startup costs: $73,500, paid once from $155,000 in startup money.
- About 5% of each year's income is still owed to us at year end.
- Tax: none, as a nonprofit.
- Every dollar amount is an estimate. Replace them with your own quotes and real budget.

Startup Costs