Rural Health Transformation Program: Themes Emerging From Stakeholder Input

Rebecca Lopez, Heather Howard and Jamila McLean, State Health and Value Strategies

With rural healthcare in distress and looming cuts from H.R.1, there has been intense state interest in the $50 billion Rural Health Transformation Program (RHTP). Created by Congress to address concerns stemming from the deep funding cuts in H.R.1 and administered by the Centers for Medicare and Medicaid Services (CMS), the program will distribute $10 billion annually from 2026 through 2030; 50% of those payments will be distributed equally across states with an approved Rural Health Transformation Plan, while the remaining half will be distributed to states at the discretion of CMS, according to factors detailed in the funding announcement. The statute and funding announcement set up tight timelines, with state applications due November 5 and CMS required by statute to make awards by the end of the calendar year.

States are working quickly to create the Rural Health Transformation Plans that are a requirement of the application for funding. To inform their plans, most states have solicited public input via surveys and requests for information (RFIs) and taken other actions, such as hosting community listening sessions. State Health and Value Strategies (SHVS) has been tracking state action to prepare to apply for the RHTP, including efforts to educate the public and gather stakeholder input. SHVS also published an expert perspective detailing key considerations for states as they design their transformation plans and apply for the fund, including engaging rural stakeholders around shared principles.

Several states have already begun reporting themes from their efforts to engage stakeholders, including Alaska, California, Georgia, North Dakota, and Washington:

• To help guide its application for the RHTP, the Alaska Department of Health (DOH) asked for public input via an RFI. DOH published a detailed summary of the 159 RFI responses submitted by 160 external stakeholders.
• More than 350 stakeholders participated in the California Health and Human Services Agency (CalHHS) RHTP survey and CalHHS summarized some of the proposed initiatives. 
• The Georgia Department of Community Health (DCH) also sought public input to shape its RHTP application and posted a spreadsheet of the 169 submissions it received.
• North Dakota Health and Human Services (HHS) posted a slide deck containing a summary of results from its public survey, and connected survey themes that the state identified with sample initiatives. 
• Finally, the Washington State Health Care Authority (HCA) shared that they received 285 written responses to their request for information regarding the RHTP and published a bulleted list of common themes.

This expert perspective summarizes the key themes that have emerged across these five states during their stakeholder processes, as identified by the states. Many of these align with the priorities established by CMS in its strategic goals for the program and the Notice of Funding Opportunity, which go beyond the core statutory provisions in H.R.1.

Modernizing Care Delivery

Across all five states, public input called for initiatives to modernize care delivery, whether through payment reform or expanding the location and model of delivery. The largest category of responses Alaska DOH received (27%) was “care delivery and integration” and included recommendations such as expansion of mobile crisis services, pilot projects to support access to behavioral health services in schools, and the creation of a model of care for integrating Indigenous Traditional Healing in Alaska Native village clinics. One of California’s proposed initiatives is a “transformative care model” that would create primary and maternal care collaboratives to drive long-term, sustainable improvements in healthcare delivery. 

In Georgia, “supporting innovative models of care” was a common category, with 64 of 169 responses. Proposals within this category included suggestions such as: funding for statewide implementation of medically necessary home modification services; and community-embedded and alternative care delivery models, such as community-based teams, mobile clinics, and partnerships with community-health workers and Marketplace Navigators. 

Two of the themes identified by North Dakota in its analysis of survey responses were “make North Dakota healthy again” and “bring high-quality healthcare closer to home.” The former included proposed initiatives such as creating a Medicaid value based purchasing program for critical access hospitals and embedding nutrition into training, workflow, and treatment plans for the North Dakota healthcare workforce. The latter included proposals such as expanding mobile clinics for delivering primary care, specialist care, and dental care. Themes related to modernizing care delivery also emerged in Washington, such as payment reform and school-based care. 

Leveraging Data and Technology

Leveraging data and technology to improve interoperability and virtual access was another consistent focus, with proposals centered on modernizing electronic health records (EHRs), creating closed-loop referral systems, and expanding the use of telehealth infrastructure. For example, 22% of the responses Alaska received were related to “data and technology,” including proposed investments in telemedicine, remote patient monitoring, equipping providers with data analytic and artificial intelligence (AI)-enabled tools to improve diagnostic capabilities and coordination across providers, and upgrading electronic medical records and health information technology capabilities. California’s proposed initiatives to improve “technology and tools” similarly included telehealth, remote monitoring, and electronic medical records as well as improved data exchange. In Georgia, 90 of the 169 responses received related to “promoting technology driven solutions,” including telehealth and virtual specialty care, remote patient monitoring, leveraging AI, and upgrading EHRs as well as analytics. North Dakota highlighted “connect tech and data for a stronger ND” as an emergent theme, including calls to modernize the state’s healthcare data environment, promote data interoperability, and harness AI. Washington listed technology, data and EHR infrastructure, and telehealth among the emergent themes in its stakeholder process. 

Investing in Workforce Development

Investing in the rural workforce also emerged as a major theme across all states, with specific attention to maternal and behavioral healthcare. In Alaska, 20% of the responses proposed recruitment, training and retention strategies. Ideas included developing multi-sector coalitions to assess workforce needs and coordinate recruitment efforts, leveraging technology-enabled platforms to expand training, certification, and continuing education opportunities, and implementing loan repayment or forgiveness programs* and housing supports for healthcare workers. 

Respondents to Georgia’s survey proposed activities including expanding mobile healthcare teams, training for traditional midwives and doulas, and developing telehealth training for care teams. Of the 169 respondents, 70 focused on payments to healthcare providers, 71 on technology based training, and 94 on clinical workforce recruitment. Strengthening and stabilizing the rural health workforce was the most popular priority area identified in North Dakota. Key survey themes included expanding healthcare training pipelines, and using technology to extend the reach of rural providers. Respondents proposed initiatives such as expanding residency training and loan repayment opportunities*, providing specialized training in areas such as obstetrics and behavioral health for primary care workers, and equipping health facilities with remote monitoring and smart technology to reduce reliance on physical staff. 

Finally, Washington and California both identified workforce development as one of the themes in their survey responses. In California, stakeholders identified key target workforces including midwives, doulas, and allied health professionals as well as potential levers such as high school and community college pipeline programs, and behavioral health training.        

Financial Stability and Long-Term Sustainability

In Alaska, some responses in the “other” category (10%) related to sustainability, such as a call to implement sustainable payment models for pharmacist services. According to Alaska’s analysis, 32% of the proposed projects that emerged through public input can be categorized into CMS’ strategic goal of sustainable access—these responses included “projects that help rural providers become long-term access points for care by improving efficiency and sustainability.”

California also highlighted that there was an emphasis on “sustainable improvements in health care delivery” within the proposed initiatives to create a transformative care model. In Georgia, 85 of the 169 survey responses were categorized as “other ideas to promote sustainable access” and included proposals to enhance care coordination to ensure high quality care while lowering costs, and to support community health worker training to promote sustainable access to rural health.

Within the category of “bring high quality health care closer to home,” North Dakota highlighted responses focused on sustaining revenue, such as a call for technical assistance to providers to diversify their revenue streams, and incentive grants for existing providers to expand into more home and community-based care. In Washington, responses emphasized the need for payment reform. 

Prioritizing Population Health

Across states, proposals focused on specific populations, such as individuals and communities affected by mental health and substance-use conditions; older adults and individuals with physical, intellectual, or developmental disabilities requiring long-term services and supports; individuals with complex medical, behavioral, and social needs; and maternal health. In Alaska, 20% of proposals related to behavioral health, with proposed projects aimed at developing an “integrated behavioral health and substance use disorder access plan.” Another 9% of proposals related to long-term services and supports, including care for individuals with physical, intellectual or developmental disabilities, and elder care. 4% of proposals focused on complex care (e.g., developing specialized shelters for individuals experiencing homelessness who are elderly or have complex medical needs) and another 2% related to maternal health (e.g., implementing postpartum home visits using nurses and peer counselors). Maternal health was also a priority in California, with proposed initiatives to establish a Maternity & Primary Care Model and enhance the midwife and doula workforce. 

In Georgia, 57 of 169 survey responses focused on supporting access to opioid and substance-use disorder treatment, and within those, a number of responses called for increased mental health services as well as safe and stable housing for homeless individuals. North Dakota highlighted proposals to develop a care coordination program for patients with chronic disease or behavioral health conditions. And within the category of “connect tech and data for a stronger ND,” proposals called for increased engagement of non-traditional partners in the use of health data to support population health. Washington highlighted behavioral health, opioid-use disorder treatment, youth-focused services, special healthcare needs, and maternity and perinatal care among its common themes. 

Which Stakeholders Are Engaging?

In addition to highlighting the themes, Alaska provided an overview of RFI responses by stakeholder type, noting that 36% of individuals/entities were healthcare providers (including Tribal health providers), followed by health technology vendors (15%), health consulting firms (15%), and patient advocates (11%).

California also provided an overview of the stakeholders who participated in its survey—57% were healthcare providers, and the 43% who were non-providers included county governments or departments, city or local governments, academic centers, community-based organizations, and health plans. Washington published a list of the wide range of groups that responded to its survey, including rural hospitals and districts, nonprofit organizations, state agencies, interested individuals, and more. 

Next Steps

In addition to the states reporting on their stakeholder engagement efforts, several states (Colorado, Mississippi and New Mexico) have announced that they are engaging consultants to help them prepare their applications. 

In an important effort for transparency, Alaska shared a draft of six broad initiatives that will form the backbone of the state’s RHTP application, which were informed by the RFI responses. Washington posted a chart (under “key priorities for RHTP funding” on its RHTP webpage) detailing the priority initiatives for its RHTP application, as informed by public input. Washington also hosted a webinar to provide a broad overview of its draft application and, in a webinar Q&A document, committed to sharing its application materials publicly on its RHTP webpage.

Engaging with stakeholders in deliberate, inclusive ways is critical to building trust and developing plans that have the potential to meaningfully transform rural health. Indeed, in the funding announcement, CMS makes clear that it expects “robust stakeholder processes.” Notably, the funding announcement requires states to describe in their RHTPs “how [they] have involved and will involve rural stakeholders when planning and carrying out this program.” Further, maintaining transparency throughout this process, from stakeholder engagement to application design and implementation, can increase public confidence and foster more effective collaboration between the state and rural communities. 

SHVS will continue to monitor public reporting of state stakeholdering efforts and will update this expert perspective to reflect new developments.

*CMS has clarified in a recent frequently asked question that issuing direct student loans and funding student loan repayment programs are unallowable uses of RHT funds.