Optimizing funding in the Rural Health Transformation (RHT) Program

Designing, launching and managing a five-year $1b innovation portfolio justifies a structured, disciplined program management team and governance structure. The scale, pace and performance expectations of RHT create significant delivery risks for state agencies, subrecipients and community partners. Consistently exceeding CMS Checkpoint Model milestone expectations requires detailed initiative-level planning and collaborative operating model design. Further, states unable to obligate Budget Period 1 grant awards by October 30, 2026, and spend those funds on allowable uses by September 30, 2027, will see existing RHT funds reallocated to other states and reductions in future RHT grant awards.

Many states that focused on moving quickly to issue subgrants have subsequently realized an exponential increase in program delivery risks and subrecipient compliance risks. While states still own the risk, the ability to collaboratively plan and proactively engage with subrecipients may be lost. These states are solely reliant on monitoring subrecipients to ensure RHT spending remains aligned with the state’s CMS-approved RHT strategy, initiatives and allowable uses of funds. To proactively manage this risk, several states and large subrecipients are reviewing and refining existing grant compliance processes and providing technical assistance to grant recipients to proactively manage these risks, including training on federal and state grant compliance requirements; proactive grant risk assessments; and development of ongoing compliance monitoring plans, processes and reporting.

Delivering innovation and cross-sector collaboration in communities requires building trust. This goes beyond periodic community listening sessions and stakeholder surveys to gather input and feedback. Instead, we have found it’s more effective to engage cross-sector health ecosystem stakeholders in collaborative working sessions focused on addressing unmet needs across the end-to-end rural constituent persona. These persona-based workshops have encouraged public-private sector collaboration required for implementation. More importantly, these events build trust by helping to overcome siloed behavior and align stakeholders around shared priorities at the intersection of unmet rural health needs and emerging technology possibilities.

Aggregating and integrating data across public health, the private sector and community stakeholders will be increasingly critical to demonstrating the impact and documenting the outcomes for RHT initiatives. In most cases, this will require building new capabilities beyond existing electronic health records (EHRs) and health information exchanges (HIEs) to adequately capture, integrate and analyze structured and unstructured longitudinal data. Further, this will require states to revisit data use agreements with cross-sector ecosystem stakeholders.

RHT emphasizes the sustainability of investment spending — building infrastructure and capabilities supported by long-term value creation — which requires states and their subrecipients to clearly define the business model logic and operating model realities of each RHT initiative. Sustainability requires understanding the clinical, financial and operational value drivers that inform the business case and return on investment (ROI) for each rural health ecosystem stakeholder. By starting with the financial business case for investment, states can identify potential gaps and assumptions that will limit long-term economic viability and sustainability.