Improving health outcomes requires more than expanding access to medical care. For many individuals, factors such as housing, transportation, food security, and behavioral health services have just as much impact on overall well-being. As rural areas account for more than 60% of all Health Professional Shortage Areas in primary care, dental, and behavioral health, connecting people in these areas to these resources depends on strong coordination between health care providers and community organizations.
The Rural Health Transformation Program (RHTP) provides $50 billion over five years to help states strengthen rural health systems. While funding can support workforce development, technology, and scope-of-practice expansions, many states are taking a broader approach by investing in the infrastructure that connects health and human services. As states begin implementing RHTP, they are using these dollars to strengthen referral networks through Community Care Hubs and other coordinating organizations, highlighting that lasting improvements in rural health require sustainable cross-sector infrastructure.
Investing in Systems: Community Care Hubs
The expansion of Community Care Hubs (CCH) is gaining momentum in Medicaid as they serve as centralized organizations that coordinate networks of community-based organizations, manage referrals, support contracting, and collect reporting data. As states map out how to best implement RHTP, many are recognizing CCHs as the backbone infrastructure needed to build sustainable health and human service referral networks.
States Proposals:
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North Carolina: Selected five organizations to serve as leads for the North Carolina Rural Organizations Orchestrating Transformation for Sustainability (ROOTS) Hub for the state’s Rural Health Transformation Program (NCRHTP).
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Missouri: Proposed establishing a network of 30 organizations to serve as Transformation of Rural Community Health (ToRCH) Care Hub Anchors, making clinical and non-clinical services more seamless for all residents.
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Kentucky: Designed the Rural Community Hubs for Chronic Care Innovation Program to address the prevention and management of chronic conditions with an initial focus on diabetes and obesity.
Building Referral Infrastructure: Improving Care Coordination Networks
Not every state is creating CCHs. Instead, many are using RHTP funding to expand community-based workforce capacity and improve the technology and infrastructure that support health and human service referrals. These investments focus on improving care coordination, modernizing health information technology, and enhancing information sharing across organizations. Together, these efforts can reduce fragmentation and help ensure people have access to the services they need.
State Proposals:
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Illinois: Plans to invest in regional care coordination and health systems navigation by developing a new training and certification program for Community Health Workers and Peer Support Specialists. These workers play a crucial role in bridging gaps in the health and human services system by providing culturally responsive education, advocacy, and care coordination.
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Maryland: Proposed centralizing telehealth technical infrastructure and expanding health information technology (HIT) connectivity via CRISP (Maryland’s state-designated Health Information Exchange) to reduce system fragmentation and securely share patient updates in real time.
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Nebraska: Mapped out a multi-sector regionalized network that embeds Community Health Workers across local agencies and links county, tribal, and veteran Electronic Health Records (EHRs) to build seamless, bi-directional referral loops.
Looking Forward: The Path Towards Sustainable Infrastructure
While RHTP investments vary across states, a common theme is emerging: improving rural health outcomes requires more than funding individual programs. It requires building the infrastructure that allows health care providers, community organizations, and social service systems to work together.
Health and human service referral networks are only effective when organizations have the capacity to communicate, share information, and coordinate care over time. Without this infrastructure, individuals will continue to experience fragmented systems in which accessing a referral does not always result in receiving services. By investing in Community Care Hubs, health information technology, community health workers, and regional coordination efforts, states are designing more sustainable cross-sector referral networks for human and health services.
With RHTP funding available only through 2030, these infrastructure investments are more important than ever. By investing in the systems that support coordination and collaboration, states can create lasting networks that continue improving rural health outcomes long after the program ends.
Written by Jenna Jeon (Class of ’27)
Written by Jenna Jeon (Class of ’27)