.jpg "Daniel Godla")
The Rural Health Transformation (RHT) Program, backed by $50 billion in federal funding, offers US states an opportunity to address healthcare for rural populations. This includes strategically investing in infrastructure and innovative models that deliver measurable, sustainable improvements.
For state health leaders and the Rural Health Clinics (RHCs) they serve, expanding care management and care coordination programs offers significant upside. They directly address the RHT Program’s core goals of efficiency, innovation, and technological advancement.
What are the goals of the Rural Health Transformation Program?
The RHT Program, established under the One Big Beautiful Bill Act, mandates a system-wide transformation. The Centers for Medicare & Medicaid Services (CMS) is looking for state plans that are comprehensive, enduring, and focused on improving access, quality, and outcomes.
To receive funding, state applications must commit to utilizing the funds for at least three of the approved uses or goals, many of which align with care management:
- Make rural America healthy again
- Sustainable access
- Workforce development
- Innovative care
- Tech innovation
How can Rural Health Clinics receive funding?
RHT Program funds are not granted directly to individual Rural Health Clinics (RHCs) or rural hospitals.
The funding is awarded to the State government through a Cooperative Agreement with CMS.
The process involves:
- State application and Transformation Plan (Due Early November 2025): The state submits an application to CMS via a Notice of Funding Opportunity (NOFO). This application must include a detailed Rural Health Transformation Plan. It should outline the specific initiatives the state will fund, the expected outcomes, and the criteria for allocating resources.
- Required stakeholder engagement: The state must certify that its plan was developed in collaboration with rural stakeholders, including the State Office of Rural Health, Medicaid agency, and local providers. This is a point of influence for Rural Health Clinics.
- CMS award and allocation: CMS approves the winning state applications by December 31, 2025. Funding is allocated annually over five years, with a portion distributed based on rural population size and facility needs.
- State-to-provider subawards: Once funds are received, the State distributes them, typically through subawards, subgrants, or subcontracts, to healthcare systems and individual providers like RHCs. The State's original Transformation Plan dictates the process and criteria for these subawards. States must justify to CMS how these payments will either fill a gap in care or change the existing care delivery model.
For states: Developing a technology-driven initiative, such as scaling Chronic Care Management and Remote Patient Monitoring programs across all RHCs and qualifying providers statewide, is a measurable and targeted approach for the Transformation Plan.
For RHCs: RHCs must advocate to be prioritized in the State's plan as recipients of funds for technology, technical assistance, or workforce development tied to care management.
Care Management: How to address RHT goals
At a high-level, CMS care management programs, such as Chronic Care Management (CCM) or Remote Patient Monitoring (RPM), offer patients more direct access to their providers. This includes:
- Monthly telehealth or telephonic conversations to discuss their health
- A personalized care plan that’s regularly reviewed and discussed with their clinician
- Condition and general health education for better chronic disease management
- The use of individual data to inform interventions and lifestyle changes
- Access to behavioral health resources, especially as to how they may relate to certain conditions
How care management aligns with five RHT goals
The following three goals from the RHT Program align to strengths of care management.
Goals are in bold, quoted from CMS.
1. Make rural America healthy again
Goal: “Support rural health innovations and new access points to promote preventative health and address root causes of diseases. Projects will use evidence-based, outcomes-driven interventions to improve disease prevention, chronic disease management, behavioral health, and prenatal care.”
Care Management programs, specifically Chronic Care Management (CCM), Principal Care Management (PCM), and Remote Patient Monitoring (RPM), can offer an essential framework for states to meet this comprehensive goal.
Promoting evidence-based prevention and management
CCM and PCM establish a structured, monthly clinical interaction focused on patients with one or more chronic conditions. This is the definition of a targeted, evidence-based intervention for chronic disease management.
These programs facilitate the creation and tracking of a comprehensive care plan. This can help deliver preventative services and address root causes of poor rural health outcomes.
Creating new access points and addressing behavioral health
Remote Patient Monitoring (RPM) and care management expand the RHC's reach, establishing new access points for patients who face transportation barriers.
This continuous, relationship-based engagement is ideally suited to integrate and screen for behavioral health issues. CMS also supports programs like Behavioral Health Integration (BHI) that can be paired with other programs. This can help enable early intervention and seamless referral within the comprehensive care plan.
Using outcomes-driven interventions
RPM provides objective, real-time data (e.g., blood pressure, blood glucose) that serves as immediate feedback.
Care management software and analytics aggregate this data to measure the success of interventions. This can help allow RHCs to report clinical metrics, demonstrating effectiveness.
2. Sustainable access
Goal: “Help rural providers become long-term access points for care by improving efficiency and sustainability. With RHT Program support, rural facilities work together—or with high-quality regional systems—to share or coordinate operations, technology, primary and specialty care, and emergency services.”
Investing in care management, including Remote Patient Monitoring (RPM), can be an effective way for states to meet this mandate.
Care management, as supported by CMS, can:
Drive financial sustainability through efficiency
RPM and non-visit-based CCM/PCM services allow existing RHC staff (care managers) to engage a larger patient population.
This improves efficiency without requiring new physical infrastructure, creating a scalable, billable revenue stream. This can support the RHC's long-term financial stability. CMS offers multiple CPT codes for each of these programs.
Ensure long-term access and proactive care
RPM provides continuous, real-time data on chronic conditions.
It also facilitates a proactive, personalized relationship between the care manager and the patient. This shift from reactive, episodic treatment to preventive intervention may help reduce costly hospitalizations.
Research demonstrates RPM’s efficacy in rural settings, particularly for diabetes, heart failure, and chronic obstructive pulmonary disease (COPD).
Foster system-wide coordination
Care management technology (software and analytics) serves as a centralized platform for administration. These systems can identify needs and seamlessly coordinate referrals and data sharing with larger regional hospitals and specialty providers.
3. Workforce development
Goal: “Attract and retain a high-skilled health care workforce by strengthening recruitment and retention of healthcare providers in rural communities. Help rural providers practice at the top of their license and develop a broader set of providers to serve a rural community’s needs, such as community health workers, pharmacists, and individuals trained to help patients navigate the healthcare system.”
Care management programs can help RHCs with a sustainable workforce strategy by:
Attracting and retaining talent with technology
Implementing modern RPM and care management technology signals to prospective providers (physicians, Nurse Practitioners, PAs) that the RHC is committed to innovative, high-quality care.
The access to cutting-edge tools and data-driven workflows makes rural practice more attractive to a highly-skilled workforce.
The creation of a predictable, non-visit-based revenue stream from CCM/PCM/RPM also contributes to the RHC's financial stability. This can help ensure staff retention and competitive compensation are sustainable.
Enabling providers to practice at the top of their license
By shifting the routine, labor-intensive tasks of follow-up, patient education, and data collection to care managers and technology, primary care physicians and advanced practitioners are freed to focus on complex diagnoses and clinical decision-making, allowing them to practice
Primary care physicians can practice at the top of their license through care management.
They can help shift routine, labor-intensive tasks, such as follow-up, patient education, and data collection, to care managers and technology. Advanced practitioners can be freed to focus on complex diagnoses and clinical decision-making.
Care management software also consolidates patient data, giving providers comprehensive, longitudinal views that inform better and faster clinical judgments.
Developing a broader, integrated care team
Care management and RPM programs can directly enable the integration and funding of Community Health Workers (CHWs) and pharmacists.
These personnel are essential for delivering the non-face-to-face services (e.g., medication reconciliation, addressing social determinants of health) that form the core of chronic disease management
Digital platforms can help establish an organized, trackable workflow for the entire care team. This can help ensure that all providers are working collaboratively to meet the patient's needs.
4. Innovative care
Goal: “Spark the growth of innovative care models to improve health outcomes, coordinate care, and promote flexible care arrangements. Develop and implement payment mechanisms incentivizing providers or Accountable Care Organizations (ACOs) to reduce health care costs, improve quality of care, and shift care to lower cost settings.”
Chronic Care Management (CCM) or Principal Care Management (PCM) can help US states:
Create structure for innovative care
Care management programs provide the process for care coordination. They are essential for any advanced care model, including Accountable Care Organizations. By managing complex patients' conditions and transitions of care, rural providers can be high-value partners in risk-based payment arrangements.
Promote flexible, lower-cost care
These programs offer flexibility with monthly patient engagement and attention. By focusing on preventative lifestyle change, medication adherence, and proactive management, care is shifted to lower-cost settings (the patient's home or the clinic) and away from the emergency room.
Improve outcomes and add value
Care management helps implement payment mechanisms that incentivize providers to improve quality and reduce overall spending.
5. Tech innovation
Goal: “Foster use of innovative technologies that promote efficient care delivery, data security, and access to digital health tools by rural facilities, providers, and patients. Projects support access to remote care, improve data sharing, strengthen cybersecurity, and invest in emerging technologies.”
A strategic investment in care management software can help states achieve this mandate by:
Enabling and scaling remote/digital care
A dedicated tool or platform is the essential foundation for implementing and scaling these programs. Software solutions can provide a comprehensive, standards-based, and auditable way for delivering the required care to rural patients.
Improving data sharing and security
Effective care management platforms integrate with Electronic Health Records (EHRs) and other systems, streamlining workflows and improving data sharing. It can also support strengthening cybersecurity for sensitive patient data in rural facilities.
Fostering efficiency and emerging technologies
Software centralizes patient data and care plans, providing care managers with a single source of truth to manage complex populations. Through care management, RHCs can use emerging technologies, such as AI, to triage high-risk patients or optimize outreach efforts.
Partnering for growth: How ThoroughCare can help
As an expert software and clinical advisory services provider, ThoroughCare is uniquely positioned to help RHCs and their state partners achieve the goals of the RHT Program.
We offer the technology, tools, and expertise needed to implement and scale effective care management programs.
Technology to drive efficiency and innovation
ThoroughCare's comprehensive platform supports a range of crucial programs, including Chronic Care Management (CCM), Principal Care Management (PCM), and Remote Patient Monitoring (RPM). We provide the digital foundation for a successful rural health transformation.
Our software helps RHCs meet the program's technology goals by:
- Enabling scale: Streamlining patient enrollment, care coordination, and billing while maintaining high-quality care.
- Enhancing patient engagement: Providing care managers with a single, integrated patient view that includes the care plan, call history, and relevant data. Patient education from WebMD Ignite empowers patients and reinforces health goals.
- Delivering insights: Data analytics track key performance indicators, such as billable minutes, successful outreach, and services completed. ThoroughCare can provide a clear picture of both clinical productivity and financial impact.
- Seamless integration: Integrating with multiple third-party EHR systems to enable care managers to access consolidated patient data in one place. This can help ensure efficiency and accuracy.
Real-world success in rural health: 2-G Consulting Healthcare Solutions
The success of 2-G Consulting, a care management service provider serving rural south-central Texas, illustrates the power of this approach. Facing limited clinical resources and rural health barriers, 2-G partnered with ThoroughCare to close the healthcare divide.
By using ThoroughCare, 2-G was able to:
- Double its patient population in one year.
- Achieve an average patient retention of 23.4 months.
- Boost successful patient calls by 36%.
This growth was supported by the platform's streamlined workflows, compliance checks, and the data insights needed for proactive care.
For RHCs, this case study serves as a clear model for how to use RHT funds.
ThoroughCare helps RHCs manage more than 100,000 patients
Another rural telehealth provider we work with has used Remote Patient Monitoring to improve patient engagement and data collection. Data show:
- Among patients enrolled 0–30 days, 71.3% had readings within the normal range
- At 121–150 days, that increased to 81.8%
- At 151–180 days: 90.3%
- At 241+ days: 90.9%
This clearly shows a positive clinical impact over time.
Get insights from our clinical advisory team
In addition to ThoroughCare’s software, our Clinical Advisory Services team can conduct an Opportunity Analysis. This quick assessment can help you analyze, improve, and implement an organization’s care management programs.
Our Opportunity Analysis aligns with the RHT Program's goal of right-sizing care delivery and driving efficiency by focusing on:
- Workflow standardization
- Compliance strengthening
- Operational efficiency
