Early lessons from Rural Health Transformation
This article explores what Florida, Washington, and Tennessee learned while planning and implementing at the same time.
During the first year of the Centers for Medicare & Medicaid Services Rural Health Transformation Program (RHTP), states faced an unusual challenge: planning and implementation had to happen at the same time.
State leaders engaged stakeholders, designed programs, established governance structures, released funding opportunities, awarded grants, built oversight systems, and began implementation, often under compressed timelines and intense scrutiny.
Experiences from Florida, Washington, and Tennessee point to six early lessons for turning ambitious rural health investments into lasting change:
- Build on existing systems and relationships.
- Make partnerships the foundation for implementation.
- Use transparency to build trust.
- Invest in technical assistance, not just funding.
- Establish evaluation and learning systems early.
- Design for sustainability from the start.
The Year 1 Challenge: Planning and Implementing at the Same Time
Implementation did not follow planning: both occurred simultaneously. States built program offices while developing procurements, hired staff while engaging stakeholders, and established oversight and evaluation systems while releasing funding opportunities and negotiating awards. They also navigated legislative approvals, reporting requirements, and public expectations associated with one of the largest rural health investments in decades.
Lesson 1: Build on existing systems and relationships
New funding can create pressure to establish new structures. States instead drew on institutions, relationships, and planning already in place.
Washington leveraged its Office of Rural Health, community health worker programs, tribal consultation processes, and partnerships between agencies and local communities. Tennessee drew on county health councils, its Rural Center of Excellence, and lessons from earlier rural health investments.
The lesson: Transformation can move faster when states strengthen systems that already have credibility, relationships, and local ownership.
Lesson 2: Make partnerships the foundation for implementation
Rural health challenges cross organizational boundaries. Workforce shortages, transportation barriers, behavioral health needs, provider capacity, and chronic disease outcomes cannot be addressed by a single agency or sector.
Florida used requests for information, community meetings, town halls, and discussions with providers and local organizations to gather input and define priorities and funding strategies. Washington created a governance model spanning state agencies, tribal representatives, healthcare partners, and community stakeholders to foster shared ownership of outcomes. Tennessee used county health councils and existing local planning structures to connect investments directly to community-defined priorities.
The lesson: Partnerships aren't simply a stakeholder engagement activity. They are part of the infrastructure required to implement and sustain change.
Lesson 3: Use transparency to build trust
Large funding opportunities inevitably create both excitement and uncertainty. Providers, communities, and other stakeholders need to understand how decisions will be made and what they can expect from implementation.
Tennessee communicated clearly about timelines, competitive processes, scoring criteria, and funding decisions, an especially important practice when many applicants would not receive funding. Florida used FAQs, webinars, community meetings, stakeholder briefings, and implementation convenings to clarify opportunities and limitations.
The lesson: Clear, consistent communication about funding processes and decisions can help build trust, particularly when not everyone receives funding.
Lesson 4: Invest in technical assistance, not just funding
Funding is necessary but rarely sufficient. Rural hospitals, clinics, community organizations, and other local partners often operate with limited staffing and administrative capacity. Programs therefore need to consider whether recipients have the support required to implement successfully.
Florida put this principle into practice by incorporating technical assistance through regional contract leads, specialized vendors, monitoring, and grants management systems. Washington’s example underscored the need to balance accountability with flexibility and help local organizations work through implementation challenges.
The lesson: Technical assistance is an investment in program success. Strengthening local capacity can improve implementation today and leave communities stronger after funding ends.
Lesson 5: Establish evaluation and learning systems early
All three states consistently emphasized that evaluation should begin before implementation is underway.
Washington’s experience highlighted the value of establishing baseline measures and using evaluation for continuous learning, not only compliance. Florida paired formal performance monitoring with external evaluation and regional collaboratives to capture quantitative results alongside local perspectives. Tennessee is also tracking evaluation metrics while looking to public-private partnerships to sustain and build on what works.
The lesson: Don't wait for long-term health outcomes to learn. Early indicators such as partnership development, program milestones, stakeholder engagement, and infrastructure deployment can show whether implementation is moving in the right direction.
Lesson 6: Design for sustainability from the start
All three state representatives agreed that planning beyond the initial investment should begin in Year 1, not Year 4.
Florida emphasized that funding cycles often move faster than outcomes mature, making early work on financing strategies, policies, and partnerships essential. Washington focused on institutions and systems that could continue after grant funding ended. Tennessee described public-private partnerships, communities of practice, and collaborative networks designed to carry the work forward.
The lesson: Sustainability isn't the final phase of transformation. It's a design principle that should shape decisions from the beginning.
Conclusion: Building the conditions for lasting change
Rural health transformation is not only a question of where states invest. It is also a question of how they build the capacity to implement, learn, adapt, and sustain those investments.
The experiences of Florida, Washington, and Tennessee point to a common principle: lasting transformation is more likely when states build from trusted local systems, share ownership with communities and partners, create capacity alongside funding, and plan for learning and sustainability from the start.