Ask any physician where patient care is most likely to break down, and many will point to the handoff. The shift change, the discharge, or the referral that leaves one office and never arrives at the next. Everyone involved does their job, but the patient still risks falling into the space between.
I think about that space a lot, especially as states move into the second year of the Rural Health Transformation Program (RHTP). State agencies write the plans, manage the subawards, and answer to the Centers for Medicare & Medicaid Services (CMS). Meanwhile, rural hospitals and clinics deliver care and produce the data that shows whether it is working. Both sides are committed, but some of the most consequential work happens in the handoff between them. Without it, the impacts are tangible: a new service line fails to launch, a clinic can’t take on the work, and patients lose out on the care they deserve.
Historically, navigating this handoff has been challenging, especially for rural providers already strapped for resources. However, RHTP’s emphasis on stakeholder engagement gives both sides a path forward, so let’s talk about why the state-provider partnership matters beyond Year 1, where it tends to break down, and how both sides can build a partnership that lasts through 2030 and beyond.
Why RHTP Stakeholder Engagement Matters
So far, most stakeholder engagement involved in the Rural Health Transformation Program has occurred before a single dollar moved. States held listening sessions, opened comment periods, and collected responses to requests for information while completing their applications — all of which helped shape the future of each state’s RHTP plan.
However, these early conversations are only part of the equation. According to RHTP’s Notice of Funding Opportunity (NOFO), each state’s application must include an engagement framework showing how it will keep rural stakeholders involved through implementation. Additionally, states must outline how project governance will reflect the communities they are engaging — including patients and providers — which, in practice, should give providers a seat at the table where decisions are made. From there, some states made these commitments specific. Tennessee’s RHTP application, for example, set targets for stakeholder engagement sessions and promised regular updates through newsletters, public dashboards, and open meetings.
Each year, CMS measures whether states are following through. States submit annual reports on initiative milestones, metrics, and spending — including any engagement targets they set in their applications — and CMS uses these reports to recalculate each state’s technical score and workload funding. Falling short can shrink a state’s share of future RHTP funding, along with the subawards rural providers rely on, which makes a strong state-provider partnership a functional requirement that benefits both sides.
The Structural Gap Between States and Rural Providers
Accountability in RHTP runs downhill. CMS holds states responsible for progress, states hold subrecipients responsible for data, and the reporting burden settles on organizations with the least room to carry it. Without steady collaboration between states and providers, this pattern risks becoming a vicious cycle.
On the provider side, it starts with what we call the capacity chasm: rural providers with the greatest need for support are often the least equipped to get it. Workforce shortages and slim margins leave critical access hospitals, rural health clinics, and community health centers with little administrative bandwidth, so data capture and compliance reporting compete for the same few hours as billing, credentialing, and — most importantly — patient care. With resources stretched thin, sustainable transformation becomes difficult to achieve.
Meanwhile, states face their own obstacles. State agencies must audit, validate, and monitor every subaward, and they pass much of that reporting obligation to subrecipients through subaward agreements. The outcome data CMS cares about lives in provider systems, leaving state teams to depend on submissions they didn’t produce and can’t easily verify. Reviewing results across a full portfolio of subrecipients — without the clinical insight needed to interpret unusual numbers — risks creating a severe administrative bottleneck that slows work and leaves room for error.
Unfortunately, each side’s difficulties make the other’s worse. Rural providers struggle with reporting, poor data weakens the state’s progress case, and the state’s funding comes under pressure, all of which pushes the same rural providers further behind.
Building a Partnership that Works in Both Directions
Breaking this cycle takes deliberate effort from states and providers alike. Both sides control something the other needs, and the strongest RHTP partnerships are built around that exchange.
For state agencies, building a strong partnership with rural providers involves:
Treating providers as co-designers throughout implementation, using standing feedback channels instead of relying solely on one-time comment periods.
Utilizing policy and administrative levers to help reduce barriers, such as drawing on state health data systems where possible.
Designing additional reporting requirements in ways that small providers can meet.
Facilitating collaboration through resources like toolkits, ongoing workshops, and advisory councils.
Endorsing or funding services, like technical assistance (TA) programs, to help providers maintain compliance.
For rural providers, building a strong partnership with state agencies involves:
Participating in state RHTP activities early and often by applying for council and workgroup seats and responding to requests for information and comment periods.
Tracking the state’s funding opportunity calendar, since many states release subaward opportunities in rounds across all five years of the program.
Forming regional partnerships to advocate as a group when one organization can't do so alone.
Leaning on membership organizations like the state’s primary care association, hospital associations, and national organizations (NACHC, NRHA, etc) to vet and endorse trusted partners who can fill gaps related to data, reporting, and/or compliance requirements.
For both sides, it’s also important to build reporting and compliance readiness from the beginning. States can settle metric definitions, data sources, and reporting templates before subawards go out, so providers know what they’ll be asked for and why. For providers, it’s critical to set up tracking and documentation early — including the compliance discipline federal awards require under 2 CFR Part 200 — so they have clean data from the start.
Turning Trust into Transformation
In healthcare, the safest handoffs follow a shared process. Both sides know what information has to change hands, both confirm it arrived, and both own what happens next. The state-provider partnership under RHTP works the same way, and getting it right pays off twice.
During the program lifespan, the first payoff is tangible. More usable data between states and rural providers opens the door for stronger progress reports, while early alignment through feedback channels, councils, and reporting systems can make later years more productive. Plus, each round of subawards can build on lessons from the previous, allowing states to adjust tools and requirements so programs better fit the realities of rural healthcare while funds continue to flow.
The second payoff is harder to measure, but it will also last after the program ends. Relationships and trust built through one initiative make the next collaboration easier to start, and support in one area — such as reporting or workforce development — often opens the door to others. As a result, states with stronger connections to rural providers will better understand what those organizations need, while providers will better understand how to work with their state to get those needs met.
How Arcadius Health Can Help
At Arcadius Health, our work spans both sides of the state-provider partnership. For state agencies, we provide technical assistance services designed to help rural providers increase bandwidth and subject-matter expertise, so they can close the capacity chasm once and for all. For rural providers, we help offload the data collection, compliance, and reporting responsibilities necessary for RHTP, so providers have more time to take care of patients and communities.
Whether you’re just starting your RHTP journey or your organization is already well underway, contact us today to learn how Arcadius Health’s experts can support your journey to make rural health transformation possible.
