Improve Healthcare for Residents in Every Location

Millions of Americans face disability and premature death due to the structure of most rural health systems. Many of these deaths are preventable. At its core, the rural-urban health gap is not simply a clinical challenge. It is an access, coordination, and communication challenge shaped by provider shortages, geographic isolation, and a fragmented care system.¹

The U.S. Centers for Medicare and Medicaid Services (CMS) Rural Health Transformation (RHT) program aims to address these systemic gaps and inequities. Backed by $50 billion over five years, the program is designed to help states build the connected, sustainable care infrastructure rural communities need. The ambition is clear. The hard part is execution.

Rural healthcare in the United States is delivered across a highly distributed network of independent organizations, including hospitals, FQHCs, primary care and specialty clinics, behavioral health services, home health agencies, social service providers, virtual care providers, and remote patient monitoring services. But across rural communities, these participants are too often separated by distance, disconnected technologies, and incompatible systems. The result is a care landscape in which critical information remains fragmented across multiple electronic health record (EHR) platforms, clinical applications, and business systems.

Fragmentation makes it difficult for healthcare professionals to exchange information and coordinate activities across the care continuum and makes it difficult for patients to navigate the care journey. When a patient is discharged from a rural hospital, the receiving primary care provider may not learn about the visit for days, if at all. When a behavioral health provider develops a care plan, they may have no visibility into the patient’s recent medical history or outstanding referrals. When a care manager tries to intervene with a high-risk patient, they may be working from incomplete or outdated information. When care extends across disciplines, teams cannot easily share care plans, track progress, or adjust interventions.

These challenges are compounded by the realities of rural care. Workforce shortages are commonplace. Medical services are limited. And patients often have to travel long distances for specialty care.

The consequences are predictable. Rural residents often don’t receive the timely and adequate care they deserve. In fact, nearly 42,000 deaths in rural America each year are considered potentially preventable, underscoring the impact of delayed or fragmented care.²

For RHT program sponsors, fragmentation is not just a clinical problem; it is a financial problem. CMS distributes a significant share of ongoing RHT funding based on measurable outcomes. Fragmentation limits the ability of leaders to assess and demonstrate performance. States that cannot reliably track care activity, referral completion, care transitions, and population health metrics across their networks will struggle to qualify for ongoing funding.

Addressing fragmentation in rural healthcare requires more than simply enabling data exchange. What’s missing is a shared foundation that brings that information together and supports its consistent use across the care continuum.

Effective coordination depends on a common, trusted view of the patient that reflects activity across settings, along with integrated workflows that allow different participants to act on that information in a coordinated way. When that foundation is in place, the dynamic changes. Care teams can track referrals and follow-up activity without manual effort, manage transitions with greater visibility, and respond to events as they occur rather than with a delay. Providers and insurers can align actions more easily. Patients experience a more connected and frictionless path through the system. And RHT program leaders can more easily measure and demonstrate program performance. Achieving this in practice requires full participation.

For RHT programs to reach their full potential, every organization in the network must be able to take part, regardless of size, technical acumen, or financial means. If an approach only works for large, well-funded institutions, smaller clinics, behavioral health providers, and community organizations are left out. The most effective approaches support a wide array of participants and integrate seamlessly with existing systems and processes.

InterSystems has been a trusted partner to health systems, data exchanges, and government health programs for decades, with deep expertise in health data interoperability, identity management, and clinical workflow integration. InterSystems Regional Health Connections provides the connected data and workflow backbone for rural health transformation programs, enabling states and regional networks to unify data across participants, coordinate care activities, and support the measurement and reporting required for performance-based funding. The solution creates a shared patient record across providers, health plans, and community organizations without requiring participants to replace existing systems.

Contact us to learn how InterSystems can help your organization build the connected foundation needed to support CMS Rural Health Transformation goals.

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This reflects both current capabilities and future roadmap direction.
1 - https://www.cdc.gov/rural-health/php/about/leading-causes-of-death.html
2- In 2022, many deaths in rural America were potentially preventable, including 20,000 from heart disease and stroke, 6,000 from cancer, 10,000 from unintentional injuries, and nearly 6,000 from chronic lower respiratory disease, according to the CDC.