shao-chee sim | EHF
The Texas Health and Human Services Commission (HHSC) recently submitted a $1 billion application for the Rural Health Transformation Fund (RHT) at the Center for Medicaid and Medicare Services. The RHT is made available under the passage of the One Big Beautiful Bill Act (OBBBA) earlier this summer and supports innovative efforts that help rural communities strengthen local care systems and improve health by expanding access to services and community-based solutions.
HHSC proposes a sweeping, sustainable strategy called the Rural Texas Strong plan to address persistent health challenges facing rural communities across the state. The plan focuses on chronic disease prevention, technology, workforce, and rural hospital sustainability.
Several of the plan’s priorities closely align with Episcopal Health Foundation’s (EHF) updated Strategic Framework as well as strengthen several legislative wins made during the past two legislative sessions, particularly in the areas of:
- advancing diabetes prevention, food and nutrition security, and maternal health,
- supporting a robust safety-net provider sector that includes rural hospitals and federally qualified health centers,
- and building a robust community health worker (CHW) workforce.
These priorities are well positioned to address the persistent health challenges that rural Texans face. Rural communities across Texas face significant barriers to health care access, which contribute to poor health outcomes. From issues like insufficient primary care to the lack of sustainable hospitals in rural counties, through the alignment of EHF’s strategies and Texas’ RHT application, we can maximize the impact of coordinated investments and build sustainable, community-rooted solutions that strengthen rural health systems for the long term.
EHF’s Strategic Alignment with Statewide Innovation
Advancing Diabetes Prevention
EHF’s recent annual health policy poll indicates that almost half of all Texas adults experience diabetes or prediabetes in their household, with 35% of those being in rural areas of the state. The Rural Texas Strong plan recognizes diabetes as a critical rural health issue and proposes the following:
- Grants to rural hospital districts and clinics to create or enhance community-based diabetes prevention, wellness, and nutrition programs.
- Required local solutions such as diabetes education, chronic disease screenings, and partnerships with local food resources.
- Measurable outcomes, including reducing diabetes-related emergency room visits, increasing the number of dietitians in rural counties, and boosting participation in diabetes self-management education.
These diabetes prevention efforts mirror EHF’s commitment to scaling evidence-based diabetes prevention programs and addressing the non-medical, root causes of chronic disease in rural Texas. The exploration of diabetes prevention efforts is also seen in Texas Medicaid with the recent decision to study the cost effectiveness of the CDC’s National Diabetes Prevention Program and how it could be implemented for Medicaid recipients at risk of developing Type-2 diabetes, which was included as a budget rider during the 89th Texas legislative session.
Food and Nutrition Security
The United States Department of Agriculture (USDA) defines Nutrition Security as consistent access to nutritious foods that promote optimal health and well-being. As noted in EHF’s recent annual health policy poll, Texans who say they struggle to access grocery stores and healthy food are more likely to be people of color, people who live in rural areas, and people who have lower household incomes. The Rural Texas Strong plan recognizes that food insecurity continues to stand in the way of better health for many rural Texas communities, ultimately proposing that rural hospital districts:
- Develop partnerships with regional grocery stores, farmers’ markets, and food pantries to sponsor pop-up markets, healthy cooking demonstrations, and nutrition-conscious meal programs.
- Provide transportation support to help rural residents access healthy food and pharmacies.
- Integrate food access strategies into broader chronic disease prevention and wellness initiatives.
If implemented, the Rural Texas Strong plan would supplement HHSC’s effort in implementing House Bill (HB) 26 that passed in the 89th Texas legislative session. In HB 26, for the first time, Texas Medicaid is testing how food and nutrition services can improve health for pregnant Texans with chronic conditions. HB 26 allows managed care organizations to offer nutrition services “in lieu of” other Medicaid-covered medical services when clinically appropriate and cost-effective. The law also establishes a pilot program to provide medically tailored meals and nutrition counseling for pregnant Medicaid recipients facing chronic health conditions. These investments are directly aligned with EHF’s strategic priority to advance food and nutrition security as a foundation for better health.
Maternal Health
Rural maternal health outcomes lag behind urban areas in Texas, with higher rates of complications and limited access to health and health care services. The Rural Texas Strong plan addresses this by:
- Supporting rural hospitals and clinics to maintain and expand obstetric services.
- Investing in workforce recruitment and retention, including incentives for providers in maternal and child health.
- Integrating maternal health into broader chronic disease and wellness initiatives, ensuring that women in rural communities receive comprehensive, coordinated care.
These proposed strategies complement various state efforts to address maternal health challenges including the recently approved state budget which dedicates $5 million to a maternal health outcome grant program to address severe obstetric complications across the state. EHF’s focus on improving maternal health outcomes through system-level change and community-based support, resulting in a $3 million investment to help launch the North Texas Maternal Health Accelerator.
Clinically Integrated Networks and Community Health Centers
A cornerstone of the Rural Texas Strong plan is the support and expansion of clinically integrated networks (CINs) and Federally Qualified Health Centers (FQHCs). CINs are groups of health care providers who share information, align care plans and coordinate services, so patients receive consistent, higher quality care across different clinics, hospitals, and specialties.
EHF has a history of working to support CINs across the state including the CIN established by the Texas Organization of Rural & Community Hospitals, which had grown to 32 participating hospitals in spring 2024 to improve their financial stability by negotiating more favorable contracts with payers. EHF has also offered financial resources to support the planning and implementation phases of a CIN project at Texas Association of Community Health Centers, name My Texas My Health.
The Rural Texas Strong plan includes:
- Investing in technology and data infrastructure to connect rural providers, including FQHCs, through health information exchanges and patient portals.
- Using CINs and accountable care organizations to improve purchasing power, coordinate care, and enable value-based payment models.
- Prioritizing group purchasing and shared technology solutions to help rural FQHCs and clinics access advanced tools for care management, analytics, and telehealth.
The CIN model has been recognized as a promising model that facilitates Alternative Payment Model (APM) contracts between safety-net providers and managed care organizations. APMs are ways of paying for health care that reward providers for improving patient health rather than for the number of services they deliver, and they are a great way to advance sustainability of medical and non-medical care in rural Texas.
The Community Health Worker (CHW) workforce
During the 88th Texas legislative session, lawmakers passed HB 1575, which allowed Texas Medicaid to reimburse CHWs and doulas for providing case management support services under HHSC’s Children and Pregnant Women program. EHF supports the belief that leveraging trusted community members to bridge gaps in care, prevention, and health education can improve health outcomes. To support the CHW and doula workforce in taking advantage of opportunities in HB1575, EHF is currently supporting CHWs and doulas in learning, navigating, and seeking Medicaid enrollment, credentialing, and contracting.
As a complement to the work happening in the state, the Rural Texas Strong plan the application includes:
- Expanding the pipeline of CHWs through career path development, scholarships, and local recruitment.
- Supporting CHW retention through mentoring, continuing education, and community engagement.
- Setting measurable goals to improve the ratio of CHWs to populations in rural counties and increase the number of primary care providers and EMTs.
The Rural Texas Strong plan prioritizes specific CHW metrics that, if achieved, will help to build a sustainable, community-rooted workforce to address rural health challenges for the long term.
Key Metrics in the Rural Texas Strong Plan:
- Improving Population-to-CHW Ratio: In 2024, there was only one community health worker for nearly 16,000 people living in rural Texas. The goal is to improve this so that by 2031, there will be one community health worker for every 11,000 people.
- Prioritizing Recruitment & Retention: To build a stronger community health worker workforce in rural Texas, the plan includes locally driven strategies like career pathways, scholarships, and relocation bonuses, along with required retention plans for all grantees, ensuring that more dedicated health workers can serve and stay in their communities.
- Supporting Mentorship & Continuing Education: Supporting mentorship and continuing education is a key part of strengthening the community health worker workforce in rural Texas, with the plan aiming for at least a 5% increase in rural providers offering formal mentoring and ongoing learning opportunities for CHWs.
Conclusion
The HHSC Rural Health Transformation Fund application is a comprehensive, forward-looking blueprint for rural health in Texas. If funded and implemented, Rural Texas Strong has the potential to transform rural health systems, reduce health disparities, and ensure that every rural Texan has a better opportunity to live a healthier life.
Many of the priorities within the Rural Texas Strong plan build upon EHF’s recent programmatic progress and recent legislative wins. Some of these efforts could deepen the financial investment needed and accelerate the pathway to achieve health improvements in rural Texas. Additionally, this alignment can help to accelerate progress on these rural challenges and lay the foundation for lasting improvements.
During the development of the state’s plan, EHF supported HHSC in convening rural health stakeholders to encourage further alignment and information sharing across the state. EHF looks forward to supporting and partnering with HHSC and many key stakeholders in implementing this important work going forward.
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