Why rural transformation funding will not create sustainable capacity by itself
Rural leaders must fund the people, partnerships and operating model required to turn awards into lasting capacity.
A strong proposal can secure funding. It cannot implement itself, and that distinction matters more now that the Rural Health Transformation Program has moved from application and award announcements into active implementation.
CMS awarded all 50 states first-year funding under the $50 billion program, with 2026 awards ranging from roughly $147 million to $281 million and averaging about $200 million per state. States are now translating those plans into grants, regional initiatives, workforce investments, technology projects and new care models, which means rural providers are moving from asking what might be funded to deciding what they can actually execute.
The first two installments of this series focused on understanding the program map and then examining how much transformation work can be supported by technology an organization already owns. The next question is more operational: who will be responsible for making the work function every day once the funding is awarded?
Someone still has to manage the project, redesign workflows, configure technology, coordinate community partners, train staff, monitor measures and resolve problems when implementation does not go according to plan. If those responsibilities are not clearly assigned and adequately supported, even a well-funded initiative can become one more obligation placed on people who are already stretched thin.
An award is the beginning, not the implementation
The Rural Health Transformation Program was structured around more than good ideas. CMS application guidance required states to address a detailed project narrative covering rural health needs, transformation goals, proposed initiatives, implementation plans and timelines, stakeholder engagement, metrics and evaluation, and sustainability. A separate budget narrative was also required. Rural organizations pursuing state-level opportunities should bring the same discipline to the initiatives they propose.
When leaders build a proposal, the technology or clinical program is usually easy to see because it is tangible. The labor surrounding it is easier to miss, even though every new platform, care model or community intervention creates work before it creates results. A remote-monitoring program requires enrollment, education, device support, clinical review, escalation protocols and follow-up; a behavioral-health initiative needs screening workflows, referral relationships, documentation standards and care coordination.
The same is true for population health and community-based programs. Data must be validated, patients must be contacted, performance must be monitored and someone must remain accountable when referrals, interfaces or operating assumptions fail. Funding the technology or program alone is therefore not enough. Depending on the state opportunity and its allowable-cost rules, leaders should identify the implementation work explicitly and determine how that work will be supported.
Fund the people who will do the work
This is one of the areas I encourage rural organizations to examine most carefully. If a program depends on someone's time, that time is part of the program, not an administrative detail to be absorbed later. A proposal may need a project manager to own the timeline and dependencies, clinical leadership to translate the intervention into a workable care model, and IT or informatics support to configure systems, connect data and troubleshoot problems.
It may also require grant-management expertise to oversee budgets and reporting, community health workers or care coordinators to connect patients with services, data and quality staff to validate measures, training capacity to reinforce new workflows, and executive sponsorship to remove barriers that frontline teams cannot resolve on their own. A small rural organization may not need eight different people to fill those functions; one person may hold several roles, and some capabilities may be shared regionally. What matters is that each function has a real owner.
The question is not whether everyone needs a new title. The question is whether the work has been identified, assigned and resourced before implementation begins. Too often, organizations assume existing staff will absorb grant responsibilities alongside their regular duties. That may work temporarily, but it is not a reliable operating model when the emergency department is full, a system goes down, a key employee leaves or an urgent compliance issue pushes the transformation project to the bottom of the list.
If a role is necessary to produce the promised outcome, it belongs in the implementation plan. That does not always mean adding permanent headcount, but it does mean making the labor visible enough to decide whether it should be funded, reassigned, contracted, shared or explicitly deprioritized elsewhere.
Make accountability visible
Before implementation begins, leaders should be able to identify one person who owns the result. That does not mean one person performs all the work; it means someone is responsible for knowing whether the initiative is on schedule, whether partners are engaged, whether workflows are functioning, whether staff are using them consistently and whether the data are reliable enough to support the outcomes the organization promised.
Clinical, technology and community initiatives often cross departments and organizations, which makes this kind of accountability especially important. Without it, every participant can complete an assigned task while the overall care model still fails to function. A technically successful interface, for example, does not solve an implementation problem if the receiving team does not know what action to take with the information.
That is why leaders should define executive accountability, day-to-day project ownership, responsibility for each segment of the care or service pathway, the process for resolving operational failures and the person or team responsible for measuring results. These questions may sound basic, but they become substantially harder to answer after funding has been awarded and every participating organization has developed a different understanding of its role.
Build partnerships around complementary strengths
A partnership should be built around the work, not simply around the organizations named in a proposal. The practical question is which organization is best equipped to perform each part of the model, and rural providers should not assume that every capability has to be created internally.
The state project abstracts published by CMS describe regional partnerships, shared technology, hub-and-spoke models, technical-assistance structures and collaborative workforce strategies. Those approaches reflect a practical reality: rural communities can often achieve more when organizations combine complementary capabilities rather than attempting to duplicate every service at every site.
One hospital may have a strong addiction-treatment program while another has deeper maternal-health expertise. A federally qualified health center may be better positioned for community outreach, while a regional partner may provide informatics, cybersecurity, analytics or grant-management support. The objective should not be to reproduce every capability locally; it should be to determine which functions must remain local, which can be shared and which partner is best equipped to provide them.
Those relationships still need an operating model. Leaders should know who employs the personnel, who carries financial responsibility, how information will be shared, how performance will be measured and what happens when the initial funding ends. A memorandum of understanding can document intent, but it cannot tell a frontline employee what to do when a referral fails, a partner is unavailable or a patient needs help outside the expected workflow.
Collaboration should strengthen local control
Partnership does not require a rural organization to surrender its identity or its relationship with the community. Local trust is one of rural healthcare's most valuable assets, and patients often know the clinicians, hospital leaders and community organizations involved in their care in ways that are less common in larger systems.
Transformation efforts should build on that trust rather than unintentionally moving decisions farther away from the people affected by them. Rural leaders should enter partnerships with a clear understanding of what their organization does well, what the community expects it to protect and where outside support would create genuine value.
The largest organization in a regional model should not automatically become the organization that controls every component. A stronger approach assigns responsibility according to capability, preserves trusted local access where it matters and creates explicit escalation paths when a shared service or partner cannot deliver what was expected.
Design for the day after funding ends
I encourage leaders to put the final day of grant funding on the planning calendar and ask three questions early: what will still be operating the next morning, who will own it and how will it be paid for? Sustainability cannot be a paragraph added at the end of a proposal; it has to influence staffing, contracting, technology choices and partnership design from the beginning.
CMS made that expectation explicit in its application requirements. The agency's program FAQ instructed states to describe measurable outcomes, sustainability beyond the program period and the stakeholders required for each initiative. Rural organizations should apply the same test locally: what part of the program remains when the federal funding cycle is over, and what operating mechanism keeps it alive?
Some programs may become sustainable through reimbursement. Others may reduce avoidable utilization, improve workforce retention, eliminate duplicated costs or become affordable once several organizations share the expense. A new workflow may endure because it has been integrated into the EHR and routine clinical practice rather than existing as a parallel grant-funded process.
Not every initiative will generate direct revenue, and it would be unrealistic to require that standard. But every initiative should have a credible explanation of how its staffing, technology and operating costs will be supported over time. That requires understanding the full cost of ownership, including maintenance, licensing, interfaces, cybersecurity, training, turnover, data reporting, partner coordination and the people required to operate the program.
Transformation cannot ignore financial reality
The Rural Health Transformation Program represents an extraordinary opportunity, but it arrives in a rural healthcare system that remains financially fragile. That reality should shape implementation decisions because a program designed without regard to the underlying economics can create obligations that outlive the funding intended to support them.
The 2026 Chartis analysis found that 41.2% of rural hospitals were operating at a loss and identified 417 hospitals as vulnerable to closure. Those figures do not mean every financially stressed hospital will close, but they illustrate how little margin many rural organizations have for absorbing new staffing, technology or administrative responsibilities after temporary funding disappears.
Transformation funding cannot solve every structural problem in rural healthcare, and leaders should not design proposals as though it can. What the program can do is help organizations create stronger operating capabilities, build more useful partnerships and implement care models that address documented community needs. That will happen only when proposals support the people, infrastructure and accountability required to carry the work forward.
A funded idea is not yet a sustainable program. Transformation begins when an organization has the capacity to execute, can demonstrate that the model is producing the intended result and has a credible plan for keeping the necessary capacity in place after the award funding is depleted.
Janet Desroche is associate vice president at MEDITECH, an electronic health record software company.