ToRCH, Rural Health Transformation Program Have Potential to Improve Outcomes

The Missouri Rural Health Association (MRHA) recently published a community needs assessment that underscores the state of rural health. The outcomes of the assessment are sobering. According to the report: “Rural Missouri is dying. Citizens of the region consistently experience worse health outcomes in most areas of life. The rural population accounts for 1.5 million people who are overrepresented in every leading cause of death. Life expectancy is shortening, and there are not enough providers to meet health care needs. Overdose, suicide, and mental health outcomes are growing exponentially, resulting in devastating outcomes. The rural health crisis is overwhelming, complex, and in immediate need of intervention.”

The outcomes

There are 114 counties in Missouri, of which 99 are considered rural. According to the assessment, rural Missourians outpace their urban counterparts in all 10 leading causes of death. This includes a 7% higher infant mortality rate. And over the last decade, fatal drug overdoses have increased by 127%, with only 20% of those individuals receiving prior substance use treatment.

Education and economics also contribute to increased poverty, leaving children the most vulnerable. Higher levels of education are independently associated with lower prevalence of chronic disease, according to the National Institutes of Health. The life expectancy for those who hold a bachelor’s degree is greater than that of those with a high school diploma or equivalent. In rural Missouri, approximately 13%-14% of residents lack a high school diploma. The result is higher incidences of cardiac disease, alcoholic liver disease, drug overdose, and suicide. Additional outcomes include higher uninsured rates, circumventing access to quality care.

A lack of economic opportunities further exacerbates social drivers of health. This leaves rural Missourians strapped when it comes to acquiring food, housing, and transportation. 16% of rural Missourians — including children — live in poverty. “One in six children in rural counties experience poverty; this results in substandard child health outcomes and decreased psychological well-being into adulthood,” according to the assessment. Higher unemployment rates for rural Missourians are another social driver that fuels deaths of despair, drug use, poor health, mental health disorders, and shorter life expectancy.

Access to health care poses yet another barrier for rural Missourians. The majority of rural Missouri is designated as a health professional shortage area (HPSA) by the Health Resources and Services Administration. A HPSA is a geographical area, population group, or facility lacking enough primary medical, dental, or mental health providers to meet community needs. To bring this home, rural Missouri has 62% fewer providers per 100,000 rural residents compared with metropolitan areas. “The number of primary care physicians (PCPs) has steadily declined to 48 PCPs per 100,000 rural residents,” the assessment states.

Hospital closures add insult to injury. Between 2014 and 2020, 10 rural hospitals closed. This means that roughly half of rural Missouri residents must travel more than 40 minutes to reach an ER. According to data cited in a December 2025 report in Becker’s Hospital Review, 29 rural Missouri hospitals (50%) are at risk of closure, with 12 facing immediate closures. These challenges are worsened by a lack of broadband to access telehealth services, nonemergency medical transportation, and access to insurance, according to 17, 85, and 10 percent of assessment respondents, respectively.

ToRCH and The Rural Transformation Program

Perhaps help is on the way. Late last year, the Centers for Medicare and Medicaid Services (CMS) announced $50 billion in awards to all 50 states aimed at strengthening rural health care. The Rural Health Transformation (RHT) program is slated to expand access to care in rural communities, strengthen the rural health care workforce, modernize rural facilities and technology, and support innovative models to bring high-quality, dependable care closer to home.

As part of this investment, the Missouri Department of Social Services (DSS) is leading a statewide effort through a program called Transformation of Rural Community Health (ToRCH) to transform how rural health care is delivered and sustained. The Missouri Medicaid program design includes a “connected system of local community hubs to ensure every rural Missourian has access to the high-quality care they need through a delivery system that is well-aligned, community anchored, and built to last.”

Program goals include:

  • Expanding access to care by ensuring rural Missourians receive primary and mental health care close to home, have community-based maternity options, and have connections to specialists and complex care via telehealth and provider interoperability.
  • Improving health outcomes through integrated care coordination and evidence-based practices that provide seamless, high-value care.
  • Strengthening provider sustainability by reinforcing long-term sustainability of rural providers. This includes targeted investments in infrastructure, adoption of innovative technologies, and payment models that reflect the realities of rural care.

RHT will allocate $1 billion over five years to cover what ToRCH details as its five coordinated initiatives:

  1. Building Regional Coordinating Networks and Local Community Hubs to coordinate local care delivery and expand entry points for physical health, behavioral health, and social services.
  2. Designing and launching alternative payment models to sustain ToRCH by rewarding collaboration that leads to high-quality and high-value outcomes.
  3. Establishing a digital backbone that enables ToRCH to function, including platform interoperability and data modernization.
  4. Building a rural health workforce pipeline that encompasses the cultivation, recruitment, training, and retention of rural clinicians and a broad array of health care professionals.
  5. Investing in operational innovations that modernize and increase the sustainability of rural providers.

Ultimately, the Medicaid initiative leverages rural hospitals as community hubs to integrate health care with social services to address social determinants such as food, housing, and transportation. The initiative also connects providers and community-based organizations (CBOs) to streamline referrals and care coordination using a secure community information exchange called Unite Us. 

Strategic community collaborations are integral to closing the gaps

If successful, ToRCH will serve as a game changer for rural Missourians, as it will address some of the most significant needs as voiced by the 417 respondents who participated in MRHA’s qualitative needs assessment. According to their estimation, the following are the most dire needs to fix what ails rural communities the most:

  1. Create a more robust health care pipeline and workforce.
  2. Expand the scope of practice for advanced practitioners.
  3. Grow transportation services to support long-distance medical transport.
  4. Include low-cost patient transportation available outside of normal business hours.
  5. Deploy more mobile clinics and crisis units.
  6. Increase mental health services.
  7. Increase support and health care navigation for Medicaid recipients.
  8. Garner additional funding to support rural health initiatives.
  9. Develop cross-disciplinary coalitions.
  10. Increase support for existing programs.
  11. Enhance outreach initiatives.
  12. Reduce staff isolation and burnout.
  13. Develop a shared vision to improve rural health.

“The problems rural stakeholders are continuously challenged with continue to grow,” as stated in the assessment. “The needs of the rural community are great, and a significant amount of collaborative effort will be required to develop programs which address the full scope of challenges. If existing organizations and advocates in rural Missouri can become engaged in the collaboration, and linked with external resources, then sustainable solutions can be developed.”

To learn more about MRHA, and to download the full community needs assessment, visit MRHAssociation.org.