Incorporating age-friendly strategies into the Rural Health Transformation Program

The Rural Health Transformation Program (RHTP) represents one of the most significant federal investments in rural health care in recent history. It was authorized through H.R.1 (Public Law 119-21, Chapter 4), which seeks to protect rural hospitals and providers, and was enacted in July 2025. The RHTP provides up to $50 billion over five fiscal years (FY 2026–2030, $10 billion annually). These funds support state-led efforts to strengthen rural health systems, stabilize access to care, modernize infrastructure, expand and sustain the workforce, and advance innovative care and payment models.

In late December, all 50 states were awarded RHTP funds ranging from $147 million in New Jersey to $281 million in Texas. Fifty percent of RHTP funds are distributed evenly among approved states as baseline funding. The remaining 50 percent were allocated based on workload factors such as rural population size, facility needs, and the quality and scope of state proposals. This structure reflects an understanding that rural health challenges vary widely across states. It also recognizes that every rural community requires a foundational level of investment to maintain essential services. 

RHTP emerged at a moment of both opportunity and urgency when rural health systems across the country continue to face workforce shortages, aging infrastructure, hospital closures, and financial instability. Broader federal funding cuts, particularly the pending cuts affecting Medicaid, further increase risks for rural providers and the populations they serve. Against this backdrop, the RHTP has been widely viewed as both a transformative opportunity and a stabilizing intervention for rural health systems that are most affected by these federal funding cuts. States were required to select at least three eligible activities – such as workforce development, infrastructure investment, health technology advancement, innovative care models, or system integration – and were also permitted to propose additional strategies designed to promote sustainable access to high-quality rural health care services. This range of activities presents a critical opportunity for states to embed age-friendly strategies across all RHTP pillars, even when older adults were not explicitly named in the original applications.

Why age-friendly care matters in RHTP implementation

After states submitted their RHTP applications in November 2025, attention quickly shifted from proposal development to preparing for implementation. While applications outlined high-level priorities, most states consistently emphasized that implementation decisions, rather than application language, will ultimately determine the program’s impact, particularly for populations with complex and ongoing health and social needs including older adults.

As rural America is aging more rapidly than urban regions and older adults represent a disproportionately large share of rural health care users, there is an urgent need for effective policies and programs to address the challenges of aging in rural communities. Rural older adults are more likely to live with multiple health challenges associated with chronic conditions, experience functional limitations, rely on Medicare and Medicaid, and face barriers related to transportation, social isolation, food insecurities, workforce shortages, and access to specialized care. As a result, many aging-focused organizations including the National Rural Health Association (NRHA), The John A. Hartford Foundation (JAHF), and Stratis Health have drawn attention to the fact that the success or failure of the RHTP implementation will be felt intensely by older adults and the rural health systems that serve them.

Why NRHA and Stratis Health convened small group discussions with state leaders

Within this critical transition period from application development to submission, NRHA, in partnership with Stratis Health, convened two national small group discussions with state leaders to identify and discuss opportunities for incorporating age-friendly strategies into the Rural Health Transformation Program. These discussions were convened through the National Rural Age-Friendly Initiative (NRAFI), which is supported by The John A. Hartford Foundation.

While developing their applications, many states requested public input and engaged stakeholders to inform their RHTP priorities. Through the initiative, NRHA and Stratis Health conducted a scan of publicly available state preparation materials and stakeholder input summaries developed by Princeton University to track states' preparation, which indicated that age-friendly programs were infrequently referenced. These findings were further supported by NRHA state-level RHTP tracking conducted by NRHA’s Government Affairs team, which similarly reflected limited mention of age-friendly programs in many states' RHTP proposals. Based on these reviews, NRHA, through the NRAFI and in collaboration with Stratis Health, identified the need and opportunity to elevate and advocate for the inclusion of age-friendly programs within states' RHTP plans and implementation.

The two forums were held on Dec. 4 and 8, 2025, purposely timed after application submission but before awards to create time and space in the post-submission, but pre-award, timeframe for state leaders and partners to consider strategies or implementation. These discussions were designed to elevate state-level perspectives on how age-friendly strategies could be incorporated into the RHTP implementation to draw directly from the experiences of state leaders and partners who were involved in their states’ RHTP applications and who are expected to play a role in the implementation.  

Participants' learning expectations:

• Hear from other state leaders regarding ways age-friendly strategies have been included as part of their RHTP plans.
• Discuss opportunities and mechanisms for ensuring that RHTP activities incorporate strategies that address the needs of older adults in rural communities.
• Identify tools and resources that support the incorporation of age-friendly best practices into RHTP activities.
  
  

The convenings created space for peer learning, open dialogue, and problem-solving among state leaders and partners who were involved in their states’ RHTP application plans and/or will be involved in implementation. While the two sessions were held separately with distinct participants, they surfaced remarkably consistent themes, shared challenges, and promising opportunities. Participants also emphasized the value of learning from one another at a time when states were beginning to translate broad RHTP priorities into concrete actions.

To ground the discussions in real-world implementation experience, NRHA and Stratis Health structured both convenings around a set of guided questions designed to elicit candid reflections from state leaders and partners. These questions focused on how older adults and age-friendly strategies were considered during the RHTP application process, where opportunities exist to more intentionally integrate age-friendly approaches during implementation and what resources or supports states need to translate plans into action. The discussion questions provided a consistent framework across both sessions and allowed participants to share state-specific experiences while identifying common themes, challenges, and opportunities that cut across geographic and programmatic contexts.

The sections that follow synthesize participant responses to each question, which are shared insights directly drawn from the dialogue.

Did your state specifically identify strategies related to older adults as part of its RHTP application? If yes, please share.

Participants described diverse approaches across states, and several participants noted that older adults or age-friendly strategies were not explicitly named in their state’s RHTP application, often due to compressed timelines and the need to focus on broad system-level priorities. In these cases, aging-related needs were frequently addressed implicitly through priorities such as workforce development, telehealth expansion, transportation, and infrastructure modernization.  Two participants shared examples where age-friendly strategies were incorporated:

• In Oregon, the state explicitly incorporated the Connected Care for Older Adults Program model into Oregon’s RHTP plan (see page 27) and cited strong partnerships, existing data, and demonstrated outcomes as key enabling factors. The Connected Care for Older Adults program is an innovative pilot program that uses community health workers (CHW) in primary care settings to improve care for frail older adults in rural areas. The participant noted that Oregon publicly shared its plan and encouraged other states to share their plans, as well as share their age-friendly work impact across states to build the evidence to keep the age-friendly work going.
• Mississippi approved a bill (HB 1401) in 2025 to establish a statewide CHW certification program in part due to a focus on improving age-friendly care. This focus on CHWs was considered a strong asset within the workforce component of their RHTP application. Core elements of their proposed RHTP work included statewide assessments, coordinated regional integrated systems, workforce expansion, health technology advancement, and telehealth adoption.
  
  

When you consider the key areas of your state’s RHTP, where do you see opportunities to ensure the needs of older adults are incorporated into implementation? Do you anticipate challenges to including age-friendly strategies?

When participants were asked to reflect on where opportunities exist to ensure the needs of older adults are incorporated into their states' RHTP implementation, the discussion centered on how existing age-friendly efforts could be aligned with RHTP priorities and scaled through implementation activities. In particular, participants highlighted how states can align existing Age-Friendly Ecosystem work and Multisector Plans for Aging with RHTP priorities, such as all prevention, dementia (brain health) initiatives, telehealth, social engagement initiatives, transportation initiatives, and aging workforce development.

Across both convenings, participants consistently identified a common set of age-friendly priorities/initiatives where implementation activities could meaningfully address the needs of older adults. Key themes included improving transportation access, addressing social isolation, integrating CHWs into health care delivery, strengthening workforce development efforts including caregiver support programs, expanding fall prevention initiatives, addressing internet/broadband access issues, and exploring the role of Program of All-Inclusive Care for the Elderly models as part of broader system transformation efforts. Participants emphasized the benefits of working collaboratively with age-friendly partners, leveraging existing data, and expanding and replicating successful age-friendly programs and approaches. 

Anticipated challenges to including age-friendly strategies

In addition to identifying opportunities, participants raised several concerns and questions related to implementation. Some participants questioned how CMS will identify states and communities with the greatest need and ensure that RHTP funds are distributed equitably. There was also concern about how CMS will ensure that funds remain targeted to rural communities over time rather than being redirected to non-rural areas during implementation. Participants repeatedly emphasized that RHTP funds should be directed to areas of greatest need.

Participants also discussed emerging concerns and questions related to technology and innovation. Several asked how states have addressed or plan to address the use of artificial intelligence (AI) within their RHTP applications and implementation strategies and whether AI efforts are primarily connected to telemedicine and telehealth or extend to other cases. One participant shared that Maine is planning a rural AI hub as part of its broader approach to age-friendly innovation.

Additional implementation-related concerns and questions focused on program flexibility and accountability. Participants asked whether states will be able to modify their plans during the implementation phase, whether technical assistance or support will be available during evaluation, and how states can connect to share learning and support throughout the evaluation process.

Finally, participants expressed concerns about the importance of addressing Medicare and Medicaid considerations as part of state's RHTP implementation. Questions were raised about how states can better support older adults who rely on Medicare and Medicaid, how to engage health care systems as partners, and how to strengthen partnerships with primary care providers. Participants also discussed the need to improve linkages between older adults and mobile or community-based resources and noted that partnership development remains both a significant opportunity and an ongoing challenge.

What information or resources would be helpful to support integration of age-friendly strategies into your state's RHTP implementation?

Participants identified several types of information and resources that would support the integration of age-friendly strategies into their state RHTP implementation. The discussion highlighted the importance of practical, accessible, and actionable supports that states can readily apply during implementation, focusing on how existing age-friendly efforts could be aligned with states' RHTP priorities and scaled through implementation activities. Most participants stressed that RHTP implementation presents a significant opportunity for states to build upon age-friendly work that is already underway to strengthen implementation and sustainability. This emphasizes the value and power of safety-net systems and age-friendly resources that are already in place.

Participants drew attention to the need for information about age-friendly initiatives from other states, particularly from state RHTP plans that clearly demonstrate how age-friendly strategies are being operationalized. Evaluation tools, implementation frameworks, and ongoing technical assistance were also identified as essential resources to support states. In addition, participants advocated for clear guidance on funding flows and allowable uses of funds to support effective and compliant implementation.

Relationship building and collaboration emerged as central themes during both discussions. Participants called attention to the importance of fostering multisector collaboration models that engage Medicaid agencies, health systems, community-based organizations, faith-based organizations, and state-level partners. State-to-state collaboration was also identified as a valuable mechanism for shared learning, peer support, and collective advocacy. Several participants noted that stronger collaboration among associations and partners could amplify advocacy efforts and elevate rural perspectives at the state and federal levels. Additional opportunities called out by participants included:

• Developing community care hubs –  particularly in rural and Tribal communities – can serve as a means of coordinating services, strengthening referral pathways, and connecting older adults to health and social support. 
• Digital literacy for both providers and consumers was identified as a significant area of need to ensure equitable access to technology-enabled services and support. 
• Data utilization and storytelling were repeatedly cited as essential tools for advancing age-friendly RHTP implementation, as leveraging data helps demonstrate impact, strengthen advocacy efforts, and help tell the rural story by highlighting unique challenges and opportunities.
  
  

Finally, participants emphasized the importance of intentional engagement with government leaders, state leaders, and other individuals in positions of influence. Advocacy at the government level was identified as a necessary component of sustaining age-friendly implementation and ensuring continued attention to the needs of older adults within RHTP activities.

Moving from planning to implementation

Across both discussions, participants echoed that implementation, not application language, will ultimately define the success of states' RHTP. This calls for intentional integration of age-friendly strategies to ensure this historic investment strengthens rural health systems in ways that are equitable, sustainable, and responsive to the realities of rural aging. Now that RHTP state awards have been made, incorporating age-friendly strategies in implementation is immediate and urgent. NRHA and Stratis Health, look forward to supporting states, communities, and leaders in serving the nation’s rural older adult population through their RHTP implementation. 

Through the National Rural Age-Friendly Initiative and NRHA’s ongoing efforts to advance age-friendly integration within states' RHTP implementation, NRHA was invited by the American Society on Aging (ASA) to author a blog titled Integrating Rural Age-Friendly Care Initiatives into States' RHTP Implementation, which has now been officially published in ASA’s Generations Now.

In addition, NRHA, Stratis Health, and six other aging-focused organizations recently collaborated to develop Rural Healthy Aging: Policy and Infrastructure Opportunities for RHTP. This resource document provides states with guidance on policy, infrastructure, and resources to leverage existing aging systems and strengthen rural healthy aging outcomes by intentionally integrating healthy aging priorities and strategies into their RHTP implementation. This document will be updated periodically as new relevant resources become available. 

Finally, NRHA’s policy team has developed a comprehensive summary of all state RHTP applications and in collaboration with the initiative has also produced an additional analysis of state applications that embed age-friendly programs and strategies.

More information on RHTP is available on the NRHA RHTP page. For specific policy updates related to RHTP, contact Carrie Cochran-McClain or Marguerite Peterseim.

To learn more about NRHA’s NRAFI, visit the National Rural Age-Friendly Initiative Resource Hub. For more information about the NRAFI, contact Laura Hudson or Rebecca (Becky) Yeboah.

This blog and the highlighted small group discussions are activities of the National Rural Age-Friendly Initiative Implementation Grant, NRHA’s partnership with The John A. Hartford Foundation.

NRHA developed the above piece in partnership with The John A. Hartford Foundation and Stratis Health for publication within the Association’s Rural Health Voices blog.

Authors include Stratis Health president and CEO Jennifer Lundblad, PhD, and Director of Program Management Karla Weng, MPH, as well as NRHA program services coordinator Rebecca Yeboah, MDP, chief policy officer Carrie Cochran-McClain, DrPH, and senior government affairs and policy coordinator Marguerite Peterseim, MPH.