The Road to Better Health Outcomes

Halima Ahmadi-Montecalvo: Good afternoon, everyone, and thank you so much for spending part of your day with us. My name is Halima Ahmadi-Montecalvo. I’m the VP of Research and Evaluation at Unite Us, and I’ll be moderating today’s conversation.

Just a quick word on why I’m excited about this one. I live and breathe data, program design, and program evaluation in population and community health. That’s what my team works on every single day, so a conversation about what actually moves health outcomes and how we know it’s working is right in my wheelhouse. I’m looking forward to digging in with our speakers.

A couple of quick housekeeping notes before we jump in. First, we are recording today’s session, and we’ll be sending the recording out right after the webinar along with a few resources tied to what we cover. If you click on the three dots on your Zoom screen, you’ll see the resources listed there. Second, and this is the important one: please drop your questions in the Q&A box. We’ve saved time toward the end of the hour to get through as many of those as we can.

With that, here’s what we want to dig into today. There’s a lot of talk about investment to impact, but the path between those two things is where it gets complicated. How do we set expectations that are actually realistic? How do we spot the early signals that something is working, before that big outcome shows up in the data? How do we build accountability that holds across sectors when no single organization owns the whole picture? And once you see that improvement, how do you keep it going?

I couldn’t ask for two better guides for today’s discussion. Our panelists have shaped rural health policy from both sides of the federal-state divide — one setting the national agenda, the other proving what’s possible on the ground.

We have the pleasure of having Alina Czekai, who directs the Office of Rural Health Transformation at CMS, where she works at the intersection of government and industry on health policy. Before this role, she was Senior Advisor to CMS Administrator Seema Verma, where she helped build the agency’s very first value-based rural care model. Her connection to this work isn’t just professional — she grew up in a farming family in upstate New York, which shows up in how she thinks about rural communities.

Our second panelist, Kody Kinsley, served as North Carolina’s 18th Secretary of Health and Human Services. During his tenure, the state expanded Medicaid to more than 600,000 residents and secured over $835 million for behavioral health. He also launched the Healthy Opportunities Pilots, the first large-scale test in the country of whether Medicaid could pay for things like food and housing to improve health.

Here’s why that’s so important for this conversation: we’ve seen the results. A summative evaluation from UNC’s Sheps Center found that participants had fewer ED visits and fewer hospitalization stays, with more care shifting to lower-cost outpatient settings. That shift translated into savings of around $164 per member per month. That’s roughly the arc we’re here to talk about — investment to evidence to impact.

Kody now serves as a Senior Policy Advisor at Hopkins, a Senior Advisor with the Milken Institute, and an Aspen Institute Fellow. Alina, Kody, welcome, and thank you so much for being here today.

Kody Kinsley: Great to be here.

Alina Czekai: Thanks for having us.

Halima Ahmadi-Montecalvo: I want to kick off the conversation talking about how we define success and set expectations. CMS has emphasized that rural health transformation should improve outcomes, not simply fund a collection of programs. Alina, in that context, what does success actually look like, and where do you see the biggest gap between what states expect and how long results actually take?

Alina Czekai: It’s a great question, and it’s one I often get. When we think about success from the CMS perspective for the Rural Health Transformation Program, you can think about it in two distinct phases: first, structural transformation, and then clinical outcome changes that follow from that.

In the near term, success looks like states focused on building the foundation — getting initiatives established and up and running, building out teams and operations, potentially deploying workforce into communities, establishing the underlying infrastructure for digital initiatives, building integrations. Very much “we are getting started here.” That’s how we’re viewing success from a scoring standpoint for the states, too.

All states submitted their annual reports to CMS on August 31st, so we’re using that information both to report out on state progress and to rescore for their year two funds. We’re not looking for population health outcomes — it’s been since January. We’re looking for state progress against the milestones they set out in their own initiatives. We call it a checkpoint framework. We want to see how far states are getting in their own initiatives, and it’s going to look different for every state. It would be an apples-to-oranges-to-bananas comparison otherwise. If we can take the framework of scoring and assessing states against their own plans, that’s a way we can show how far a state has come. And we have incentives and encouragement for states to make fast progress baked into the plans.

In the longer term, success looks like states using this infrastructure and these established initiatives to fundamentally change how care is delivered on the ground. The biggest gap there is the timeline from getting initiatives up and running to population health outcomes. There’s naturally a lot of excitement around this program. Everyone wants to see reductions in things like unnecessary ER visits, or drops in chronic disease complications. But probably everyone on this call knows that’s not going to happen in one year or two years. Healthcare transformation is an engine, not a light switch. It’s going to take time. The more thoughtful states can be in how they build the physical, operational, digital, and workforce infrastructure to get those outcomes, the more that’s true success — and that’s only going to happen over multiple years as those structural systems mature.

I’d also note there’s a misconception that CMS runs this program in a silo. We’re working really closely with our colleagues at HRSA and CDC to think long-term about what metrics we should be looking at from a population health standpoint, and how we can ensure there’s coordination across all federal initiatives focused on rural health.

Halima Ahmadi-Montecalvo: I’m so glad you brought up the length of time it actually takes for population health level outcomes to be realized. From the Unite Us perspective, we navigate that gap quite often. So as a follow-up: what should states be watching in the meantime? What short-term or intermediate outcomes should they be paying attention to?

Alina Czekai: Definitely paying attention to how states are progressing along their own program designs. How engaged is the local community? How engaged is political leadership within the state? What do the initial investments look like? What are the mechanisms by which the state is identifying partners, procuring assets, or building out contracts? Really focused on operational success.

Another big piece is how states are thinking about sustainability. That’s a key metric by which we assess state progress. Is a state making an investment because it’s the flashy thing at the time, or does it have the potential to outlive this five-year program? Really thinking through what initiatives the state is building out, and how those types of models statistically and historically impact population health.

A big example I like to use is hub-and-spoke models. Hub-and-spoke models, clinically integrated networks — what are the frameworks being built in these early years in the state, and how can that translate to population health impact if it’s done smartly?

Halima Ahmadi-Montecalvo: That makes sense. Kody, you and Mandy Cohen recently wrote that HOP was framed from the very start as a test with defined endpoints — so not exactly a guaranteed win. And that honesty is part of what earned bipartisan credibility for the pilot. How much of that rested on genuinely being willing to accept a negative result? And in the years before those endpoints arrive, what does a credible early signal of success look like on the ground?

Kody Kinsley: Hi everyone. Let me just start by saying I think there’s probably no person who has a harder job in government right now than Alina — moving at a truly fast pace and trying to roll out a program that a lot of folks are really excited about. I’m super excited about it.

A little over a year ago I wrote a piece for State Health and Value Strategies, to state health secretaries across the country, saying: look, this is going to be hard, but it’s a great and exciting moment for transformation, and we need to work together to figure out what that vision is. To the point of some threads I just heard in Alina’s comments and in your question, we’re not starting from scratch. We’ve had a long journey on the road to trying to improve population health. We know we’re tackling incentives in the healthcare system that are really misaligned and too short-term focused. So that question of how do we make things sustainable, how do we build on past learnings, how do we put things together — those are really fundamental, even more so than just wanting to make sure programs don’t end abruptly at the end of five years. If you’re not building toward sustainability, and you’re not learning from what we’ve passed on, then you’re not going to be able to have the success that you want and that we really desperately need.

With the Healthy Opportunities Pilots — what we colloquially call HOP in North Carolina — real credit to then-Administrator Verma, and I’m sure Alina had a bit of a hand in this at the time, for saying: let’s structure out a pilot in very small areas. At the time there was an appetite to test some things we maybe didn’t have the best evidence on, to grow a little bit further, but we wanted to do it in a very focused way. And in North Carolina, it was only three regions.

I have said on the record many times that I was surprised at how much impact we had and how quickly. Two years in, we saw a statistically significant reduction in hospitalizations and a reduction in emergency department visits — and those are very expensive things. We know the cost of care in those spaces is very high. We also learned that the primary tip of that spear, the thing that was making the difference, was food. The evidence base around food as medicine is huge.

How does that translate to the Rural Health Transformation Program and other work? Build on that. What does that look like? There are a lot of different strategies — different strategies in North Dakota versus North Carolina. Maybe it looks like food-as-medicine meals coming to your home. Maybe it looks like local farmers bringing food to your home, or community care hubs. So, really echoing Alina on how you build those paths. But what I would say is: how are we building on the evidence that already exists? How are you building on the infrastructure you already have in your community, to then leapfrog forward into that future space?

Halima Ahmadi-Montecalvo: That all makes sense. I want to shift a little bit and get more to implementation. We’ve talked about setting realistic expectations. This is a question to both of you: when you look at staffing, governance, and data infrastructure, which of those choices tends to make or break a rural health transformation effort?

Alina Czekai: Can I say all of the above?

Halima Ahmadi-Montecalvo: You can.

Alina Czekai: Definitely all of the above, but for me, I think governance. Governance really is the foundation that could make or break the effort. Data infrastructure is what connects all of the pieces across the board. You can hire brilliant team members, you can deploy state-of-the-art tech, but if the governance model within the state has different stakeholders and parties operating in a silo — health systems over here, state Medicaid agencies here, community partners there — the strategy stalls out.

The states making the most progress right now were really thoughtful and intentional about how all of the puzzle pieces within the state work together. Having those plans laid out from the get-go is allowing states to move quickly, which means they’re making their investments more quickly, laying that infrastructure, and then they can have an impact more quickly. So governance, if I had to choose just one. But all of the other pieces are very critical as well.

Halima Ahmadi-Montecalvo: Kody, any thoughts there?

Kody Kinsley: I’ll speak from some of the challenges. To be a bureaucrat for just a moment: sometimes it feels like nothing can move faster than the speed of state procurement. A lot of states are wrestling with how to navigate that. This goes back to where you had existing infrastructure in place — where maybe there was some early investment in building out population health work in your state, then you have the opportunity to double down in those spaces to navigate those procurement challenges.

This program has come about very quickly, and in some states, when you’re building out networks, people have got to learn. They can only learn so fast. The second piece that helps you move quicker is when you’ve got networks you can lean into. Maybe it’s a clinically integrated network, associations of particular providers, existing spaces in rural communities, maybe anchor partners like FQHCs that already have deep trust in those communities.

The last thing I would say is a bit of an encouragement to everyone. I always say we want to be smart in our design and implementation of things. We also want to be elegant. Alina would know better than I, but in looking at states across the country, some have created pretty interesting but pretty complicated approaches to solving this that feel very out of whole cloth. That can be challenging, because then you’re adjusting so many new variables at the same time.

One of the through points in all of this that I really encourage states to think about baking in from the beginning — something I think we did in HOP — is: how are you creating a centralized measurement tool? I know that’s part of the review and analysis requirements, and I think it’s smart by design of the RHTP and the application to say you’ve got to have an evaluation strategy from the beginning, and you have got to be tracking common information across all these spaces. Because that is one of the challenges when you’re going into a lot of different rural communities and trying to build something that meets those separate communities where they are. How are you still cutting across common data elements and common information, so we can really learn not just what works, but how it worked?

Halima Ahmadi-Montecalvo: You talked about deep relationships in communities. We know rural communities may be facing workforce shortages and limited service capacity, but they often have really deep, meaningful relationships and strong local knowledge. How should state strategies build on those strengths? I’m curious about both of your perspectives, but Kody, if you could talk especially about your experience in North Carolina, and whether that was an essential part of the success.

Kody Kinsley: Absolutely. We designed our Healthy Opportunities Pilots — and the North Carolina rural health program has been further designed — really around the community care hub model. How do you have local linchpins or network leads that are figuring it out? Part of that was meeting North Carolina where it was. It’s a large, very diverse state, with a large number of people living in small communities. That’s different from having large, vast areas with remote people; there’s more density in that space.

So we really leaned into: who are those linchpin communities in our Healthy Opportunities Pilots, those network leads that already had relationships? Sometimes it was relationships with the local churches that were operating food pantries, and that was the right answer in that community. Elsewhere it was a well-established food bank in the eastern part of the state. We like to say we move at the speed of trust. If you can, for lack of a better phrase, co-opt existing trust, that’s going to be a heck of a lot faster than establishing an entirely new relationship.

I also think about the opportunity here. We’re in the frame of how we’re paying for healthcare differently, but public health has been doing community health assessments through local public health departments for years. They have a lot of knowledge, insight, and leverage. So it’s also a challenge to bring together other levers and pieces across different operators, to understand what you’re showing up to do.

Halima Ahmadi-Montecalvo: Any thoughts there, Alina?

Alina Czekai: In rural health and rural communities, trust is currency. That’s a big reason why workforce was so woven throughout the design of the Rural Health Transformation Program. We know that in order to transform, we need to have a solid workforce — but it needs to be people who really feel connected to the community, who want to stay, who feel committed to serving those people. I’ve been really excited to see in state plans how they’re weaving workforce throughout to help build that trust.

But to Kody’s point, there are a number of mechanisms outside of workforce development that can support this. It’s building relationships with local communities, churches, schools, community organizations. I’ve been pleased to see across state RHTP websites minutes from community meetings and stakeholder sessions where different organizations, or even individuals, come and share their observations and feedback. It’s been exciting to see not only state-led, capital-led initiatives, but also grassroots, ground-up ones.

Maybe I’ll take a moment to share a story from a recent site visit. I don’t know if we have anyone from New York on, but I attended the New York site visit last week and just loved it. One, I live in New York right now, and it’s a beautiful time of year — the leaves are starting to change. We toured Hudson Headwaters Health Network, an FQHC, and I learned the story of how they came to be.

It was in the ’70s. A physician came down to the Adirondacks — I think he was coming from Boston, and he was on a canoe trip. During his travels he saw how challenging the healthcare setup was in the Adirondacks. He saw the underserved, very remote communities, a doctor who had retired there, and a big gap in care. Recognizing that need, he organized local community leaders and ended up establishing this clinic, which is now a really big system. But he didn’t come in and say, “Okay, I’m coming from the city, this is what this community needs.” He went around and talked to the people and the communities.

From my perspective, that’s the essence of this program. It’s not being led outside of Washington. We distributed the funds as quickly as we could — two days before the deadline, I’ll note, December 29th. We got the dollars out the door to the states, and the states are in the driver’s seat, but they’re supported by counties, health systems, universities. It’s a team effort to get movement here. Trust is absolutely paramount, and that includes trust from the people who are ultimately receiving the care.

Kody Kinsley: I just want to rhyme a bit with Alina on this question of trust. One of the things we learned during our implementation of Healthy Opportunities, especially as we were navigating North Carolina as a purple state, is that we were all working together in different ways. Our Republican leadership really supported Healthy Opportunities.

I like to say that healthcare and healthcare financing can feel so incredibly complex. But the common sense of giving people healthy food as a way to prevent them from needing to go to the hospital is just that — it’s common sense. It’s not so hard. That’s some of the richness that comes out of engaging with local community members, as Alina was saying, because they understand that nobody goes into a hospital to stay healthy. You’re going into the hospital because, unfortunately, something bad has happened. The cheapest thing to do, and the healthiest way to be, is to never have to go in the door. So what are all the ways we can prevent you from having to interact with those parts of the healthcare system? An ounce of prevention, a pound of cure — these are common sense things, and people can bring that creativity into the work. I think that’s important.

Halima Ahmadi-Montecalvo: I love that backstory, Alina, of how that organization was actually started. I’m all for community engagement and learning from the communities — that’s exactly how we can actually make a difference, not by having a big-picture idea and trying to implement it across the board.

I’m curious, as funding and political priorities shift, Alina: what keeps state and federal actors accountable to each other over the long haul?

Alina Czekai: The Rural Health Transformation Program is a five-year program, so we’re naturally going to see changes in Washington, and we’re going to see changes in the states. It’s a governor-championed program in the state, so we’ll probably see some changes there.

What maintains consistency and accountability is, one, the program design. That’s never going to change, no matter who is in office in DC or in the states. States are required to carry out the program design from their initial application. Yes, we can have some flexibility in there, depending on — as long as things are consistent with the overall spirit, the plans outlined, the population served. Generally the initiatives, all of those things, have to stay the same. But there’s some gray area, and we absolutely work with states to accommodate for that.

On the federal side, our guidance is consistent. The team members working hand-in-hand with the states are bringing back feedback on what they’re hearing on the ground: what do we need to clarify, how do we need to ensure states have the guidance?

And then the big piece is the reporting and scoring. That is all locked for the five-year program. It gives states clarity from the get-go on how they’re going to be assessed by CMS, what they’re accountable to showing, how they know what success and improvement looks like. That was all issued pretty early on. It was a feat getting that out the door while we were reviewing budgets and helping states get moving, but it was deliberate, because we didn’t want any states to go off and build things without knowing how they were going to be assessed. So we feel a very strong sense of accountability to the states, just as the states feel an accountability to CMS and to our office. I’ll also note that we have a very open, bi-directional chain of communication with states, and that will never stop.

Halima Ahmadi-Montecalvo: I’m glad you brought up those implementation realities — it’s going to be different for each state. And you very nicely got us to the topic of measurement: how do we actually know what’s working? If improved health outcomes are the destination, how do we avoid mistaking activity for impact? For example, when do we look at referral volume, partner participation, service utilization? When do we look at those in the bigger context of measurement and outcomes?

Alina Czekai: This one’s interesting, because for us, impact and progress for the first few years will look like those operational metrics — getting new modes of care established, hiring, an increase of 10 to 20% in the workforce in rural communities. Those very operational metrics are going to be success. They will tie to meaningful metrics like increased access and decreased wait times to care, but still more of those structural-type measures.

On the population health standpoint, states, for the most part, are in the driver’s seat, and that’s the beauty of this program. We’re giving states the flexibility to innovate, to choose the issue areas and the chronic disease issues they want to focus on, the disease burdens and challenges there. But they have a sense of when they think they’ll make some movement. For example, a decrease in unmanaged diabetes — there are a number of states who expect to see that in these five years.

So, one, we need to be realistic that the first few years it’s going to be success from those more utilization- and infrastructure-focused metrics. But I’m very confident and hopeful that we’re going to see progress on the population health metric side as well. Maybe not nationally — it’s going to be slow change — but I do think that within the five years we’ll have a number of states we can point to and say, look what this state is doing, and this is how they were able to more tightly manage blood pressure and hypertension, these types of issues, for rural patients.

Then we can share those learnings through our office with other states. “Hey, you’re making great progress on the Rural Health Transformation Program. Looks like you’re focused on maternity care, EHR integrations, and workforce development. But this is working in this state — you can consider layering these types of approaches into your initiatives as well.” We want to have that cross-learning, and as we see impact and progress wins, we will be sharing that both across states and externally.

I’m confident, too, that there will be learnings that can be applied to urban centers and suburban communities. I say all the time that rural America has been innovating for years because it’s had to. There are a lot of lessons and a lot of impact to be drawn from this opportunity — and now rural communities have the support and the capital to be able to make these investments.

Halima Ahmadi-Montecalvo: I love that, and I agree that those learnings, as they come up, should be shared across the board. Kody, I’m curious if you have any thoughts on that question.

Kody Kinsley: Looking a little bit into the Wayback Machine of Healthy Opportunities, and echoing the truth that the first couple of years — for us it was really the first year — was about getting program participants signed in and plugged into the pilot, and getting the networks established. Those metrics of success looked like contracts and technology and connections and enabled folks. And frankly, challenges: we had people who wanted to be in the network who felt like they couldn’t be in the network, and navigating through all of those dynamics.

But I will say, in the silver lining space, two years in we had a savings of $85 per member per month in the program. In that moment, because we had rolled things out in a phased way, it was deeply connected to food. So if you’re starting in a space where you see a strong burden of chronic kidney disease, and you’ve got high diabetes prevalence, and that’s an area of focus, and you’ve got the right infrastructure — that could be something where you could maybe turn the tide a bit faster. Especially when you’re focusing on some of our sickest folks, which was ripe for change, and when you know, from the evidence, about transportation. So there are some promising areas to move faster on population health measures. But I do appreciate the tempering of expectations for all of us that this is really an infrastructure-building thing.

At the same time, I’d challenge everyone to think about the moment we’re in. A lot of the Hill-Burton hospitals in rural communities are full of infrastructure debt and all kinds of other challenges. There’s a lot of local community pressure to save and rebuild these hospitals, to do other things. There are challenges with maternity care deserts and closing emergency departments.

So the opportunity of the Rural Health Transformation Program — and I love the “transformation” keyword — is this: as we look ahead down the road in this country, we could be pumping trillions upon trillions of dollars into legacy rural healthcare infrastructure and not getting better population health measures, and that would be a tragedy. This program is an opportunity to really think about how we take a different turn there. We’re still going to have to put more money into rural health down the road. But in this moment, really experimenting to figure out what could work differently is the challenge that’s really exciting.

Halima Ahmadi-Montecalvo: Kody, North Carolina’s General Assembly let Healthy Opportunities lapse during last year’s budget impasse, and then voted in July to bring it back once the evaluation results came in. What was it about the data that actually moved skeptical lawmakers? And what data didn’t move the needle?

Kody Kinsley: I don’t believe in skeptical lawmakers. I love all of our lawmakers. They have hard jobs, and it’s really tough — particularly right now, because states across the country are facing tightening budget pressures, so every marginal dollar is going to have more scrutiny. I totally understand that.

It’s important to know that in North Carolina we didn’t have any budget get passed, period. North Carolina, unlike many states, has an automatic continuing resolution that goes into place, save any special things that are put into conflict. So what actually happened was that they didn’t pass any budget, and the program just lapsed. It was less of a concerted decision to let it lapse and more that it just kind of paused. There was controversy and questions about it, and I think those are good dialogues that always need to happen.

But the most recent report that came out showed that in the four years of the program it was saving about $164 per person per month, taking into account administrative costs. Really promising and exciting — and again, just common sense. If we can keep people out of the hospital and other places that are really expensive to get care, then that’s good. Hence reauthorizing the program.

And look, I’ve said this multiple times: the program was designed to be a pilot. We always wanted to fail forward fast. If we were covering a whole bunch of different services and we found out some of those services weren’t turning the dial on health, then let’s not do it.

I also think, when I talk about food often, that we can do better to think about how SNAP and Medicaid work together. We’re putting more money into food-as-medicine strategies; we have to make sure we’re also appropriately leveraging the programs we have that are really fit for purpose by design. So there’s still a lot of work we can do in this learning space. That willingness to have those sorts of conversations, and to be clear about what works and what doesn’t work, is how you build trust — whether it’s with lawmakers or with your partners.

Halima Ahmadi-Montecalvo: I want to get back to measures and evaluation. Alina, how will evaluation account for differences across rural geographies, rather than treating all rural communities as one population?

Alina Czekai: We know that rural America varies in communities, geography, and demographics. If you’ve seen one rural community, you’ve seen one rural community. We definitely account for that. The farming communities where I live in upstate New York are very different from the frontier land of Wyoming, or the rural parts of Hawaii.

We account for this first by putting states in the driver’s seat. We are collecting a number of national statistics and national metrics for this program, but mostly what we’re collecting is state-led metrics and program evaluation that ties to their unique programs. This is by design. The states built out their programs, they designed them, and we asked them: what does success look like to you in this particular initiative? How will you serve the community in this region? Putting it back on the states to define that, at its core, will ensure we’re looking at every state differently — again, by design. But we also have the national metrics and the national data that allow us to look at the whole.

There are, of course, a lot of themes. A lot of states are focused on telehealth access. A lot of states are focused on supporting maternity care. So there will be things we can tease out from the states’ individual evaluation programs and share. But at its core, this approach will account for the differences in rural communities.

We also take a very milestones-based approach, because we know some states are already ahead of the game — they might have been investing in some of these rural health initiatives from the start, or before — whereas others are just getting started. We want to make sure we’re meeting states where they are and helping them build from that baseline.

Halima Ahmadi-Montecalvo: I’m keeping an eye on the time, and we promised our audience Q&A time, so I want to close this out. In, let’s say, 20 seconds or less: what’s your advice to states just starting this work?

Alina Czekai: My advice to states is to be very thoughtful in your contracting and procurement approach. That’s been an interesting observation. I know Kody alluded to this earlier, but states are taking very different approaches, and what I’m seeing is that states working more with partners, or with a more sophisticated approach, are able to move more quickly.

If you feel like you have the staff support, the operational support, and the governance support to manage hundreds and hundreds of direct contracts yourself, that’s great — power to you, do that. But you need to be honest with yourself and your leadership if that feels like too much. Don’t take that on in the name of transformation. It doesn’t all have to be directly from the state. I saw a laugh from Kody there.

Think about sub-organizations — whether it’s contracting support, tech organizations, community organizations, health systems. Think about who else is in your ecosystem who can help you drive the change. You’re still having direct engagement, direct oversight, direct management of the program. But you don’t have to manage hundreds and hundreds of awardee contracts on your own.

Kody Kinsley: That’s so wise. My 20 seconds, to repeat something I’ve said already, is: fail forward fast. In pilots like this you have got to accept individual risk, you’ve got to try new things, and you’ve got to have the boldness and the bravery to say “that didn’t work,” and tell everybody it didn’t work, and move forward.

Don’t accept systemic risk. If you find yourself not setting yourself up for success — as Alina said, because you’ve got a contracting team of two and you’re doing 150, which I think is a common problem right now — that is a systemic risk, and it can be dangerous to your success. So think about the design. But this is a time to try newer things and be bold.

Alina Czekai: I echo that. That was a great point, Kody. We expect there will be failure. That’s how we will all learn from this.

Halima Ahmadi-Montecalvo: Great advice. We have a bunch of really good questions, so I’ll jump right in. The first one: what can be done to get states to adopt a common service taxonomy and catalog across SDOH platforms? It always helps when we speak the same language. Whoever wants to take this.

Kody Kinsley: I’ll jump in and say this is a journey many states have been on for some time. But let’s look back and accept that it’s taken us a really long time to get to a common taxonomy for things already in the healthcare system. As we move into the SDOH space — what is a mattress, what is a food box, what is a thing — those are hard definitions.

In North Carolina, we came up with a taxonomy code in that space and standardized it in a single tool that we made everybody use, and that’s how we standardized. I know other states have taken different approaches, with common data definitions and data lakes. Alina may know better than I, but I think that’s New York, and other folks have done different things.

Where we’re probably marching collectively is toward how we get those taxonomies into things like an HIE. What does that look like? Those are bigger questions for my former colleagues and friends at the Office of the National Coordinator for Health IT, and for thinking about that framework. CMS may have thoughts there, but I think it’s still a journey, where there have been a lot of different external groups and collaboratives working in that space.

Halima Ahmadi-Montecalvo: Alina, any additional thoughts on this, or should we move on to the next question?

Alina Czekai: I think Kody covered that one. Good to move on.

Halima Ahmadi-Montecalvo: So this next one: in the conversation about measuring outcomes, and Alina, your comment regarding state learnings — how does CMS plan to share out the impacts and lessons learned?

Alina Czekai: We will definitely be issuing some type of annual report at the end of each year, so that is to come. We also have a number of learning collaboratives with the states — that’s particularly for the states, not outside organizations. That’s another place where we bring in other federal partners, so CDC and HRSA, and we have cross-country learnings, evaluation, and discussion. It’s also an opportunity for states to share the challenges and pain points they’re facing.

Again, we’re just getting through the first year, so it was a lot of rapidly getting operations set up and getting the program built. Year two will be much more focused on what we’ve learned so far and what strategies we can share out. Communications is going to be a big focus, and really telling the story of what we’re seeing so far in the states. So more to come, for sure, on that point.

Halima Ahmadi-Montecalvo: Kody, how did North Carolina do this? How did you all share lessons learned?

Kody Kinsley: We had built a collaborative across our individual network leads. That was, again, part of our design: we tried slightly different things in three different regions of the state so that we could learn together quickly, and we brought them together for routine facilitation.

I know part of North Carolina’s RHTP program design includes a similar approach. They’ve been working with the Duke-Margolis Institute to bring the network leads and the hub leads together for those conversations as they’re learning. That’s where you may find that someone has started to crack the code on a certain thing somewhere, and when you can bring those up and replicate them, that’s important. It’s a good way to create visibility.

Halima Ahmadi-Montecalvo: All right, moving on to the next question. You mentioned that success will be directly tied to the initial design and metrics outlined by states when funding was awarded. Now that the first annual reports have gone out, are there any recurring missed opportunities that you’re seeing that states should be mindful of?

Alina Czekai: I don’t want to get out ahead of things, since we haven’t done any reporting on the annual reports. But I would re-up my comment earlier about contracting. That has been a challenge for states — wanting to move quickly, but being slowed by the method of contracting or procurement they’ve taken. So don’t be afraid to partner with others in the state who can help you. But yes, more to come on annual reports.

Halima Ahmadi-Montecalvo: Sounds good. How should leaders respond when early results are mixed, or when implementation is slower than expected?

Alina Czekai: That’s something all of our project officers — we have a whole team behind me at CMS — are working on hand-in-hand with the states. States should share those observations and learnings with their project officers. I mentioned that we have a level of flexibility baked into the program, so if a state is finding that this isn’t working, or this is having mixed or detrimental impact, we will work with them to adjust and change course as needed.

Also, there’s not always going to be impact, and that’s okay. But states will need to share that information in their reporting, because that’s how we all will learn.

Halima Ahmadi-Montecalvo: Any additional thoughts on that, Kody?

Kody Kinsley: Again: transparency, transparency, transparency. And something Alina pointed to earlier, where people are posting meeting notes and creating opportunities for public engagement. The more folks you can bring into the process, and who trust the process, then when you as a leader open up and say “this is what I know, this is what I don’t know, this is what worked, and this is what doesn’t work” — that’s how you maintain trust through those moments.

Halima Ahmadi-Montecalvo: Along those lines, there’s another question here. Trust is so key, and it’s one of the reasons subcontractors and community partners have been so critical. When engaging with organizations that aren’t as standardized, or don’t have recurring reporting behaviors and commitments, what would you say states and the people handling governance should be mindful of, while still balancing trust and the value of the work that folks are doing?

Alina Czekai: That’s a good question. I think the state should really bring these subcontractors and community partners along, rather than setting them off on their own. If the organization doesn’t have that existing trust in the community or with other partners, have someone from your office be part of those early conversations, or make sure the connectivity is there.

It all goes back to strong governance. Make sure that the state leaders, the subcontractors, and the community partners are all connected to each other in some web-type fashion. Otherwise there will be silos popping up within the state, and that’s not what we need to see in rural transformation.

Halima Ahmadi-Montecalvo: Here’s another question. It’s great that CMS is providing funding to each state to transform rural health, but each state seems to be doing things on their own. Would it be more efficient to have a baseline of technology solutions offered to all states, to avoid duplicate efforts and inefficiency?

Alina Czekai: Maybe it would be more efficient, but that’s not the design of the program. The program was explicitly designed by Congress and by CMS to give states the flexibility to transform. The federal government is also not in a position to give states a list of vendors to choose from, or a list of companies or technologies to consider.

What we are in a position to do is say to the states: here are some examples of initiatives you might find helpful as a starting point. If you look back to the Rural Health Transformation Program NOFO, we talk about examples of really strong hub-and-spoke models, like Vermont’s opioid hub-and-spoke, or the Rough Rider clinically integrated network, or approaches to telestroke monitoring, or remote patient monitoring for blood pressure. We give states frameworks, but they are the ones to ultimately determine how their state dollars are spent and the types of technologies and solutions they think will solve their unique problems.

Kody Kinsley: I’ll just add that state leaders are super busy, but they’re also constantly chatting with their peers. The National Academy for State Health Policy does a beautiful job of convening state health secretaries and leaders — and a little plug, I’ll be doing a panel there on rural health in a few weeks. Leaders come together to talk about this. They’re sharing ideas and replicating, so some of the “what works and how do we scale it” happens and unfolds there. I think that’s better than a top-down “you must do it this way.” They’re figuring it out, so I really value that design and the opportunity for those kinds of standards to be set by what works.

Halima Ahmadi-Montecalvo: Thank you both. I’m looking at the time, and we’re unfortunately coming to the end of our webinar. But I see one more question that maybe we have a minute for: how are you thinking about autonomous AI for healthspan and comorbidity compression? That’s an interesting question — maybe give it about 20 seconds each.

Alina Czekai: I don’t know if I’m the expert on this one, but I’d say generally we’re excited to see the approaches states are taking with regard to tech, including AI. That one’s getting a little technical for me. Kody, I don’t know if you…

Kody Kinsley: I’ll throw in this, in the same spirit of — the key word in RHTP is “transformation.” I think we all recognize that AI has tremendous power, albeit we need to make sure we have good guardrails, especially when it comes to health. But it has tremendous power to unlock a very different healthcare delivery system that could look radically different from what bricks-and-mortar healthcare looked like 50 or 60 years ago, when Hill-Burton built a bunch of hospitals across the country.

The challenge in this moment is that we’re building that plane of what AI healthcare delivery and an AI backbone can help us do, but it’s also something we’ve got to build to skate to where the puck is going. So I think we keep having these open conversations about what’s developing there, what’s developing there safely, and also how we’re building toward where we need to be.

One very particular thing that’s really exciting is the measurement space. This is where states can be thinking about how they’re leveraging AI in the background to do data collection, to capture it, to capture the learnings, to find trends and patterns across all those grants and metrics and measures. That’s an exciting space that can help us do the work faster — not just in the healthcare delivery using AI space.

Halima Ahmadi-Montecalvo: That’s great, really insightful. Thank you, Kody.

Well, thank you to our panelists, and thank you to all of you for spending this hour with us. Here’s what I’m taking away: nobody gets to better health outcomes alone. It takes policy, care delivery, community capacity, and data pulling in the same direction, long enough for it to really matter. And you have to know what you’re looking for along the way — better access, stronger networks, tighter coordination. Those aren’t the finish line, but they’re how you know you’re on the right road.

We’ll send the recording along with the few resources I mentioned in the next couple of days. Thank you again, and I hope you enjoy the rest of your afternoon. Thank you, everyone.

Alina Czekai: Thank you.