Missouri’s ToRCH Pilot Turns Rural Hospitals Into SDoH Hubs

Jan. 17, 2025
With funding from the state Medicaid program, six rural hospitals are engaging community-based organizations in county-wide efforts

We have high hopes that this will be at least a partial solution to the financial challenges and the population health challenges of rural America.

Missouri HealthNet Division’s Transformation of Rural Community Health (ToRCH) program is taking an unusual approach to social determinants of health — deploying rural hospitals as community health hubs in addressing population health goals in partnership with community-based organizations. 

The program seeks to empower rural communities to collaborate to address healthcare-related social needs among their Medicaid population, with a focus on driving better health outcomes. Kirk Mathews, the chief transformation officer for Missouri HealthNet, the Show Me state’s Medicaid program, recently spoke with Healthcare Innovation about the program’s launch. 

Healthcare Innovation: Could you talk about some of the challenges folks in rural Missouri are facing and the origins of the ToRCH program?

Mathews: Rural hospitals in Missouri and across the country are facing challenges that can actually threaten their very existence. We've seen rural hospitals leave the marketplace, not only in Missouri, but across the country. We have a belief that that is a result of the historical reimbursement methodologies. More and more of our rural Missourians are driving past their local hospital in order to seek care in urban and suburban settings. There are a lot of reasons for that, and many of them are legitimate reasons, particularly when they need more complex care and surgery, and the inability of rural hospitals to recruit specialists and surgeons. But that places those rural hospitals in a distinct disadvantage to be able to compete under the historical reimbursement methodologies. They're not providing the most expensive and quite frankly profitable procedures. So their care is reduced to emergency room and some limited primary care.

What ToRCH is attempting to do is to improve health at the county population level by making investments that historically have not been made in the social determinants of health arena. After looking at a lot of data and studying a lot of models, we believe that if we make those investments at the population health level, and minimize or decrease those more expensive procedures, it will bring the cost of care for those participants down, and there will be savings generated to the Missouri Medicaid program. This model, in a couple of years, pivots into a shared savings model in which the state will share up to 75% of those savings back with those hospitals in order to not only sustain the model, but possibly help sustain the very existence of the hospitals.

HCI: I understand that you started with six hospitals, but the idea is to expand that to more rural hospitals going forward, correct? 

Mathews: Yes, one of the eligibility criteria for a rural hospital was that they are the only hospital provider in their county. We did that just to minimize attribution, so we could have a defined population of the Medicaid residents that reside in that county. We went to the Missouri legislature and asked for $15 million. They approved that, and that budget allowed us to serve six counties and six rural hospitals. Our intention is to go back to the legislature, once the data is flowing that proves the concept, and add a second cohort, a third cohort, a fourth cohort, until we exhaust the interest of all the rural hospitals in the state.

HCI: So you'll be looking at the Medicaid data to try to see the impact of the program on costs and patient outcomes?

Mathews: Yes. One of the one of the premier characteristics of the model is local control, and each local hospital has established a governance committee that consists of not only hospital people, but primary care partners and partners that operate local, community-based organizations. They decide what their population health goals are. Then we take what they submit, and we are establishing benchmarks on all those population health goals for the outcomes piece. And then, of course, we're tracking the cost as well. We’re tracking the inpatient costs. So, yes, we will have measurements on both the clinical and the financial performance of the model.

HCI: So the hospitals themselves are acting as that community hubs that reach out to the community-based organizations that will provide some of the services to address the social needs of these patients?

Mathews: That's correct. The hospital is the hub, and the dollars flow through the hospital, but they flow through several different revenue streams. They are the custodians of those funds and they are able to make grants to the community-based organizations in some of the communities. Of course, in some places there is a scarcity of community-based organizations. There might be communities that lack food pantry resources or other social needs, so we've empowered them through this model to make capacity-building grants to help stand up a transportation system for non-emergent medical transportation that may not exist in their county currently.

HCI: I understand you are using the software platform from Unite Us to create these community information exchanges. Will the community-based organizations be able to use that to bill for their services?

Mathews: Exactly right. The Unite Us platform does several things for us. It is sort of the linchpin that ties the whole program together. The Unite Us platform enables all those connected to one of these hubs to both send and receive referrals for social care. But one of the unique things about the Unite Us platform is they have a payments management platform through which the the community-based organizations can send invoices for what we're referring to as b3 services. So the program is approved by CMS through a 1915(b) waiver that already existed in our state. That's the waiver through which our authority for managed care is provided and and we have amended that waiver to include b3 services, and there's a handful of services that CMS has approved for us to provide social care, and the Unite Us platform is the enabler to make sure that those services are paid for.

HCI: When Missouri was formulating the idea for this, did you look at things going on in other states? I know North Carolina has something similar, and I think they use the Unite Us platform as well.

Mathews: Yes, we did. We looked at North Carolina’s Healthy Opportunities program. There was a program in Wisconsin that we looked at. I don't think that any of these programs that are exactly alike, but they do share some common characteristics.

HCI: I know that you are in the early stages of this, but have there been any lessons learned or course corrections along the way yet?

Mathews: One of the lessons learned from the state's perspective was really understanding more of the rural hospitals’ operational challenges. This pilot program provides funding for them to hire community health workers to do social determinants screenings. I think we at the state underestimated the time that it might take to put those kind of people in place in some of these very small communities in our state. 

Also, the state is is really working to walk a fine line between total local control and being overly prescriptive with some of our mandates. But we want to be providing support that can benefit all six hubs. This is a really unique relationship. I described to all of our hubs that all six of them and the Transformation Office at Missouri Medicaid are a family of guinea pigs, and we are learning as we go, and it places a different dynamic on the relationship. These hospitals are used to being, by their own admission, very linear thinkers, very regulated. You know, check the box, make sure we follow the rules, etc. And we're asking them to think outside the box with this and asking them to trust us. We love our six initial partners. They all have different management styles and cultures, but we're learning that there are a lot of common challenges across those six hubs. 

HCI: This is a really interesting idea. Anything else you’d want to mention about it?

Mathews: I would say we have really high hopes for this pilot. I had the opportunity to share it on a call with about 25 or 30 other Medicaid directors from around the country, and I think it's going to capture a lot of attention. We have high hopes that this will be at least a partial solution to the financial challenges and the population health challenges of rural America. For instance, Missouri has not ranked well in our maternal infant health outcomes historically. If we can ensure that our rural Medicaid moms get adequate and good prenatal care — maybe their transportation is challenged, maybe they are nutritionally challenged — and if we can address those things and improve our healthy birth weight ratios and avoid wildly expensive NICU stays, those dollars could add up pretty fast. That could be shared back with those local hospitals. 

HCI: We have written about these community hubs being set up in other states, but I don’t think they often involve the rural hospital as the hub as Missouri is doing.

Mathews: It is kind of a complicated model to deploy on the front end, so it took a while for everyone to understand what we really were trying to get at. But almost across the board, for our hospitals the proverbial light has gone on, and they're saying we have uncovered a ton of other social resources that we knew existed but we had never really communicated with. 
One of the foundational principles of the model is to not just rely on the state's dollars, but to pursue a braided funding approach. And there are grants, resources, and organizations out there. Even in these smaller communities, the hospital was aware of their existence, but they were kind of doing their own thing. The Area Agency on Aging might be providing services, but no one really coordinated with them in a real social benefit effort. If nothing more than that coordination occurs, it'll be a success. Across the board, all of our hospital hubs have said this has been pretty remarkable to get all of us on the same page and coordinating our efforts.

Sponsored Recommendations

Cloud Communications: Connecting Care at the Core

Cloud communications is the present, the recent past, and the future of collaborative healthcare.

The Ultimate HIPAA Security Guide for Cloud Communications

The healthcare industry is leading the charge in innovation, embracing cutting-edge technologies to enhance patient care and optimize operations. Forward-thinking organizations...

Improving Workplace Safety and Patient Care in Behavioral Health

In 2023, Vail Health enhanced safety in their behavioral health clinic, but the impact went beyond their expectations. Read their case study to see how prioritizing workplace ...

Transforming Hospital Capacity Through Smarter Patient Progression Strategies

Helping patients move seamlessly through every stage of their care, from admission to discharge, is critical to ensuring patient safety, improving outcomes, and optimizing capacity...