Doctor and Patient with the text "Transformation of Rural Community Health"

The Transformation of Rural Community Health (ToRCH) pilot project will address critical social care challenges that compromise individuals’ ability to maintain their health and effectively manage chronic conditions. DSS Director Robert Knodell calls ToRCH “a groundbreaking initiative that empowers and encourages rural communities to collaborate to address healthcare-related social needs among their Medicaid population, with a focus on driving better health outcomes.”


Transformation of Rural Community Health

What is ToRCH?

The ToRCH model depends on strong partnerships among three main entities within the rural community: the hospital, primary care and behavioral health clinics, and community-based organizations (CBOs) offering social services. These partners will utilize the Community Information Exchange (CIE) software from Unite Us, a secure digital tool that streamlines care coordination by sharing resources, making referrals, and ensuring the completion of the referral process. This system aims to bridge the gap between individuals and the services intended to assist them.

The ToRCH model, approved via an amendment to Missouri's 1915(b) waiver, serves as a Primary Care Case Management model concentrating on addressing social determinants of health needs. ToRCH presents a coordinated approach to tackle these needs at a community level and opens up potential new funding sources for rural hospitals taking a lead in implementing the model. Jon Doolittle, the President and CEO of the Missouri Hospital Association and former President of Mosaic Medical Center - Albany in rural Missouri, highlights that Missouri boasts innovative hospitals that are pivotal to the health and well-being of their communities. "The investments by MO HealthNet acknowledge the significance and leadership of these hospitals, supporting them to enhance their roles as health improvement hubs. By enhancing resources for community partners and improving care coordination, ToRCH will aid hospitals in enhancing lives and fortifying communities."

Why is ToRCH Needed?

Healthcare providers nationwide recognize the significant impact that non-medical factors have on their patients' health outcomes. They are increasingly exploring ways to identify and address these needs. As per the U.S. Department of Health and Human Services, these factors, known as social determinants of health (SDOH), encompass the environmental conditions where individuals are born, live, work, learn, play, worship, and age. These factors influence various health, quality of life, and functional outcomes and risks. Examples of SDOH include safe housing, transportation, access to healthy foods, and opportunities for physical activity.

Kirk Mathews, the Chief Transformation Officer for MO HealthNet, emphasizes the need for a shift in payment systems. He highlights how hospitals have not been adequately rewarded for addressing the underlying causes of health issues. "The ToRCH program allows hospitals to receive compensation for proactively tackling issues that contribute to poor health outcomes. This model incentivizes hospitals to focus on healthcare rather than sick care, promoting a more preventive approach."

MO HealthNet Director Todd Richardson commented, “This model aligns perfectly with our primary objectives for the Medicaid program. We are confident that this creative strategy will enable our partner communities to concentrate on enhancing health outcomes, ultimately reducing program costs.”

Who Will Participate?

Six rural hospitals were selected in June 2023 to participate in the first cohort of the pilot. Future cohorts could be launched every 2-3 years. View the ToRCH Awardees Map.

  • Bothwell Regional Health Center in Sedalia, Missouri (Pettis County)
  • Citizens Memorial Hospital in Bolivar, Missouri (Polk County)
  • Golden Valley Memorial Healthcare in Clinton, Missouri (Henry County)
  • Phelps Health in Rolla, Missouri (Phelps County)
  • Ray County Memorial Hospital in Richmond, Missouri (Ray County)
  • Salem Memorial District Hospital in Salem, Missouri (Dent County)

What Does ToRCH Do?

ToRCH funding will enable the hospital to act as a central community "hub," bringing together partners to implement strategies that address SDOH needs and reduce preventable hospital admissions and emergency room visits. The model involves incentivized goals for enhancing population health within the served community, offering shared savings for achieving the following:

  • Decreased rates of avoidable hospitalization, including readmissions, at the participating hospital
  • Lowered rates of avoidable ED use at the participating hospital
  • Reduced overall hospital utilization for all Medicaid recipients in the served community, irrespective of where the hospitalization occurs

How Does ToRCH Work?

The hospital "hub" plans to establish a local leadership board comprising key clinical and community partners to supervise and manage all aspects of the ToRCH model. This board will leverage the expertise of its members in both community understanding and clinical practice to strategically address health-related social needs (HRSN) services that are anticipated to significantly impact hospital outcomes and community health. Through the Unite Us CIE platform, community partners, including clinical and social service providers, will collaborate to send, receive, and resolve referrals for HRSN services identified for patients via individual screening. These services may vary and could involve providing transportation to medical appointments or delivering healthy and nutritious food.

How is ToRCH Funded?

To support staff at the rural hospital or other project needs, ToRCH funding is available. This financial support includes expenses for convening the Leadership Board, monitoring MO HealthNet claims data, building relationships with CBOs, overseeing their performance, managing funds, seeking additional funding sources to align with ToRCH goals, and addressing any obstacles to success. Importantly, this funding is designated for ToRCH initiatives that benefit Medicaid participants in the targeted county of the hospital hub.

Additionally, during the initial model years, CBO Capacity Building Funds are allocated to enhance capacity by offering extra space, staff, training, IT/equipment, and other infrastructure. These resources empower smaller community-based partners to address the identified HRSNs within the community. The funds are managed by the "hub" through the Leadership Board, under the supervision of MO HealthNet.

The ultimate aim of ToRCH is to enhance health and manage chronic conditions more effectively for rural Medicaid beneficiaries by coordinating health-related SDOH services. As health outcomes progress, savings will be produced. The ToRCH model thrives when the shared savings are ample to maintain its operations and adequately reward the rural providers involved.