This blog series takes a closer look at targeted health priorities being advanced by states in their Rural Health Transformation program (RHTP) applications. As authorized under the One Big Beautiful Bill Act (OBBBA), the Centers for Medicare and Medicaid Services (CMS) will provide states with $50 billion over 5 years to strengthen and modernize health care in rural communities. Each state developed a plan in their applications to expand health care access, strengthen workforces, build infrastructure and technology, and support care delivery innovation within rural communities. CMS has awarded RHTP funds to states for the first year, ranging from $147 to $281 million.
Rural Health Resources
Access to behavioral health care is a central focus across many states’ Rural Health Transformation program (RHTP) applications, shaping both overarching goals and investment strategies. State approaches generally align across four core areas:
- Expanding access to integrated primary and behavioral health care services
- Strengthening the rural behavioral health crisis continuum
- Building and sustaining the rural behavioral health workforce
- Embedding mental health and substance use services across broader rural health payment approaches and technology investments
Together, these strategies reflect emerging trends in how states are using RHTP program funds and point to key policy and implementation priorities likely to shape rural mental health and substance use systems over the coming years. Across these areas, states are increasingly directing investments toward evidence-based, measurable interventions that can be scaled.
Behavioral Health Integration in Primary Care
States are prioritizing integration of mental health and substance use services into primary care, particularly in Federally Qualified Health Centers and Rural Health Clinics, making this the most common behavioral health investment area.
Collaborative Care Model (CoCM): States like South Dakota are proposing to expand the availability of CoCM, an evidence-based, team-based approach that integrates behavioral health into primary care. The CoCM model can improve access, coordination, and outcomes for rural patients with mental health needs in primary care. Investments in CoCM can address start-up costs needed to implement the workflow, data, and staff training and to encourage uptake in primary care clinics. These investments are also an opportunity to align RHTP program investments with other payment and financing strategies moving toward sustainability.
School-Based Behavioral Health Integration: States are proposing to use RHTP program funds to expand school-based health services in rural communities (see NASHP resources on state approaches and models), bringing behavioral health care to students where they learn. These investments support early identification, timely intervention, and better coordination of mental and physical health care for children and adolescents. Ohio is proposing to establish school-based health centers on K–12 and college campuses offering primary care, behavioral health, dental, and telehealth services. States can draw on a range of evidence-based school behavioral health models, such as school-based health centers and a multi-tiered system of support framework, to guide effective implementation and maximize impact in rural communities.
Certified Community Behavioral Health Clinics (CCBHCs): States are using RHTP program funds to expand mental health and substance use services through CCBHCs, which follow federally defined standards (e.g., 24/7 access) and track measurable outcomes (see 2024 outcomes report). North Carolina is proposing to develop CCBHCs within regional care networks, enhancing assessment and treatment programs and piloting collaborative workforce models to connect rural residents to care. Alabama is proposing to improve behavioral health access by converting Community Mental Health Centers into CCBHCs. Leveraging CCBHCs allows states to advance RHTP program goals by delivering community-driven, measurable improvements in rural behavioral health.
Behavioral Health Crisis Continuum
States are making broad investments to strengthen the behavioral health crisis continuum, building statewide infrastructure that improves coordination, stabilization, and post-crisis support.
Crisis Stabilization: Many states are expanding crisis stabilization capacity. Rhode Island is planning to open two 24/7 walk-in crisis and stabilization centers, up to four recovery community centers, and a substance use disorder (SUD) bridge clinic to provide immediate support and connect individuals to ongoing care. Wyoming is piloting a statewide tele-specialty and behavioral crisis stabilization program, linking rural communities to crisis expertise remotely.
Paramedic-Led and Mobile Integrated Models: States are incorporating paramedic-led and mobile integrated approaches into their RHTP strategies to strengthen substance use disorder response. These models deploy specially trained paramedics to initiate treatment, provide in-home follow up care, and reduce unnecessary emergency department use. South Carolina is strengthening community paramedicine alongside mobile crisis teams and pop-up clinics to bring behavioral health and substance use services closer to rural communities. North Carolina is planning to expand a paramedic-initiated pilot to connect individuals with opioid use disorder treatment at the point of contact. Vermont proposes a Mobile Integrated Health model that delivers post-discharge and substance use disorder care in patients’ homes.
Mobile Crisis Response: States are investing in mobile crisis teams to meet people where they are, connect them to the broader crisis continuum, and reduce hospital and criminal justice involvement. Mobile crisis services are supported by growing evidence, Medicaid guidance, and are recognized as an effective and scalable crisis response strategy. States are adapting these models to address rural needs and workforce challenges. Idaho is proposing to enhance mobile crisis teams and better align them with substance use treatment services, while Washington seeks to expand mobile crisis supports as part of broader efforts to strengthen its rural behavioral health system.
Behavioral Health Workforce
States are making investments in the behavioral health workforce through the RHTP program, recognizing that workforce shortages remain a major barrier to access and a particular challenge in rural communities. States are advancing evidence-informed approaches grounded in research, practice-based experience, and lessons from prior initiatives across a variety of workforce development strategies.
Using Workforce Data to Guide Investments: States are strengthening workforce data and planning tools to better understand regional shortages and target resources. California, for example, is proposing a statewide workforce mapping tool to identify needs at the regional, county, and sub-county levels. Workforce data is widely recognized as foundational for aligning training, recruitment, and incentive strategies with local demand.
Building Career Pathways and “Grow Your Own” Pipelines: States are investing in career pathways that expand entry into behavioral health professions and support rural retention. Texas is advancing pathways for high school students and recent graduates, supported by scholarships and local partnerships, while California is prioritizing “grow your own” strategies to strengthen a homegrown rural workforce.
Incentives Linked to Rural Service Commitments: Targeted financial incentives remain a key recruitment and retention strategy. Alaska is proposing upfront bonuses tied to multi-year service commitments, with incentives weighted toward later years to encourage retention. Service-based incentive models are commonly used in rural workforce policy and can support longer-term stability when paired with other supports.
Integrating Behavioral Health into Broader Rural Initiatives: Payment Approaches and Technology Investments
As states move toward advanced behavioral health integration, the RHTP program offers a pathway to scale and expedite those efforts through targeted technology and flexible payment initiatives.
Alternative Payment & Value-Based Care Initiatives: States are also using RHTP program funds to advance alternative payment and value-based care approaches that better support behavioral health integration in rural communities. South Dakota is proposing payment models that explicitly include behavioral health services, creating opportunities to better align financing with whole-person care. New Hampshire is focused on strengthening accountable care organization readiness to enable federally qualified health centers and other safety-net providers to participate in value-based payment and two-sided risk arrangements, including models that support integrated behavioral health.
As states consider how to sustain RHTP investments, aligning these efforts with other behavioral health funding streams — including opioid settlement funds — may offer a pathway to strengthen substance use disorder services, particularly for justice-involved and rural populations. A braided funding approach can support longer-term system improvements beyond grant cycles. NASHP highlighted this strategy in A Braided Funding Approach: Leveraging Opioid Settlement Funds to Strengthen Supports for Justice-Involved Populations.
Technology: Behavioral health was excluded from some federal technology infrastructure investments (e.g., the HITECH Act), resulting in lags in data integration with broader health systems. Today, states are targeting some RHTP funding to build sustainable, integrated health systems including behavioral health. By embedding behavioral health into data infrastructure investments, interoperability and telehealth strategies, and emerging technology initiatives, states are developing models that could redefine rural behavioral health care delivery.
- Interoperability: Many states are improving interoperability, so providers can share patient information more easily. Rhode Island plans to link doctors, behavioral health providers, and community organizations into a coordinated, team-based system, using interoperable technology. Research shows that these connected systems can improve care coordination.
- Telehealth: Telehealth is being widely deployed to increase access to care for rural populations. States like Arizona plan to leverage RHTP program funds to expand telehealth capacity to connect patients with behavioral health services, reducing the need for travel and enabling timely interventions. Telehealth for mental health is well-supported by research as an effective strategy for improving access and patient outcomes in rural communities.
- Emerging Technologies: States are increasingly exploring tools such as remote monitoring, Artificial Intelligence (AI) enabled applications, and consumer-facing digital platforms to strengthen rural health systems. While behavioral health is not always explicitly named, these technologies show growing promise in supporting mental health and substance use disorder care across prevention, treatment, and recovery. A strengthening evidence base (e.g. Peterson Health Technology Institute on virtual solutions for anxiety and depression) is helping clarify which digital tools deliver measurable clinical value.
Behavioral health is a strong throughline across RHTP programs, spanning integration, crisis services, workforce, and technology. These initiatives create an opportunity to scale evidence-based practices and learn from real-world implementation.
Note: The examples highlighted here are taken from publicly available state RHTP applications prior to December 29, 2025. These strategies may continue to evolve, as states finalize plans and begin implementation of activities in the coming months.
Acknowledgments
Support for this work was provided by West Health and Foundation for Opioid Response Efforts (FORE).
