Published On
July 22, 2026
Authors
How RHTP Can Scale School-Based Health Care
The $50 billion, five-year Rural Health Transformation Program (RHTP) gives states a rare opportunity to fundamentally reshape rural health care delivery. One trend is already emerging from states’ first-year investments: many are looking to schools to serve as trusted access points for improving children’s and adolescents’ health outcomes. School-based health care is not new but scaling it in rural communities has historically been difficult because most school districts lack the clinical and operational infrastructure needed to sustain it.
What makes today different is not simply RHTP’s scale, but its timing and flexibility. The need has never been greater— rural workforce shortages and access gaps persist, with behavioral health particularly strained, as youth mental health and substance use needs continue to grow. But the tools have also never been better. Telehealth and partner-led care models have matured and allow providers to extend scarce clinical capacity into rural schools without asking districts to become health care providers. Unlike many traditional grant programs, RHTP allows states to invest in workforce strategies, technology, new delivery and payment models, prevention, and behavioral health, and can be awarded to local partners, making school-based care an increasingly attractive and scalable setting. Just as the COVID-19 public health emergency finally cemented telehealth as a durable component of rural health care delivery, RHTP has the potential to do the same for school-based models.
The most successful models will recognize that schools and health care organizations bring different strengths and build partnerships that combine schools' trusted relationships with families and health care organizations’ clinical, operational, and administrative capabilities. The question is no longer whether schools should play a larger role in rural health care, but whether states can design partnerships that make that role sustainable.
How States Are Using Schools in RHTP Strategies
Manatt's review of states’ RHTP applications, procurements, and early grants points to four recurring priorities for leveraging schools to improve rural health access and outcomes.
Goal | Why states are investing | Illustrative state examples |
|---|---|---|
Expand behavioral health access | Schools are where unmet behavioral health needs are highly visible, families are often easier to engage than in traditional outpatient settings, and addressing needs has direct educational impact. | “Building Bridges” initiative uses schools as multi-generational behavioral health entry points, beginning in pre-K through 5th grade, incorporating evidence-based practices from the pediatric collaborative care model. proposes leveraging funding for dedicated, in-school space for parent-selected behavioral health professionals to see students during the school day. |
Build virtual care infrastructure | States are building virtual care infrastructure in schools to extend scarce clinical workforce into rural communities, leveraging schools’ reliable internet, structured environments, and adult supervision to support telehealth and remote monitoring. | proposes expansion of a proven school-based tele-behavioral health program into more rural schools to address psychiatric provider shortages. is investing in chronic disease remote patient monitoring in schools, extending virtual care beyond behavioral health. |
Build in-person clinical infrastructure | States are building in-person clinical capacity in schools, from school-based health centers (SBHCs) to mobile providers to school nursing models, to provide direct care to students and, in some models, families and communities. | plans to establish new SBHCs, including piloting autism spectrum disorder screening technology and plans to couple this funding with technical assistance support to ensure successful implementation. Ohio also plans to build on its, to provide mobile vision, hearing and dental care in collaboration with participating school districts. is launching a rural school nursing access program that funds a nurse consultant to support three rural/frontier districts, coordinating school nurse extenders, telenursing and local public health RNs. |
Advance prevention and whole-child health | States are investing in school-based nutrition, physical activity, and other prevention initiatives that signal a shift toward viewing schools as community access points for improving long-term health, not simply as sites for episodic care delivery. | is funding School Kitchen Modernization Grants to enable rural schools to transition toward scratch cooking and access to whole fresh foods. is funding nutrition and physical activity programming in partnership with rural school districts and requiring referral pathways that connect students and families to clinical and community nutrition services. |
The pattern across these investments indicates that states are not asking every rural school to become a clinic. Instead, they are matching specific health needs with partnership models that allow schools to serve as access points while larger health care organizations absorb the clinical and administrative complexity.
Three Design Principles for Sustainable School-Based Care
Early RHTP investments suggest that the most durable school-based health models will not necessarily be those that invest the most, but those that are intentionally designed from the outset. Three principles stand out.
- Treat schools as access points, not health care delivery organizations. Schools are uniquely positioned to connect children and families with care because they are trusted, geographically distributed and deeply embedded in their communities. But most districts are not designed to provide clinical care or manage the billing, compliance, reporting and administrative infrastructure that health care delivery requires. The strongest models recognize each partner’s distinct strengths. Schools provide trusted access to students and families, while FQHCs, hospitals, behavioral health providers, and other health care organizations bring the clinical expertise and operational capabilities needed to deliver care sustainably. States should focus less on expanding what schools do themselves and more on designing partnerships that allow each organization to contribute what it does best.
- Define how partners work together. Launching a school-based health initiative requires more than funding services or purchasing equipment. Success depends on intentionally designing how health care and education systems will work together, recognizing that they operate under different missions, governance structures, privacy laws, funding mechanisms and regulatory frameworks. Clearly defining roles, decision-making processes and accountability structures at the outset allows schools, providers, and community partners to contribute according to their strengths while meeting their respective operational and regulatory requirements. Clear and detailed partnership agreements and supportive technical assistance can help translate that design into effective execution.
- Build for sustainability from the beginning. CMS has consistently emphasized that RHTP is a time-limited source of funding intended to seed transformation that outlives it. Few school-based health partnerships can survive without Medicaid financing—whether through fee-for-service or managed care, Medicaid school-based services, or FQHC PPS—so engaging Medicaid on long-term coverage and reimbursement pathways from the outset is critical for sustainability. Equally important is building the provider partnerships, operational infrastructure and implementation capacity needed to sustain these models after RHTP funding ends.
What Success Requires from Each Stakeholder
The models most likely to endure will be those that stakeholders approach as long-term infrastructure investments requiring coordinated design, rather than as isolated programs.
- States should resist treating funding as the end goal. Their central task is building the operational infrastructure that enables schools—including in smaller and more rural districts—and providers to participate successfully, including technical assistance, shared implementation, sustainable financing pathways (including Medicaid and CHIP coverage), and mechanisms to identify and scale successful partnership models.
- County and regional planners should view schools as part of a broader rural health care delivery system, not as standalone outposts. School-based investments should be planned alongside regional provider capacity, health needs assessments, referral pathways, and workforce and telehealth planning to ensure they strengthen the surrounding care system rather than duplicate it.
- Health care providers should identify the partnership models and reimbursement pathways that support long-term participation and embed their services and operations alongside existing school staff and student supports.
- School districts and education leaders should define the role they can sustainably play while protecting their educational mission. Successful partnerships identify early what legal, consent, workflow, billing, and compliance support they will need from health care partners or intermediaries.
- Technology vendors should design for the intersection of health care and education. Successful solutions will support interoperability, consent management and workflows that accommodate both health care and education regulatory requirements while fitting into school operations. Because RHTP funds typically flow through a state-based lead applicant, vendors are best positioned when they partner with on-the-ground providers and districts.
The Bottom Line
Early RHTP investments signal that states increasingly view schools as critical access points for rural health. But deploying year one funds is only the first step, and CMS has made clear that sustainability is central to how it will measure success. RHTP’s lasting value will come not from turning schools into health systems, but from helping states build durable partnerships that pair schools' trust and community reach with health care partners equipped to deliver and sustain clinical services. Whether this rare opportunity produces lasting rural health infrastructure or a round of short-lived pilots will depend on the design choices states make now.
