Earlier this month at HIMSS, I had the opportunity to represent the Gravity Project at the HL7 International exhibit, presenting alongside Katie Keating, Vice President of Solutions Engineering, on the role shared data standards play in powering rural health transformation. 

From Activity to Impact: Shifting How We Think About SDOH Data

For the past decade, there’s been a meaningful shift in how we think about health. Community-based services that address social drivers of health (SDOH)— or the non-medical factors that impact our health like food access, housing support, transportation, and maternal health services—are no longer seen as adjacent to healthcare, but as essential components of it.

We’ve also worked with our customers to build a growing body of evidence showing that when these needs are addressed, we see real outcomes: reduced total cost of care, fewer ED visits, and improved clinical measures like A1C and blood pressure control.

But one of the biggest challenges has remained: proving ROI consistently and at scale.

Moving from activity tracking (“a referral was made”) to outcome attribution (“this intervention improved this person’s health and reduced cost”) requires more than programs and partnerships. It requires a shared language.

Why Data Standards Matter

That’s where SDOH data standards come in.

Standards-based infrastructure,  like the work advanced through the Gravity Project and enabled through HL7 FHIR, allows clinical providers, community-based organizations, payers, and states to speak the same language. It creates consistency in how we:

• Capture social risk and needs
• Send and receive referrals
• Document services delivered
• Track outcomes and close the loop

Without that shared foundation, even the most well-designed programs struggle to demonstrate impact in a way that is measurable, repeatable, and scalable.

What This Looks Like in Practice

We’re now seeing leading states operationalize data standardization in meaningful ways.

In North Carolina’s Healthy Opportunities Pilots (HOP), the state built a first-of-its-kind program to pay for evidence-based, non-medical services for Medicaid members. In its interim evaluation, the program demonstrated $85 PMPM savings for enrolled members.

That result didn’t happen by chance. It required the ability to connect data across many different stakeholders like managed care plans, clinically integrated networks, and community-based organizations, and to consistently track services delivered and outcomes. 

Similarly, Missouri’s Transformation of Rural Community Health (ToRCH) initiative is showing how a hospital-led, community-based model can improve care coordination while also reducing administrative burden. Connecting hospitals and community organizations through shared, standards-based infrastructure, show the program is enabling more timely follow-up, better visibility into services, and HEDIS gap closures. 

In both cases, standards-based infrastructure t makes it possible to link actions to outcomes, with proven results. 

Why Data Standards Matter for Rural Health

This conversation is especially timely as states begin preparing for the Rural Health Transformation Program (RHTP), a significant, time-bound federal investment aimed at strengthening rural health systems.

At its core, the opportunity is not just to fund new programs, but to build systems that are sustainable. 

That means:

• Supporting rural providers under financial strain
• Expanding workforce capacity, including community health workers and doulas
• Investing in infrastructure that connects clinical and community care
• Demonstrating measurable improvements in cost and outcomes

But across all of these priorities, one requirement stands out: the ability to measure impact.

And in rural communities, where care often involves a complex network of providers, community organizations, and support services, that measurement challenge is even more pronounced.

Bringing It Back to the Individual: A Maternal Health Impact Story

Maternal health is a key priority across many states’ RHTP strategy. During our session, we used this as a lens to illustrate why standards-based infrastructure is critical to achieving meaningful, measurable outcomes.

Pregnancy-related mortality is up to 50% higher for rural individuals compared to their urban counterparts, and in some analyses, rates are nearly twice as high in rural areas. We also see higher rates of severe maternal morbidity, infant mortality, and complications like preterm birth in rural communities.

At the same time, access to care is declining. Over two-thirds of rural counties lack hospital-based obstetric services, and many patients are traveling 30–50+ minutes to reach care, if it’s available at all.

Imagine a pregnant patient in a rural community. She may be enrolled in Medicaid and receiving clinical care from a provider located over an hour away, without access to transportation and fresh produce. So when states set goals like improving maternal health outcomes as part of their rural health strategies, this is the reality they need to help individuals overcome. 

States may employ strategies to meet the pregnant mom where she is – connecting her to a community health worker to navigate access to transportation and food, and a doula to provide important prenatal education, supportive services, and advocacy. These non-clinical supports might be approved to be reimbursed by Medicaid within their state. Meanwhile, her provider is documenting in an EHR, the birthing hospital is documenting in another system, and the CHW/doulas in a third system, or using spreadsheets. At the policy level, a state Medicaid analyst who has never met the member, is trying to answer a critical question:

What actually improved outcomes for this patient, and what should we scale in order to positively impact more pregnant individuals?

That’s where standards-based infrastructure becomes essential. By understanding the social risk data the individual was experiencing (LOINC, snomed), what referrals were sent and what supportive services the individual was able to access and what outcome occurred (FHIR), what billable services were provided and reimbursed (Z-codes, HCPCs codes, X12 EDI), and enabling all of these stakeholders to be able to support this pregnant individual on their journey to receiving care (FHIR APIs), the analysts at the policy level are able to understand how programs on the ground are running and whether those interventions are making the impact they need. Without a shared language across all of these actors, it’s incredibly difficult to connect interventions to outcomes. This is why the work the Gravity Project does to create shared language and exchange is fundamental for programs to be scalable, replicable, and sustainable.

The Path Forward: Leveraging Data Standards to Power Better Rural Health Outcomes

Rural health transformation isn’t just about funding or new programs. It’s about building the infrastructure to enable providers to coordinate care across the continuum through secure data exchange, speak the same language through shared terminology, and measure the impact of programs in order to ensure sustainability. Standards are the foundation of that work, turning fragmented data into coordinated systems, and uncovering insights on impact.

Thanks to the important work done by the Gravity Project, technology infrastructure can adopt these shared standards and leverage interoperable exchange through HL7 FHIR to connect clinical care, community services, and policy analysis. This is what makes it possible to measure, scale, and sustain interventions.

When everyone is speaking the same data language, we don’t just track one-off activities. We can see what works and expand it to improve care for more people in rural communities.

Learn more about partnering with Unite Us for rural health transformation

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NEW YORK – January 14, 2026 –  Unite Us, the nation’s trusted technology partner for integrating health and community-based care, released results from a new evaluation of Missouri’s Transformation of Rural Community Health (ToRCH) program. Supported by Missouri Medicaid and powered by Unite Us infrastructure, the ToRCH program demonstrates how hospital-led, community-based care coordination can improve health outcomes, reduce costs, and mitigate administrative burden to help residents thrive across rural communities.

Through ToRCH, rural hospitals serve as regional hubs that connect patients to critical community services addressing non-medical drivers of health, including food access, transportation, housing, and more. Across six participating counties, the program has already generated measurable results: 

• 99% invoice acceptance rate
• 18% increase in timely behavioral health follow-up after emergency department visits
• 19.6% increase in individuals with controlled blood pressure
• 17 minutes saved per referral

“Rural health funding gives communities the chance to stop thinking in short-term fixes and start building for the future,” said Taylor Justice, CEO and Co-Founder of Unite Us. “ToRCH shows what’s possible when underfunded communities pair ingenuity with the right infrastructure. Missouri is proving that rural communities can cut costs and reduce inefficiencies, while building sustainable capacity that delivers value across the entire system.”

A Blueprint for Scalable Rural Health Innovation

With rural health funding recently awarded via the Rural Health Transformation Program (RHTP), the ToRCH program offers a replicable blueprint for states committed to optimizing their rural health funding. 

The program, referenced by CMS as an example in the RHTP applications, demonstrates how rural communities can use data and technology to align incentives, leverage existing funding streams, and empower hospitals to integrate community care models in a sustainable way.

An Innovative Model for Rural Care Coordination

Since July 2024, six ToRCH hub hospitals have coordinated care for nearly 2,800 individuals through the Unite Us platform, connecting them to more than 900 community services. Sixty-six percent of referral activity was initiated directly by hub hospitals, reinforcing their role as anchors for cross-sector collaboration in rural settings.

“To hear the stories of the participants’ lives who have been impacted in a positive way—improving their health while also improving the financial health of the Missouri Medicaid program—that’s been very gratifying for my team,” said Kirk Mathews, Chief Transformation Officer at MO HealthNet.

Technology Driving Efficiency, Accountability, and Compliance

Beyond improving patient care, the ToRCH program demonstrates how centralized technology can reduce administrative complexity for providers and states alike. Survey results further underscore the model’s impact: 88% of respondents agreed that ToRCH improves overall patient care, and a majority reported reduced stress related to documentation and follow-up.

The full case study, Lighting the ToRCH: Powering Rural Health Transformation through a Hospital-Led Hub Approach, is available today. Read it here.

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Can you start by telling us a little bit about Española Pathways Shelter and your role there?

Española Pathways Shelter has been serving our community for about seven years. I’ve been with the organization since the beginning, helping provide overnight shelter services for both men and women experiencing homelessness.

In addition to the shelter, I oversee Eagle Village Recovery Housing, a transitional program for individuals coming out of treatment. Participants must have completed at least six months in a treatment facility, and they can stay with us for up to 18 months while receiving case management, supportive services, and connections to other local resources through Unite Us.

What are some of the unique strengths and challenges of serving a rural community like Española?

I’ll start with the strengths; one of our biggest strengths is our close-knit community. I was born and raised here, and people really look out for each other. There’s a strong sense of family and local support, which helps us work collaboratively with both clients and their loved ones.

But rural areas come with their challenges too, transportation being a big one. Resources are spread out, and while we do have public transit, it doesn’t always reach the outskirts of our county. Río Arriba County is one of the largest in New Mexico—roughly the size of Maine—so getting services to everyone can be difficult.

What are some of the biggest barriers to health and well-being your clients face, and how do you help address them?

Access to care can be tough in rural areas. It can take a long time to establish primary care or find a provider who’s accepting new patients. Again, transportation is a major hurdle, especially for the elderly or those who aren’t comfortable with technology.

At Pathways, we use Unite Us to help clients connect with other local organizations. The ability to make referrals and warm handoffs through the network helps us navigate some of these barriers, bridge care gaps, and help people get the support they need. 

Can you share a success story from your work using Unite Us?

Absolutely. A few months ago, I received a referral through Unite Us for a client who was relocating from Santa Fe to Española to be closer to family. Through that referral, I was able to  access information about his goals and previous services.

That made it easy to pick up right where the other provider left off. As soon as he arrived, I was able to connect him with local resources right away. It made the transition seamless for him and saved us both a lot of time and effort.

Since joining Unite Us, how has your approach to connecting clients to care changed?

I’ve been a navigator on Unite Us’ platform for almost seven years now, and I’ve seen firsthand how it’s evolved. It’s made collaboration much easier for our case managers and shelter staff.

Beyond the platform itself, monthly navigator meetings—hosted by Santa Fe County—give us the chance to connect with others across the region. We share challenges, success stories, and best practices, which strengthen our community as a whole. Unite Us has become a crucial tool for ensuring that even outlying rural areas have access to coordinated care.

What’s the value of being part of a broader care network for a rural organization?

It’s huge. Being connected through Unite Us means we can see who’s in our network and refer clients quickly for the services they need. In rural areas where people may only get to town once a week, that efficiency and immediate access to local resources really matters.

The platform also helps us stay connected with other providers, even when we can’t meet face-to-face. It gives rural organizations a broader reach and helps us better serve our clients.

What advice would you give to other rural providers who are considering joining Unite Us?

I’ve been out in the community banging the drum about how critical it would be to get us all connected on the Unite Us network. For rural communities, they’d instantly have a broader base of opportunities to provide access to resources for the clients that we serve. 

I tell them that it’s extremely user-friendly—and I say that as someone who’s not very tech-savvy at all! The tech support is amazing. Any issues or any questions I’ve ever had, I get resolved quickly. Even if technology isn’t your strong suit, you’ll always have help and guidance from Unite Us. It’s a platform built to make collaboration easier, not harder.

Finally, what gives you hope for the future of health and human services in rural New Mexico?

I’m hopeful about the growing use of technology and platforms like Unite Us that bring providers together in one cohesive network. As more providers and organizations join, our ability to serve clients efficiently will only continue to improve. 

The more connected we become, the better we can overcome the barriers that make rural care challenging. I truly believe this kind of collaboration will shape a stronger future for rural communities everywhere.

About Española Pathways Shelter:

Española Pathways Shelter provides shelter, recovery housing, and supportive services to individuals and families in northern New Mexico. Through their partnership with Unite Us, the organization offers an evidence-based approach, as well as a wrap-around supportive services model, that provides comprehensive care alongside shelter and vital links to more permanent housing and stability.

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Washington, D.C. — Nov. 3, 2025 — Lumeris, a leader in healthcare technology and services, today announced the formation of a coalition – Collaborative for Healthy Rural America (CHRA)™. Formed to help state leaders accelerate their efforts in the Rural Health Transformation Program (RHT) administered by Centers for Medicare & Medicaid Services (CMS) – the coalition includes Lumeris, Teladoc Health, Nuna, Deloitte*, and Unite Us.  

CHRA members will work together to deliver an AI-enabled interoperable operating platform that accelerates state RHT participants’ abilities to realize their visions. The platform will connect patients and clinicians—bringing national economies of scale to the local delivery of care in rural communities. 

“The Rural Health Transformation Program makes possible a new paradigm for healthcare access and delivery for millions of rural Americans,” said John Doerr, chairman of Kleiner Perkins. “We formed this collaborative to give states an immediate execution path towards their visions, with an AI-driven operating platform of class-leading technologies.”  

The need is urgent. Millions of Americans live in rural communities and many of them are covered by Medicaid and Medicare programs. According to the U.S. Health Resources and Services Administration, the nation faces a shortfall of more than 87,000 primary care physicians over the next decade, a gap especially acute in rural and underserved communities. 

The American Hospital Association reports that nearly 190 rural hospitals have closed since 2005 and more than 600 remain financially at risk. These challenges have left millions of Americans without consistent access to basic care. According to a study by the National Association of Community Health Centers and Health Landscape at the American Academy of Family Physicians, more than 100 million Americans lack access to primary care, and another 100 million receive care that is fragmented or suboptimal. 

CHRA aims to address these challenges through shared infrastructure, unified data, and modern technology. At the center is Primary Care as a Service (PCaaS)—a scalable platform to expand access, strengthen preventive care, improve chronic disease management, and coordinate care—while reducing administrative burden and stabilizing rural healthcare.

National scale, delivered locally

CHRA will adapt to the needs of each state while delivering benefits of scale—creating a flywheel of rising quality and lower costs. 

“CHRA was founded to leverage the government’s catalytic Rural Health Transformation investment as seed capital for a strategic, private-sector–funded solution to rural healthcare,” added Mike Long, chief executive officer, Lumeris, a CHRA founding member. “We fully support RHT’s goal to build a sustainable rural healthcare delivery ecosystem for future generations—one that ultimately lifts the burden on strained state and federal budgets.”

“The mission of CHRA aligns with Google Cloud’s efforts to help healthcare organizations improve operations and help clinicians provide better care, through the use of AI and cloud technologies. There is no better place to advance this work than underserved populations in rural America,” said Aashima Gupta, global director of healthcare strategy and solutions, Google Cloud. 

Guiding Principles of the Collaborative

• Provide comprehensive, scalable, technology-driven healthcare solutions to serve rural Americans
• Share benefits of national economies of scale to serve rural community needs
• Track sustainability metrics such as reduced preventable hospitalizations, higher patient satisfaction, higher patient self-sufficiency, stabilized provider finances and reduced administrative burden 
• Offer increased access nationwide within six months, and enhanced capabilities within 18 months, recognizing this goal may be limited by data access approvals and available infrastructure 
• Fully leverage and extend the capabilities of local care delivery resources

Founding Organizations and Roles

• Lumeris — Primary Care as a Service Platform. Through its AI-enabled Tom™ platform, Lumeris provides the backbone technology, workflows, and population-health visibility that make primary care function as a utility for rural America. Google Cloud’s AI models and infrastructure power AI-enabled Tom™ to bring together the best of AI, cloud computing, primary care expertise and proven solutions to help solve one of healthcare’s most intractable problems.
• Teladoc Health — High Quality Virtual Care Delivery. With the largest nationwide network of virtual care providers including licensed clinicians, therapists and health coaches, Teladoc Health delivers and orchestrates primary care, 24/7 urgent care, mental health, and chronic care services to expand access and improve outcomes in rural communities.
• Nuna —Daily Virtual Coach for Chronic Disease: Nuna’s platform includes an AI-native mobile app, a daily ‘coach’, to support patients to follow their physicians’ care plans. Nuna’s app notifies clinical care teams for support or intervention when necessary.
• Deloitte — Execution & Program Operations. Deloitte provides systems interoperability and data integration across IT platforms, using analytics and population data, to drive and measure program outcomes. Deloitte provides program execution and supports alignment of state efforts with the CMS Rural Health Transformation program guidelines.
• Unite Us — Human Services Coordination & Community Network Integration. Unite Us’ Self Sufficiency Score establishes a benchmark and measures the ongoing effectiveness of human service interventions, connecting rural residents to medical, behavioral, and community support services via an integrated care coordination and payment platform.

¹https://www.hrsa.gov/rural-health/about-us/what-is-rural

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Learn more about how to:

• Build cross-sector partnerships between hospitals, providers, and CBOs that break down silos and strengthen local leadership.
• Leverage technology and data for real-time coordination, measurable outcomes, and smarter strategies.
• Design for sustainability through models like ToRCH’s shared savings approach that reinvest in rural systems.

Key Takeaways:

• Practical lessons from Missouri’s ToRCH model that demonstrate the power of community-led innovation.
• Insights into how technology can strengthen trust, streamline coordination, and create lasting impact.
• Strategies for building sustainable, resilient rural health systems that keep communities at the center.

The post Rural Health: A Guide for Digital Health Transformation appeared first on uniteus.com.