RHTP Funding – A Golden Opportunity to Fill the Advance Care Planning Infrastructure Gap

How states can use RHTP funding to embed advance care planning as interoperable infrastructure across rural care settings

By Scott Brown, President & CEO

States across the country are allocating Regional Healthcare Transformation Program (RHTP) funds to modernize care delivery in rural communities. The priorities are clear: improve health access, care coordination, and outcomes through infrastructure modernization, workforce development, and innovation.

Those are the right priorities, and more than a few states are working to take advantage of available funds to fill a longstanding gap in their advance care planning (ACP) structures so they can treat ACP as interoperable infrastructure instead of a local initiative, finally aligning coordination investments with clinical reality.

Rural Demographics Expose the Risk . . . and the Golden Opportunity

Consider what aging demographics look like in rural states.

Data recently shared by CyncHealth Nebraska, Nebraska’s statewide health information exchange (HIE), reflects demographic realities common across many rural regions:

• 20% of residents are age 65 or older

• 40% of aging adults live in rural areas

• 70% of rural older adults have at least one chronic condition

• The average one-way travel distance for healthcare is 32 miles

• Residents in the most rural ZIP codes travel 1.5 times farther for medical care than Nebraskans in less rural areas

• Rural patients with Alzheimer’s disease experience 14% more emergency department visits than their urban counterparts

These are utilization signals.

High chronic disease prevalence, long travel distances, and elevated emergency department use create environments where care decisions frequently occur during crisis transitions. In those moments, uncertainty drives escalation. Escalation drives utilization. Utilization drives cost.

Transformation funding that modernizes connectivity without ensuring goal- and order-concordant care doesn’t fully address this exposure.

Fortunately, forward-thinking states are seizing the golden opportunity to train rural healthcare professionals, improve ACP processes, and expand infrastructure to ensure high-quality, structured ACP documentation, including advance directives, living wills, and portable medical orders such as POLST and DNR forms, becomes widely accessible to medical teams so they aren’t forced to default to high-intensity interventions.

Successful Rural Health Transformation Requires Goal and Order Alignment

RHTP funds submissions we’ve reviewed frequently support:

• Care coordination programs

• Data analytics and dashboards

• Infrastructure upgrades

• Health information exchange connectivity

• Rural health access initiatives

These investments are necessary. But coordination without accessible patient goals of care and medical intervention orders creates a structural blind spot.

Goal-concordant care requires at a minimum that patient preferences be documented, structured, and retrievable across settings. Order-concordant care requires even more – portable medical orders must follow the patient across transitions of care, including EMS, community paramedicine, and other emergency care teams delivering care in the field, as well as emergency departments, skilled nursing facilities, and home-based care.

If ACP documentation remains siloed within local systems, paper records, or single-provider portals, statewide healthcare coordination infrastructure is incomplete.

For patients and their loved ones, siloed documents mean low-benefit, high-intensity treatments and interventions that may not align with their values. For mobile healthcare professionals, they lead to significant moral distress and burnout. And for state healthcare policymakers and health system leaders – especially those operating in value-based care environments – the ACP structural gap translates into measurable operational and financial exposure.

Federal Direction Is Clear

Along with many of MyDirectives’ longstanding friends in the industry, I attended last week’s annual meeting of the Assistant Secretary for Technology Policy in Washington, D.C., where federal leaders delivered a clear and direct message: use the tools that already exist.

In the context of ACP, the tools exist.

A secure, nationwide, interoperable registry exists.
Structured ACP data standards and documentation exist.
Scalable, standards-based EHR integrations exist.
Field access for EMS, emergency care teams, and community paramedicine exists.

The policy environment is also evolving.

The Centers for Medicare & Medicaid Services (CMS) has advanced proposed quality measures such as MUC2025-020, reflecting growing attention to documenting and aligning care with patient goals and medical orders across settings. As accountability expands across transitions of care, concordance between documented preferences or medical orders and delivered care becomes measurable, not to mention legally and financially relevant.

At the Federal legislative level, bipartisan efforts such as the MAP for Care Act and the Improving Access to Advance Care Planning Act further signal national recognition that ACP must be modernized and made accessible across time and care settings. MyDirectives has publicly supported these efforts, joining organizations such as C-TAC, LeadingAge, the NPHI, and the National Alliance for Care at Home in advocating for stronger ACP access and infrastructure nationwide.

These developments define the accountability environment in which states and health systems will operate. It’s already evolving, and accountability expectations will increase.

Farsighted states allocating RHTP funds today are building infrastructure for the system CMS is shaping tomorrow. That system is not hypothetical. It’s already taking shape.

If interoperable ACP infrastructure isn’t included in your state’s funding strategies, your transformation efforts risk being misaligned with emerging Federal quality measurement and accountability frameworks.

ACP Is Infrastructure, Not a Program

Too often, healthcare stakeholders categorize ACP as:

• A social work initiative

• A hospital service line

• A palliative care program

• A community outreach effort

Those components matter. They aren’t infrastructure.

Infrastructure means:

• Digital documentation with structured data elements

• Standards-based interoperability across EHR platforms at scale

• Availability within the clinical record with little or no extra effort

• Accessibility to EMS, emergency care teams, and community paramedicine organizations delivering care in the field regardless of the ePCR platform they use

• Integration and widespread adoption through HIEs and HDUs

When ACP is embedded at the infrastructure layer, care coordination programs gain clinical alignment. EMS and emergency care teams can access medical orders during crisis response. Rural providers can retrieve preferences without delay. Hospital leaders can reduce high-intensity interventions driven by ambiguity rather than medical necessity.

Health equity in rural communities requires more than expanded access points. It requires that the information guiding decisions is present wherever care is delivered.

The Funding Imperative

RHTP and similar healthcare transformation funds are finite, and states are making infrastructure decisions now that will shape accountability for years.

Funding analytics without goal and medical order alignment creates reporting without resolution. Funding coordination teams without interoperable ACP infrastructure creates process without clarity. Funding connectivity without structured, accessible advance directive information and portable medical orders creates technical capability without decision support.

Interoperable ACP infrastructure should be identified as a discrete, funded component within RHTP strategies, not treated as an unfunded programmatic add-on. MyDirectives is already working alongside states that are actively incorporating interoperable ACP infrastructure into funding strategies, recognizing that those states failing to do so risk misalignment of their care coordination models with emerging Federal accountability expectations.

When treated as interoperable infrastructure, ACP supports goal- and order-concordant care, rural health equity, and measurable transformation outcomes.

State policymakers, HIE leadership, and health system executives developing rural health transformation funding strategies should ensure interoperable ACP infrastructure is explicitly incorporated into their plans. The tools exist. The accountability environment is evolving. Funding alignment now will determine performance tomorrow.

About the Author

Scott Brown is President and Chief Executive Officer of MyDirectives, the leader in digital advance care planning. He founded the company in 2007 with a deeply personal mission: to ensure his mother, who had multiple sclerosis, could have her voice heard and respected at the end of her life. That vision continues to guide MyDirectives as it helps people document, share, and access their care preferences anytime and anywhere.

A strong advocate for interoperability and person-centered care, Scott is co-editor of the HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan Document and a reviewer of the HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Revised Templates for Advance Directives. His work contributes to national standards that make care preferences and medical orders accessible and actionable across the healthcare ecosystem.

Before founding MyDirectives, Scott practiced international corporate, securities, and M&A law in Paris and Dallas. He earned his undergraduate degree with distinction from the University of Oklahoma, graduating Phi Beta Kappa, and received his Juris Doctor from Tulane Law School.