HSS26061-MEDSCHPSHP_AppE.pdf

Rural Health Needs and Target Population

Delaware's rural health landscape reflects the pressures of a small but rapidly transforming state with stark disparities between its northern urban areas and southern rural counties. According to the Health Resources and Services Administration (HRSA) Federal Office of Rural Health

Policy definition, Sussex County is fully rural (all census tracts designated rural), while Kent is partially rural and New Castle

County is not. Roughly 38-40% of

Delaware residents - about

400,000 people - live in these rural areas, facing healthcare challenges that far exceed their geographic footprint.1

Sussex County embodies

Delaware’s rural health crisis.

With a total population of 271,000, it is one of the fastest growing counties in the nation – expanding 29.3% from 2010-2022, compared to 7.7% nationally and

13.2% statewide.2 Growth is projected to continue through at least 2032, placing extraordinary strain on healthcare infrastructure. Yet despite this growth, Sussex County is designated entirely as a Medically Underserved Area (MUA) and a Health Professional Shortage Area (HPSA) for primary care, dental care, and mental health services. The same is true for Kent County. In fact, Delaware ranks dead last - 50th nationally - in meeting primary care needs, with only 14.85% of demand met and a shortfall of 71 primary care physicians statewide to remove HPSA designation.3 In Sussex County, the healthcare workforce crisis is acute: there are only 130 active primary care physicians serving 271,000 residents - a ratio exceeding 2,000:1, well above

HRSA's shortage threshold.4 Kent County fares slightly better at 1,700:1 compared to 960:1 in urban New Castle County. Forty percent of Sussex County residents lack a primary care provider entirely, and average wait times for new appointments have more than doubled—from 11.5 days in 2013 to 27 days in 2021.5

The pressure on this already thin healthcare workforce will only intensify. More than 26% of

Sussex County's population is aged 65 and older—significantly higher than the national rate of

17% and rising as retirees from neighboring states continue to move to Delaware’s rural coastal communities. By 2035, this aging cohort will demand 36% more trauma services, 30% more rehabilitation services, 23% more lab services, and 15% more cardiac services.6 Yet the provider pipeline remains limited. Delaware has no medical school, limited rural clinical rotation opportunities, and in turn, has not been able to implement the "train here, stay here" model that has successfully placed physicians in underserved communities nationwide.

These workforce shortages translate directly into poor health outcomes. Seven of Delaware's ten leading causes of death stem from chronic disease, with rates of hypertension, diabetes, and cancer exceeding national benchmarks.7 Approximately 10% of Delaware residents manage multiple chronic conditions simultaneously, and the state ranks in the bottom fifth nationally for prevalence of high cholesterol and chronic kidney disease—conditions requiring consistent primary care management. The burden falls heaviest on Sussex County and rural Kent County.

Adult obesity rates in Sussex are 36% - the highest in Delaware, more than one in eight adults

(13.1%) have diabetes, and 20% have poor or fair health overall.

These poor health measures reflect not only limited access to preventive care but also the compounding effects of poverty, food insecurity, and poor health education. Geography itself is also a barrier to health. Residents in western Sussex County routinely travel 50 miles to reach hospitals or specialty providers, often without reliable public transportation. The result is deferred care, preventable complications, and high health care costs.

Rural Health Transformation Plan: Key Performance Objectives

The Delaware Rural Health Transformation Plan (RHTP) confronts these realities through 15 integrated initiatives spanning workforce development, expanded access to care in rural communities, technology innovation, and prevention. Together, they will expand access through community-based delivery; strengthen the workforce pipeline through medical education and rural training opportunities; modernize rural facility operations and payment models; improve population health and chronic disease management; and offer technological innovations to promote better health. The primary beneficiaries will be the residents of rural Sussex County

(271,000 residents) and Kent Counties (~50% rural, 193,000 total residents), totaling approximately 400,000 rural residents. By investing in coordinated, community-anchored strategies, Delaware will not only prevent the loss of critical rural health capacity but create a resilient, connected, and sustainable healthcare system that truly makes rural America healthy again.

Rural Health Transformation Plan: Goals and Strategies

Figure 1: Rural Health Transformation Plan Logic Model

Improving Access: Delaware’s RHTP includes proven healthcare access strategies that address needs identified through data and community input. These strategies build on existing efforts and partnerships to create a strong network of community providers that leverages innovative technology to serve patients virtually and in-person. A Hope Center will provide transitional housing, primary care, and behavioral health services to rural homeless residents - services proven to reduce overall healthcare costs while improving health outcomes. Strategically deployed mobile health units and health pods, along with library- and school-based health centers will serve as convenient care sites that use technology and community resources to provide low-cost access points critical to value-based payment model success. Meanwhile, FQHCs and rural health systems will collaborate with payers and other stakeholders to rethink health care delivery, using new technologies to reshape both patient engagement and health care workforce needs. The Milford Wellness Village in Milford, DE, demonstrates a successful community-anchored model that will guide RHTP initiatives. This integrated wellness campus delivers skilled nursing, rehabilitation, long-term chronic care support, and wrap-around services to help older adults live longer, healthier lives.

Improving Outcomes: The RHTP’s coordinated approach to workforce expansion, access points, service innovations, and technology aims to deliver measurable improvements in the health of Delaware’s rural residents. Delaware will track population health, service utilization and workforce adequacy measures, establish baseline metrics and provide public reports. Each initiative includes specific outcomes measures and quantifiable targets. Anticipated patient-focused outcomes include:

• Earlier interventions through screenings at mobile units, health pods, libraries, and school-based health centers, resulting in earlier diagnoses, less complex illnesses, lower medical costs and improved self-management

• Adherence to lifestyle programs that complement medical interventions and mitigate disease progression with support from dieticians, behavioral health clinicians, and community health workers.

• Improved glucose and blood pressure control through remote monitoring, “Food is

Medicine” counseling, and the Diabetes Wellness Program

• Reductions in potentially avoidable hospitalizations and emergency department visits.

Workforce: Delaware ranked last among all states in meeting primary care needs, with only

14.85% of need met1, and faces growing workforce demands from a rising and aging population2 and workforce. One challenge is that Delaware is one of only three states without an in-state medical school – neither public nor private. As a result, Delaware has been challenged to offer medical students crucial clinical rotations in its rural facilities and cultivate the next generation of primary care physicians. Moreover, Delaware’s existing programs for Advanced

Clinical Practitioners (NPs, PAs) and other critical positions remain financially out of reach for qualified students. In response, Delaware’s RHTP will support programs that train medical professionals in a defined range of licensed roles who commit to five years of rural service. Key

RHTP components include establishing Delaware’s First Medical School, a “Train Here, Stay

Here" residency program that encourages physician trainees to build roots in the rural community through educational awards, and new and expanded training programs for NPs, PAs, behavioral health professionals, long-term care staff, and other key roles. A newly developed

Healthcare Workforce Data Center will monitor progress towards full staffing and report on

RHTP success related to Delaware’s medical workforce.

Technology Use: Delaware recognizes the need to optimize the healthcare experience for rural patients, providers and caregivers in a tech-enabled world. Through the Rural Provider and

FQHC Value-Based Care Readiness initiative, the state will competitively fund providers and health facilities to adopt technological solutions that enable patient-centered and efficient care delivery. Healthcare providers will identify health IT investments that prepare them for value-based payment initiatives, enable participation in CMS’ Aligned Networks pledge and promote

CMS Interoperability Framework goals. Eligible investments will include AI Scribes and other

HIPAA-compliant tools to reduce documentation burden, allowing providers to “kill the clipboard” and focus more fully on patients; software and technical assistance to model the financial impact of value-based payment methodologies; and EHR Integration. Separately, the state will launch a Catalyst Fund to help health tech vendors bring new innovations to rural

Delawareans. Delaware also will support a Diabetes Wellness Pilot that integrates new technologies with high-touch care management and lifestyle changes to improve outcomes.

Partnerships and Stakeholder Engagement: Delaware state agencies have built strong relationships across health policy issues. The RHTP will be led by the Delaware Department of

Health and Social Services (DHSS), the Division of Public Health (DPH), and the Governor’s

Office, who will engage health systems, payers, consumers, educators and others in implementing the RHTP. To expand training opportunities, our plan supports the creation of a

Delaware medical school and related training programs. We will partner with community-based organizations to implement “Food is Medicine” programs and deploy mobile “health hubs” in accessible locations. Our initiative to expand health access services at Delaware's public libraries leverages existing infrastructure and established partnerships among the Division of Substance

Abuse and Mental Health (DSAMH), DPH, and DHSS. The technology-centered Catalyst Fund will directly support companies as they develop and deploy consumer-facing solutions.

To develop this application and the various RHTP initiatives, the Governor’s Office requested input on rural health priorities. Delawareans responded with over 200 ideas and recommendations, which were used to develop the comprehensive plan. Governor Meyer embarked on a Rural Health Tour in Delaware, visiting multiple major hospitals systems and rural-focused FQHCs. This tour culminated in an open press roundtable where the Governor directly heard feedback from doctors, nurses, FQHCs, hospital leaders, state legislative leaders and others to refine Delaware’s plan. The Governor’s Office also reached out to both of

Delaware's recognized tribes — the Lenape Indian Tribe, largely located in central Kent County, and the Nanticoke Indian Tribe, largely in Sussex — and closely engaged with Delaware’s

Community Health Advocacy Mobilization Group for feedback on the State’s approach. Most notably, Delaware has secured unprecedented statewide support for the RHTP, as documented in the Other Supporting Documentation section of this application. The State has received a letter of support from Delaware's entire legislature committing to regulatory changes around scope of practice and certificate of need—critical policy reforms that will enable the full implementation of this transformation plan. Additionally, every hospital in Delaware has signed a letter supporting the RHTP approach, demonstrating the unified commitment across Delaware's healthcare delivery system to implement these evidence-based strategies. This extraordinary level of legislative and provider alignment ensures that RHTP’s initiatives will not face regulatory or institutional barriers, and positions Delaware to implement reforms that have stalled in other states.

State leadership will provide ongoing guidance on measures, outcomes and reporting through existing committees and workgroups. This leadership includes Delaware DHSS (which includes

Medicaid); DPH; the Delaware Health Care Commission (DHCC) ; the Delaware Department of

Insurance (DOI); the Primary Care Reform Collaborative (PCRC) and its ongoing Value-Based

Care Model Workgroup; the Delaware Office of Rural Health; the Delaware Institute for

Medical Education and Research (DIMER); and the Delaware Workforce Development Board.

Financial Solvency and Cause Identification: Delaware's rural hospitals operate within integrated health systems rather than as standalone facilities, which has helped the state avoid the widespread closures affecting rural America. However, these facilities face mounting financial pressures: declining inpatient volumes, high Medicare and Medicaid payer mix, rising labor costs driven by housing unaffordability, and workforce shortages exacerbated by the lack of in-state medical training programs. Without intervention, Delaware's rural healthcare system risks gradual erosion through service reductions and increasing emergency department (ED) reliance for primary care. The RHTP addresses these underlying causes through multiple interconnected strategies:

• Value-Based Care Readiness: Technology infrastructure funding for EHR integration, telehealth, and remote patient monitoring will enable participation in value-based payment models that create new revenue streams.

• Reduce ED Utilization: Mobile Health Hubs, library-based health services, and school-based health centers will expand preventive care access and reduce costly ED utilization.

• Improved Behavioral Healthcare: Supporting CCBHC development and expanding behavioral health workforce training will address the Mental Health HPSA designation and improve payer mix.

• Data-Driven Optimization: The expanded Health Care Workforce Data Center and RHTP program vendors will use system-wide data to maximize federal Disproportionate Share

Hospital (DSH) payments and coordinate resources across Delaware.

By addressing root causes—workforce and training gaps, outdated care delivery models, and underutilized payment mechanisms—rather than providing temporary subsidies, the RHTP creates sustainable financial stability for rural providers while improving access and outcomes.

Data-driven solutions: Delaware brings a strong health data infrastructure, including My

Healthy Community for public health data, the Delaware Health Information Network (DHIN) which oversees a leading health information exchange and advanced all-payer claims database, and Delaware Health Force providing interactive workforce planning dashboards. Through

RHTP funding, Delaware will strengthen these systems with a rural health focus, enabling real-time tracking of progress toward measurable and quantifiable targets across all initiatives. The state will expand the legislatively-supported Health Care Workforce Data Center to track supply, demand, distribution, Health Professional Shortage Areas, medically underserved populations, workforce research, and policymaking—with particular emphasis on rural communities facing the most severe workforce constraints. This comprehensive data infrastructure will support continuous monitoring of clinical outcomes, access improvements, workforce development milestones, and technology adoption metrics, ensuring that each RHTP initiative demonstrates tangible impact and can be adjusted based on performance data.

Data Driven Factors A.2 and A.7

Delaware is one of four states that does not have a Certified Community Behavioral Health

Clinic (CCBHC). However, DHSS is currently developing two providers for CCBHC readiness with plans to release a Request for Information assessing additional provider interest in CCBHC operation. The state has a CCBHC planning grant from SAMHSA to support this capacity building and prep work, with a goal to open two CCBHCs in Kent or Sussex County. One acute care hospital in Delaware qualifies for Medicaid DSH payments. Per Delaware’s Medicaid State

Plan, qualifying hospitals must have inpatient facilities located in Delaware, meet other federal and state requirements and in some cases must also have been enrolled as providers with

DMMA's MCOs and the Medicaid fee-for-service program in the consecutive 24 months immediately preceding the month of DSH payment.

Legislative and Regulatory Action:

State Policy Technical Factor

Current State Policy Actions Delaware Commits To Pursuing

B.2 Health and Lifestyle

Delaware has established a comprehensive health policy framework through the Benchmark Initiative for tracking health care spending and quality, the Primary Care Reform Collaborative, and the Office of Value Based Health Care Delivery. The state's Title 18 insurance code regulates commercial health insurance spending and coverage, establishes prescription drug payment caps, and sets requirements for Pharmacy Benefits Managers (PBMs). Executive Order 8 created the Delaware Interagency Collaborative to End Homelessness, aiming to reduce homelessness by half and eliminate youth homelessness within five years.

Delaware commits to requiring schools to reestablish the Presidential Fitness Test aligned with federal guidance associated with Executive Order 14327.

Timeline: Executive action to be taken by December 31, 2028.

Improvement to Access, Quality, Cost of Care:

Establishes baseline fitness data for early identification of rural youth at risk for obesity and chronic diseases, enabling targeted school-based interventions and connections to health resources.

B.3 SNAP

Waivers

DHSS received USDA approval to waive the Able- Bodied Adults Without Dependents (ABAWD) SNAP three-month time limit in Kent and Sussex counties due to unemployment rates being over 20% above national average for FY 2025.8

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B.4 Nutrition Continuing Medical Education

Delaware’s Title 24, Chapter 1700 requires physicians to complete 40 hours of continuing medical education through approved Category 1 AMA courses for each registration period, with 20 hours required for first time renewals. 9

Delaware commits to requiring nutrition to be a component of continuing medical education for physicians.

Timeline: Regulatory amendments drafted by March 31, 2028; Board of Medical Licensure and Discipline approval by September 30, 2028; effective for licensure renewals beginning January 1, 2029.

Improvement to Access, Quality, Cost of Care:

Provides rural physicians evidence-based nutrition knowledge to counsel patients on dietary interventions, improving preventive care and reducing specialist referrals.

Current State Policy Actions Delaware Commits To Pursuing

C.3 Certificates of Need

Delaware’s Title 16, Chapter 9303 requires a Health Resources Management Plan to guide health resource allocation, including regulating hospital and nursing home bed capacity and preventing excessive purchasing of medical equipment.10

Delaware commits to eliminating or loosening Certificate of Need laws (known as “Certificate of Public Review” in DE) to reduce regulatory barriers for providers establishing new facilities in rural areas.

Timeline: Legislation drafted by September 30, 2026;

legislative sponsor identified by January 31, 2027;

brought to vote by June 30, 2027.

Improvement to Access, Quality, Cost of Care:

Removes regulatory barriers that prevent new facilities from opening in underserved rural areas, increasing local access to care and reducing transportation costs and time for rural patients.

D.2 Licensure Compacts

Delaware’s Division of Professional Regulations has enacted Medical11, Nursing12, EMS13, Psychology14, and Physician’s Assistant15 licensure compacts, establishing multi-state licensure eligibility and recognizing telemedicine authority.

Delaware commits to maintaining participation in existing licensure compacts (Medical, Nursing, EMS, Psychology, and Physician Assistant) and promoting their utilization by rural providers.

Timeline: Outreach campaign to rural providers launched by March 31, 2027; annual compact utilization reports published December 31, 2027.

Improvement to Access, Quality, Cost of Care:

Increases the pool of providers available to serve rural communities through telehealth and cross-state practice, reducing wait times and expanding access to specialty services without provider relocation.

Current State Policy Actions Delaware Commits To Pursuing

D.3 Scope of Practice

Delaware’s Title 24, Chapter 17 Medical Practice Act establishes the Board of Medical Licensure and Discipline as the exclusive authority to issue and regulate medical practice certificates,16 sets accreditation requirements for office-based surgery facilities, and requires state oversight of physician services.

Delaware commits to expanding scope of practice regulations to allow nurse practitioners, physician assistants, pharmacists, and dental hygienists to practice at the top of their training and licensure.

Timeline: Legislation drafted by September 30, 2026;

legislative sponsor identified by January 31, 2027;

brought to vote by June 30, 2027.

Improvement to Access, Quality, Cost of Care:

Enables advanced practice providers to practice independently in rural areas, allowing them to open practices and deliver appropriate care without costly oversight requirements, improving access.

E.3 Short-term, Limited-duration Insurance

Delaware’s Title 18 Insurance Code 1320 establishes minimum standards requiring policies be issued for no longer than three months, maintain consistent underwriting standards, provide required notice, achieve 60% minimum loss ratios, and receive Insurance Commissioner approval. 17

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F.1 Remote Care Services

Delaware’s Title 24, Chapter 60 authorizes licensing boards to allow telehealth and telemedicine delivery by some out-of-state providers with interstate compacts, requiring remote services meet the same standard of care as in-persons services. 18

Delaware commits to enacting comprehensive telehealth reimbursement parity requiring all payers to reimburse telehealth services at the same rate as in-person services without restriction.

Timeline: Legislation drafted by September 30, 2026;

legislative sponsor identified by January 31, 2027;

brought to vote by June 30, 2027 Improvement to Access, Quality, Cost of Care:

Ensures sustainable telehealth programs through adequate reimbursement, expanding rural access to specialty and behavioral health services.

Proposed Initiatives and Use of Funds

1. Rural “Hope Center” Initiative

Description: The State of Delaware proposes replicating its highly successful Hope Center model19 by establishing two new, geographically essential Hope Centers to serve the homeless rural populations of Kent and Sussex Counties. These Centers will be created through the strategic renovation, staffing, and equipping of existing state-owned facilities, transforming underutilized infrastructure into comprehensive, integrated hubs for healthcare, behavioral health, and housing stability services. The Delaware State Housing Authority, in partnership with

DHSS, will lead the development of each Hope Center. These centers will offer critical non-congregate temporary housing—including at least 20 transitional beds specifically for individuals with serious mental illness (SMI) and substance use disorder, plus safe individual and family units. Each center will integrate social services and evidence-based interventions to promote long-term stability and self-sufficiency. This initiative directly addresses critical gaps in the rural healthcare safety net by enhancing access to primary care, behavioral health treatment, and chronic disease management for unhoused residents and those at high risk for substance use disorder (SUD). Data demonstrates the urgent, unmet need for integrated services in rural

Delaware:

• Growing Homelessness: Delaware’s homeless population rose from 1,245 in 2023 to

1,358 in 2024, a 9% increase, according to the latest Point-in-Time Count report20.

• Existing Service Strain: Currently, 25% of individuals served at the existing New Castle

County Hope Center travel from rural Kent and Sussex Counties. This documents a significant geographic barrier and unmet need for services within home communities.

• Health and Cost Disparities: Homeless individuals enrolled in Medicaid incur excess costs of $4,611 to $5,218 per person annually, compared to housed enrollees (2019 data), primarily due to high use of acute care. Moreover, 19% of individuals who received publicly funded substance use and mental health treatment in DE between 2019 and 2021 reported homelessness, with the rate rising to 22% for Black clients.

The geographic isolation of rural homeless residents creates persistent and profound barriers to continuity of care, effective care coordination, and successful transitions to stable housing. By strategically locating new Hope Center facilities within Kent and Sussex Counties, Delaware will immediately eliminate travel burdens, dramatically enhance service access, and build robust partnerships with local healthcare systems, Federally Qualified Health Centers (FQHCs), community-based organizations, and housing providers. On-site, interdisciplinary teams

(including partnered homelessness response organizations, licensed medical providers, behavioral health specialists, SUD treatment professionals, community health workers, state social workers, and care coordinators) will deliver a holistic continuum of care that addresses both acute health needs and the critical underlying social determinants of health. The Centers will integrate with electronic records systems and provide related technical training to on-site providers. Services offered at the Centers will include:

• Integrated Healthcare: Primary and behavioral healthcare.

• Transitional Housing with Wraparound Services: Designated transitional housing beds for individuals with SMI and substance use disorders, providing evidence-based treatment including cognitive behavioral therapy, MAT, life skills training, relapse prevention, and employment support.

• Intensive Case Management: Individualized care planning, benefits enrollment, and assistance with rapid permanent housing placement.

• Self-Sufficiency Programs: Connections to vocational training and workforce readiness programs.

• Community Coordination: Robust coordination with local social service agencies and community support networks.

Critical to the success of these integrated services is the implementation of a closed-loop referral tracking system. Each Hope Center will deploy technology infrastructure to ensure that all referrals for healthcare, behavioral health, housing, and social services are formally opened, actively tracked throughout the service delivery process, and systematically closed upon completion. This closed-loop system will enable real-time monitoring of service utilization, identify gaps in care coordination, ensure accountability across partner organizations, and generate data-driven insights to continuously improve service delivery and patient outcomes. By sustaining rural residents' connection to integrated care within their home communities, the new

Hope Centers will:

1. Drive Significant Improvements in Long-Term Health Outcomes.

2. Reduce Costly and Avoidable Emergency Department Visits and Hospitalizations.

3. Strengthen the Resilience of Local Care Networks.

This initiative directly aligns with federal priorities of advancing rural health equity, improving comprehensive behavioral health access, and reducing homelessness through a proven, integrated service delivery model.

Main strategic goal: Make Rural America Healthy Again

Permissible Uses of funds: A, B, G, H, J, K

Technical score factors: B.1, B.2, C.1

Key stakeholders: Governor's Office (lead); Delaware State Housing Authority; DHSS including DPH, the Division of Social Services (DSS), DSAMH, Division of State Service

Centers, and the Division of Social Services; Rural Health Clinics; FQHC’s; CCBHC’s; local healthcare providers; community-based organizations and foundations

Outcomes:

• Reduction in avoidable emergency department visits among program participants

(baseline to be established from participant data 6 months pre-enrollment; target: 15% reduction by Year 3)

• Number of successful transitions to stable housing in home county (target: 25% within 12 months of leaving the Center by Year 3)

• Reduction in rates of rural residents from Kent and Sussex Counties traveling to New

Castle County for homeless services (baseline: 25% of New Castle Hope Center residents from rural counties; target: 25% reduction by Year 4)

• Number of established partnerships with local rural healthcare providers and community organizations for care coordination and referrals (target: minimum 5 new partnerships by

Year 5

Impacted Counties: Sussex County and Kent County

Estimated Required Direct Funding: $97.5 million for two new Hope Center locations

Sustainability plan: By Year 4, the state will pursue formal partnerships with local jurisdictions for ongoing operational support and integrate the new Hope Centers into the state's healthcare delivery infrastructure. Housing, clinical and care coordination services will transition to a subsidized fee-for-service model while maintaining a safety net for uninsured individuals through state funding and community partnerships.

2. Rural Community Health Hubs

Description: Establish a comprehensive network of mobile health units throughout rural Sussex and Kent Counties to eliminate transportation barriers and deliver evidence-based preventive care, chronic disease management, behavioral health services, and specialty care directly to underserved rural communities. This initiative responds to persistent provider shortages and high rates of chronic disease in rural Delaware, where geographical and financial barriers continue to limit access to essential health services and insurance coverage.

Delaware DHSS will award funds through competitive procurement to FQHCs and qualified organizations demonstrating capacity to deploy staff, equip, and operate mobile health units in

Delaware’s rural communities. Preference will be given to applicants partnering with existing health systems for clinical integration and continuity of care. Funding will also be used for a dedicated State Coordinator of Mobile Health who will oversee the initiative and ensure optimization. All mobile health units will connect to the patient electronic medical record (EMR) and link with the DHIN – Delaware’s Health Information Exchange (HIE). As part of the public comment period for the RHTP funds in August 2025, Delaware received strong proposals from multiple healthcare organizations—including ChristianaCare, Highmark Health Options, Nemours Children's Health, and Westside Family Healthcare—expressing readiness to implement and expand their mobile health solutions to address access gaps in rural communities.

These organizations identified critical needs including cancer and chronic disease screening, stroke care, maternal and infant health, substance use disorder treatment, pediatric services, and emergency medical services, outlining their capacity and commitment to immediate implementation. Mobile health units will be strategically deployed to familiar, accessible community locations including schools, churches, town centers, and community parking lots, bringing medical services directly to rural residents where they live and gather, especially for physically disabled, elderly residents, and Native American residents. Deployment will be guided by Delaware’s community data and the Centers for Disease Control and Prevention’s Social

Vulnerability Index (SVI), a data tool that identifies areas with the greatest barriers to healthcare access based on socioeconomic status, household composition, housing type, and transportation.

The SVI assigns each area a percentile score from 0 (lowest need) to 1 (highest need). DHSS will use county and census tract SVI data, along with community profile reports, to prioritize applications to deploy mobile health units to rural locations with the greatest service gaps.

Main strategic goal: Make Rural America Healthy Again

Permissible Uses of funds: A, B, G, H, K

Technical score factors: B.1, B.2, C.1, C.2

Key stakeholders: Delaware DHSS (lead), healthcare systems, FQHC’s, schools, faith-based organizations, community centers, Native American organizations, pharmacies.

Outcomes:

• Number of new mobile units deployed in rural Sussex and Kent counties (target:

minimum of 4 new units by Year 2)

• Number of patient encounters at mobile health units annually (target: 1500 encounters across Sussex and Kent counties annually by Year 3)

• Number of chronic disease screenings conducted through mobile units (cancer, diabetes, hypertension, HIV) (target: 1,000 screenings across Sussex and Kent counties annually by Year 3)

• Number of individuals receiving specialty services through mobile units (maternity care, dental care, substance use disorder treatment) (target: 100+ annually across Sussex and

Kent counties by Year 3)

Impacted Counties: Sussex County and Kent County

Estimated Required Direct Funding: $10 million

Sustainability plan: By Year 4, transition to sustainable operational models through fee-for-service billing and health system investment. DHSS will also pursue ongoing state appropriations and explore cost-sharing and value-based payment models to maintain long-term operations.

3. School-Based Health Centers Expansion Initiative

Description: Expand Delaware's network of school-based health centers (SBHCs) in rural

Sussex and Kent Counties to provide comprehensive physical, behavioral, and preventive health services directly to students and families, eliminating transportation barriers and improving access to primary care, mental health services, chronic disease management, and nutrition counseling. SBHC’s have historically been associated with better access to care, support for children’s behavioral health, fewer absences and better learning outcomes.2122 Currently, 73% of

Delaware's 40 SBHCs are in New Castle County, leaving rural communities, particularly in

Sussex County, with limited access to school-based healthcare. In Sussex County, only 1 middle school and 1 elementary school currently have SBHCs, despite the county having 22 elementary schools and 12 middle schools across seven school districts.2324 Expanding SBHCs to these grades in Sussex and rural Kent Counties will allow early interventions, increase preventive care, and reduce behavioral health referrals. To allocate the RHTP funding, the Delaware Division of

Public Health’s Adolescent Health Program will conduct a competitive procurement to establish four new SBHCs in Sussex and Kent elementary and middle schools over the funding period.

Awards will be given to “medical sponsor partnerships” (e.g., hospital systems, FQHCs, or clinics) capable of staffing, coordinating care with a medical home or primary care provider, and supporting ongoing operations at schools with school board approval and readiness for implementation. Preference will also be given to SBHCs that can expand services to nearby schools through a “hub and spoke” model increasing impact and efficiency. Seaford Middle

School and Indian River School District in Sussex County have already expressed readiness to implement centers immediately. Funding will also support minor building renovations to establish clinical space (exam rooms, counseling offices, screening areas), purchase equipment and supplies, and establish operations. The four new SBHCs will provide interdisciplinary care teams including physicians or physician assistants, nurses, mental health counselors, dietitians, and community health workers, delivering services by appointment during school days with parental consent. Services will include well-child exams, chronic disease management (asthma, diabetes), physical fitness testing, depression and substance use screenings, mental health counseling, nutritional counseling, sexual and reproductive health services including STI screening and testing (with parental and school board approval), and referrals to specialty care, coordinated with a medical home or primary care provider.

Main strategic goal: Make Rural America Healthy Again

Permissible Uses of funds: A, B, G, H, J, K

Technical score factors: B.1, B.2, C.1

Key stakeholders: Delaware DPH (lead), Sussex County school districts, healthcare systems, FQHC’s, school boards, families

Outcomes:

• Number of new SBHCs established in rural Sussex and Kent County elementary and middle schools (baseline: 0; target: minimum 4 additional centers by Year 4)

• Number of students receiving preventive services through the new SBHCs (well-child exams, preventive services, STI screenings) annually (baseline:0; target: 400+ annually by Year 3)

• Number of mental health evaluations and behavioral risk assessments delivered through the new SBHCs (baseline:0; target: 150+ annually by Year 3)

• Number of completed new applications for Delaware-recognized SBHC status (target: 4+ applications submitted by Year 4)

Impacted Counties: Sussex County and Kent County

Estimated Required Direct Funding: $10 million

Sustainability plan: By Year 4, establish sustainable operational models through Medicaid reimbursement for eligible services and medical sponsor commitments to incorporate SBHCs into their community benefit programs and value-based care arrangements. Schools and districts will integrate SBHCs into their educational support infrastructure. The state will pursue ongoing appropriations for core SBHC operations.

4. Food is Medicine Infrastructure Initiative

Description: In rural Kent and Sussex counties, food-insecure older adults show 59.7% hypertension and 27.8% diabetes prevalence rates, adding $1,800 in annual medical costs per person. Food is Medicine (FIM) interventions - including food prescriptions, medically tailored meals/groceries, and culinary medicine - have been proven to significantly reduce A1C and blood pressure, generating major cost savings. Yet rural implementation of these interventions faces three barriers: lack of sustainable billing mechanisms, minimal nutrition training in medical education (<1% of medical curriculum), and a limited workforce of dieticians and community health workers.

As part of this initiative, DHSS will establish a FIM infrastructure in rural Kent and Sussex counties through competitively procured vendor(s) working in partnerships with Delaware’s primary rural health providers. The Delaware Food is Medicine Committee will provide ongoing advisory support to DHSS through the development and implementation of all three infrastructure elements described below.

• Element 1 (Payment Infrastructure & Research): Vendors and participating rural health providers will develop and implement sustainable billing mechanisms including

CPT code 99213 culinary medicine consultations, Medicaid “in lieu of services” pathways, and Accountable Care Organization (ACO) payment arrangements. This element also includes deployment of an EMR-integrated billing toolbox for provider use and establishment of a rigorous evaluation framework with published findings. The goal is to secure value-based payment arrangements with at least two payers.

• Element 2 (Technology & Workforce): Vendors will hire 4-5 community health workers and 1 registered dietician to serve patients in rural health practices across Kent and

Sussex counties by providing nutrition counseling, education and coordination. Vendors will also deploy an EMR-decision support tools for participating providers, a telehealth nutrition consultation platform, a patient-facing mobile application, and remote patient monitoring systems.

• Element 3 (Training & Pilot): The program will certify 15 Culinary Medicine Teachers to train 150 rural practitioners (70% rural serving) and implement a pilot for 375 participants with diabetes or hypertension in rural Kent and Sussex counties. Specific communities will be identified in consultation with the Delaware Council on Farm &

Food Policy. The pilot will provide a six-month intervention including nutrition education, culinary medicine consultation, and remote monitoring.

DHSS will provide program oversight, vendor procurement, and coordination with the Delaware

Council on Farm & Food Policy for community identification and technical assistance. The

Delaware Food is Medicine Committee will provide advisory support throughout development and implementation. Vendor(s) will manage day-to-day program operations, ensure CMS compliance, hire and deploy workforce resources, implement technology platforms, and provide quarterly progress reporting. Participating rural health providers will provide patient referrals, clinical integration, and billing implementation. This model is systems focused and ensures replicable FIM infrastructure that lowers healthcare costs and improves rural health outcomes.

Main strategic goal: Make America Healthy Again

Permissible Uses of funds: A, B, C, D, G, I, K

Technical score factors: B.1, B.2, C.1, Key stakeholders: Delaware DHSS (lead), DPH, Delaware Council on Farm & Food Policy, Food is Medicine Committee, FQHC’s, rural healthcare providers and health systems, payers

Outcomes:

• Improved clinical outcomes (target: 40% of participants achieve >/=0.5 point HbA1c reduction and/or >/= 5 mmHg blood pressure reduction by Year 5)

• Reduced healthcare utilization and food insecurity (target: 20% reduction in ED visits;

25% reduction in food insecurity by Year 5)

• Workforce capacity (target: hire 5-6 FTE staff with 80% retention; train 150 rural practitioners with 80% implementing FIM within 6 months; certify 15 Culinary Medicine

Teachers by Year 3)

• Sustainable infrastructure (target: $500,000 annual FIM reimbursement; value-based payment agreements with 2+ payers by Year 4; 20 rural sites with EMR-integrated tools;

2 peer-reviewed publications; 5+ new partnerships annually)

Impacted Counties: Sussex County and Kent County

Estimated Required Direct Funding: $8 million

Sustainability Plan: The recently launched a Delaware Food is Medicine Committee leads statewide efforts to integrate nutrition into healthcare. Building on Delaware’s First State Food

System Grant Program (now State-funded), this initiative provides a policy foundation for sustainable FIM infrastructure. RHTP start-up funds will demonstrate clinical and cost-saving impacts, supporting long-term payer reimbursement. By Year 4, value-based agreements with 2+ payers, $500,000 annual reimbursements, EMR-integrated billing tools, trained workforce, and statewide culinary medicine educators will sustain operations. Partnerships among producers, retailers, and healthcare systems, reinforced by evaluation data and publications, will embed FIM into Delaware’s systems, ensuring enduring health and economic improvements.

5. Rural Libraries Health Access Initiative

Description: Expand health access services and operating hours at nine rural libraries up and down Delaware to deliver telehealth, health navigation, and social services support at locations within seven miles of most rural residents. Rural libraries serve as trusted community anchors where residents already gather, making them ideal access points for health services that would otherwise require travel. Children and older adults are frequent library patrons, and Delaware's public libraries have developed a nationally recognized telehealth and service delivery model leveraging existing infrastructure such as high-speed internet, private spaces, and trained specialists to address healthcare access barriers in underserved communities. The Delaware

Division of Libraries has established partnerships with several DHSS divisions, including DPH and DSAMH to connect library patrons to primary care, substance use disorder treatment, and mental health services. DSAMH specifically promotes private library spaces for medication-assisted treatment (MAT) appointments, recognizing libraries as safe and accessible locations for sensitive services. This initiative builds upon proven success by expanding library services through additional specialized staff and hours of operation. Newly hired library-based community health specialists will assist rural residents with scheduling and completing virtual health visits, supporting health insurance applications (Medicare, Medicaid), facilitating

Electronic Benefits Transfer (EBT)/ Supplemental Nutrition Assistance Program (SNAP) benefits applications, providing referrals to community partners, offering courses on health literacy, and delivering other health programming including Aging in Place support, chronic disease management, naloxone training, nutrition education, and wellness activities. Specialists will also provide non-health services including job interview coaching and legal resources, addressing broader barriers to economic and social stability that impact health outcomes. By meeting people where they already are, this initiative eliminates transportation barriers and reduces stigma associated with seeking health services. Funding will support a project coordinator across all libraries to supervise staff and manage outreach; three full-time telehealth specialists; three full-time digital navigation specialists; a part-time specialist for on-site support and resource connections; extended operating hours at nine rural libraries; software upgrades;

outreach and marketing supplies; and technical assistance and staff training.

Main strategic goal: Make Rural America Healthy Again

Permissible Uses of funds: A, C, F, G, H

Technical score factors: B.1, F.1, F.3

Key stakeholders: DE Division of Libraries (lead), DHSS, DPH, DSAMH, community-based organizations

Outcomes:

• Number of rural libraries with expanded services (baseline: 0; target 9 by Year 3)

• Number of residents assisted with telehealth appointments through library assistance annually (target: 250+ by Year 2)

• Number of health insurance and/or benefits applications completed through library assistance annually (target: 250+ by Year 2)

• Number of new partnerships established between libraries and local healthcare providers, community organizations, and social service agencies to deliver programming (county-level tracking; target: minimum 4 new partnerships by Year 3)

Impacted Counties: Nine rural library locations across Sussex and Kent Counties

Estimated Required Direct Funding: $3 million

Sustainability plan: By Year 4, establish sustainable operational funding through state and local appropriations. Libraries will leverage existing partnerships with DSAMH, DPH, DHSS, and other partners to ensure services continue beyond the funding period.

6. Rural Provider and FQHC Value-Based Care Readiness Initiative

Description: Delaware has made significant progress in transitioning its healthcare system from one dependent on fragmented, misaligned fee-for-service payments to one focused on caring for whole populations in value-based care models: more than half of the state’s primary care providers participate in a commercial value-based payment arrangement; four of the state’s largest provider organizations participate in a Medicaid accountable care program; and Delaware has high participation in the Medicare Shared Savings Program. Yet, value-based payment adoption among rural providers and FQHCs has been slow, held back by smaller patient populations that make it difficult to assume risk, limited resources for technology investments, and challenges in expanding care teams and services without funding and stable payment structures. This initiative will build upon current state policies and investments while also setting up Delaware for durable transformation after funding ends.

Delaware is interested in participating in an AHEAD model and has had direct conversations with staff at the Center for Medicare and Medicaid Innovation about the feasibility of this approach. However, even if not selected for an AHEAD award, Delaware—and our rural health providers— are committed to a future built on value-based care and look forward to using these funds to hasten our progress. To address barriers and accelerate rural providers’ transition to value-based care, this initiative establishes three complementary strategies overseen by DHSS: 1) innovative technology investments to reduce administrative burden and promote patient-centered data exchange; 2) strategic funding to expand high-value services and care teams;

and 3) a sustainable framework for collaboration between providers and payers that informs the design of new payment models that position rural providers for sustainability and helps guide implementation. Together, these components create a pathway for Delaware’s rural providers and FQHC’s to successfully engage in value-based payment arrangements while increasing their service offerings to residents.

1. Innovative Technology Investments: Rural providers, including FQHCs La Red Health

Center and Westside Family Healthcare, along with rural health systems like Tidal

Health, Beebe Healthcare, and Bayhealth will participate in a competitive procurement process to fund health IT investments that prepare providers for value-based payment initiatives; enable participation in CMS’…