PURPOSE: This rule establishes the Transformation of Rural Community Health (ToRCH) program. The purpose of ToRCH is to direct new resources to rural communities that commit to addressing social conditions that lead to poor health.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) This rule implements the Transformation of Rural Community Health (ToRCH) program. ToRCH is a hub-based model that is designed to allow rural communities to have the flexibility to address health-related social needs (HRSN) among their MO HealthNet populations in a manner that focuses on improving health outcomes. ToRCH will integrate social care supports into clinical care, so that clinical outcomes are less likely to be compromised by social challenges. ToRCH will also create a new role for rural health care providers, and a new path to sustainability for these providers.

2. (2) Definitions. For purposes of this rule, the following words and phrases are defined as follows:

   1. (A) “Community” shall mean a county or group of counties considered by the ToRCH entity as its core service region, and for whose health outcomes the leadership board will be held accountable;
   2. (B) “Community Based Organization (CBO)” shall mean a public or private not-for-profit entity that provides specific services or resources to the community or targeted population within the community;
   3. (C) “Community Health Needs Assessment” shall mean a community-wide assessment that identifies key health needs and issues through systemic, comprehensive data collection and analysis;
   4. (D) Emergency Department Prevention Quality Indicators (ED PQIs) are measures developed by the Agency for Healthcare Research and Quality (AHRQ) that assess whether visits for a set of chronic and ambulatory care sensitive conditions that could have been more appropriately treated in a primary care setting occurred;

   5. (E) “Health-related social needs (HRSN)” shall mean an individual’s unmet, adverse social conditions that contribute to poor health. These needs can include, but are not limited to—

      1. 1. Food insecurity;
      2. 2. Housing instability;
      3. 3. Unemployment or under-employment; or
      4. 4. A lack of reliable transportation;
   6. (F) Pediatric Quality Indicators (PDIs), also developed by AHRQ, focus on quantifying potentially preventable complications and iatrogenic events for pediatric patients treated in hospitals and on preventable hospitalizations among pediatric patients, taking into account the special characteristics of the pediatric population;
   7. (G) Prevention Quality Indicators (PQIs) are measures developed by AHRQ. A composite measure assesses whether hospitalizations occurred as a result of complications from chronic conditions that would likely have been preventable due to better condition management;
   8. (H) “Rural community health hub” shall mean a partnership among the ToRCH entity, primary care, behavioral health, and community-based organizations, to provide communitylevel care management services, including but not limited to strategic coordination of community-based services;
   9. (I) “ToRCH entity” shall mean the leader of a rural community health hub that will provide community-level care management services, i.e., strategic coordination of community-based services that primary care partners are then able to utilize in a systematic way to more fully achieve the goals of primary care case management on an individual patient level. A ToRCH entity shall be located in a county deemed eligible for ruraltargeted funding by the Federal Office of Rural Health Policy at the time of its application. Selection criteria for ToRCH entities are specified in section (4); and
   10. (J) “ToRCH model” shall encompass the ToRCH entity and its partners, operating a rural community health hub, making strategic and data-informed decisions in order to earn valuebased payments as described in this rule.

3. (3) ToRCH entities shall provide primary care case management (PCCM) services as defined at 42 U.S.C. section 1396d(t) (2011), as well as utilize a waiver under the Social Security Act, section 1915(b) (1921) to address HRSN at a rural community level. This includes but is not limited to—

   1. (A) The strategic coordination of community-based services to allow primary care providers to utilize these services in a systematic way to more fully support positive health outcomes on the individual patient level;

   2. (B) Engaging Community Based Organization (CBO) partners to participate in a Community Information Exchange (CIE) platform;

      1. 1. The purpose of the CIE platform is, in part, to allow

ToRCH entities to locate HRSN services that case managers and other screening providers can use to better coordinate HRSN services across multiple CBOs, and to monitor enrolled participants in need of these services;

1. 2. Furthermore, the CIE platform is designed to send

referrals for HRSN services from medical or clinical providers to CBOs and track the resolution of each referral, to aggregate referral activity at the community level, to pre-screen for eligibility, to manage ToRCH model invoicing, and to assess ToRCH model performance; and

1. 3. ToRCH entities shall agree to use the CIE platform

designated by MHD; and

1. (C) Paying for HRSN services that correlate with better health outcomes and reductions in health care spending.

1. (4) ToRCH entity selection criteria.

   1. (A) A ToRCH entity shall be located in a county deemed eligible for rural-targeted funding by the Federal Office of Rural Health Policy at the time of its application.
   2. (B) A ToRCH entity shall be a hospital, a federally qualified health center, a rural health clinic, or a local public health agency.

   3. (C) A prospective ToRCH entity shall apply to participate by submitting a Preparation, Approach, and Implementation Plan based on the following criteria:

      1. 1. Provide a well-thought-out plan for the creation of a

Leadership Board to oversee and administer all aspects of the ToRCH model at the rural community level.

1. A. This plan shall identify the organizations and the

individuals who the provider intends to participate in the Leadership Board.

1. B. The Leadership Board shall include hospital leaders

necessary to successfully administer the program, as approved by the division.

1. C. The Leadership Board shall consist of organizations

across all domains (hospital, primary care, behavioral health, local public health agency (LPHA), and social care organizations).

1. D. The Leadership Board shall have a defined structure

that includes voting policies for decisions related to ToRCH, defined meeting frequency, recording of minutes, and other procedures common to similar types of bodies and which acknowledges the fiduciary responsibility and risk-bearing status of the ToRCH entity.

1. E. The purpose of the Leadership Board shall be to

harness the members’ knowledge of their community and their clinical expertise to strategically focus on HRSN services likely to have the greatest influence on hospital outcomes and population health;

1. 2. Provide a list of existing and potential partners with

strong letters of support from at least one (1) from each domain: primary care, behavioral health, CBOs, and local public health agencies;

1. 3. Demonstrate CBOs’ current readiness and anticipated

needs for support, including technical assistance;

1. 4. Use a Community Health Needs Assessment (or other

similar report) to identify the challenges and unmet needs of the community, demonstrating understanding of local population health concerns and providing a preliminary indication of which population health goals the community health hub may wish to prioritize through the ToRCH model;

1. 5. Provide a written statement of commitment to data

sharing among clinical partners, and indicate how data will be shared at the individual or aggregate level; and

1. 6. Demonstrate a strong commitment by leadership

through one (1) or more letters of support that—

1. A. Express a vision and enthusiasm for the model and a

willingness to be held accountable;

1. B. Discuss the team (with relevant skills) who will be

running the model;

1. C. Describe current efforts to screen/address Social

Determinants of Health (SDoH) in the community; and

1. D. Describe insights gained from the interactive

Community Information Exchange (CIE) demonstration or other data sources.

1. (D) A prospective ToRCH entity shall provide a narrative that demonstrates a full understanding of the ToRCH model as follows:

   1. 1. How the flexibility and customizability of the model will

be used to address community needs that connect back to the overarching health goals;

1. 2. The specific actions that the provider will take to

achieve the health goals;

1. 3. How data will be used to inform and guide efforts;
2. 4. How course corrections will be made; and
3. 5. How the strengths of the rural community will be

leveraged.

1. (5) A ToRCH entity shall enter into a Participation Agreement with the MO HealthNet Division for the operation of a ToRCH program by the provider. The Participation Agreement (12/07/2023) is incorporated by reference in this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/mhd/ToRCH, on May 1, 2024. This rule does not incorporate any subsequent amendments or additions.

   1. (A) Participation agreements shall include details on data sharing requirements and responsibilities among ToRCH hub clinical partners and with the division, as well as enumerating requirements and responsibilities for financial reporting and attestation of ToRCH model activities.
   2. (B) A Participation Agreement shall be valid only in geographic areas in which the division has approved the ToRCH entity under this rule.
   3. (C) A Participation Agreement may contain additional terms and conditions agreed to by the parties if the terms and conditions are consistent with the provisions of the Social Security Act, section 1915(b) (1981) waiver, this rule, and relevant state or federal law.

2. (6) Payment Methodology.

   1. (A) Payments to a ToRCH entity in good standing will vary over time. Payments in year N are indicated as “ToRCH(N)” and are determined according to the following formula:

ToRCH(1) = CBF(1) + CSS + SB3(1) ToRCH(2) = CBF(2) + CSS + SB3(2) + PH(2) + AV(2) + AH(2) ToRCH(3) = CBF(3) + CSS + SB3(3) + PH(3) + AV(3) + AH(3) + SS(3) ToRCH(4) = CBF(4) + CSS + SB3(4) + PH(4) + AV(4) + AH(4) + SS(4) ToRCH(5+) = CSS + PH(5+) + SS(5+).

1. (B) The components identified in subsection (6)(A) are defined as follows:

   1. 1. CBF—Capacity Building Funds. The amount in model

years one (1) and two (2) is one hundred sixty thousand dollars ($160,000) per year for a small rural county, two hundred forty thousand dollars ($240,000) for a medium rural county, and three hundred twenty thousand dollars ($320,000) for a large rural county. In year three (3), the amount is reduced by one third (1/3). In year four (4), the amount is reduced by two-thirds (2/3). In year five (5) and beyond, the amount is zero (0). These amounts are to be trended forward for inflation for additional cohorts after the first cohort and are to be awarded to local CBOs that agree to participate in the ToRCH model according to guidance established by the division. For purposes of this rule—

1. A. A small rural county shall mean a rural county with a

population of less than fifteen thousand (15,000);

1. B. A medium rural county shall mean a rural county

with a population from fifteen thousand (15,000) to twentynine thousand nine hundred ninety-nine (29,999); and

1. C. A large rural county shall mean a rural county with a

population of at least thirty thousand (30,000);

1. 2. CSS—Community Strategy Services. This amount

is comprised of two (2) actuarily-determined components to deliver community strategy services. The first is a base allocation that supports two (2), three (3), or four (4) full-time personnel (for small, medium, or large counties, respectively) to administer and manage the ToRCH model; the second covers screening and referral activities for MO HealthNet participants, multiplied by the most recent quarter’s enrollment data for the ToRCH county or counties, and payable quarterly;

1. 3. SB3—Supplemental B3 services and activities. In model

years one (1) and two (2), this is a budgeted amount to be used by the ToRCH entity to provide supplemental services in accordance with section 1915(b)(3) of the Social Security Act. In year three (3), as the funding source for these services and activities begins to transition to Shared Savings (SS), the amount is reduced by one third (1/3). In year four (4), the amount is reduced by two thirds (2/3). In year five (5) and beyond, the amount is reduced to zero (0);

1. 4. PH—Population Health incentive payments. For each of

the identified population health goals referenced in the ToRCH entity’s Participation Agreement, the Supplemental HRSN services budget will be increased by two percent (2%) if the goal for the prior year is met and by three percent (3%) if the goal is exceeded. Thus, the value of PH(2) equals up to fifteen percent (15%) of SB3(1). The value of PH(3) equals up to fifteen percent (15%) of SB3(2). The value of PH(4) equals up to fifteen percent (15%) of the sum of SB3(3) and SS(3). The value of PH(5) equals up to fifteen percent (15%) of the sum of SB3(4) and SS(4). The value of PH(6+) equals up to fifteen percent (15%) of SS(5+);

1. 5. AV—Avoided Visits incentive payments. Based on

calculations of avoidable Emergency Department visits, a pool is created across the ToRCH cohort, i.e., across all ToRCH entities that are in the same model year. Using Emergency Department Prevention Quality Indicators (ED PQIs), hospital services are probabilistically identified as potentially avoidable, and the dollar amount associated with these services is calculated at baseline and after each model year for services that occurred in the ToRCH hospital. The combined reductions achieved by all hospitals achieving reductions will comprise the Avoided Visits Pool. First, these changes are expressed as percentage changes for each hospital, negative numbers representing better performance. The percentage change for any hospital with worse performance is set to zero. Second, these percentage changes are summed to determine the total percent change across the cohort. Third, each hospital’s share of the total percent change is calculated as the ratio of the above two (2) steps. Fourth, this share is multiplied by the total value of the reduction achieved across the cohort to determine a prorated share of the reduction, assuming any reductions occurred, and the Pool value is therefore positive. AV for each hospital equals its prorated share of the reduction, or zero if the Pool value is zero. Original values for the first cohort will refer to calendar year 2023 measurements. (Note: if a ToRCH entity is not a hospital, then it will not participate in the Avoided Visits Pool.);

1. 6. AH—Avoided Hospitalization incentive payments. Based

on calculations of avoidable hospitalizations, a pool is created across the ToRCH cohort, i.e., across all ToRCH entities that are in the same model year. Using Prevention Quality Indicators (PQIs) and area-level Pediatric Quality Indicators (PDIs), hospital services are identified as potentially avoidable, and the dollar amount associated with these services is calculated at baseline and after each model year for services that occurred in the ToRCH hospital. The combined reductions achieved by all hospitals achieving reductions will comprise the Avoided Hospitalizations Pool. First, these changes are expressed as percentage changes for each hospital, negative numbers representing better performance. The percentage change for any hospital with worse performance is set to zero. Second, these percentage changes are summed to determine the total percent change across the cohort. Third, each hospital’s share of the total percent change is calculated as the ratio of the above two (2) steps. Fourth, this share is multiplied by the total value of the reduction achieved across the cohort to determine a prorated share of the reduction, assuming any reductions occurred, and the Pool value is therefore positive. AH for each hospital equals its prorated share of the reduction, or zero if the Pool value is zero. Original values for the first cohort will refer to calendar year 2023 measurements. (Note: if a ToRCH entity is not a hospital, then it will not participate in the Avoided Hospitalization Pool.);

1. 7. SS—Shared Savings payments—Beginning in year three

(3), ToRCH entities will be eligible for shared savings payments based upon the estimated savings that MHD calculates as occurring through reductions in all-cause hospitalization (inpatient and outpatient) among the MO HealthNet residents of the ToRCH community. The estimate will be calculated relative to the utilization of MO HealthNet residents of rural, non-ToRCH counties and will be adjusted for the demographic composition of the county, including differences in enrollment by Category of Aid. To phase in the Shared Savings component of the ToRCH model, SS(3) will be, at minimum, equal to twenty percent (20%) of the calculated amount saved between years one (1) and two (2). SS(4) will be, at minimum, forty percent (40%) of the calculated amount saved between years two (2) and three (3). SS(5) will be, at minimum, sixty percent (60%) of the calculated amount saved between years three (3) and four (4). For N>5, SS(N) will be, at minimum, sixty percent (60%) of the calculated amount saved between years N minus two (2) and N minus one (1). When the PH incentive payments are added, the total shared savings rate may be up to seventy-five percent (75%);

1. (C) The Participation Agreement shall include detailed examples of the methodology described above, including trend rates and algorithms used, in order to ensure clarity for the ToRCH entities.

AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2024.* Emergency rule filed April 22, 2024, effective May 6, 2024, expired Nov. 1, 2024. Original rule filed April 22, 2024, effective Dec. 30, 2024. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.