Building a hub-and-spoke model that supports long-term success

With the $50 billion Rural Health Transformation Program (RHTP) now moving money into all 50 states, hub-and-spoke care has gone from a whiteboard concept to a funded strategy. The Centers for Medicare &  Medicaid Services (CMS) is distributing $10 billion annually from 2026 through 2030, and states have submitted plans built around this idea.

A centralized hub delivers higher-acuity and specialty services, while local spokes handle routine care, prevention and community-based support. CMS endorses the approach and has floated the idea of creating new rural regional health authorities to coordinate it.

The structure looks clean on paper, but the reality is more difficult. States that have tried this approach through substance abuse networks, maternal care coordination, behavioral health integration and regionalized acute care systems have faced challenges. Building a durable hub-and-spoke model takes far more than a diagram. With five-year federal dollars now on the table and annual renewals tied to results, the difference between a model that lasts and one that collapses comes down to a handful of foundational conditions and a real commitment to collaborate among participating organizations.

Start with trust

Trust must exist at the outset or be built on purpose. Rural hospitals operate in scarcity. Their workforce is thin, margins are fragile, capital is limited and outside entrants compete for profitable outpatient lines. Asking these hospitals to join forces with a regional hub can feel like a threat to their service lines, patient volume and even their identity in the community. Hub-and-spoke models take root only when every organization believes they are entering a shared-value arrangement. The moment it reads as a takeover, the model stalls.

Fund it for the long haul

Financial stability is a top priority for leaders. Rural hospitals have disproportionately high labor costs, chronic staffing shortages and heavy exposure to public payers.

A hub-and-spoke model will not fix those pressures on its own, and without upfront investment and predictable payments, it can make them worse. Spokes need resources to maintain a core set of services, and hubs need dependable volume and financing to sustain specialized capacity. What that means is multiyear funding through global budgets, shared savings, transformation grants or aligned multipayer reimbursement. The RHTP’s five-year horizon helps, though its annual renewals put a premium on models that show progress early and hold together over time.

Share the data

Coordination runs on information. Referrals must flow, records must follow the patient and performance must be measured across the whole network. Many rural hospitals lack the analytics infrastructure, health information exchange or data governance to plug into a modern regional system. That technology gap is well documented, and it is why CMS put data infrastructure, encounter notification and low-cost rural reporting at the center of their rural strategy. Without a shared platform, a hub-and-spoke model is a loose affiliation of providers with the same name. Durable systems invest early in shared dashboards, common quality measures and data-sharing agreements so every organization works from the same foundation.

Govern as equals

Even ideal conditions fail without collaboration. The strongest models share decision making. Hubs tend to assume authority because of their size and clinical depth, yet spokes sit closest to the community and understand what will work in local workflows. Governance councils with shared voting power, community representation and clearly defined roles keep the model from tipping into a power imbalance. CMS has proposed rural regional care collaboratives as shared coordinating bodies.

Collaboration also means deciding together which services belong where rather than centralizing everything in the hub. Rural communities depend on proximity for behavioral health, prenatal care, chronic disease management, screenings and post-acute support. These services cannot work if every visit requires a long drive. A durable model weighs clinical appropriateness, travel burden, workforce patterns, facility readiness and financial sustainability before it moves any service upstream.

Plan the workforce together

The hub-and-spoke model changes where care happens and how it is staffed. Hubs need specialists, intensivists, behavioral health clinicians, maternal care teams and telehealth support. Spokes need cross-trained staff, community health workers, paramedicine partnerships and fully licensed nurses.

Without shared recruitment, joint training, rotational staffing and teleconsultation, the model risks overwhelming local clinicians or concentrating shortages in the hub. Labor costs in rural areas are climbing faster than overall inflation, a point chief financial officers (CFOs) raise consistently, and rural emergency medical services (EMS) feel this acutely as longer transports strain volunteer ambulance services already stretched thin. Coordinated workforce planning is the operational backbone of the whole network.

The connective tissue reaches past hospitals and clinics. Public health agencies, behavioral health providers, schools, long-term services, EMS and community organizations all shape whether the model works.

A rural resident might see a local spoke for routine care, travel to the hub for diagnostics, receive specialty treatment, and then need follow-up from home health services or a medication-assisted treatment provider close to home. Miss the handoffs and patients fall through the cracks.

Clear the regulatory friction

States also have to solve for regulatory load. Small rural hospitals carry a higher compliance burden per bed than their urban peers, from interoperability and cybersecurity to environmental rules and expanded reporting. A network becomes untenable if every spoke needs to manage that complexity alone. States can centralize reporting, simplify requirements and share resources such as regional cybersecurity support or a state-level health information exchange to lighten the load. RHT dollars can fund this.