Almost 5,600 Rural Health Clinics (RHCs) serve the primary care needs of rural residents in 44 states. Based on the recognition of the important role that RHCs can play in local delivery systems, the Federal Office of Rural Health Policy allows State Flex Programs (SFPs) to undertake projects to support Critical Access Hospital (CAH)-based RHCs under Flex Program funding. This brief reviews the 16 SFP CAH-based RHC initiatives for the 2023-2024 funding year. These initiatives included projects in the areas of quality improvement, financial and operational improvement, and population health.

In addition to the summary of the sixteen SFP initiatives, we conducted interviews with seven SFPs with extensive experience in working with CAH-based RHCs to understand the challenges to supporting these important rural resources and identify opportunities to encourage additional SFPs to do so. This brief explores the work of these seven SFPs and the lessons they learned from their work. It is an important resource for SFPs interested in undertaking work to support and sustain CAHs and their RHCs in the provision of primary care services, care management, wellness, behavioral health care, and other essential services.