WebMD Ignite, CCS Health and Medicine for the Greater Good are launching the Collaborative Care Network (CCN), a locally governed, clinical-community-led operating platform designed to help communities transform rural health with the $50 billion in federal funding being made available over the next five years. Executives from the three organizations responded via e-mail to Healthcare Innovation’s questions about the goals of their partnership

The three founding organizations bring complementary capabilities to CCN:
• WebMD Ignite brings what it describes as the world’s largest corpus of clinical-grade health content, advanced digital engagement technology, evidence-based health risk assessments and analytics that measure engagement and outcomes, building on its recently launched Health Education & Access for Rural Transformation (HEART) program. 
• CCS Health brings care-coordination technology, workforce training, the Community Health Record and performance analytics.
• Medicine for the Greater Good, a Johns Hopkins Medicine initiative, brings its model for building trusted, sustained partnerships among clinicians and the communities they serve.

WebMD Ignite President Ann Bilyew says the opportunity the Rural Health Transformation Program offers is enormous, but so is the complexity. States are being asked to address access, workforce, technology, prevention, chronic disease and long-term sustainability across rural communities with very different needs and levels of readiness, she added. “They must also do it while navigating limited local capacity, compressed procurement and implementation timelines, fragmented data and persistent workforce shortages. One of the greatest risks is that these investments become a collection of disconnected programs rather than a durable system of care.”

Most rural communities already have hospitals, clinicians, public health agencies, community organizations, employers and others doing important work, Bilyew added. “The challenge is connecting those resources around shared priorities, clear responsibilities and measurable outcomes. That is a major reason we created the Collaborative Care Network. Rather than introducing another stand-alone solution, CCN provides a locally governed model for bringing existing clinical and community resources together, with local leaders determining the priorities, participating organizations, financing strategies and measures of success.”

Bob Harnach, founder and CEO of CCS Health, described how a rural community might use the Collaborative Care Network platform: “A community would start with what it already has. Most rural communities have hospitals and clinicians, public health, Area Agencies on Aging, emergency medical services, Community Action Agencies, community organizations, employers and other organizations doing important work,” he explained. “Some already have Community Hubs aligning healthcare and social care. The first step is not to replace those resources or create another program — it is to identify the community’s priorities, understand where the gaps are and organize those existing capabilities into one locally governed network,” he said. 

The Collaborative Care Network provides the operating blueprint and infrastructure to make that possible, Harnach added. A community can develop and deploy a trained community health workforce, implement evidence-based interventions, coordinate healthcare and community services, address transportation and other access barriers, extend support into homes and trusted community settings, and use remote monitoring where appropriate. “The Community Health Record and interoperability capabilities allow participating organizations to rapidly share appropriate information, coordinate referrals and services, and measure what happens across the network rather than within isolated programs.”

The result, he said, is a community that can move from identifying a need to coordinating a response and measuring the outcome. “That is particularly important with Rural Health Transformation funding. Communities have an opportunity not simply to add new programs and access points, but to connect those investments into sustainable infrastructure that improves outcomes, reduces avoidable utilization and total cost of care, demonstrates ROI and strengthens rural hospitals and communities after the grant funding ends. Sustainability, measurable outcomes and ROI are essential if communities are going to provide continuous whole-person care beyond the initial investment.”

Harnach said the Community Health Record is designed to complement, not replace, the electronic health records that hospitals and clinicians already use. The EHR remains the clinical system of record for the healthcare provider. The Community Health Record helps connect that clinical information, as appropriate and authorized, with the broader network of organizations and people involved in supporting the individual outside the traditional healthcare setting. The CHR has the capability to connect with more than 80 EHRs and health information exchanges, he said.

The Community Health Record can exchange appropriate information with EHRs and other health information systems so the network can coordinate care without requiring every participant to use the same technology. "That is particularly important in rural communities, where hospitals, physician practices, federally qualified health centers, Area Agencies on Aging, Community Hubs, public health agencies and other organizations may all operate on different systems,” Harnach said. 

The Community Health Record adds a whole-person, community view. It can help the network understand referrals and services, social and community needs, evidence-based interventions, transportation, nutrition and Food as Medicine, community health workforce activity, remote monitoring and other support occurring beyond the clinical encounter.

Panagis Galiatsatos, M.D., M.H.S., co-founder and director of Medicine for the Greater Good, noted that MGG has extensive insight in working in rural areas. “Since 2023, MGG has led various pulmonary-related initiatives in rural Maryland, focused on lung cancer screening resources, transportation issues, and food insecurities. Much of the strategies focused on community liaisons, such as community health workers. In addition, MGG has an active engagement with Cheyenne River Sioux in South Dakota, a rural region of the Lakota Nation. The focus has been on addiction services and social needs.”

Looking at rural care transformation models being developed across the country, the approaches with the greatest promise combine regional scale with trusted local delivery, Bilyew said. For example, a hub-and-spoke model can make specialty expertise, virtual care and shared infrastructure available across a region, while community health workers and local organizations help residents navigate care and address barriers such as transportation, food access and digital connectivity. Value-based care arrangements can then help align incentives around prevention, access and outcomes.

"What is particularly interesting to us is how those capabilities can be organized around the needs and resources of an individual community,” Bilyew said. “That is central to CCN. Depending on local priorities, a network could bring together hospitals and clinicians with public health agencies, EMS, Area Agencies on Aging, employers, schools, pharmacies, food and nutrition organizations and other community partners. Technology can help connect those pieces, but the goal isn’t simply to introduce more technology. It is to make the resources already available in a community work together more effectively and extend care into the places where people live, work, learn and gather.”

Bilyew said the group is in discussions with state and regional stakeholders, including rural healthcare organizations, hospital networks and potential clinical and community partners, as they translate approved plans into implementation models. “We are respecting the confidentiality of those discussions, so we are unable to identify specific participants at this stage. The conversations have become increasingly practical: which communities and use cases should come first, which organizations need to participate, how responsibilities and data will be shared, how quickly programs can launch, how outcomes will be measured and what can sustain the work after federal funding. That shift from broad program design to operating detail is encouraging. It also reinforces the need for models that combine the necessary capabilities while allowing each community to set its own priorities and build on its existing strengths.”