In December, the Centers for Medicare & Medicaid Services announced awards to all 50 states through the Rural Health Transformation Program (RHTP), marking a significant federal investment in rural health care delivery. Across publicly posted state applications, priorities varied—from stabilizing rural hospitals to expanding behavioral health—but one theme appeared consistently: without a strong workforce, rural health transformation cannot succeed.

Within that workforce focus, states repeatedly elevated the nursing workforce as essential to sustaining rural access to care. These efforts take on added significance in a policy environment where there are concerns that access to financing for advanced nursing degrees may become more constrained due to proposed changes in federal education loan policy. As states invest in loan repayment, tuition assistance, and employer-supported training through RHTP, these tools may increasingly function not just as incentives, but as critical access points into the nursing profession.

Below are a core set of approaches included in state RHTP applications.

Growing the Rural Nursing Pipeline

Many states emphasize the importance of training nurses who already live in rural communities, recognizing that local students are more likely to remain in rural practice after graduation. These efforts typically span the full education continuum, from career exploration activities aimed at middle and high school students to paid clinical training for nursing students.

What this looks like in practice:
Minnesota emphasizes training health care workers who already live in rural communities through “earn-and-train” pathways. Grant funds will be used to cover tuition and training costs for rural workers, including those pursuing nursing credentials, while they continue working part-time for rural employers. By allowing rural residents to advance along career ladders without leaving their communities, Minnesota explicitly frames workforce development as a way to grow local capacity rather than rely on external recruitment.

Recruiting and Retaining Nurses Where They Are Needed Most

States also acknowledge that rural providers are competing in a tight labor market. As a result, many RHTP plans include financial incentives aimed at both recruitment and retention, such as loan repayment, tuition assistance, and service-linked bonuses.

What this looks like in practice:
Wyoming proposed individual education support awards for people entering clinical pipelines, including nursing roles from entry level positions, such as a Certified Nursing Assistant (CNA), through highly trained positions, like an Advanced Practice Registered Nurse (APRN). These awards will follow the individual rather than the institution and are paired with a five-year service commitment to Wyoming health care providers. The model functions as a direct tuition assistance mechanism, lowering the cost of nursing education while ensuring that graduates remain in rural practice settings where shortages are most acute.

Making Rural Nursing Practice Sustainable

A notable shift across state applications is explicit attention to non-wage factors that influence whether nurses stay in rural practice. Housing availability, childcare, transportation, and professional isolation are increasingly cited as drivers of turnover.

What this looks like in practice:
Alaska is explicit that retaining nurses in rural and frontier communities requires addressing cost-of-living barriers alongside education and recruitment. Thus, Alaska proposes pairing structured workforce incentives with housing placement coordination, time-limited housing stipends, and childcare supports, including onsite or near-site childcare partnerships.

Expanding Nursing Roles Through Team-Based Care

Many states combine workforce investments with delivery system redesign, enabling nurses to practice at the top of their license. These models are especially important in rural areas with limited physician supply.

What this looks like in practice:
Washington links workforce investments to delivery system redesign by expanding rural training opportunities and advancing team-based care models supported by telehealth and care coordination technology. These models rely on multidisciplinary teams—including nurses and advanced practice providers—to manage chronic conditions, support preventive care, and extend access in rural settings.

Why These Investments Matter

With this wide range of strategies, states are not simply trying to hire more nurses. Instead, states are using combinations of education pipelines, recruitment incentives, retention supports, and care model redesign to create sustainable rural practice environments.

Aurrera Health works with states and partners to assess how workforce policy choices translate into access on the ground. If your organization is thinking through how workforce investments or related policy decisions may affect rural health care access and implementation outcomes, we welcome the opportunity to connect.If you are interested in discussing how to support the rural workforce, please reach out to Lauren Block or Kristal Vardaman.

Authors

Kristal Vardaman [Managing Principal]

Investing in the Nursing Workforce to Strengthen Rural Health Transformation