Highlights recent trends in the development and implementation of State Flex Programs, whose goal it is to strengthen the rural healthcare infrastructure using CAHs as the hub of organized, local systems of care. A major portion of the FY2003 funding dollars continue to target state program infrastructure development; however, the role of this infrastructure is shifting from supporting conversions to the ongoing availability of appropriate health care services for communities served by CAHs (e.g., CAH performance improvement, EMS integration, systems development, and community engagement). States are pursuing these areas with a variety of strategies including the use of local, interstate, and regional collaborations to share lessons learned and advance their knowledge in key areas for success (e.g., performance and quality improvement, health information technology, and capital planning). Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.