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Rural Project Examples: Social determinants of health

Super-Utilizer Pilot Project
Added November 2017
  • Need: To address patients' complex physical, behavioral, and social health needs in order to reduce unnecessary visits to the emergency department or inpatient admissions.
  • Intervention: A pilot project in rural Montana provides intensive outpatient care management to high-need and high-cost patients.
  • Results: With the program's first 27 patients, the healthcare team in Kalispell has saved more than $1.6 million in hospital costs.
funded by the Federal Office of Rural Health Policy Northern Dental Access Center Medical-Legal Partnership
Updated/reviewed October 2017
  • Need: To help low-income patients in rural Minnesota overcome legal barriers to oral healthcare and self-sufficiency.
  • Intervention: The medical-legal partnership of Northern Dental Access Center and Legal Services of Northwest Minnesota provides free consultations and support services.
  • Results: The innovative and collaborative approach has been recognized regionally and nationally, and over 9,000 new patients have been screened for legal issues.
funded by the Health Resources Services Administration Outer Cape Health Services Community Resource Navigator Program
Updated/reviewed August 2017
  • Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance abuse services while reducing the burden and costs to town agencies, hospital emergency rooms.
  • Intervention: The Community Resource Navigator Program works with local social services and town agencies, faith-based institutions, hospitals, the criminal justice system, and others to identify and connect clients to needed services.
  • Results: Clients are gaining access to the care they were once lacking. The program also helps community partners and stakeholders work together to reduce the impact of risks associated with behavioral health symptoms, substance use disorder, and social determinants of health.