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Healthy People: Healthy Communities

  • Need: Spotlight chronic disease risks in rural south central Kentucky, specifically stroke and heart disease.
  • Intervention: A case management program for Kentucky counties of Boyle, Garrard, Lincoln, and Mercer.
  • Results: Decreased the risk of stroke and heart disease among program participants.


Promising (About evidence-level criteria)


Ephraim McDowell logo The Ephraim McDowell Health Care Foundation, along with 5 consortium partners, created the Healthy People: Healthy Communities program to assist people at risk for chronic conditions, specifically cardiovascular disease. Ephraim McDowell Regional Medical Center (EMRMC), in partnership with four county health departments and one extension office, coordinated screenings for stroke risk.

These screenings were held semi-annually and measured cholesterol and glucose levels, body mass index (BMI), height, weight, and blood pressure. This information was used to complete a stroke risk scorecard developed by the National Stroke Association.

Healthy People Healthy Places screening

Registered nurses served as case managers and followed up with service recommendations for clients. They reviewed the stroke risk information with clients and discussed lifestyle changes and appropriate community-based services that could assist clients in achieving their health goals. The EMRMC project coordinator then orchestrated participating health departments' nurses for monthly client follow up.

This intervention provided needed lifestyle adjustment education to achieve program goals. This program was modeled after the University of Kentucky Heart Health Program, a program used to assist clients with setting personal goals, provide concise teaching materials for health education.

Healthy People Healthy Places screening

The program was supported by a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant.

As of 2017, the program continues to perform Spring and Fall screenings.

Services offered

Clients received printed and verbal educational materials and tools to help them achieve their goals.

Referrals were made to:

  • Wellness centers/SilverSneakers, an exercise program for older adults
  • Primary care providers
  • Dietitians
  • Pharmacists
  • Hospice for grief counseling
  • Free clinics
  • Affordable care access
  • Reduced fee clinics
  • The Salvation Army for social services
  • Mental health clinics
  • Support groups
  • Diabetic and smoking cessation classes


Results from the original grant cycle were:

  • Decrease in stroke risk calculated from the stroke risk scorecard
  • Prevalence of heart disease dropped from 10.7% in 2011 to 8.2% in 2014
  • Increased screening cholesterol levels, from 88% to 90.3%
  • 94% individuals not screened in the previous five years had blood pressure checked
    • Of those who had their blood pressure checked:
      • 80.9% were told they had high blood pressure
      • 41% were diagnosed more than once with high blood pressure
      • 90.6% took action to reduce their blood pressure
  • The projected 5 year medical savings expenditures were $6,869,264, or a return on investment of $18.68 per dollar spent

Healthy People: Healthy Communities is also featured in RHIhub's Rural Health Promotion and Disease Prevention Toolkit Program Clearinghouse.


Some challenges this program faced included:

  • Maintaining client confidentiality
  • Lack of a secure recording and reporting system
  • Health department registered nurses with varying degrees of computer skills and comfort with electronic recording keeping
  • Project coordinator spent a significant amount of time coaching and teaching basic computer navigation skills
  • Different sites created some difficulty with continuity of work


In order to create a similar program, it is important to:

  • Find a secure Virtual Private Network (VPN) network for information exchange
  • Have staff report to a central location for client case management and recording
  • Create monthly and bi-monthly meetings addressing consistency issues
  • Develop communication efficiencies between nurses and patients
  • Develop an initial orientation for training staff on data reporting

Contact Information

LaVerne Slone MSN., RN, Community Service/Faith Community Nursing
Ephraim McDowell Health Care Foundation, Inc.

Cardiovascular disease
Chronic disease management
Health screening
Wellness, health promotion, and disease prevention

States served

Date added
September 14, 2015

Date updated or reviewed
November 6, 2017

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.