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Rural Health Information Hub

Rural Project Examples: Social determinants of health

Effective Examples

Community Health Worker-based Chronic Care Management Program
Added May 2020
  • Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
  • Intervention: A community health worker-based Chronic Care Management program demonstrated such a level of success in a single West Virginia county that it was further scaled for implementation in a multi-center, 3-state area of Appalachia.
  • Results: When analysis of the disseminated program's results also demonstrated improved health outcomes and decreased healthcare costs, sustainability became possible due to innovative financial reimbursement models.

Other Project Examples

Healthy Adams County
Updated/reviewed August 2022
  • Need: Health initiatives in rural Pennsylvania communities to address locally-identified health disparities.
  • Intervention: Healthy Adams County was created by its rural community members to promote community-wide health.
  • Results: Community task forces have been formed to address breast cancer prevention, food policies, behavioral health, health literacy, oral health, tobacco prevention, and other rural, community-identified needs.
Lakewood Engage Food Access Initiatives
Updated/reviewed August 2022
  • Need: Lakewood, Minnesota is classified as a food desert, where many rural families face food insecurity and low availability of both nutritious and affordable provisions.
  • Intervention: A collection of programs address food insecurity and the dietary health of members of the community, from children and families to older adults, supplying them with locally-sourced fruits, vegetables, and meat.
  • Results: Lakewood Engage conducts around 30,000 food insecurity screenings each year. Fresh produce, meat, and other goods are distributed to roughly 140 families (around 500 individuals), 200 seniors, and 70 school-aged children annually.
Rural Libraries and Health Cooperative Agreement
Added May 2022
  • Need: To increase access to healthcare and social services in rural South Carolina via library systems.
  • Intervention: Pilot sites are hiring social workers and community health workers to provide consultations, case management, and referrals.
  • Results: One library's social worker program currently has 62 active clients, and another library screens an average of 215 residents a month.
Healthy Monadnock Alliance
Updated/reviewed February 2022
  • Need: Improved health outcomes for Monadnock Region, a rural area of New Hampshire.
  • Intervention: A wide-scale effort across multiple sectors is aiming to improve health outcomes throughout the region.
  • Results: Community health trends have been tracked over time, and progress on goals such as increasing the number of residents with healthcare coverage, opportunities for physical activity, access to healthy foods, and smoking cessation has been made.
Great Plains Senior Services Collaborative
Updated/reviewed November 2020
  • Need: To help rural, low-income older adults in rural Minnesota, Montana, and North Dakota maintain their independence and improve their health and well-being.
  • Intervention: The Great Plains Senior Services Collaborative improves service coordination, promotes social engagement, and provides programs like healthy cooking classes and caregiver support.
  • Results: Phase I served more than 1,550 vulnerable older adults in 80 communities, who reported lower stress and better quality of life.
Healthcare Georgia Foundation's CDFI Investments
Added December 2019
  • Need: In rural Georgia, poor health outcomes and high poverty rates require innovative approaches.
  • Intervention: As the only statewide private foundation in Georgia with the sole focus of improving health, Healthcare Georgia Foundation supports Community Development Financial Institutions (CDFIs) to do the same.
  • Results: With a program related investment from the Foundation, 2 statewide CDFIs and 1 national CDFI are providing low-interest loans and other support to rural healthcare efforts.
funded by the Health Resources Services Administration Outer Cape Health Services Community Resource Navigator Program
Updated/reviewed December 2019
  • Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance use disorder services while reducing the burden and costs to town agencies and hospital emergency rooms.
  • Intervention: The Community Resource Navigator Program works with local social services, 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, as measured by improvements in self-sufficiency. 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.