Rural Project Examples Addressing Social determinants of health

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.

Georgia Health Initiative's CDFI Investments
Updated/reviewed October 2023

Need: Across Georgia, especially in rural areas, poor health outcomes and high poverty rates require strategic investments to reduce disparities and improve health across the state.
Intervention: Georgia Health Initiative invests in Community Development Financial Institutions (CDFIs) working in Georgia to build a strong ecosystem of mission-driven community lenders focused on rural and low-income communities. The capital and capacity building provided by CDFIs support systemic change to reduce inequality and improve health across the state.
Results: Since 2017, grants and Program Related Investments (PRIs) in CDFIs working in low-income, medically underserved rural communities have generated impact through stronger and growing Community Health Centers, expanded affordable housing, green energy loans and jobs, and growing small businesses owned by women and people of color.

Healthy Monadnock Alliance
Updated/reviewed September 2023

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.

Healthy Adams County
Updated/reviewed August 2023

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 2023

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 40,000 food insecurity screenings each year. Fresh produce, meat, and other goods are distributed to roughly 140 families (around 500 individuals), 200 seniors, and 75 school-aged children annually.

Rural Libraries and Health Cooperative Agreement
Updated/reviewed July 2023

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 screens an average of 215 residents a month, and another library's programming reached over 800 female patrons.

The Rural Outreach Center
Added June 2023

Need: To expand services for individuals and families living in poverty in rural Western New York.
Intervention: The Rural Outreach Center (ROC) offers care coordination, therapy, budgeting assistance, and multiple other services and opportunities to help address immediate needs as well as empower individuals to work toward long-term freedom from generational poverty.
Results: The Rural Outreach Center serves approximately 250 adults and children each year through counseling, care coordination, and empowerment opportunities. The ROC reports that many participants have achieved and sustained goals related to housing, savings, employment, and other social determinants of health – which are also measures of poverty.

Outer Cape Health Services Community Resource Navigator Program
Updated/reviewed March 2023

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.

Rural Aging Action Network
Added February 2023

Need: To connect underserved and isolated older adults in rural Minnesota, Montana, North Dakota, and South Dakota to services and supports so they can age in place.
Intervention: The Rural Aging Action Network is a collaborative of organizations that offer different services like caregiver support, behavioral health, financial counseling, and assistance with chores and household maintenance.
Results: Since 2015, the collaborative has reached over 4,000 older adults and caregivers in over 100 rural communities.

Rural Project Examples: Social determinants of health