Step 1: Define the Program and Scope of the ROI Analysis

To conduct an ROI analysis of a rural health program, start by clearly defining the program.

Consider a hypothetical program example called the Healthy Hearts Education Program. Suppose a rural county health department has partnered with a Critical Access Hospital and several community-based organizations to deliver free heart health educational workshops to community members.

Define the Program

• State the goals of the program: Improve heart healthy behaviors and reduce avoidable emergency department visits.
• Describe who the program serves: Adults aged 40 years and older who are at risk for high blood pressure and heart disease.
• Identify the intended results or changes expected: Increased use of preventive care, improved self‑management of chronic conditions, and fewer emergency department visits for preventable cardiovascular events.

Tools like a logic model can help rural program leaders to outline the program’s activities, outputs, and intended results or outcomes. For the Healthy Hearts Education Program, a simple logic model can be used to show how the educational workshops contribute to behavior changes and, over time, improved health outcomes and lower emergency department use.

Decide What the ROI Analysis Will Measure

Rural program leaders should consider the types of benefits for the ROI analysis:

• Direct financial savings, such as lower healthcare costs.
• Economic benefits, like new jobs or lower costs.
• Community or social benefits, such as stronger partnerships or improved well‑being.

In this example, rural program leaders decided to include both financial and social benefits.

• Financial benefits:
  • Fewer emergency department visits related to uncontrolled blood pressure
  • Fewer hospital admissions for heart related events
• Social and community benefits:
  • Improved health knowledge and confidence
  • Stronger partnerships with churches and community organizations
  • Better access to preventive health information for rural residents

Rural program leaders should also choose the perspective of the ROI analysis. This means deciding whose costs and benefits will be included: a single organization, a group of partner organizations, or the broader rural community. The perspective determines which costs and benefits are counted in the ROI analysis.

The Healthy Hearts Education Program uses two perspectives:

1. Healthcare system perspective (hospital and clinics)
2. Community perspective (residents and local partners)

Identify the Counterfactual

In an ROI analysis, you need to identify the counterfactual — what would happen without the program. This gives you a clear baseline to compare against, so you can estimate what improvements the program adds.

The counterfactual can be the previous process used before the program started or conditions in similar communities that do not have the program. This helps to show whether the program provides value. Programs can also compare the condition to the status quo.

One approach often used is pre-post counterfactual analysis, which involves comparing the outcomes before and after a program to understand what would have happened without the program.

In the Healthy Hearts Education Program, rural program leaders use a pre-post comparison:

• Emergency department visit rates for heart‑related conditions in the year before the program
• Emergency department visit rates among participants in the year after attending workshops

They also compare trends with a nearby rural county that did not offer a similar program. This helps estimate the incremental benefit of the education program beyond usual practice. For resources to help identify useful health and demographic indicators, see the Finding Statistics and Data Related to Rural Health topic guide.

Questions to Consider Before Moving Forward

Using the Healthy Hearts program as a hypothetical example, the questions below can help define the scope and approach for an ROI analysis:

• Who works on the program, and what roles do they play?
  One program coordinator and two community health workers deliver the educational workshops.
• How much staff time is used to operate the program?
  Staff spend about 20% of their time on this program.
• Besides staff time, what other costs are required to run the program?
  Other costs include educational materials, facility space, and travel for staff.
• Which partners are involved (for example, hospitals, health departments, community organizations)?
  Partners include the hospital, one health department, and 15 community-based organizations.
• From an ROI perspective, who incurs the costs and who realizes the benefits?
  The hospital incurs most of the costs, while both the hospital and community benefit.
• What outputs has the program produced (for example, number of trainings, partnerships)? These can be included if it is possible to place a dollar value on these outputs.
  Outputs include 24 heart health educational workshops, 320 participants, and 15 community partners.
• Who benefits from the program (an organization, the community)?
  In the Healthy Hearts Education Program, financial benefits accrue mainly to the hospital through avoided emergency visits, while social and health benefits accrue to participants and the broader rural community.

Asking these questions early helps build a strong foundation for the ROI analysis and ensures that financial, operational, and community impacts are captured in later steps.

Resources to Learn More

Community Development in Rural Health Toolkit
Website
See the Assessment Tools & Templates section for the Asset Inventory Tool for Rural Health Communities, used to identify assets and organize these assets into physical, human, and institutional categories, which can be helpful for planning for ROI.
Organization: National Organization of State Offices of Rural Health

Community Health Worker Return on Investment Study Final Report
Document
Summarizes evidence and case studies on the return on investment of community health worker programs, including financial and social impacts.
Author(s): Christiansen, E. & Morning, K.
Organization(s): School of Community Health Sciences, University of Nevada, Reno
Date: 5/2017

Compare Results to the Counterfactual
Website
Explains impact evaluation methods for comparing results to a counterfactual.
Organization: BetterEvaluation

Impact Evaluation in Practice, Second Edition
Document
Provides practical guidance on designing and implementing impact evaluations, including methods to estimate program effects, assess value, and inform decisions about scaling, sustainability, and return on investment, which is useful for evaluating community‑level health interventions.
Authors: Gertler, P.J., Martinez, S., Premand, P., et al.
Organization: World Bank
Date: 2016

Return on Investment (ROI) Calculator for Healthcare Partnerships to Address Social Needs
Website
Provides an interactive calculator to help users estimate the financial return of health-related social needs interventions and community health programs.
Organization: HealthBegins