Human Services to Support Rural Health
Human services play an important role in ensuring that rural residents and families have resources to maintain or improve their own health. The availability of safe and affordable housing, income supports, food assistance, job training, and other services help low-income rural residents take care of themselves so they can stay healthy. When faced with health challenges, people whose basic needs are met are better able to concentrate on recovery and take steps to avoid future problems. Some rural hospitals even employ their own social services staff, in an effort to provide patients with needed services that may help them avoid readmission.
By addressing the social determinants of health through the provision of human services, communities may be able to reduce healthcare costs and develop a more efficient healthcare system. Ensuring that patients who use the healthcare system frequently, such as those with chronic conditions, have their other needs met may lessen the stressors that contribute to their chronic conditions, reduce the amount of healthcare resources they require, and reduce hospital readmissions. This would allow healthcare providers to focus more on preventive care and population health.
Rural healthcare providers and facilities can help patients find services to meet their basic needs by recommending benefit programs, providing referrals, or coordinating services with human services providers. Likewise, rural human services providers may find that working with healthcare providers is an effective way to identify unaddressed needs. Connecting human services to healthcare can help make limited resources go further and leverage the close-knit nature of rural communities.
This guide focuses on human services that affect healthcare, including:
- Income supports like Temporary Assistance to Needy Families (TANF) and Earned Income Tax Credits (EITC)
- Weatherization and energy assistance
- Housing supports
- Job training and placement
- Child care assistance
- Child welfare programs
- Home visitation programs for parents and children
Access to healthy food and to transportation also impact health. These issues are covered separately in RHIhub's other topic guides:
Frequently Asked Questions
- How does the availability of human services affect rural residents' health?
- What rural housing and weatherization programs are available?
- How do income assistance programs help rural low-income residents and families?
- What resources are available to support rural jobseekers?
- How are the challenges of addressing child welfare different in rural communities?
- How do human services programs interact with the healthcare system?
- How is the provision of human services different in rural areas?
- What are benefits to the rural healthcare system of helping address the social determinants of health through the provision of human services?
- How can rural healthcare providers help their patients access needed social supports? What programs have been designed to do this?
- How can rural human service providers work with the healthcare system to address patients' basic needs?
- What types of funding are available for coordinating with human services and providing human services benefit enrollment in a healthcare setting?
- What are some of the barriers to integrating human services with healthcare in a rural setting?
- Where can I find information about the different ways human services can be integrated within a rural healthcare organization?
- What human services may be available to rural residents who are affected by the opioid crisis?
How does the availability of human services affect rural residents' health?
Human services can play an important role in low-income rural residents' health status. People who have access to support services and networks are more likely to improve their well-being, by reducing stress that can affect their health and allowing them more time and resources to care for their own health and the health of their families.
Many rural communities lack access to adequate human services. According to the USDA Economic Research Service's Rural Poverty & Well-Being, the 2016 poverty rate was higher in nonmetro areas (16.9%) compared to metro areas (13.6%) and in some regions, like the nonmetro South, poverty was as high as 21.3%.
A May 2015 U.S. Census Bureau report, Dynamics of Economic Well-Being: Participation in Government Programs, 2009–2012: Who Gets Assistance?, shows that nonmetropolitan participation in six national assistance programs is higher than for the nation as a whole:
What rural housing and weatherization programs are available?
The U.S. Department of Agriculture (USDA) provides direct assistance to low-income rural homeowners and renters. Rural Housing Service programs assist with the purchase and rehabilitation of single and multi-family homes. Its programs offer mortgage financing and loans to low-income and working families who are unable to obtain financing from conventional sources. The Multi-Family Housing Rental Assistance Program is also available for low-income rural residents.
The U.S. Department of Housing and Urban Development (HUD) offers programs to help individuals and rural communities with access to affordable and safe housing. These include:
- Community Development Block Grant Program (CDBG)
- Rural Housing and Economic Development (RHED)
- Indian Housing Block Grant Program (IHBG)
- Rental Assistance
The Housing Assistance Council (HAC) is a national organization that helps local organizations build affordable homes for low-income residents in rural communities. HAC offers low-interest loans and technical assistance to organizations in all rural areas.
The Low Income Home Energy Assistance Program (LIHEAP) is offered through the U.S. Department of Health and Human Services and helps people with low incomes pay their energy bills, improve home weatherization, or complete energy-related minor home repairs to reduce energy consumption. The Weatherization Assistance Program from the U.S. Department of Energy helps low-income families permanently reduce their energy bills by making homes more energy efficient through repairs and weatherproofing.
The Healthy Homes Program works to protect the health of children and families by addressing home environmental health concerns including mold, lead, allergens, asthma, carbon monoxide, pesticides, and radon. Healthy Homes grants are available to organizations, state and local governments, federally-recognized Indian tribes, and colleges and universities. These grants can be used to develop effective hazard intervention methods and provide public education to decrease housing-related environmental safety problems.
How do income assistance programs help rural low-income residents and families?
The Earned Income Tax Credit (EITC) provides a refundable tax credit for many low-income working individuals and families. The amount of the benefit depends on the recipient's income and family size. The document Earned Income Tax Credit Plays Outsized Role in Rural reports that a higher percentage of non-core rural taxpayers (23.4%) received EITC payments compared with metropolitan taxpayers (19.8%).
Temporary Assistance to Needy Families (TANF) provides time-limited financial assistance and services to low-income families. TANF benefits are funded through block grants to states and federally recognized Indian tribes. States and tribes have some flexibility in how they implement the program. The report TANF in Rural America: Informing Re-authorization compares rural-urban differences in TANF participation rates and reports that in 2009 over 11% of rural low-income families received TANF benefits compared with almost 14% of urban low-income families. The smaller percentage of low-income rural families using TANF could be due to their lack of access to human services and stigma connected with receiving government assistance in rural communities.
Healthcare providers can help patients access assistance programs by directing them to local human services agencies or online resources. Benefits.gov provides information and links to federal and state benefit programs, including TANF, state general assistance programs, Supplemental Security Income (SSI), unemployment benefits, and other programs that can help rural low-income families.
What resources are available to support rural jobseekers?
Job training programs help workers develop and improve their skills to obtain and keep steady employment. Workforce Development Boards are a network of federal, state, and local offices that support workers and employers. They oversee American Job Centers, which help businesses address workforce needs and help jobseekers with job training and finding employment. The Northern Rural Training and Employment Consortium in Northern California is one example of a rural program providing job training and employment services to build and support a strong rural economy.
The National Farmworker Jobs Program helps migrant and seasonal farmworkers and their families with services such as education, job training, housing, and childcare. The federal program partners with state and community organizations to help workers obtain employment.
There are fewer childcare providers and childcare centers in rural communities than in urban areas, and for this reason accessing reliable and affordable child care outside the home may be a challenge for many rural working families. As a result, many residents rely on informal arrangements with family, friends, or other caregivers, who might or might not be a licensed childcare provider. Local social service agencies and Child Care Resources Inc. (CCRI) may offer recommendations for providers who want to be licensed, including training on child safety and early childhood development.
How are the challenges of addressing child welfare different in rural communities?
Child Abuse and Maltreatment
The report Understanding Child Abuse in Rural and Urban America: Risk Factors and Maltreatment Substantiation provides a comparison of child maltreatment cases in rural and urban areas. The authors report that rural families with a substantiated child abuse report — cases with sufficient evidence to conclude child abuse has occurred — are more likely to experience multiple stressors such as drug and alcohol issues, domestic violence, and mental health issues. Geographic isolation and scarcity of social services can make it difficult for rural families to receive intervention services and to access programs which promote a healthy family life.
The National Advisory Committee on Rural Health and Human Services document Exploring the Rural Context for Adverse Childhood Experiences (ACEs) outlines programs from numerous federal government agencies that aim to prevent and respond to ACEs in rural communities. In the report, the committee raises concerns about whether funds block-granted to states sufficiently reach communities with high needs but low populations.
For more information, see the RHIhub Violence and Abuse in Rural America topic guide.
Foster Care and Adoption
The article Finding Homes for Rural Foster Children discusses difficulties finding foster homes in rural areas, with the result that many foster children must leave their community for care. All foster parents must be licensed by the state, which requires background checks, tuberculosis testing, home inspections, and training about the child welfare system. Religious organizations, community groups, and county offices can help foster families by providing financial support for background checks and home modifications. Rural Adoptions: A Different Kind of Rural Trust provides examples of successful adoption initiatives in rural communities.
The Child Welfare Information Gateway, a service of the Administration for Children and Families, provides rural child welfare resources to help professionals improve children's health and welfare, reduce child abuse and neglect, increase the number of adoptions, and support foster parents.
How do human services programs interact with the healthcare system?
Cooperation between the human service system and the healthcare system is not new, and has been known by many names, including:
- Integrated health and human services
- Wrap-around services
- Community and public health
- Care management
- Community Oriented Primary Care
Integration of services is becoming more accepted, and its importance more generally acknowledged.
The Rural Policy Research Institute's (RUPRI) report Place-based Policies and Public Health: The Road to Healthy Rural People and Places offers a brief history of this approach, from its beginnings in the 1980s. Community Oriented Primary Care (COPC), a term first used in 1987, is a population-based approach to primary care, in which providers took into account determinants of health and ways to promote health. Two reports issued in 2005, one from the National Advisory Committee on Rural Health and Human Services and another from the National Academies, called for improved coordination across health and social services and a consideration of community health issues.
The Federal Office of Rural Health Policy administers the Rural Health Care Services Outreach Grant program, which promotes community health service collaboration. The RUPRI Rural Human Services Panel studied the pool of grantees, many of which designed programs involving health and human service integration. The resulting report noted these characteristics in integrated health and human service programs in rural areas:
- Integration does not guarantee overall savings. Further, costs and savings may differ among partners.
- Evidence-based approaches to service integration that work well in certain settings may not be good fits in rural settings.
- Communities experiencing demographic changes or new challenges, such as increased drug use, may benefit most from service integration.
- Other key community organizations, such as schools and the courts, can be included, though they likely will need support and program flexibility.
- Behavioral health integration with primary care was the most common type of service integration, and a natural next step would be prevention programs for at-risk groups.
- If offering a full range of services is not possible, addition of just one new provider, such as a behavioral health specialist, may be sufficient for service integration.
- If patients are treated in their own homes or schools, rural transportation problems may be avoided.
- Reliance on community volunteers can keep costs down but may make it difficult to maintain services.
Visit RHIhub's Services Integration Toolkit to learn how rural communities can implement programs that integrate health and human services.
How is the provision of human services different in rural areas?
In many rural communities, residents must travel far from home to access support programs. Local agencies and community-based organizations may find that in order to publicize their services, they will need to invest time and effort on outreach.
Rural residents may hesitate to ask for help because of a strong tradition of self-reliance. However, integrating human services with the healthcare system may be easier in rural communities due to the importance and strength of relationships between local stakeholders and service providers. Providers in small, rural communities may need to offer several different types of services. In this situation they develop a better understanding of people's needs and problems and are better positioned to meet those needs. Rethinking Rural Human Service Delivery in Challenging Times: The Case for Service Integration describes this aspect of rural places:
The creativity and resilience of rural people, and the informal networks so prevalent in rural areas would further complement and enhance an integrated services approach… A rural service integration system would allow the flexibility to combine processes that take advantage of these creative local networks, while addressing the unique needs of a changing rural demographic, particularly with the expanded growth of immigrant and aging populations.
How does the rural healthcare system benefit by addressing the social determinants of health through provision of human services?
HealthyPeople.gov's page on Social Determinants of Health reports that people's health is affected by many factors, including:
- Availability of social and economic opportunities
- Resources available at home, in local neighborhoods, and in communities
- Quality of local schools
- Workplace safety
- Access to clean water, clean air, and nutritious food
- Healthy social interactions and relationships
People with chronic health conditions that require extensive healthcare services often have other problems, such as poverty and hunger. These may exacerbate their illnesses.
In 2008, the Institute for Healthcare Improvement (IHI) advocated the Triple Aim concept of improving patient experience, improving population health, and reducing per capita costs of healthcare for the overall improvement of healthcare in the U.S. Several provisions of the 2010 Affordable Care Act (ACA) focused on delivery of care and how providers are paid by federal programs, shifting the traditional payment for healthcare from volume- to value-based care. An example of this shift to value-based care and payment is the rise of Accountable Care Organizations (ACOs). ACOs emphasize a shared accountability between providers and healthcare organizations to achieve the goals of the Triple Aim. ACOs and other value-based programs provide an incentive for members to work together with human services agencies to expand traditional services, improve the patient experience, improve population health, and reduce cost of care.
A related shift is occurring, from focusing on providing healthcare when people are sick to a more comprehensive population health approach that focuses on the health of communities and the social determinants of health. To facilitate this approach, the federal government requires nonprofit hospitals to conduct a community health needs assessment (CHNA) every 3 years to retain their tax status. Rural hospitals can benefit from this requirement by identifying the areas of greatest need in their communities and the sources of highest healthcare costs. Hospitals and their communities then must create an implementation strategy which can coordinate with human services to address identified social needs and reduce healthcare costs, while at the same time improving population health. Additional information and resources related to conducting community health needs assessments are available on RHIhub's Conducting Rural Health Research, Assessments, and Evaluations topic guide.
A healthcare system that coordinates and collaborates with human service programs and community services has a greater opportunity to address these social determinants of health, likely reducing the need for and overutilization of healthcare services, reducing burdens on healthcare providers, and avoiding value-based reimbursement penalties. See RHIhub's Social Determinants of Health for Rural People for additional information.
The CDC Community Health Improvement Navigator provides tools and resources to help healthcare, social services, public health, and other community organizations work together to improve community health.
How can rural healthcare providers help their patients access needed social supports? What programs have been designed to do this?
Healthcare providers can help patients find social supports by co-locating healthcare services with social services, or by adding a social worker or case manager to the clinic staff. Examples of co-locating services in rural areas include:
- In rural Humboldt County, California, a Federally Qualified Health Center (FQHC) is located in the same building as a Family Resource Center, as discussed in a 2012 RUPRI Human Services Panel report. The Family Resource Center provides community services such as case management, food distribution, child care, and benefits application assistance to community members in need. The co-located FQHC and Family Resource Center share front-desk and administrative staff, easing the transition from medical services to social services.
- The implementation of the Blueprint for Health in Vermont includes social workers as part of multi-disciplinary Community Health Teams that operate in a Medical Home framework. The Blueprint also provides for an additional administrative payment to support these Community Health Teams. This program connects patients with services including benefit applications, housing needs, weatherization and energy assistance, and offers support in cases of domestic and child abuse. This also helps physicians stay informed about service options available to their patients.
Efforts to better coordinate care are creating a more formalized process to involve social services in the provision of healthcare. These programs are being implemented in rural settings:
- The Robert Wood Johnson's Aligning Forces for Quality supports programs such as Humboldt County's Care Transition program in northern rural California that assigns a social worker to the most frequent users of the healthcare system. Community Health Teams that include social workers and community service providers working with a primary care physician are being implemented in rural states across the country, often supported by Medicaid funding.
- The Northwest Oregon Network (NEON) Pathways Community Hub is a pay-for-outcome model that uses trained Community Health Workers (CHWs) to connect patients with the appropriate resources to address their health needs. CHWs identify high-risk patients, determine the best pathway for improved health, and educate them about the health and social services available in their community. The CHWs also help patients find the needed resources. Once the pathway is successfully completed, payment is made to the employing organization.
- The Maine Rural Health Research Center's report, Integrated Care Management in Rural Communities, provides examples and strategies for implementing integrated care in long-term care services, many of which are funded under Medicaid, and involve coordination or integration with acute care providers under Medicare.
How can rural human service providers work with the healthcare system to address patients' basic needs?
Family or Community Resource Centers are particularly effective in rural communities. These centers are located in states including North Carolina, New York, and California. The centers provide human services to low-income families in inviting and accommodating settings, and also may offer basic healthcare services, such as screenings, preventive care, and immunizations. These centers provide services to the entire community, thus reducing the stigma associated with receiving safety net services. As mentioned in a 2012 publication by the RUPRI Rural Human Services Panel, in rural California,
The ‘decentralized’ Family Resource Centers are community sites for a number of activities that promote healthy people in healthy communities, including parent education, food and clothing, social services, local health and behavioral health, and sites for meetings, including family meetings. These centers provide varied services driven by the needs of the community in an approachable manner.
Another type of program, the full-service community school (FSCS), integrates health and social services to support community development along with youth development, family support, and academics. By forming partnerships with elementary and secondary schools, educational agencies, and community-based organizations, FSCSs can coordinate academic, social, and health services; improve the quality of education; and help children meet academic standards. The Coalition for Community Schools website provides additional resources about FSCS and shows what local communities and states are doing to support them.
The RHIhub's Rural Services Integration Toolkit provides rural-specific resources including program models, implementation considerations, and examples of working models for rural communities seeking to develop a health and human services integration program. Also, the Human Services Value Curve toolkit developed by the American Public Human Services Association (APHSA) may be useful as a reference document for rural agencies and community organizations working to better integrate health and human service systems.
What types of funding are available for coordinating with human services and providing human services benefit enrollment in a healthcare setting?
The Federal Office of Rural Health Policy offers community-based grants that can be used to coordinate human services with healthcare services. The Rural Health Network Development Grants support rural providers who work in formal networks to integrate administrative, clinical, technological, and financial functions. Networks should have a significant history of organizational collaboration and an agreement to participate in the grant. The Rural Health Care Services Outreach program can support a wide range of non-clinical activities that improve health and healthcare in rural communities.
The Affordable Care Act (ACA) created incentives for states and their local service agencies to integrate health and human service program application and case management technology. With new groups of individuals now eligible for Medicaid under the ACA expansion, states need to modernize their eligibility and enrollment systems. Funding was provided in the ACA to create new technology to achieve this, by allowing human service programs to share programs and technology needed by Medicaid programs. Many states are creating new systems, utilizing an increased focus on the Insurance Affordability Program (IAP).
For rural specific funding for human services projects with a healthcare component, see the Funding section of this guide.
What are some of the barriers to integrating human services with healthcare in a rural setting?
One of the most significant challenges to integrating human services with healthcare is the difficulty of billing for services provided by a social worker or other human service provider in a fee-for-service healthcare payment model. Many insurers will not pay for phone consultations that social workers conduct for case management services with patients. The Commonwealth Foundation's report Care Management for Medicaid Enrollees through Community Health Teams notes that this problem can be addressed by creating Community Health Teams and Medical Homes, using Medicaid funding.
Another significant barrier to integrating human services with healthcare in a rural setting is having human service programs and operating staff available to coordinate with the healthcare system. Since rural human service providers often lack adequate resources, it may be difficult for them to provide needed services in the community, regardless of the setting. As the RUPRI Human Services Panel states in their report, Rethinking Rural Human Service Delivery in Challenging Times: The Case for Service Integration, sometimes even services deemed essential are unavailable.
Other challenges include:
- Compliance with federal and state laws and regulations
- Navigating privacy laws to allow data sharing without compromising confidentiality
- Mitigating liability
- Availability of transportation
- Stigma associated with receiving services
- Lack of infrastructure or technology
- Community members' lack of awareness of services available
- Lack of local revenue to support the programs
Where can I find information about the different ways human services can be integrated within a rural healthcare organization?
The human service system interacts with the healthcare system in many ways, from general referrals to a human service provider, to creating new programs among physicians, human service providers, and community organizations. In the report, Stimulating Local Innovation for Rural Health and Human Services Integration: A Critical Review of ORHP Outreach Grantees, the RUPRI Rural Human Service Panel discusses themes, characteristics, and case studies of innovative and non-conventional approaches of integrated health and human services projects in rural areas.
What human services may be available to rural residents who are affected by the opioid crisis?
In 2017 the U.S. Department of Health and Human Services declared the opioid crisis to be a nationwide public health emergency. In recognition of the fact that the problem requires attention not only from healthcare agencies but also from organizations providing human services, many resources have become available on the local and national level.
The Office of National Drug Control Policy's October 2018 document Federal Resources for Rural Communities to Help Address Substance Use Disorder and Opioid Misuse features a list of social services resources on pages 110-112.
Last Reviewed: 3/12/2019