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Social Determinants of Health for Rural People – Models and Innovations

These stories feature model programs and successful rural projects that can serve as a source of ideas and provide lessons others have learned. Some of the projects or programs may no longer be active. Read about the criteria and evidence-base for programs included.

Effective Examples

Medical Legal Partnership of Southern Illinois
Updated/reviewed June 2019
  • Need: Legal barriers often prevent economically disadvantaged people in Southern Illinois from obtaining positive health outcomes despite receiving medical care.
  • Intervention: The Medical Legal Partnership of Southern Illinois (MLPSI) was formed to create a system where medical providers can refer patients in need of legal assistance to local attorneys.
  • Results: Over 4,300 patients have utilized MLPSI since its founding in 2002. The program has relieved over $8.1 million in medical debt for both hospitals and patients.

Other Project Examples

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.
Super-Utilizer Pilot Project
Updated/reviewed November 2020
  • Need: To address patients' complex physical, behavioral, and social health needs with the goal to reduce unnecessary visits to the emergency department and reduce inpatient admissions.
  • Intervention: A registered nurse and community health worker used technology to address patients with high risk and high costs in their home setting through a 90-day intensive intervention.
  • Results: The healthcare team in Kalispell saved more than $1.8 million in hospital costs with the project's first 36 patients.
funded by the Federal Office of Rural Health Policy Northern Dental Access Center Medical-Legal Partnership
Updated/reviewed January 2020
  • Need: To help low-income patients in rural Minnesota overcome legal barriers to oral healthcare and self-sufficiency.
  • Intervention: The medical-legal partnership of Northern Dental Access Center and Legal Services of Northwest Minnesota provides free consultations and support services.
  • Results: The innovative and collaborative approach has been recognized regionally and nationally, and over 9,000 new patients have been screened for legal issues.
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.
Schoharie County ACEs Team
Updated/reviewed July 2019
  • Need: Agencies in Schoharie County, New York were seeing a widespread trend of Adverse Childhood Experiences (ACEs) in children and families they served.
  • Intervention: The Schoharie ACEs Team was formed as a way to educate rural communities about ACEs, the brain science behind it, and ways to build resiliency.
  • Results: The ACEs Team has put on 4 half-day educational conferences and 10 trainings for various groups across the region, trained 3 school districts on trauma-informed care, and provided resources for families exposed to trauma.
Fostering Futures in Menominee Nation
Updated/reviewed September 2018
  • Need: Since the late 1800's, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
  • Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
  • Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 85% since 2008.

Last Updated: 11/25/2020