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 August 2023

• 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 5,400 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

Rural Aging Action Network

Updated/reviewed January 2024

• 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.

Schoharie County ACEs Team

Updated/reviewed December 2023

• Need: Agencies in Schoharie County, New York were seeing a widespread trend of Adverse Childhood Experiences (ACEs) in the children and families they served.
• Intervention: The Schoharie ACEs Team was formed as a way to educate rural communities about ACEs, the associated brain science, and ways to build resiliency.
• Results: The ACEs Team has put on 5 half-day educational conferences, 2 virtual conferences, and 10 trainings for various groups across the region. The team has also trained 3 school districts on trauma-informed care and provided resources for families exposed to trauma.

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.

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.

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.

Pride in Idaho Care Neighborhoods

Added December 2022

• Need: Patients who identify as LGBTQ+ in rural settings may face barriers to receiving appropriate care, including a knowledge gap among healthcare providers regarding HIV prevention, hormone replacement therapy, and other types of care.
• Intervention: A partnership between a Critical Access Hospital, statewide residency program, nonprofit organization and other regional entities provides training, virtual consultations, and resources to rural providers across Idaho.
• Results: Physicians experienced in gender-affirming care have performed virtual consultations for rural physicians and patients around the state, and the number of local providers trained in PrEP management has doubled.

Fostering Futures in Menominee Nation

Updated/reviewed August 2022

• 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 94% since 2008.