Value-Based Care News

Transforming Pilot Models into Sustainable Rural Health Programs

Rural health programs oftentimes start as small pilot projects, so what happens after grant funding runs out? Four programs share their strategies for sustainability.

pilot models transform into sustainable rural health programs

Source: Getty Images

By Emily Sokol, MPH

- Addressing rural health disparities can be challenging as these communities often have sparse resources and limited access to healthcare services. To combat this problem, many small, local grants fund projects aimed at addressing diseases that are disproportionally burdensome to rural communities.  

The challenge many project leaders face is sustaining their program after initial grant funding has expired. Some programs are unable to maintain their work, leaving the beneficiaries of these programs without the resources to continue promoting better health.

RevCycleIntelligence.com explored four programs that are breaking this cycle by integrating sustainability into project development. While all four programs tackle different health issues across the country, common themes articulate best practices in rural areas.

Sickness Prevention Achieved through Regional Collaboration (SPARC)

Common preventive services such as vaccinations and cancer screenings are performed at disproportionately lower rates in rural areas. As a result, fewer people in remote areas are receiving much-needed care that can prevent disease or catch diseases earlier when they can be more easily treated.  

In order to address this disparity and promote preventive services in rural communities, Doug Shenson, MD, MPH, MS, MA, president and co-founder of SPARC and professor at Yale University School of Medicine developed the Sickness Prevention Achieved through Regional Collaboration (SPARC) program.

The program rolled out in 1994 in the northeast and has since expanded to rural communities across the country.

One of the most successful aspects of the SPARC program was the Vote & Vax initiative in which flu shot clinics were set up at local polling sites to deliver the seasonal flu vaccine to voters.

“You’ve got something that is delivered every year – voting – right smack in the middle of flu shot season. The place where you vote is a place everybody knows. These places are statutorily supposed to be available to people with disabilities, so even the most vulnerable people in the community have access,” Shenson said. “On a single day, a lot of people pass through there. We helped Walgreens set up their flu shot services at polling places. It’s an example of how folks can work together to accomplish something that’s a win-win.”

The Vote & Vax program was able to deliver over 30,000 flu shots across the country during national elections and has shown to increase rural counties' vaccination rates.

“Just like we say all politics is local, all healthcare is local. It’s a model that has been successful,” maintained Shenson.

One of the biggest barriers to scaling the program is disseminating information about it and its benefits, Shenson said.

“Most folks don’t know about the program. We had to figure out how to get the word out. What is the pathway into a particular community?” he explained. “One of the things all communities share is a resistance to folks on the outside coming in and telling them how to do things. That’s totally understandable.”

To help make their case, the SPARC team focused on publishing studies about the program’s effectiveness and ensured their work was seen across multiple platforms. The aim was to broaden the spread of their work, making it easier for communities to find these resources and understand the benefit of SPARC.

“If you have ambitions to be a model for everywhere, you want to publish pieces and list on websites to help people find you,” Shenson advised. 

Living well through Intergenerational Fitness and Exercise (LIFE)

Individuals living in rural areas have decreased rates of physical activity compared to their urban counterparts. Older adults are disproportionately affected by this as they can be restricted to their homes and less likely to seek exercise opportunities despite it showing increased benefit to their health.

To combat this challenge, Sarah Francis, PhD, MHS, RD, associate professor and extension and outreach specialist, nutrition and wellness, at Iowa State University worked with partners at the university to create the Living well through Intergenerational Fitness and Exercise (LIFE) program.

“The program is an interdisciplinary team comprised of a kinesiologist, exercise physiologist, a lifespan psychologist, a development specialist, a nutrition expert, and a program development expert,” Francis said.

The 16-week program is divided into two parts. In the first eight weeks, a youth leader recruited from one of the local schools or universities leads participants through exergaming classes. During the second half of the program, the youth leader identifies someone within the group to sustain the program.

The classes are held in local community organizations or retirement community recreational rooms. The pilot phase of the study showed older adults who participated in the program increased strength, flexibility, activity levels, and confidence in their ability to be physically active. Preliminary results also showed that youth leaders demonstrated reduced ageism and increased knowledge of aging.

“The first question we’re asked by the community organization we approach is always ‘well, what’s the benefit?’” Francis pointed out. “If you don’t have any hard data to talk to them about you have a really hard time recruiting.”

After the pilot phase of the program, Francis and her team synthesized their materials, creating an easy outline for other organizations to understand how to get the program up and running.

“We kept a log of all the fees that were associated with the program. All the training materials are online, so people can access them,” she said. “This program can be implemented for $400.”  

The goal is for the template to be a guide for other organizations looking to apply for a small community grant.

“We need to get everything framed out for them so they’re able to write a successful grant application,” Francis explained.

The biggest barriers to implementation are the upfront costs. If organizations are successful in obtaining the small community grant to start the program, the program can sustain itself after.

“We modified our recruitment materials to include testimonials from previous participants and some of the outcomes that we found with the pilot study so people could see the benefits,” said Francis.

Francis hopes these testimonials will generate buy-in and recruit participants, thereby making upfront costs the only true barrier to adopting the LIFE program.

Rural Restaurant Healthy Options

Rural populations have higher obesity rates compared to the rest of the US, according to the Centers for Disease Control and Prevention (CDC). The Rural Restaurant Healthy Options Program was developed to help combat the obesity epidemic in a small but powerful way.

Faryle Nothwehr, PhD, associate professor at the University of Iowa and principal investigator of Rural Restaurant Healthy Options, found that people tended to eat less healthy when they were out to eat. Her team surveyed rural restaurant owners to discuss the problem and found that small owner-operated rural restaurants were hesitant to put healthy options on their menu because they did not have the resources to calculate nutritional content and disseminate that information.

“There was a lot of talk about how bad restaurant food was and owners didn’t want to feel like they were contributing to people’s heart attacks. They were motivated to do something, but at the same time, they needed to make a living,” explained Nothwehr.

Restaurant owners were also hesitant to change their menu for fear that customers would not like it.

“We went through a list with owners about what they would consider, and we came up with this idea of table signs that would prompt people to ask for healthier options the restaurant already offered,” Nothwehr said. “It didn’t cost the restaurant anything and they didn’t have to change their menu.”

The idea was piloted in one rural restaurant in Iowa. To measure the program’s success, Nothwehr and her team surveyed whether the signs stayed in place and were visible to clients. They asked restaurant owners how customers responded to the signs and asked customers if they noticed the signs or if the signs altered their ordering patterns.

“There were positive responses from both the owners and the customers, and the signs stayed in place,” Nothwehr noted.

After initial success and owner buy-in, the program expanded statewide.

“For a lot of other interventions, you need specialists or a big budget. Those are barriers to widespread dissemination,” Nothwehr continued. “It would be nice if you could get restaurants to change their entire menu, but that’s not very realistic. There’s a trade-off.”

To help disseminate information about the program to other restaurant owners, Nothwehr and her team were able to create a toolkit for implementation that other restaurants could use to adopt the idea.

“We intentionally made things simple and affordable so that these restaurants would be able to do it. This helped when we were trying to disseminate information because we didn’t need a whole team of people,” Nothwehr stressed. “We were able to come up with a toolkit that was simple. All the restaurant owners need to do is get the table signs and create a few materials. But they have their choice of what they use. It’s simple enough that they can do it for a very low cost.”

Safe Routes to School National Partnership

Poorly lit and high trafficked streets with no sidewalks can be dangerous, making it difficult for kids to safely walk to school, according to the Safe Routes Partnership program. As a result, many students in rural areas drive to school sometimes for over an hour.  

The Safe Routes Partnership promotes safe walking and biking to and from school and encourages increased physical activity for children of all races, income levels, and abilities. The national non-profit has partners across the country working to make structural changes that promote healthy habits for kids regardless of race, income level, or abilities.

The program is recognized by the CDC as one of their “HI-5” programs that show positive health impacts and cost-effectiveness through community-wide approaches. The program began with grant funding 15 years ago and since has expanded across the nation. Cass Isidro, MBA, is the president and executive director of Safe Routes Partnership.

“We focus on the six E’s: education, encouragement, engineering, enforcement, evaluation, and equity,” said Isidro. “There are challenges and barriers to each of these depending on the community. When you’re looking at a rural community, you’re looking at engineering challenges and logistical challenges because of how far away people are in the community.”

To combat this challenge, Safe Routes promotes remote drop-off locations. Parents can drop their students off at these locations and they will walk with their peers the last half mile to school.

“This allows kids the opportunity to get together as a community to walk to school. You get physical activity before the school day, which improves learning, attendance, and time-on-task. Then you get a little bit of social time beforehand, too,” Isidro explained. “When you can’t physically have students walking or rolling to school, we’re creating these opportunities to do it.”

An evaluation showed that the Safe Routes program was associated with increases in active school travel, walking, and biking. These efforts likely have downstream implications on fitness levels in students as well as social benefits that can be difficult to quantify.

After demonstrating initial success, the program successfully advocated for funding to be a budget item in local, state, and federal budgets.  

“Funding is tied into the department of education and department of transportation to some extent. It hits a couple of different areas, so we, as an organization, look at advocacy and programmatic aspects from both sides. It was never intended to be a one and done,” stated Isidro. “We’re not 150 percent in a community and then two years later gone. We consider it our responsibility to figure out what’s after.”

Takeaways for sustainability

All four programs started because of grant funding, but they each used different strategies to promote sustainability once grant funding declined. SPARC and SafeRoutes were able to leverage their funding to grow into large non-profit organizations while LIFE and Rural Restaurants ensured their programs were simple and easily repeatable to allow other organizations to replicate their work.  

The four program leaders recognized that funding was a large part of program sustainability, but organizations should not focus on it exclusively. 

“I’ve seen pretty amazing things done on a very small budget when organizations collaborate a little bit and have some good connections,” Nothwehr said.

Leveraging community partnerships can help these pilot programs lean on additional resources, identify areas of need in the community, and establish their work as integral to the community’s development.  

“Rural communities are really good at this kind of stuff because there’s a limited number of providers, so all different social service providers work together on a range of issues,” noted Shenson.

Generating evidence is important to help promote buy-in for a program, but it also should not be the sole focus of a program. 

“It’s important to measure the impact, but perception and the relationship building is equally as beneficial,” Francis said.

Evidence-based programs are often tested in non-rural areas, so adapting them to different settings areas can be challenging and require altering the evidence-based steps.  

“There’s starting to be an awareness of the need to be more flexible and encourage people to do what they can rather than try to be so hard-lined getting everything done exactly in the way it was originally,” stated Nothwehr.

Isidro noted the importance of not waiting for evidence to act.

“If we waited until everything was thoroughly researched, we wouldn’t have nearly as much movement as we’ve had. I think it’s a balance. It’s important to be grounded in evidence-based practice, but the case studies help fuel the trend,” she maintained.

Emphasizing evidence-based programs and proper funding is critical to success, but these are not the be-all-end-all of successful rural health programs. The most successful programs make an impact with limited funding, build sustainability into their practices, and emphasize adaptability to different situations.