Human Services to Support Rural Health
Human services play a vital role in ensuring that rural families have the resources to support their own health. The availability of safe, affordable housing, income supports, food assistance, job training, and other critical services help poor and vulnerable rural residents take care of themselves so they can stay healthy. When faced with health challenges, people who have their basic needs met are better able to direct their resources to recovery and take steps to avoid future challenges.
Addressing the social determinants of health through the provision of human services has the potential to help control healthcare costs and attain 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 unnecessary hospital readmissions. This would free up healthcare providers to address the needs of other patients and also to focus more on preventive care and population health.
Rural healthcare providers and facilities can assist patients with finding human services to meet their basic needs through “prescribing” benefit programs, providing referrals, or coordinating services with human services providers. Likewise, rural human services providers may find working with healthcare providers is an effective way to identify unaddressed human service 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 a wide-range of human services that impact healthcare, including:
- Income supports like Temporary Assistance to Needy Families (TANF) and Earned Income Tax Credits (EITC)
- Weatherization and energy assistance
- Job training
- Child welfare programs, including child care, adoption and foster care
Access to healthy food and to transportation also impact health. These issues are covered separately in RAC’s other topic guides:
Frequently Asked Questions
- How does the availability of human services for rural residents impact their health?
- What are some rural housing and weatherization programs?
- How do income assistance programs help rural low-income families?
- What types of job training programs are available in rural communities?
- How are 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? Can activities related to this help meet ACA requirements for addressing community health needs?
- 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?
- What are the different possible levels of integration?
How does the availability of human services for rural residents impact their health?
Human services can play an important role in low-income rural residents’ health status. Access to support services and networks gives individuals a chance to improve their well-being, reducing stress that can adversely impact health, and allows them more time and resources to better care for their own health and the health of their families.
The need for human services is great in many rural communities. According to the 2011 report, Federal Tax Policies and Low-Income Rural Households, the poverty rate is higher in rural areas (15.1%) compared to urban areas (12.9%).
Human services that can have an impact on a rural residents’ health status include:
- Income supports such as Temporary Assistance to Needy Families (TANF) and the Earned Income Tax Credits (EITC)
- Supplemental Nutrition Assistance Program (SNAP)
- Weatherization and energy assistance
- Affordable housing
- Job training
- Child welfare programs including child care, adoption and foster care
A May 2015 U.S. Census Bureau report, Dynamics of Economic Well-Being: Participation in Government Programs, 2009–2012: Who Gets Assistance?, shows that non-metropolitan participation in six national assistance programs is higher than for the nation as a whole:
Data Source: Dynamics of Economic Well-Being: Participation in Government Programs, 2009–2012: Who Gets Assistance?, Appendix Table 1
What are some rural housing and weatherization programs?
The U.S. Department of Agriculture (USDA) provides direct assistance to low-income rural homeowners and renters. The Rural Development Housing and Community Facilities Programs assist with the purchase and rehabilitation of single and multi-family homes. This program offers mortgage financing and loans to low-income and working families who are unable to obtain financing from conventional sources. The Rental Assistance Program is also available for rural residents.
The U.S. Department of Housing and Urban Development (HUD) offers programs to assist individuals and rural communities with affordable and safe housing including:
- Community Development Block Grant Program
- Rural Housing and Economic Development
- Indian Housing Block Grant Program
The Housing Assistance Council (HAC) is a national organization which 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.
Low Income Home Energy Assistance Program (LIHEAP), which is offered through the U.S. Department of Health and Human Services, helps low-income households 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 installation of better weatherproofing.
The Healthy Homes Program works to protect the health of children and families by addressing a variety of home environmental health hazards including mold, lead, allergens, asthma, carbon monoxide, pesticides and radon, which can all cause disease or injuries. 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 families?
The Earned Income Tax Credit (EITC) provides a refundable tax credit for 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 and Rural Households reports that taxpayers in rural areas (21.4%) were more likely to claim the EITC than taxpayers in metropolitan areas (18.7%). For the 2012 tax year, the smallest population areas had the largest percentage of households claiming the EITC.
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 each state has some flexibility in how it implements 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 to 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 social services and a larger stigma with receiving government assistance in rural communities.
Benefits.gov provides information and links to federal and state benefit programs, including Temporary Assistance to Needy Families (TANF), state general assistance programs, Supplemental Security Income, unemployment benefits, and a variety of other programs that can help rural low-income families.
What types of job training programs are available in rural communities?
Job training programs help workers develop and improve their skills to obtain and keep steady employment. Workforce Investment 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 as well as 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.
How are challenges of addressing child welfare different in rural communities?
The Child Welfare Information Gateway, which is part of the Administration for Children and Families, provides rural child welfare resources for professionals to improve children’s health and welfare, reduce child abuse and neglect, increase the number of adoptions, and support foster parents.
Accessing reliable and affordable child care is an important aspect for child welfare and may be a challenge for many rural working families. The number of skilled and available child care providers in rural areas is more limited than in urban communities and child care centers are less common. Many residents rely on informal arrangements with family and friends for child care. Although these arrangements can be less expensive and more flexible, caregivers are generally not licensed and may lack formal training. Local social service agencies and the Child Care Resource & Referral can address these concerns by helping providers become licensed and by building a training infrastructure that includes education on child safety and development.
Child Abuse and Maltreatment
The report Rural Families with a Child Abuse Report are More Likely Headed by a Single Parent and Endure Economic and Family Stress provides an analysis of child maltreatment in rural areas. The authors report that rural families involved in Child Protective Services are more likely than those in urban areas to have high family stress and financial problems. Geographic isolation and a lack of access to social services can be a barrier for rural families to receive intervention services and programs which promote a healthy family life.
Foster Care and Adoption
The article Finding Homes for Rural Foster Children discusses difficulties finding foster homes in rural areas, resulting in many foster children having to leave their community for care. All foster parents must be licensed by the state to provide foster care, which requires background checks, tuberculosis testing, home inspections and training on the child welfare system. Religious organizations, community groups, and county offices could help foster families by providing financial help to pay for background checks and home modifications for people who are willing to provide foster care. Rural Adoptions: A Different Kind of Rural Trust provides examples of successful adoption initiatives in rural communities.
How do human services programs interact with the healthcare system?
The interaction of the human service system with the health system is not a new approach to services. In fact, it has been known by many names, including:
- Integrated health and human services
- Wrap-around services
- Community health
- Care management
- Community Oriented Primary Care
Integration of services is becoming more accepted, and its importance more acknowledged.
In Place-based Policies and Public Health: The Road to Healthy Rural People and Places, a brief history of this approach is described, from its beginnings in the 1980s. Community Oriented Primary Care (COPC) was one of the first examples for primary care to consider health determinants and health improvement beyond the visit to the physician. Then, in the early 2000s, a National Advisory Committee on Rural Health and Human Services report and an Institute of Medicine report called for improved coordination across health and social services and a consideration of community health issues.
The Affordable Care Act, enacted in 2010, has specific programs tailored to improving population health and individual well-being, particularly in Title IV (Prevention of Chronic Disease and Improving Public Health). These new programs provide guidance to coordinate multiple programs and policies that impact individual health and well-being. Applicants for Community Transformation grants (Section 4201), for instance, had to develop relationships across a community, including within healthcare and other sectors. Place-based Policies and Public Health: The Road to Healthy Rural People and Places lists additional ACA programs intended to improve individual and community well-being.
The Federal Office of Rural Health Policy at the U.S. Department of Health and Human Services administers the Rural Health Care Services Outreach Grant program, which has as one of its goals to promote community health service collaboration. Many of the grantees design programs that integrate with human service providers. The RUPRI Rural Human Services Panel examined these grantees to find examples of health and human service integration. In the resulting report, Stimulating Local Innovation for Rural Health and Human Services Integration: A Critical Review of ORHP Outreach Grantees, the Human Service Panel found particular themes to integrated health and human service programs in rural areas:
- Integration does not guarantee overall savings, and costs versus savings may not be evenly distributed among partners.
- Evidence-based approaches to service integration may not necessarily be proven to work in a rural setting.
- 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.
- Sustainability of any additional positions, such a behavioral health specialist, should be considered.
- Delivering services where clients are, such as at home or school, can help address rural transportation barriers.
- Reliance on community volunteers can keep costs down but may make it difficult to maintain 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. The Workforce Investment Act requires several programs to be partners in the one-stop delivery system. One-stop centers incorporate various program offices in a single location. TANF is a suggested partner, and states can require TANF to be a partner. Many one-stop centers also accept applications for food stamps and Medicaid as well as provide information about programs operated by community-based organizations and other providers. Local agencies and community-based organizations may find that in order to get the word out, they may have to invest significant time and effort on outreach.
Many rural residents may hesitate to seek assistance because of a strong tradition of handling personal problems themselves. However, integrating human services with the healthcare system may also be easier in rural communities due to the importance and strength of relationships built among a small set of local stakeholders and service providers. And in small, rural communities, one provider may, by necessity, provide many services and therefore may have a fuller understanding of an individual’s needs, problems and solutions that can be coordinated to meet those needs. In Rethinking Rural Human Service Delivery in Challenging Times: The Case for Service Integration, this uniqueness of rural places is described:
“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.”
What are benefits to the rural healthcare system of helping address the social determinants of health? Can activities related to this help meet ACA requirements for addressing community health needs?
A 2012 document, Community Health Centers Leveraging the Social Determinants of Health, reports that healthcare accounts for a relatively small percentage of an individual’s health status over time. Other factors have a great impact on health status including genetics, health behaviors, social and economic factors, and environmental factors.
According to the American Public Human Services Association, a community’s health and vitality cannot be solely determined by access to healthcare since human services also play a critical role in positive health outcomes. Individuals who have chronic healthcare conditions that require extensive healthcare services often have challenges in their life, such as poverty and food insecurity, which exacerbate these healthcare conditions. Prior to the Affordable Care Act’s expansion of health insurance, choices were limited for people with pre-existing conditions, economic hardship, and employment that did not offer insurance. These individuals were more likely to be without health insurance as well. 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, therefore likely reducing the need for healthcare services and reducing their costs, much of which may be uncompensated.
The Affordable Care Act created a new requirement for non-profit hospitals to conduct a community health needs assessment every three years in order to retain this tax status. The Centers for Disease Control and Prevention website has Resources for Implementing the Community Health Needs Assessment Process. Additional information and resources related to conducting community health needs assessments are available on RAC’s Conducting Rural Health Research, Assessments, and Evaluations topic guide.
Non-profit hospital systems can use the requirement of a community health needs assessment to learn where the greatest healthcare costs originate in their communities and create an implementation strategy that takes steps to reduce those costs. As an example, the St. Joseph hospital system in Eureka, California had been conducting a community needs assessment prior to the ACA requirement and determined that utilizing existing social service programs would allow them to provide services to the most frequent users of their healthcare system. They believe that proactively addressing a person’s overall well-being is a step towards reducing their need to enter the healthcare system.
How can rural healthcare providers help their patients access needed social supports? What programs have been designed to do this?
One of the most direct and coordinated methods for healthcare providers to help their patients access needed social supports is to co-locate healthcare services with social services, or to bring a social worker or case manager on to the staff of a clinic. Examples of co-locating services in rural areas include:
- In rural Humboldt County, California, a Federally Qualified Health Center is located in the same building as Family Resource Center, which provides community services such as case management, food distribution, child care and benefits application assistance to community members in need. This combined FQHC/Family Resource Center share front-desk and administrative support, which eases 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 in health service areas. This program connects patients with all types of potential services, including benefit applications, housing needs, weatherization and energy assistance, as well as support for cases of domestic and child abuse. This also helps physicians stay regularly informed about service options available to their patients.
New national care coordination efforts 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 Care Transitions 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. Vermont’s Blueprint for Health also has Community Health Teams as the centerpiece of their healthcare system reform in the state.
- 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 the acute care provider under Medicare.
How can rural human service providers work with the healthcare system to address patients' basic needs?
A resource particularly well-suited to rural communities are Family or Community Resource Centers. These Centers are in states across the country, including North Carolina, New York, and California. The Centers are designed to provide human services to low-income families in settings that provide an inviting and accommodating atmosphere, but they also often offer basic healthcare services, such as screenings, preventive care and immunizations. These Centers provide services to the entire community, not just those accessing human services, which can decrease the stigma associated with receiving safety net services. 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. “
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. As mentioned above, the Rural Health Care Services Outreach program expands healthcare delivery in rural areas. Funding may be used to conduct health screenings, health fairs, education and training, and any other health service delivery activity that does not involve inpatient care.
The Affordable Care Act has created new 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 Affordable Care Act 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).
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 those 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 would conduct for case management services with patients. Creating Community Health Teams and Medical Homes using Medicaid funding, alone or in combination with other payers, is a solution examined in the Commonwealth Foundation’s report, Care Management for Medicaid Enrollees through Community Health Teams.
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 are often under-resourced, 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, “At times, even the most basic essential services may not be accessible or may not even exist.”
What are the different possible levels of integration?
The human service system interacts with the healthcare system at many different levels, from general referrals that a physician provides to a human service provider for a patient, all the way to creating new programs between physicians, human service providers and often the community. 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 some themes and characteristics of integrated health and human services projects in rural areas.