A Primer for Multi-Sector Health Partnerships in Rural Areas and Small Cities

A tool to guide cross-sector collaborations between the community development, finance, public health, and healthcare sectors to support partnerships in rural areas and small cities.

This primer aims to assist multi-sector approaches that increase community-centered investments to support opportunities for all individuals to live long, healthy lives, regardless of their income, education, race or ethnic background. Acknowledging the unique opportunities and challenges to working in rural areas and small cities, we recognize the importance of incorporating resources that reflect these realities creating freedom for locally generated solutions to accelerate through innovative partnerships.

While rural areas, towns and small cities represent a related set of geographies distinct from dense, urban places, they are as a group far from uniform. As many working in the field will attest, the definitions of rural are numerous, and often those developed for funding do not necessarily connect to people and residents, or are reflective of history and culture. Additionally experiences of small cities can vary depending on their proximity to urban centers. As we listen to our partners, we acknowledge the challenges they face, and lift up some of their unique assets that make cross-sector perspectives particularly suitable for making significant changes to health outcomes in these communities.

As America emerges from the greatest public health challenge of a generation, innovative and non-traditional partner approaches such as those shared by the Build Healthy Places Network (BHPN) will be needed more than ever to ensure everyone has the opportunity to live their healthiest life. By applying cross-sector solutions to the root causes of health inequities, we can strive to ensure that recovery incorporates adequate care for all across the country as well as within communities while embedding resilience into systems, approaches, and partnerships for challenges that lay ahead.

Many Native communities experience similar challenges to those described here but in addition face some unique barriers to accessing healthcare, financial services and legacies of persistent exclusion from infrastructure investment. While we do not delve into these issues in detail here, our plan is to focus and lift up this perspective in a future addition to our Factsheet Series.

Quick Links

Section 1:
Introduction and 101
Section 2:
Small Cities and Rural Areas Toolbox

SECTION 1

A brief introduction to the roles that different sectors play in community health and well being in rural areas and small cities, and the opportunities that cross-sector partnerships can offer in creating conditions that support health.

Healthcare’s Role in Rural and Small Cities

Rural hospitals, Clinics and healthcare centers play a central role in rural areas and small cities through essential provision of healthcare service. In addition, they are community anchors, providing jobs and avenues to economic stability. Rural hospitals are closing at alarming rates, with 70 percent predicted to be at risk of financial distress. They are often challenged by managing the care of older, sicker and lower wealth populations where poor health outcomes can be linked to social determinants of health. Social determinants of health account for about 80–90% of the modifiable contributors to population health. These factors, the social factors outside of the health system itself, such as housing and the built environment, influence health and have been subject to years of disinvestment and the impacts of intergenerational poverty. Major challenges to accessing broadband connectivity curtail options for telehealth that could mitigate inaccessibility due to lack of transportation.

Community Development’s Role in Rural and Small Cities

Community development corporations (CDCs) and community development financial institutions (CDFIs) play a critical role in the support and promotion of neighborhood development. These organizations bring in needed capital for undercapitalized rural communities, enabling more efforts that addresses many of the social determinants that impact the health of creating availability of safe and affordable housing stock and building other infrastructure, including Federally Qualified Health Centers (FQHCs), rural and critical access hospitals, health clinics, grocery stores and child care centers. They are challenged by poor infrastructure and impacts of a concentration of residents who struggle financially. 47% of rural renters are housing cost burdened and additionally, attracting capital in a competitive system geared towards urban economies of scale and impact can be challenging.

Opportunities: Why Cross-sector Partnerships can Increase Investment to Improve Social Determinants of Health and Health Equity

There is an ‘interconnectedness’ and close-knit ties embedded in the fabric of rural and small city communities that supports community engagement and lends itself to multi-sector solutions that can bring meaningful change in a way that reflects the infrastructure and social network of the communities they are trying to serve.

There are calls to change the narrative around areas existing outside of urban centers to recognize the unique assets embedded in these enduring communities. Organizations operating in rural areas and small cities are good at utilizing their network of folks that bridge sectors. Scale may be small, but smaller investments in return can have big impacts here. Multi-sector health solutions can leverage the strengths of the natural networks that thrive in rural and small cities, and rural philanthropy can play a critical role in supporting the development and capacity building for these efforts.

BHPN advocates for more coordinated multi-sector solutions to address the upstream social determinants of health impacting outcomes. We are also committed to promoting community-rooted solutions that bring the community voice, an essential element in understanding the lived experience and the diversity of rural areas and small cities and is embedded in the Principles for Building Healthy and Prosperous Communities developed by BHPN and derived from the common themes of organizations across sectors working in this area . Community knowledge of local challenges should be a resource placed at the center of approaches.

SECTION 2

Rural and Small Cities Toolbox to Get Started:

Build Healthy Places Network (BHPN) has created this mini-tool box of our existing resources to help facilitate cross-sector collaboration that fosters investments that improve where we work, live, play and worship, supporting better health outcomes in rural communities and small cities. As we continue to grow our offerings, we will update this toolbox with additional resources tailored for leaders and practitioners living and working in these communities.

Jargon Buster

As you explore the toolbox, let us help you decode the jargon and acronyms and common industry lingo in the community development and health sectors.

CDC (Community Development Corporation)

CDCs are neighborhood-level, nonprofit organizations that implement community development projects ranging from the development of affordable housing and community centers to job training and health services. Community development corporations emerged from what were called community action agencies in the 1960s. These organizations were created to build the capacity of low-income communities as part of the War on Poverty. CDCs range in size and focus and are found in many, but by no means all, neighborhoods across the country. They often function as real estate developers, dealmakers, and intermediaries between community-based service providers, public agencies, and investors like banks, philanthropic organizations, and community development financial institutions (CDFIs). The most recent national survey of CDCs found that there were more than 4,600 nationwide. The National Alliance of Community Economic Development Associations (NACEDA) and Practitioners Leveraging Assets for Community Enhancement (PLACE) are leading CDC trade associations.

CDCs are located in the low-income communities that they serve. Professional staff operates CDCs with oversight from advisory boards that include neighborhood residents. It is important to note that while CDCs are 501(c)(3) nonprofits, they self-identify as CDCs; there is no discrete tax classification for the category. The work of CDCs is primarily funded through state and federal grants, but the groups can receive funding through Community Development Financial Institutions (CDFIs), intermediary organizations, and philanthropic organizations.

Community Development Financial Institutions (CDFIs)

CDFIs are “private financial institutions dedicated to delivering responsible, affordable lending to help low-income, low-wealth and other disadvantaged people and communities join the economic mainstream” (see the Opportunity Finance Network). CDFIs include both for-profit and nonprofit institutions like community development banks, credit unions, loan funds, and venture capital funds. These institutions invest in communities by financing small businesses, microenterprises, nonprofit organizations, and commercial real estate and affordable housing. As of 2018, there were more than 1,100 CDFIs serving cities, rural areas, and Native American reservations.

CDFIs also serve as intermediaries that help commercial banks invest in low-income communities to meet their Community Reinvestment Act (CRA) requirements. Some Community Development Corporations and affordable housing developers operate CDFIs as part of their work (for example, the affordable housing developer Mercy Housing has an associated CDFI, Mercy Loan Fund).

Leading CDFI resources include the Opportunity Finance Network, the nation’s leading CDFI trade association, and the United States Treasury’s CDFI Fund, the federal government’s designated funding source for CDFIs. Established in 1994, the CDFI Fund provides financial and technical-assistance grants to certified CDFIs, and manages the New Markets Tax Credit program, among others. CDFIs must be certified through the CDFI Fund to access these programs. In 2013, the CDFI Fund distributed $172.6 million to CDFIs nationwide.

For more information on CDFI’s, check out this great video from the Opportunity Finance Network:

USDA Rural Development

USDA Rural Development offers loans, grants and loan guarantees to help create jobs and support economic development and essential services such as housing; health care; first responder services and equipment; and water, electric and communications infrastructure.

Source: USDA Rural Development

Rural Health Clinics

Rural Health Clinics (RHCs) were established by the Rural Health Clinic Service Act of 1977 that addressed an inadequate supply of physicians serving Medicare beneficiaries in rural areas and increased the use of nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs) in these areas. Medicare pays RHCs an all-inclusive rate (AIR) for medically necessary, face-to-face primary health services and qualified preventive health services furnished by an RHC practitioner. RHC practitioners are physicians, NPs, PAs, CNMs, clinical psychologists (CPs), and clinical social workers (CSWs).

Source: Centers for Medicare and Medicaid Services

See more definitions at our full Jargon Buster here.

Diversity of Approaches, Partnerships and Financing

Partnerships between community development and health can include a variety of projects and collaborations from low-complexity (co-location of services) to high-complexity (pooled investment funds). The graphic below gives a basic overview of the range of complexity in financing, partnership, and projects that have been successfully explored to date. Although we have focused on community development and health partnerships, there are many examples of broader collaborations including other sectors, as listed below, that can assist in maximizing assets, investments, and impact in rural places and small cities.

To learn more about cross-sector partnerships between community developers and healthcare, download BHPN’s Healthcare Playbook for Community Developers.

Types of projects:
Co-location of services, grants, data sharing, advocacy, and political clout

Project Example

Supportive housing for Veterans with on-site health services such as mental health counseling

Types of projects:
Rehabilitation of old properties, new construction, loans, and NMTC

Project Example

Development of a two-story building that includes a grocery store and job training center, financed with NMTCs

Types of projects:
Land swaps, pooled funding, and co-benefit investments

Project Example

Development of a pooled fund that includes a CDC, healthcare, and other private investors. Pooled fund used to purchase real estate for a wellness center that includes a Federally Qualified Health Center, workforce development, and community spaces. Funded through the pooled fund and NMTCs

Leveraging diverse Financing

New Market Tax Credits
Low-income Housing Tax Credits
Loan guarantees and credit enhancement
Line of credit and bridge loans
Direct Loans
Land swaps
Programmatic grants and reserve fund investments
Pooled funds from multiple sources
Equity Investments

Comprehensive investments

Property reuse, rehabilitation and new construction
Co-location of services
Community benefit programing and investments for social needs and social determinants of health including but not limited to: jobs, economic development, workforce; housing and homelessness; integrated health services including primary care, behavioral health, prevention and wellness; early care and education, youth development; food security

Diverse partnerships

Health systems
Community Development Corporations (CDCs)
Community Development Financial Institutions (CDFIs)
Affordable housing developers
Faith based groups
Private and public regional universities and colleges
Banks
Government
Philanthropy

Case Studies

Cross-sector Partnerships in Practice in Small Cities & Rural Areas.

Cross-sector partnerships in rural communities and small cities may still feel abstract. The case studies below illustrate in more detail what these partnerships can look like in practice. The projects featured range from low to moderate complexity (see the framework described above).

DevNW Williamette Valley, Oregon

The Power of Cross-sector Partnerships: Reducing ER visits and reductions in emergency department costs through coordinated services. (Low complexity)

In 2016, DevNW, a rural and suburban community development corporation launched a health navigator program in partnership with InterCommunity Health Network Coordinated Care Organization to connect their affordable housing residents to healthcare and social services. The health navigation program increased resident access to healthcare services, early intervention services on evictions, improved communication between housing and social service providers, and focused on upstream solutions to staying healthy in the first place. Over the last four years, outcomes include a 15% reduction in ER visits and a 19% reduction in emergency department costs per member per month. Their work also prevented 97 evictions.

This case study was featured in our fact sheet that explores how community developers can partner with health organizations to address homelessness. The full fact sheet series also explores community development’s critical role as a partner in addressing mental health and social isolation.

Kentucky Highlands Investment Corporation

The Power of Cross-sector Investments: Investing in local health facilities that provide access to quality healthcare while preserving & creating jobs. (Medium complexity)

The Kentucky Highlands Investment Corporation, a CDFI, serves 22 counties in Southeastern Kentucky by providing employment opportunities to the surrounding rural community through managerial assistance and financial investments. In 2018, it also helped preserve local healthcare in Pineville, Kentucky when its rural hospital filed for bankruptcy. This effort involved several stakeholders who partnered to retain the quality healthcare and local employment provided by the hospital. First State Bank took the initial step, purchasing the hospital’s assets during bankruptcy proceedings. The bank then called on Kentucky Highlands Investment Corporation, which was able to restructure the hospital’s existing debt into a $6.5 million USDA loan, ultimately providing the hospital with working capital through a line of credit. In 2019, the hospital bought back its assets from the bank, and Pineville Community Hospital was reborn as the Pineville Community Health Center.

This case study is highlighted in our Community Economic Development & Healthcare Playbook, an action oriented guide, developed in collaboration with NACEDA, to help community economic developers parnter with health institutions to create career pathways in low-income neighborhoods.

Rural and Small Cities MeasureUp

Data is an important tool that can help make the case for and advance cross-sector partnerships that improve community health. It can illustrate which social and community factors have the greatest impact on health outcomes in your community; support opportunities for cross-sector partners to share data that exposes health inequities in neighborhoods; and can help describe the impact of your work. Our MeasureUp micro site includes helpful datasets for health and community development practitioners working to improve health outcomes in rural, small cities, and urban communities.

The PLACES Project

A collaboration of the Robert Wood Johnson Foundation, the Centers for Disease Control and Prevention, and the CDC Foundation, PLACES enables users to browse data about health for every neighborhood and zip code in the United States. It includes 27 different health measures related to behaviors, health outcomes, and prevention practices, ranging from mental and physical health, to access to health insurance and preventive screenings. Regardless of location, local health departments can use PLACES to better understand the burden and geographic distribution of health-related outcomes that assist in planning public health interventions.

The County Health Rankings & Roadmaps

The County Health Rankings & Roadmaps program helps communities identify and implement solutions that make it easier for people to be healthy in their schools, workplaces, and neighborhoods. The tool provides data to rank every U.S. county on factors that influence health, from air pollution to obesity and teen births, and recently incorporated new measurement datasets that influence health such as access to reliable broadband.

The American Communities Project

The American Communities Project (ACP) sets out to find a better way of understanding the different types of communities that make up America to develop new and better ways of recognizing and measuring what works and what does not. Working with academics, the ACP used a wide range of different factors and a clustering technique to identify 15 types of counties, everything from Big Cities to Aging Farmlands. It has mapped those types to show where the country’s political, socio-economic, and cultural fissures are.

Some of the rural communities featured include:

The Rural Data Portal

Developed by the Housing Assistance Council (HAC), The Rural Data Portal is an easy to use, on-line resource that provides essential information on the social, economic, and housing characteristics of communities in the United States. The Rural Data Portal is targeted toward rural communities, but a wide range of information is presented for the nation, states, and counties for rural, suburban and urban areas.

This site includes:

An interactive map to see state level and county level data
A Q&A page to help navigate the portal
A data source page
Other data resources for rural communities

Partner Finder

Ready to find a community development or health partner? BHPN’s Partner Finder is a collection of directories to help you find the community development or health organization nearest to you. Below are some examples of national organizations with rural and small cities members. The full Partner Finder directory can be accessed here.

ASTHO: The Association of State and Territorial Health Officials

ASTHO is the national nonprofit organization representing public health agencies in the United States, the U.S. Territories, and the District of Columbia, and over 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, formulate and influence sound public health policy and ensure excellence in state-based public health practice.

ASTHO membership includes public health agencies serving rural areas and small cities. The organization’s website also features blogs covering public health topics relevant to rural communities.

NACCHO: Directory of Local Health Departments

The National Association of County and City Health Official’s (NACCHO) tool to search for local health departments in your area.

Learn more about NACCHO’s Rural Health Section, composed of NACCHO members and partners working together on specific rural public health issues across multidisciplinary and programmatic expertise in support of NACCHO’s mission.

The National Organization of State Offices of Rural Health

The National Organization of State Offices of Rural Health (NOSORH) was established to assist State Offices of Rural Health (SORH) in their efforts to improve access to, and the quality of, health care for 57 million rural Americans. NOSORH supports the development of state and community rural health leaders; creating and facilitating state, regional and national partnerships that foster information sharing and spur rural health-related programs/activities; and enhances access to quality healthcare services in rural communities.

Neighborworks America

NeighborWork’s members are community development organizations building strong and resilient communities, providing people with opportunities to live in safe, healthy and affordable housing.

Learn about NeighborWorks America’s Rural Initiative. An initiative dedicated to creating vibrant rural communities by delivering a range of essential services, including capital, training, and peer learning.

Rural LISC

Rural LISC’s (Local Initiatives Support Corporation) community development partners are working to address the issues faced by rural communities including housing, economic development, education, health and safety.

Rural and Small Cities Resource Library

The following section presents a collated selection of resources produced by BHPN or featured on other external sites, with rural and small city focus and relevant to the practitioner conducting or considering cross-sector partnerships.

BHPN Resources

Video Snapshots & Blogs

Video Snapahots

Social Isolation and Loneliness in Rural Communities: can cross-sector partnerships play a role in tackling the growing epidemic?

Both a rural and urban phenomenon, social isolation and loneliness can be uniquely challenging to combat in rural communities. In this brief 20 minute Video Snapshot, Build Healthy Places Network’s Ruth Thomas Squance speaks with Carrie Henning-Smith, assistant professor at University of Minnesota School of Public Health and Deputy Director of the University of Minnesota Rural Health Research Center.

During this interview, the two will discuss the obstacles of addressing social isolation and loneliness in rural communities; the role of the community development sector in tackling these challenges; and how cross-sector health partnerships in rural areas can help ensure an equitable recovery after the COVID-19 pandemic.

Video Snapahots

Building Healthy Rural Communities Together: The role of rural philanthropy in cross-sector partnership to improve community health & well-being

In this 14 minute Video Snapshot, Build Healthy Places Network’s Ashley Hernandez speaks with Allen Smart, a national spokesperson and advocate for improving rural philanthropic practice under his group–PhilanthropywoRx.

The two discuss the important contributions philanthropy brings to community development and health partnerships in rural areas. Allen Smart also provides examples of philanthropy’s key role in accelerating investments aimed at improving health and well-being in rural communities and lays out ways community developers can connect with the philanthropic sector.

Expert Insights

Keeping Everyone at the Table, Six Feet Apart

Written by Cecille de Laurentis on December 14, 2020

The National Invest Health initiative, a project of Reinvestment Fund and the Robert Wood Johnson Foundation, has brought together cross-sector collaboratives in 50 small and mid-size cities since 2016 to develop health and equity-focused strategies for community investment. This blog explores how three of the grantees have leveraged cross-sector partnerships and community engagement practices to improve community and health well-being, despite the challenges of COVID-19.

BHPN Resources

Crosswalk Essays

Crosswalk

Rural Health Professionals Think Outside the Hospital

Across the country, rural hospitals are beginning to address key social determinants of health, improving the health and well-being of their communities. Our Crosswalk essay, co-published with Shelterforce Magazine, shares examples from Kansas, Vermont, Wisconsin, and Virginia, where rural hospitals are pioneering creative partnerships with community development that pave the way for further investments in their communities.

Crosswalk

A Financial Remedy on the Reservation

Due to discrimination, federal policy neglect, and resulting intergenerational poverty, Native communities experience a painful history that has produced a tangled web of poor health and economic hardship.This Crosswalk essay highlights how Native CDFIs are bringing affordable financing to Indian Country, breaking down barriers to building wealth, and cultivating improved community health and well-being.

Crosswalk

Rebuilding Healthy Communities in Rural America

Like urban areas, poverty and disinvestment in rural communities lead to worse health outcomes. Small towns, however, face unique hurdles in economic development that require a different blueprint for community development than in urban areas. This Crosswalk essay explores several efforts to unlock investments in rural communities in order to improve overall health and well-being in rural America.

External Resources

Report

Making Community Development Work in Small to Midsize Cities

Community development investment can be more challenging to deploy in small and midsize cities. This report by the Urban Institute describes the challenges small and midsize cities can face in attracting and sustaining the capital needed to develop a pipeline of community development projects. The report also lifts up models for sustainably and successfully expanding investment, making recommendations to improve the flow of community development capital. Although this report is focused on small to midsize cities, some of the challenges outlined in the document may resonate with the experience of those living in rural communities. Therefore this report may also spark ideas for strategies that can be adapted to the rural experience.

Rural Health Information Hub

The Rural Health Information Hub (RHIhub), funded by the Federal Office of Rural Health Policy, is a national clearinghouse on rural health issues. The RHIhub is committed to supporting healthcare and population health in rural communities. It is a guide to improving health for rural residents by providing access to current and reliable resources and tools to help users learn about rural health needs and work to address them.

Aspen Institute’s Rural Groups

Convened in 2016 by the Northern Forest Center, U.S. Endowment for Forestry and Communities, and the Aspen Institute Community Strategies Group, the Rural Development Innovation Group (RDIG) is made up of rural development practitioners, intermediaries and others who have been deeply involved in advancing rural community and economic development through “wealth-building” approaches that add value to local assets, create jobs and build regional and local capacity to adapt to changing conditions.

On the RDIG website, you can learn more about it’s membership, which are made up of rural development practitioners, intermediaries and others who have been deeply involved in advancing rural community and economic development.

Learn more about the RDIG’s America’s Rural Opportunity speaker series, a series of panel conversations that invites policymakers, economic and community development practitioners, and business and philanthropic leaders to engage in real dialogue around advancing a rural opportunity agenda.

Thrive Rural

Thrive Rural, an effort of the Aspen Institute Community Strategies Group in partnership with the University of Wisconsin Population Health Institute with support from the Robert Wood Johnson Foundation, aims to create a shared vision and understanding about what it will take for communities and Native nations across the rural United States to be healthy places where everyone belongs, lives with dignity, and thrives. Thrive Rural intentionally brings into focus the convergence of racial, economic and geographic inequity in rural America. Thrive Rural elevates what works and what’s needed to bridge health with community and economic development, and connects the shared aims, reality and prospects of rural America with all of America.

At the Thrive Rural webpage, learn more about recent Thrive Rural publications, events, and it’s Theory of Change Working Group, a broad array of leading practitioners, academics and experts from the fields of health, community building and community and economic development.

Rural Matters, Podcast

Rural Matters is a biweekly, 30-minute podcast about rural education, business, and health. The podcast’s mission is to increase awareness, inform discussion, and expand the dialogue on the most important issues facing rural stakeholders every day. Guests on the podcast include rural education decision-makers, rural business owners and entrepreneurs, and rural health care representatives. The National Rural Education Association and the Center for Rural Affairs are marketing partners.