August 13, 2019

Bringing Health and Housing Together in Rural Communities

Champlain Islands Health Center

This is the third post in a five-part series on challenges and opportunity in rural communities.

Other posts in this series: 

Many rural residents experience difficulties in accessing quality and affordable healthcare. Residents with disabilities, veterans and seniors choosing to age in their homes may find it difficult to access specialized care – especially in communities that rely heavily on automobile transit. Rural residents may not seek out access to care for mental health, substance use, or chronic illnesses due to social stigma or concerns for personal privacy. Many hospitals are consolidating or closing; the University of North Carolina finds that 102 rural hospitals have closed their doors since 2010. 

Enterprise’s partners are helping rural communities respond to these challenges. Last year, we distributed more than $350,000 in grants to rural and tribal partners working in health and housing. These funds enabled rural and tribal practitioners to make progress on their efforts to provide health-related services and homes for rural seniors, individuals experiencing homelessness, native peoples, and many more. 

This is the fourth blog in our series about opportunity challenges experienced by rural residents and innovative solutions being developed by our partners. Here, we focus on the health and well-being dimension of Enterprise’s Opportunity360 framework, highlighting challenges and opportunities rural residents have in accessing services needed to live in good health.  

What is health and well-being?

Different kinds of activities have been found to influence health and well-being outcomes. Researchers find that students who receive free or reduced-price school lunches reduce their food insecurity, obesity rates, and poor health. Housing for residents with disabilities, who were previously experiencing homelessness, contributes to reductions in mental health concerns and emergency room costs. Charitable airplane services may help rural people more easily access care that is only available in distant locations. 

Although the factors that influence health are broad and diverse, this post focuses on the healthcare system. Access to these programs is highlighted in the health and well-being segment of our Opportunity360 framework, as measured at a neighborhood level through a composite index score. Our health and well-being index is calculated using seven standardized variables: percentage of adults reporting to have a personal doctor or health care provider; percentage of adults reporting to have fair or poor health status in the last 30 days; percentage of adults reporting a physical checkup in the past year; percentage of adults reporting to have diabetes; percentage of adults reporting to have chronic obstructive pulmonary disease; percentage of adults reporting to be obese; and percentage of all people without health insurance. 

What is the health system like for rural residents?

The rural healthcare system includes many different types of providers. These include traditional primary care practitioners, like doctors, nurses, and dentists, as well as, hospitals and community clinics. The United States (U.S.) government’s Indian Health Services facilities provide care to members of federally recognized American Indian and Alaskan Native tribes. Mobile clinics, telehealth, and telepharmacy services may offer residents preventative services and specialized care.

However, quality health services are not equally available for all rural residents. The University of North Carolina’s Rural Health Research Program reports that rural areas tend to have more limited access to healthcare than urban areas. Primary care doctors who exist may be overworked, and mental health and substance abuse providers are rare. Indian Health Services’ clinics are underfunded, have limited hours, and may lack critical services, like emergency rooms. Rural pharmacies are also becoming increasingly hard to find with about 16% of them closing between 2010 and 2018. 

Where are rural residents challenged to live in good health?

A look at our Opportunity360 health and well-being outcomes scores can help us see where rural residents may find it especially challenging to live in good health. These scores represent nationwide percentile rankings of census tracts. A score of 50 means that a tract is in the 50th percentile—half of all tracts in the country have a higher score and half have a lower score. 

A map of the country’s rural health and well-being index scores helps us see the location of tracts with lower scores. Many of the lighter pink tracts are found across rural Appalachia, the Deep South, and into New Mexico. In 2017, more than 12% of the rural tracts located in the states of North Carolina, Georgia, Louisiana, Tennessee, South Carolina, Alabama, Kentucky, West Virginia, Arkansas, Mississippi, Oklahoma, and New Mexico had health and well-being scores in the lowest quartile. 

A more detailed map shows many of the country’s rural medically underserved areas have scores included in the light pink color which suggests that residents of these rural communities may find it especially difficult to access the services necessary to live in good health. This includes communities designated as medically underserved areas and medically underserved populations. A medically underserved area is a place designated by the U.S. Health Resources and Services Administration as having too few primary care providers, high infant mortality, high poverty and/or high elderly populations. An area with a medically underserved population is a place where a specific population group is underserved. 

A look at these communities shows that more than two-thirds of rural, medically underserved areas have scores in the lowest quartile. Although low, this is still probably an underestimate of the need, due to data limitations. These tracts, which are shown in the two lightest shades of pink, stretch down from Michigan’s upper peninsula through Indiana and Ohio into Appalachia and the Deep South across to California and upwards into the Pacific Northwest, Northern Rocky Mountains, and Alaska. 

What innovative things are partners doing to help improve the health services of rural residents?

In response to these challenges, Enterprise’s partners are working to develop and implement creative and innovative community-based solutions. These solutions are grounded in the idea that affordably-priced healthy homes are the foundation for supporting the health and well-being of residents and families.

In Southwest Colorado, Enterprise’s partner Housing Solutions for the Southwest is working to make homes affordable and available to individuals and families who have low-incomes, are chronically homeless, or who may be vulnerable to changes in affordability due to their age or health needs, along with survivors of domestic violence. Staff members connect residents to local behavioral health providers as well as a medical center and public health agency and utilize a collaborative approach to stabilizing people. They also provide training to hospital social workers, behavioral health providers, and engage in outreach at local doctor’s offices to inform people about local housing resources, emergency housing options, and administering the VI_SPDAT Triage tool (designed to identify and support the needs of individuals experiencing homelessness). 

The Makah Tribe in Washington is using funds from Enterprise to identify ways to serve all its members by connecting them with the culturally-relevant services they need to stabilize and live in health. They are also making progress on a project that uses the Low-Income Housing Tax Credit program to make 32 healthy, affordable homes available for the residents of this rural reservation. 

The Cathedral Square Corporation is using funds from Enterprise to support pre-development efforts for the South Hero Senior Housing project, which will serve the low-income, older adults and people with disabilities living on a rural Vermont island. The project will include a community of 32 affordable homes. Residents living in these units will be able to access on-site health services and programming to help them better manage chronic diseases, coordinate care, and access preventative care and transportation services.  


Across the country, many rural residents experience difficulties accessing quality and affordable healthcare, especially in medically underserved areas. With support from Enterprise, organizations working at the intersection of health and housing are responding to these needs by helping members of their communities access affordably-priced homes, obtain necessary healthcare, and support a healthy living. For more information about how Enterprise and its partners are supporting rural and tribal residents, visit Enterprise’s Rural and Native American Initiative.

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