Rural Healthcare Needs: Meeting the Needs of SDOH Challenges


Imagine growing up in a rural area where neighbors know each other and their children. Within a ten-mile radius, you find neighbors who are a close-knit community. Farmers share extra crops, while most neighbors have gardens and share their excess harvests, baked and canned goods and crafts with each other. There is no shortage of fresh foods. In addition to fresh meats, fruits and vegetables from personal gardens and farmers’ harvests, there are three grocery stores within the rural county’s town and several corner stores throughout the surrounding communities that also sell basic needs and fresh crops.

The local economy includes educators, farmers, stay-at-home moms, retirees, law enforcement, blue-collar and white-collar employees, and even state representatives who all reside together. Within the town’s city limits are several businesses—banks, hardware stores, gas stations with repair shops, etc. Healthcare options include community and chain pharmacies, a small community hospital used for minor injuries and procedures, a rural health center and local health department, dentists and medical specialists (e.g., family physicians, optometry, podiatry, obstetrics, etc.). These businesses and resources provide the citizens’ basic necessities.

This was my experience growing up in the 1970s and 1980s in my rural community. Although many residents traveled to neighboring counties for additional resources (e.g., malls, big-box hardware stores, major hospitals, cultural events, etc.) and employment, our community’s daily needs were available close at hand.

Unfortunately, as individuals (like me) left to attend college or explore careers in other cities and senior members retired, our rural community resources dwindled. The change was evident on my return visits home and became more and more marked as the economy continued to decline, and my mother and her peers aged further.

By this time, I had taken on the role as my mother’s healthcare caregiver. The three grocery stores, robust neighborhood gardens and multi-generational farm families were no longer present. Instead, the town was left with NO grocery stores after the last chain stores closed. Healthcare options also declined with the closing of the community hospital and rural health center. Many specialists (like the community pharmacists and obstetricians) either retired or moved practices to larger cities. Left standing: one chain pharmacy and a discount retail store, neither of which sell fresh foods.

Like many of my mother’s peers, we were forced to have her primary care needs managed by physicians in the neighboring county, approximately 30 minutes from her home.

As mom’s medical needs increased and she warranted tertiary care, I requested referrals that were in my local area. Unfortunately, this meant increasing her commute to 1 hour 30 minutes and arranging transportation. Her health plan case managers often needed to familiarize themselves with many rural barriers and were not able to offer resources. Instead, I used my nursing and case management knowledge combined with my family’s awareness of the rural environment to help navigate the healthcare system and community resources to ensure that she and my elderly relatives received their necessary care despite their limitations. Frequently, this resulted in my peers from the community who also had aging parents, my siblings and I purchasing groceries, medicines and other necessities before we arrived in the county.

As a former community case manager, I had encountered many patients who faced similar barriers to quality care due to their environment and limited access. I often wonder about my mother’s peers, other senior members or individuals in the community who do not have the resources we had yet face the same challenges. Are their medical providers aware of the county’s disparities, specifically the food desert and limited medical resources? When they ask their patients to choose healthier foods, are they considering how patients can obtain them or what’s available locally? Do they know when they prescribe medicines that there is only a single pharmacy in town, yet it may be 10 to 15 miles away from the patients’ homes with limited hours? Does the patient have reliable transportation to drive the 15 miles? Are they aware that available mental/behavioral health resources are extremely limited?

Many citizens are not able to rely on family or other caregivers to supply groceries, research potential resources on the internet beyond the county radius, provide transportation to take them to medical appointments or assist in addressing other social barriers. Many do not have case managers who are patient advocates and experts in care coordination to link them to resources to promote healthy outcomes and prevent admissions due to delayed care.

Thankfully, there is increasing awareness and education surrounding social determinants of health (SDOH) within healthcare. The Centers for Disease Control and Prevention (CDC) defines SDOH as “conditions in which people are born, grow, work, live and age and the wider set of forces and systems shaping the conditions of daily life” (Centers for Disease Control and Prevention, 2022). The SDOH domains include healthcare access and quality, education access and quality, social and community context, economic stability and neighborhood and built environment. Like most communities, the need to access these domains was amplified during the COVID-19 pandemic.

As healthcare professionals, case managers understand that addressing SDOH concerns is a key driver to wellness and better patient outcomes. My organization intentionally incorporates SDOH screenings as part of our patient assessment processes. In addition to asking our patients about these vital components during our initial encounters, we leverage tools that provide data about the geographic service area and patient population. This data-driven approach (including the patient’s subjective responses and objective information) is critical to understanding the barriers, addressing our patients’ needs and promoting health equity. The CDC’s Social Vulnerability Index (SVI) is a valuable resource that displays communities’ risk or vulnerability for public health crises at the census tract level. The score encompasses four themes (socioeconomic status, household characteristics, racial and ethnic minority status and housing type/transportation), by calculating 16 social factors, such as poverty, housing crowding, transportation access, etc. (Centers for Disease Control and Prevention, 2023). The scores range from 0 (lowest vulnerability) to 1 (highest vulnerability). Case management organizations and other healthcare professionals can incorporate SVI or similar data models to identify resources or interventions to improve healthcare and provide preventive care to communities. In the example of my rural hometown, its SVI score is 0.9701, per the CDC SVI 2020. Three-fourths of the county displays as the overall highest vulnerability, with household characteristics, racial/ethnic minority status and housing/transportation themes at greatest risk. The score indicates that factors such as housing structure (mobile homes), limited transportation, aging senior population and single-parent households may make up the composition of the communities. Arming case managers, patient healthcare teams and community partners who serve this population with this information gives them insight and a leg up on how to assess patients and address the community’s needs.

As more communities suffer from economic challenges, generational changes and resource shortages like my hometown, I hope that case managers (in all settings) incorporate SDOH screenings as we engage patients and “meet the patients where they are.” We should make a concerted effort to familiarize ourselves with the patient communities we serve by having open-ended conversations about their social environments, researching the community’s vulnerabilities and needs and incorporating findings to develop effective interventions and potential advocacy opportunities. Understanding patients’ environments, challenges and lived experiences builds trust and fosters collaborative, case manager-patient relationships, which may ultimately improve our patients’ healthcare outcomes. As with my personal situation, case management knowledge and skills can be transformative in meeting the significant needs of patients and loved ones who reside in rural communities.


Centers for Disease Control and Prevention. (2022, December 8). Social Determinants of Health at CDC. Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention. (2023, July 12). CDC/ATSDR social vulnerability index (SVI). Centers for Disease Control and Prevention.

avera white

Avera White, MSN, RN, CCMis the executive director of Diversity, Equity, Access & Inclusion (DEA&I) and director of Clinical Informatics for Community Care of North Carolina (CCNC). Her 28-year nursing career includes over 20 years in community case management. Currently, Avera facilitates the organization’s diversity and inclusion strategic goals and provides clinical informatics support for case management processes.

She is a member of the Triangle CMSA Chapter in the Raleigh-Durham, North Carolina area.



Comments are closed.