Content area
Rural public health has been hit with a triple set of challenges: overstretched health care, poor health status, and limited public health capacities. MaineHealth, a nonprofit integrated 10-hospital health system, serves a mostly rural area with no local public health departments in its rural communities. By integrating primary care with public health and partnering with communities, MaineHealth has developed an infrastructure to successfully address these challenges. We believe this approach is worthy of consideration in other rural areas.
Rural public health has been hit with a triple set of challenges: overstretched health care, poor health status, and limited public health capacities. MaineHealth, a nonprofit integrated 10-hospital health system, serves a mostly rural area with no local public health departments in its rural communities. By integrating primary care with public health and partnering with communities, MaineHealth has developed an infrastructure to successfully address these challenges. We believe this approach is worthy of consideration in other rural areas.
B y leveraging the resources of the health care system and by building partnerships, MaineHealth has developed a hub-and-spokes model for community health called the Center for Health Improvement (CHI) that has successfully addressed some rural disparities and built capacity for nonregulatory functions of public health. In this unique way, CHI is able to impact some challenges faced by rural public health.
INTERVENTION AND IMPLEMENTATION
MaineHealth CHI's hub is an organizational hub of resources that includes
e health data and analytics,
e agrants office,
e operational and management resources for program planning and strategy,
e program evaluation, and
e system-wide and statewide programs that work with other providers, state and federal government agencies, statewide nonprofits, businesses, and other partners across the system and state.
CHI's spokes are community health departments in each local hospital's service area that serve all of the residents of that area. The departments (spokes) consist of a community health director and other public health professionals who oversee partnerships with primary care clinicians, local government agencies, schools, and community-based organizations (CBOs; e.g., community action programs). These partnerships are guided by a multisector community coalition that forms a council that is convened by the community health director or a community member. With resources from the CHI hub, the local community health department teams facilitate community health needs assessments (CHNAs), foster partnerships, apply for grants (that include subawards to CBOs), and oversee strategies to address health issues that are prioritized by the CHNA.
The CHI team has developed welldefined roles and responsibilities of the hub and spokes derived from the 10 essential public health services framework, competencies for the community health departments derived from national public health competencies, and standards for the community health departments that include a multisector community council that guides the local departments' work. (Figure A, available as a supplement to the online version of this article at https://ajph.org).
PLACE, TIME, AND PERSONS
MaineHealth's headquarters and tertiary care hospital are in the city of Portland, Maine, though the vast majority of its service area is rural, and all of its community hospitals are in rural areas. MaineHealth employs about 2000 providers in 200 primary care and specialty practice sites as well as in its 10 hospitals and serves 85% of Maine.
Maine's median household income is the 35th lowest, the cost of living is higher than the national average, it is the oldest state in the nation (highest median age and highest proportion of people aged older than 64 years), and it is the most rural state in the country." Like the rest of New England and much of the country, there are no local accredited public health departments headquartered in rural areas."
CHI was created in 1997 and has further developed over time to serve various needs, including evolving to a hub-andspokes model. Since 2019, when the MaineHealth system unified under one 501(0)(3), the model has been more fully defined, and CHI officially became a system-wide department in 2022.
PURPOSE
MaineHealth's motivation is driven by its vision, "working together so our communities are the healthiest in America." Three additional factors are behind the formation of CHI. First, coverage of many nonregulatory public health services by the state's public health agency is unrealistic because staffing is sparse in rural areas because of the lack of a sufficient government infrastructure, yet nonprofit hospitals with primary care practices scattered across rural areas provide an alternative infrastructure to leverage. Second, few municipal or county government agencies or CBOs in rural Maine have the resources to take responsibility for public health services, including applying for and managing government public health grants. Third, primary care providers are overstretched serving patients' health care needs to directly provide many nonclinical public health services.
EVALUATION AND ADVERSE EFFECTS
Box 1 provides several examples of how the CHI hub-and-spokes infrastructure has improved health in rural communities. There are several themes.
First, the local community health departments (spokes) provide public health leadership and assure community and primary care partnerships, including by either convening or participating in a multisector coalition that forms a council. These partnerships have been critical in addressing public health needs. For instance, during the COVID-19 mass vaccination campaign, these partnerships helped identify and provide effective community education and vaccination strategies.
In addition, using the hub's data analyses on patients' SDOH (social determinants of health) screening, showing a tripling of the screen-positive rates for those with a behavioral health diagnosis and a doubling for those who are non-English speakers, the local community health departments leveraged their partnerships to codevelop appropriate strategies. Examples include CHI's local food pantries providing satellites in addiction medicine clinics and working with ethnic CBOs to determine culturally appropriate foods and operations for food pantries in locations with large immigrant communities.
Second, CHI's hub provides centralized resources that would be otherwise challenging to replicate in rural areas. For example, MaineHealth's centralized information technology department builds connections between primary care and CHI's public health programs (e.g. the nicotine treatment program and the National Diabetes Prevention Program). And CHI's centrally located epidemiologists provide analyses on SDOH screening and other programs.
Third, CHI's work at the nexus between public health and health care in both the hub and spokes has been a critical asset. For instance, CHI's Healthy Aging and Maternal Child Health teams, both located centrally in the hub, provide trainings to clinical sites to achieve the age-friendly designation and on the Maternal Opioid Misuse Model. Local community health departments are also educated on these models, to help reinforce the importance of them in community and local clinical settings as well as to reinforce two-way linkages between these settings with SDOH and other community-based resources. In addition, our Access to Care team works across CHI with clinical sites (MaineHealth and others), CBOs, government agencies, and schools to address health coverage issues.
Box 1 illustrates just a few of our programs and their results. We believe this hub-and-spokes work also influences the overall health of our communities, which ranks highly. For instance, in the 2025 County Health Rankings, MaineHealth's nine counties served directly by CHI have z scores that average in the top two healthiest groups out of 10 groupings of peer counties nationally.'· And comparing states through America's Health Rankings' 2024 report, Maine ranked first among those states with similar median household incomes (+$5,000 of Maine's income of $73,463).'·
SUSTAINABILITY
We believe this hub-and-spokes model is a sustainable one. MaineHealth invests approximately $16 million annually in CHI, much of which counts toward the community benefits required of all nonprofit hospitals. These dollars in turn help leverage an additional $19 million in external funding, mostly federal and state public health dollars. Seventeen percent of these external dollars are subawarded to CBOs. Currently, about 300 employees work for CHI, with about half based in local community health departments and the rest in the central hub. Most have a public health education background.
Lessons Learned
Key strategies of CHI include
* developing and maintaining partnerships that include a multisector coalition at the local community level;
* hiring public health professionals to lead the local community health departments (spokes);
* engaging clinicians, which is likely easier because CHI is housed within a health system, even when engaging external clinicians such as those working in federally qualified health centers (FQHCs); and †building foundational resources in the hub (e.g., data analytics, grant writing, and grants management).
While some have encouraged us to help develop county or municipal public health departments, we feel this is unrealistic in many rural areas, because government capacity there is extremely limited, without the ability to apply for and manage federal or state grants. Community action programs, schools, and FQHCs are other common infrastructures in rural areas. However, nonprofit hospitals are distinguished by having the requirements to conduct CHNAs as well as to provide community benefits. Of note, CHNAs across Maine are co-led with the community action programs.
Challenges include sustainability, which is always a challenge for any local public health organization. However, With the requirement for nonprofit hospitals to conduct a CHNA and provide community benefits, and with the ability for the organization to seek numerous grants, CHI has existed and grown for more than 25 years. Challenges may increase with the reduction in government grant opportunities and if the federal requirements for CHNAs or community benefits are rescinded.
Also, assuring CHI's work is primarily serving the rural communities that make up the vast majority of its service area is sometimes a challenge because the health system's headquarters is in an urban community. The local (rural) community health directors, local multisector councils, the triennial CHNA with resulting plans, and a CHI leadership team that includes each local community health director help ensure CHI's work is addressing the needs of its service area.
PUBLIC HEALTH SIGNIFICANCE
Rural communities are often home to primary care networks that are members of a nonprofit hospital-based system or a FQHC system. Centralized resources of both types of systems have the potential to support local teams to work in the nexus between public health and health care, in partnership with communities. Community benefits and CHNA requirements can be leveraged in the case of nonprofit hospital-based systems. In rural areas of the country with overstretched health care, poor health status, and limited public health capacities, we believe this hub-and-spokes model can be replicated to improve health and nonregulatory public health capacity. AJPH
ABOUT THE AUTHOR
Dora Anne Mills is with MaineHealth, Portland, ME.
CORRESPONDENCE
Correspondence should be sent to Dora Anne Mills, MD, MPH, Chief Health Improvement Officer, MaineHealth, 110 Free St, Portland, ME 04101 (e-mail: [email protected]). Reprints can be ordered at https://ajph.org by clicking the "Reprints" link.
PUBLICATION INFORMATION
Full Citation: Mills DA. Integration of health care, public health, and communities: a new model for rural public health. Am J Public Health. 2025;115(12): 2002-2005.
Acceptance Date: June 20, 2025.
DOI: https://doi.org/10.2105/AJPH.2025.308233 ORCID iD:
Dora Anne Mills (5) https://orcid.org/0009-00048523-7505
ACKNOWLEDGMENTS
The work reflected in this article is that of the more than 300 team members of MaineHealth's Center for Health Improvement and its many MaineHealth, clinical, community, and governmental partners. The author is deeply grateful to all of them.
CONFLICTS OF INTEREST
The author reports no conflicts of interest.
HUMAN PARTICIPANT PROTECTION This analysis did not involve human participants, so no institutional review board approval was necessary.
REFERENCES
1. Rural Health Information Hub. Rural health disparities. November 12, 2024. Available at: https://www.ruralhealthinfo.org/topics/rural- health-disparities#disparities-and-inequities. Accessed November 15, 2024
2. National Institute on Minority Health and Health Disparities. Median household income. HDPulse: An ecosystem of minority health and health dis parities resources. Available at https://hdpulse. nimhd.nih.gov/data-portal/social/table/age=0018 age_options=ageal_1&demo 00011&demo options income 3&race=00&race_options=race 7&sex=0&sex options sexboth 1&sociatopic= 030&sociatopic_options=social_6&statefips-008 statefips_options=area states. Accessed November 10, 2024.
3. Missouri Economic Research and Information Center. Cost of Living Data Series. Available at: https://meric.mo.gov/data/cost-living-data-series. Accessed November 10, 2024
4. America's Health Rankings. Analysis of CDC WONDER, single-race population estimates. United Heath Foundation Available at: https://www. americasheathrankings.org/explore/measures/pct 65plus. Accessed November 10, 2024.
5. US Census Bureau. "Median Age by Sex" American Community Survey. ACS 5-Year Estimates Detailed Tables, Table B01002 2020. Available at: https:// data.census.gov/table/ACSDTSY2020 B01002?q= American+Community+survey&g=050XXOOLS2 6065$15000008-2020&d=ACS+S-Year Estimates+ Detailed+Tables. Accessed November 11, 2024.
6. America's Health Rankings. Analysis of US Census Bureau, American Community Survey. United Health Foundation. Available at: https://www. americashealthrankings.org/explore/measures/ pct rural b. Accessed November 10, 2024.
7. Public Health Accreditation Board. Accreditation activity. Available at: https://phaboard.org/ accreditation-recognition/accreditation-activity. Accessed November 13, 2024
8 Truth Initiative. Quitting tobacco: facts and stats. April 22, 2024. Available at https://truthinitiative. org/research-resources/quitting smoking-vaping/ quitting tobacco-facts-and-stats. Accessed September 11, 2025
9. Mils DA, Boomsma). Lessons learned from Maine's nation-leading vaccination efforts. Health Affairs Forefront July 27, 2021. Available at: https:// www.healthaffairs.org/do/10.1377/hblog20210722 638604/ful Accessed November 10, 2024
10. Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017. JAMA 2021,325(2):146-155. https://doi.org/10. 1001/jama.2020.24991
11. American Hospital Association. Creating value with age-friendly health systems. Value intiative issue Brief. August 2020 Available at: https://www.aha. org/system/files/media/file/2020/08/value-initiative issue-brief-10-creating-value-with-age-friendly health systems.pdf. Accessed May 10, 2025.
12. Mate K, Fulmer T, Pelton L, et al. Evidence for the 4Ms: interactions and outcomes across the care continuum./Aging Health 2021,33(7-8)469-481. https://doi.org/10.1177/0898264321991658
13. University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps. March 2025 Available at: https://www.countyheathrankings.org Accessed May 10, 2025
14. America's Health Rankings. 2024 Annual Report January 2025. Available at https://www.americas healthrankings.org/learn/reports/2024-annual- report. Accessed May 10, 2025.
Copyright American Public Health Association 2025