Host organization: Jefferson Healthcare

Jefferson Healthcare is a critical access hospital that provides healthcare to the approximately 27,000 residents of rural east Jefferson County on the Olympic Peninsula in Washington State. The Jefferson Healthcare Population Health Department works to bridge traditional, individual medical care and healing the social needs of the local community. The department works to expand the boundaries of health care delivery by designing and implementing projects to address determinants of health.  In 2018, efforts targeted housing, food insecurity, and social isolation.

Issue: Social isolation in older adults living in rural communities

In rural communities, low population density and geographic isolation pose barriers to the delivery of integrated care models and the development of a comprehensive care ecosystem. Healthcare facilities are often limited and remote from many community members. Access to other social, behavioral, and community services are also limited. Workforce shortages in rural areas make it difficult to recruit all the provider types who would make up an ideal model of coordinated care.

These barriers are particularly true for older adults who have complex health, behavioral, and social needs. In rural contexts, adults aging in place often live remotely and have limited transportation options once they no longer drive. Their already small social networks decline as they age, and family often do not live nearby, due to limited employment and other opportunities. For these older individuals, worsening health, living, and social conditions are exacerbated by this social isolation and lack of support, especially as their cognitive faculties may decline with age. When they are admitted to hospitals, they often end up essentially boarding there because appropriate discharge care planning is challenging and there is a small volume, if any, of available care facilities or home care services.


Jefferson Healthcare and the National Center for Complex Health and Social needs provided an opportunity for rural providers to exchange knowledge on principles of complex care as adapted for rural communities. It addressed the barrier of professional isolation for those working to address these issues.

Outcome: Maintain connectivity for rural seniors and practitioners

Through this convening Jefferson Healthcare and the National Center aimed to accomplish the following outcomes:

  • Increase knowledge among those working in rural communities by sharing approaches to complex care for older adults;
  • Catalyze ideas for new and adapted solutions to better serve rural communities;  and
  • Build networks among those who participate.

For more information on this event, please contact the host organization.

Materials from the 2019 convening

Slides and supplemental materials

Workshop breakouts:

Other materials