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In 1970, the population of Franklin County, Maine was 22,444; as of 2010, the population had grown to 30,768. The cohort was predominantly white. During the 40 years of follow-up, residents had become poorer and older; however, the ratio of residents to primary care physicians had improved. One-on-one interactions between a resident and a nurse or other health coach in any one of several programs were recorded over time. Encounters averaged 5,000 per year from 1974-1994 and 3,000 per year subsequently. By 2010, there were >150,000 encounters, an average of >5 encounters per Franklin County resident, with over 150,000 individual county resident contacts occurring over 40 years. Hypertension control had an absolute increase of 24.7% (95% confidence interval [CI], 21.6%-27.7%) from 18.3% to 43.0%. Control of elevated cholesterol had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%. Smoking quit rates improved from 48.5% to 69.5%, (which was better than state averages); however, in later years, the difference between Franklin County and Maine’s overall quit rate disappeared due to increases in smoking quit rates across the state. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006. Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010.