Madison County Kentucky and Hokuto City, Yamanashi Prefecture, Japan, are the participants in the only sister-region in the world. The relationship began in 1988 to honor Paul Rusche, a missionary from Kentucky who aided the Japanese people in Yamanashi before and after WWII, when delegations from Berea and Takane exchanged visits.

The membership has changed over the years. It started as a sister-city exchange between Berea and Takane and gradually became a sister-region in 1990 when the Japanese towns of Nagasaka, Kobuchisawa and Oizumi joined Takane while Richmond and all of Madison County joined Berea. Economic pressures caused the Japanese region to evolve further in 2004 when the towns of Takanen Nagasaka and Oizuma merged with Sutama, Hakushu, Akeno and Mukawa to form Hokuto City. Kobuchisawa merged with Hokuto City in 2006.

During the exchange, the Japanese delegation stays at Boone Tavern for five days in May while the US delegation stays at the Kiyosato Educational Experiment Project (KEEP) in the village of Kiyosato at a lodge called Seisen-Ryo during their visit in October. The US delegation includes five craftspeople who demonstrate their skills at the Yatsugatake County Fair in Kiyosato.  The program also sponsors artist and middle school student exchanges.