In January 2024, the Neighborhood Nursing program launched in Johnston Square, Baltimore to bring preventive care directly to homes and communities, enhancing health and well-being for all residents — regardless of income, health status, age, or insurance type. An interdisciplinary team, including a nurse and community health worker, visits community members in their homes or in community settings to provide person-centered care. The program is a collaboration among nursing schools at Johns Hopkins University, University of Maryland (Baltimore), Morgan State University, and Coppin State University. Neighborhood Nursing works with Sisters Together and Reaching (STAR) to provide community health workers and other services for residents.
The Neighborhood Nursing program draws inspiration from Costa Rica’s community-oriented primary health care model that uses an “all-in” geographic empanelment approach. The model demonstrates how community-based primary care, supported by community health workers, can improve health outcomes and access to care. As the Baltimore pilot nears its first anniversary, it can offer providers, payers, and policymakers lessons on scaling innovative primary care delivery models.
This Better Care Playbook webinar featured presenters with experience implementing Neighborhood Nursing who shared what they’ve learned from the pilot to inform how to provide community-based care for individuals with complex health and social needs. It explored:
- How program leaders adapted international evidence from Costa Rica as well as U.S.-based evidence from community-based care models to design Neighborhood Nursing;
- How the program is developing structures to care for individuals with complex health and social needs and those with rising levels of risk, including through integration of care in multiple settings;
- The roles of nurses and community health workers, including the skills and strategies necessary to deliver whole-person care in community-based settings; and
- Insights on financing challenges and opportunities for sustaining an innovative “all-in” approach to care for people covered by different payers, including uninsured individuals.
Presenters included Sarah Szanton, PhD, MSN, Dean at Johns Hopkins School of Nursing, Tiffany Riser, PhD Candidate at Johns Hopkins School of Nursing, and Terrence Lindsay, Community Health Worker from STAR. Asaf Bitton, MD, MPH, Executive Director of Ariadne Labs, shared insights on lessons from the Costa Rican primary care model and the opportunities for this type of model in the United States.
This webinar is part of the Better Care Playbook Implementation Lab series. These sessions explore implementation strategies for specific models or tools with demonstrated evidence.