Baltimore is home to several hospitals and renowned medical institutions, including both the Johns Hopkins University and University of Maryland medical schools and a network of federally-qualified health centers (FQHCs) that offer their services to clients for free or on a sliding fee scale. Despite this saturated geography of healthcare institutions, several studies have found Baltimore residents’ access to primary care to be insufficient (1). A recent report by RAND Health estimated a shortage of 150,000 primary care visits in Baltimore City. The report concluded that this insufficient access to primary care was a major contributor to the excess in preventable hospitalizations in Baltimore City compared to the rest of Maryland (2). The Baltimore City Task Force on Emergency Room Crowding similarly found that lack of insurance and inability to schedule a timely appointment with the client’s primary care doctor are contributors to emergency room crowding in the city. As a result of this overcrowding, Maryland has the second-highest average emergency room waiting time, 246.9 minutes, in the United States. In 2006, the task force recommended expanding access to primary care as a response to this problem. (3). Similarly, another study found that self-reported access to health care is inversely correlated with rates of hospitalizations for five chronic conditions (asthma, HTN, COPD, congestive heart failure, diabetes) in a low-income neighborhood after adjusting for prevalence of condition, health-care seeking behavior, and physician practice style (4).
In 2008, the median household income in the East Baltimore 21205 neighborhood was $29,382, compared to $70,545 in Maryland. The proportion of residents with income below federal poverty level was 29% compared to 8.1% in the state. The proportion of residents with income below 50% of federal poverty line was 14.3% vs. 3.7% in MD (8). According to the Baltimore City Health Department, the population of the Perkins/Middle East neighborhood immediately surrounding the Men and Families Center as of 2006 was 7,374, of which 92% was African-American and 32% less than 18 years of age. In 2002-2006, the median average household income (~2.59 persons/household) in the neighborhood was $14,900 (5), which is approximately equivalent to the 2009 federal poverty level definition for a 3-person household.
Charm City Clinic, Inc. sought todescribe the extent of the problem of access to primary care and other social and non-medical services among residents of the 21205 zip code, which includes the Perkins/Middle East neighborhood that surrounds the Johns Hopkins Hospital. Non-medical needs and access to various public services were included in the assessment, because they are well-known contributors to health status and clinical outcomes. For example, the Baltimore Health Department found a clear correlation between median income and life expectancy (5). Another study found that children whose families need but do not receive help paying energy bills are more likely to be hospitalized (6). Existing data suggests that many families who are eligible for certain forms of government assistance do not take advantage of them either because they lack information about how to apply, have difficulty navigating the complex web of medical resources and agencies, or because of other barriers. For example, according to the USDA Food and Nutrition Service, 13 million Americans who were eligible for food stamps in a given month in 2008 did not participate in the program (7).
The preliminary, anonymous, needs assessment included 19 neighborhood residents present at a community meeting held at the Men and Families Center at 2222 E. Jefferson Street. Although the sample size is small and those who attended the community meeting are very likely more interested in the issue of access to healthcare, our results nevertheless provide a valuable snapshot of the needs of a group of Perkins/Middle East residents. Fourteen (74%) described themselves as Black or African/American, while 21% marked “Other” in the Race/Ethnicity section. The proportion that finished high school or received a GED was 63%. Eleven percent did not finish high school, 6% started college, and 17% had finished either college or graduate school. Forty seven percent reported their income as less than $15,000, 21% reported incomes between $15,000 and $30,000, and 26% reported incomes between $30,000 and 50,000. Of the survey participants, 47% were unemployed, 32% were employed full-time, 6% were doing temporary work, and 6% were employed part-time. Fifty eight percent reported having health insurance, and 42% reported having a primary care doctor. In response to a survey question about medical services that would be helpful to themselves or someone they knew, 95% marked dental care, 74% marked vision care, and 84% marked primary care. For the same question, 15 of 19 participants (79%) thought that diabetes screening and treatment would be helpful to them or to someone they know; 74% marked hypertension screening and treatment; 84% marked screening for high cholesterol; 84% marked cancer screening; 79% marked screening and treatment of sexually transmitted diseases, and 74% marked confidential and anonymous screening for HIV/AIDS. In response to survey questions about non-medical services they would find useful, 74% of residents selected nutrition counseling, 84% marked substance abuse counseling and assistance, 79% indicated help with enrolling in a job training program, 68% noted help with getting a GED, 63% marked help with enrolling in ESL classes, 79% marked help with enrollment in food programs or getting food, and 63% marked assistance with childcare as services that would be helpful to them or someone they know. Of the 19 assessment participants, 18 (95%) thought that help with obtaining health insurance or with enrollment into cash assistance or other benefit programs would be helpful to them or someone they know.
Numerous services already existwith the intention of helping residents of the community surrounding the Johns Hopkins Hospital gain access to low-cost specialty and primary care. However, interviews with Baltimore residents and community leaders, such as Leon Purnell, the director of The Men and Families Center, and Glenn Ross, a community advocate and advisor to the Baltimore City Council, indicate that these services miss a portion of the population that could benefit from them. There is strong evidence of the additional need for free primary care services, referral to social and other non-medical services, and help with obtaining insurance and other benefits for residents of the 21205 zip code, especially the Perkins/Middle East neighborhood.
In order to address the health disparities and increase the quality of life in the Perkins/Middle East neighborhood, if even one individual at a time, we are working to setup a Health Resource Center. The Center will assist low-income Baltimore residents in obtaining medical services, health insurance and other social protections, such as unemployment assistance that these residents might need. Health Resource Center volunteers will follow up with clients by email, phone, and/or in person to ensure that clients have received the assistance that they seek. We anticipate that a Health Resource Center based in the Men and Families Center, a trusted and well-established community organization, will help low-income Baltimore residents avoid falling through the cracks of the existing healthcare infrastructure and as a community take steps toward achieving the goals of Healthy People 2010/2020.
The Health Resource Center is being established as a student-community partnership that unites student contributions with the vision, knowledge, and talents of neighborhood residents. Feedback gathered at our community meeting and discussions with stakeholders at the Men and Families Center have underscored one key priority: involving neighborhood residents in clinic operations and door-to-door neighborhood outreach are critical for building community acceptance and trust of the program, overcoming barriers to continuity of care raised by the constant turnover of student volunteers, and developing an enduring community-based healthcare resource by giving community members ownership in the program. Studies have shown that health disparities require more than a one-time health intervention – they require a sustainable long-term effort that we hope to create with the Health Resource Center.
In order to meet this priority and establish a concrete mechanism for partnering with neighborhood residents, the Center will recruit community HOWs to conduct outreach and follow-up with their fellow community members once they come to the Health Resource Center. Health workers (often called “community health workers”) have had a wide range of well-documented impacts in contexts from HIV treatment programs in resource-poor settings (9) to diabetes management (10) and antenatal care (11) in East Baltimore. Unlike hospital-based programs or those that recruit non-community residents as outreach workers, truly local HOWs can use existing social networks to reach potential clients and they have unmatched access to residents who lack strong family or social support networks (including elderly or disabled residents, residents with mental illness, and residents re-entering the neighborhood after incarceration). By building on the skills, social networks, and social capital that long-time neighborhood residents can offer, and actively promoting these residents into coordination and training leadership positions within the Health Resource Center, we believe the HOW program can become a highly effective and enduring link between the neighborhood and the Charm City Clinic’s Health Resource Center.
We aim to make the Charm City Clinic’s Health Resource Center a long-term sustainable endeavor that will promote the health of the Perkins/Middle East community for years to come.
Every three months, clinic outcomes data will be analyzed to assess number of clients who accessed our referral services over intervening period and to determine overall client satisfaction with services obtained. If possible, we will attempt to track clients already seen and ensure they remain in healthcare system. Outcomes data will be utilized to better hone our services to community needs
To cover clinic service and training expenditures in relation to student volunteers and HOWs we have set up a grants committee which will work towards continuously acquiring additional funding through city programs, private organizations, and Johns Hopkins.
Clearly, there is a need for aid in accessing primary health care and for enrolling in assistance programs in the community. With a strong and committed, yearly elected, Charm City Clinic Leadership Board, student volunteers, and dedicated HOWs, we hope to successfully meet these needs during the fellowship year and in the future.
As we develop our presence in the community, we expect to implement additional resources, including:
Provision of free primary care at the Health Resource Center by volunteer community physicians.
Based on the results of the survey, the community meeting, and interviews with key community leaders, it is clear that access to primary care among the residents of the 21205 zip code and especially the Perkins/Middle East Neighborhood remains insufficient. To ameliorate this problem, we propose to create a free clinic at the Men and Families Center that would operate for 5 hours on Saturdays. The clinic will be staffed by volunteer community physicians and nurses, who will perform all required clinical care. The students will take on an administrative role, including collecting contact information upon initial admission and making sure that all medical forms are filled out before the patient sees the physician. The students will also interview the patients about any non-medical needs the patients may have, including obtaining health insurance, gaining access to specialty or more comprehensive primary care, and any other social services the patient may need. Students who have been trained and certified in educating and counseling patients about various health concerns, for example diabetes or hypertension, may counsel the patients about these issues upon request from either the patient or the attending physician. Additionally, if, after the medical visit, the attending physician believes that there is a need for a pharmacological intervention, he will write a prescription, while trained student volunteers will determine what programs are available for the client to obtain affordable medications and assist the client with gaining access to the prescribed medications.
The Health Resource Center will thus allow for non-comprehensive but high quality effective primary care to be performed. If a client requires specialty care, the center will use its resources to refer a patient to other medical and social programs that are practical given the patient’s circumstances. Student volunteers, as well as HOWs, will serve a crucial role of encouraging neighborhood residents to seek necessary care at the Center and encouraging sustainability of healthcare interventions after clients leave the Health Resource Center.
1. Farrow, Olivia D. Baltimore City to Host Public Hearing on Primary Care Access. Baltimore City Health Department. City of Baltimore. 14 April 2009. http://www.baltimorehealth.org/press/2009_04_14.PrimaryCare.pdf
2. Gresenz C.R, Ruder T, Lurie N. Ambulatory Care Sensitive Hospitalizations and Emergency Department Visits in Baltimore City. RAND Health. November 2008.http://www.baltimorehealth.org/info/2008_12_18.RANDReport.pdf
3. Baltimore City Task Force on Emergency Department Crowding. Findings and Recommendations. June 2006. http://www.baltimorehealth.org/snapshots/Task%20Force%20report.pdf
5. Baltimore Health Department. Neighborhood Health Profiles. 2008.http://www.baltimorehealth.org/neighborhood.html Supplementary tables:http://www.baltimorehealth.org/Supplementary%20tables3.xls
6. Frank DA, Neault NB, Skalicky A, Cook JT, Wilson JD, Levenson S, Meyers AF, Heeren T, Cutts DB, Casey PH, Black MM, Berkowitz C. Heat or eat: the Low Income Home Energy Assistance Program and nutritional and health risks among children less than 3 years of age. Pediatrics. 2006 Nov;118(5):e1293-302.
7. “Food Stamp Program Average Monthy Participation.” USDA Food and Nutrition Service. February 2008.
8. City Data.Com. 212105 Zip Code Detailed Profile. http://www.city-data.com/zips/21205.html
9. Behforouz HL, Farmer PE, and Mukherjee JS. From Directly Observed Therapy to Accompagnateurs: Enhancing AIDS Treatment Outcomes in Haiti and in Boston. Clin Inf Dis 2004:38 (Suppl 5): S429-S436
10. Gary TL et al. Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes- related complications in urban African Americans. 2003 Preventive Medicine 37: 23–32.
11. Gibbons, M. Christopher. and Tyus, Nadra C. “Systematic Review of U.S.-Based Randomized Controlled Trials Using Community Health Workers.” Progress in Community Health Partnerships: Research, Education, and Action 1.4 (2007): 371-381.