Baltimore, like many other major cities, is home to an appalling health disparity: life expectancy differs by more than 20 years between its most affluent and lowest-income neighborhoods. To help combat this inequality, Johns Hopkins Health System received a three-year Health Care Innovation Award from the Centers for Medicare & Medicaid Services to increase health care access for at-risk adults. With guidance and active involvement from the community, it created Tumaini (Hope) for Health. Tumaini is an innovative partnership involving two community-based organizations, Sisters Together and Reaching (STAR) and the Men and Families Center, and the Johns Hopkins Community Health Partnership (J-CHiP). Through Tumaini, community health workers conduct regular home visits, accompanying residents to medical appointments, and identifying social needs. The program’s neighborhood navigators are assigned to specific blocks in Tumaini’s catchment area to serve as advocates and mentors. Both sets of staff are hired from the community, and their deep familiarity with the neighborhoods and residents are key components of their success.
Fostering relationships and building trust have been crucial to Tumaini’s progress. Linda Dunbar, PhD, vice president of population health and care management at Johns Hopkins HealthCare, has spearheaded the project since it began in 2012. Johns Hopkins HealthCare participates in the Center for Health Care Strategies’ Complex Care Innovation Lab, funded by Kaiser Permanente Community Benefit, which has identified the need to build meaningful community linkages as a key element for improving complex care. We recently spoke with Dr. Dunbar about lessons from Tumaini that could inform other partnership efforts between health systems and community-based organizations:
Q: Why did Johns Hopkins target East Baltimore for J-CHiP?
A: In Baltimore, very wealthy zip codes are directly contiguous with very low-income zip codes. Our target areas are the neighborhoods surrounding Johns Hopkins Hospital, which are right next to an old, white, wealthy neighborhood. Though these areas are only separated by a few blocks, the difference in life expectancy for men is 20 years. It was really appalling to consider that Hopkins had these disparities surrounding it, so we said to ourselves, “Let’s look at the seven zip codes that surround the Hopkins Hospital, and develop a community-based model of care in our own backyard.”
Q: What was Johns Hopkins’ relationship with the low-income East Baltimore communities when you started Tumaini?
A: There is a long, long history of people in the neighborhoods around Hopkins feeling like they were used for research, and that has bred deep mistrust. Community representatives said, “We’re sick and tired of you telling us that you just got a $20 million grant and then asking us to come and work for free on your advisory board. We’re tired of telling you how to get things done when you’re not even employing people from the neighborhoods where you’re working.”
Q: How did you personally build trust with individuals from the community?
A: People didn’t trust me at first. They didn’t know me, but they knew I lived in the wealthy neighborhood next door. They were very honest with me about not trusting Hopkins or thinking that we were going to follow through. And I felt like I just couldn’t be yet another Hopkins person who let them down. So I volunteered at STAR and the Men and Families Center, the two organizations we selected to partner with in this project after engaging in a number of conversations with the community. I would get lunch for everyone and ask them if they wanted to be part of building something really different, and talk about their existing resources and what they would need to get started. We’ve thrown block parties with STAR, complete with a cookout and karaoke. We also host leadership dinners, bringing in neighborhood, community organization, non-profits, and company leaders to enjoy a meal together. For the first dinner, we thought we’d have 50 attendees — but 200 people joined us, including councilmen and the chief of police. Ultimately, STAR and Men and Families Center built their own care models, but the community needed someone to listen to them, someone who they knew had the power to help finance their ideas.
Q: If an organization wants to run a community health worker or neighborhood navigator program, what are the keys to making those positions successful?
A: It all comes down to relationships and investing the time to genuinely build trust with the community — these have been the keys to our success and have helped turn the skepticism into momentum. Now there is really a sense that the community sees the neighborhood navigators as helpful, and that Hopkins is really investing in the community, which has helped people believe that Hopkins wants to change. Hiring from the community is also critical, so 100 percent of the people who are working in J-CHIP as community health workers either currently live in one of the zip codes, or have recently moved from the neighborhood to an adjacent area. There can be real distrust in neighborhoods — people aren’t going to open the door for an outsider, so it’s crucial that the community health workers have some lived knowledge of the community. We also invest a lot of resources into ongoing training to keep their skills sharp. We pay the CHWs about 20 percent over the average health worker salary, and the neighborhood navigators receive a stipend.
Q: What advice would you give others in the field of health care about approaching community partnerships and engagement?
A: Be open to challenging your conception of health and health care. Be open to learning and listening. There were times when I just wanted to say, “That’s not evidence-based, so we can’t do it.” Well, that’s not what was going to foster a good relationship — instead, finding common ground was crucial. Be really careful about not imposing your ideas on the community. STAR and the Men and Families Center provide services, but they didn’t have funds for things like building their data infrastructure. We really wanted the organizations to maintain their mission and personality so we honor what they have in place, while helping them build capacity.
Tumaini (Hope) for Health is now supported by a Maryland regional transformation grant. Through partnerships with six area hospitals, Tumaini will extend throughout East Baltimore, with several hospitals deploying community health workers and neighborhood navigators in their catchment areas. Evaluations show that J-CHiP is successfully improving outcomes.