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In Baltimore, nurses go door-to-door to bring primary care to the whole neighborhood
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Raquel Richardson arrived for work at the Johnston Square Apartments in East Baltimore this February expecting to have just another Tuesday. The 31-year-old typically spends her days solving residents’ problems, answering questions at reception and making maintenance rounds.
That day, however, she noticed a team offering free blood pressure checks in the lobby — and decided to sit for one too. Tiffany Riser, a nurse practitioner, was so alarmed by Richardson’s high reading that she checked it twice. The young woman, the nurse confirmed, was at immediate risk for a stroke.
Riser only caught this threat to Richardson’s health because she was offering convenient, preventive care as part of a new program called Neighborhood Nursing. The idea is to meet people where they are and offer them free health checks, whether they realize they need them or not. If Richardson had waited until symptoms arose, Riser says, the results could have been disastrous.
Instead, Richardson quickly got on a new blood pressure medication and received additional information from Riser about how to reduce hidden salt in her diet. Her pressure came down within weeks and remains at a healthy level months later.
Bringing care out of the clinic and into the community
Neighborhood Nursing’s teams of nurses and community health workers have started making weekly visits like these to the lobbies of three apartment buildings in Johnston Square, a predominantly Black neighborhood disadvantaged by decades of discriminatory housing policies. By next year, the team aims to visit more than 4,000 people in the Baltimore metropolitan area at least once a year.
“We're trying to turn primary care on its head and deliver it in a completely different way,” says Sarah Szanton, dean of the Johns Hopkins School of Nursing and leader of the project, which is a collaboration with the Coppin State, Morgan State and University of Maryland nursing schools. Similar efforts to reach out to people where they live have been tried by others — programs targeting patients who use the ER frequently, for example, or those who have certain types of insurance. But Szanton’s ambitions are bigger.
“What's revolutionary,” Szanton says, “is that it’s for everybody” — whether they are sick or healthy, rich or poor, young or old, and no matter if they have private insurance, Medicare, Medicaid, or no insurance at all.
The visits are free to the patient and prioritize each person’s unique goals, from managing chronic back pain to finding safer housing. They can take place in people’s homes, senior centers, libraries or even laundromats.
The idea is modeled after a similar program first tried in Costa Rica about 30 years ago, when that country was grappling with the same core problem that the U.S. is experiencing today: Patients struggle to access preventive primary care, especially in poor and rural areas. Hospitals are overflowing and basic needs from hunger to high blood pressure are spiraling into bigger, costlier problems.
Szanton believes the U.S. — which lags behind other high-income countries on many measures like infant mortality and obesity — is sorely lacking bold solutions.
Compared to other countries, the U.S. spends far more resources on treating illnesses than on preventing them. America only puts about 5 cents out of every dollar spent on health care toward primary care — and spends less than peer nations on social supports like food and housing.
“It’s like if 10% of our houses were on fire, we would say we don't have enough firefighters,” Szanton says. “But really what you need to do is prevent fires, which we've never done for medical care in this country.”
A primary care approach imported from a land 2,000 miles south
Costa Rica’s national approach to primary care is very different. “It’s pretty much night and day,” says Asaf Bitton, a primary care doctor who has studied Costa Rica’s model and directs Ariadne Labs, a health innovation center at Harvard School of Public Health.
The Central American nation of 5 million people has pioneered a nationwide version of Neighborhood Nursing. Teams of health workers visit residents’ homes at least once a year, whether the patients live in cities, on banana farms or in remote villages reachable only by boat. After three decades of this approach, the results are remarkable.
Deaths from communicable diseases like tuberculosis and hepatitis have fallen by 94%. Disparities in access to health care have improved too — as have outcomes for chronic conditions like diabetes and heart disease. Costa Rica has achieved all this progress while spending less than 10% of what the U.S. spends per person on care.
“There's both an incredible economic efficiency and effectiveness,” Bitton says of Costa Rica’s system, “and a deep humanity to it — a sense of reciprocal responsibility for every single person in the country.”
Other factors, including national investments in nutrition and sanitation programs, contributed to the country’s gains, but researchers like Bitton say that keeping nearly every single Costa Rican connected to basic primary care has helped drive significant improvements in health. Other countries, including Sri Lanka and Brazil, have borrowed from Costa Rica’s primary care playbook.
Still, it’s unclear whether Costa Rica’s model can take root in the U.S.
“The evidence is great,” says Chris Koller, president of the health care philanthropy Milbank Memorial Fund, and coauthor of a landmark national report on how to strengthen primary care in the U.S. “The challenge,” Koller says, “is how do you graft it onto our current method of delivering and financing health care?”
Who should fund preventive care?
Funding is arguably the greatest puzzle facing the Neighborhood Nursing team. The goal is to build something akin to a public utility, serving everyone regardless of the type of health insurance they do — or don’t — have. Health insurers are the most likely to finance a program like this, which is designed to keep costs down by improving members’ health.
But getting insurers to pony up would require Neighborhood Nursing to earn buy-in from a dizzying number of entities. The residents of a single county, for example, are typically covered by as many as 50 different insurers, from Medicaid plans to private Medicare plans to employer plans. “You try to keep it simple," saysAnn Greiner, president of the Primary Care Collaborative, a nonprofit group. "But inevitably when you move toward implementing a model, you come up against this complexity."
Insurers have collectively funded projects like statewide vaccination programs, so there is precedent for pooling resources to support all consumers, regardless of their coverage. An investment in the type of care that Neighborhood Nursing aims to deliver door to door, however, would represent a significant leap in scope.
Finding a path through an overstretched system
Health policy analysts also believe the program will likely struggle to connect patients to the country’s sprawling health and social services systems. If Neighborhood Nursing effectively opens a new, more welcoming front door to those systems, what awaits patients on the other side?
In many cases, unfortunately, that next step is into a complex maze that’s short on resources and heavy on bureaucracy. For example, Baltimore, ground zero for Neighborhood Nursing’s pilot program, leads all big cities in opioid overdose deaths, yet addiction treatment options there are limited. Challenges to capacity plague Costa Rica’s successful primary care system, too, where patients can wait months to see specialists or get surgeries.
In the U.S., specialty care comes with additional hurdles like the need to secure approvals from a person’s insurance plan for certain procedures or medications. People needing significant social support, such as help with affordable housing, can face years-long wait lists.
“There's no magic pill to change those structural conditions,” says Lisa Stambolis, a nurse and Neighborhood Nursing’s senior project manager. “But there are still things we can do, and we should do.”
Neighborhood Nursing has included community health workers on their teams to help people navigate these complex systems. The program is also training staff in mental-health first aid and simple techniques of cognitive behavioral therapy to make that type of basic help immediately available.
Team nurses are prepared to go the extra mile, too, to help patients like Raquel Richardson, the East Baltimore worker with high blood pressure that nurse Tiffany Riser encountered in February. Richardson initially resisted seeking care, citing past bad experiences she’d had at a local hospital. Instead of giving up, Riser switched strategies, calling a local clinic, convincing the staff to squeeze Richardson in for an urgent care visit.
Nurse Riser even accompanied her patient to the doctor. “Because I had a professional with me, I felt like they took me more seriously,” Richardson says.
Early signs of community buy-in
The Neighborhood Nursing project is still in its pilot phase, building trust and gathering feedback from the community. By 2025, staff members hope to expand their services to four neighborhoods — two within Baltimore, one in the suburbs and one in a more rural area.
So far, the evidence the approach works is only anecdotal, but the team says they are already seeing a difference in the level of trust from community members. And research has found that a trusting connection between patient and provider is key. “The first couple weeks we showed up, it was like, ‘Who are they?’” said community health worker Terry Lindsay. “Now people are opening up the doors to their homes, saying, ‘Come on in and sit down.’”
One other sign of progress, said Sarah Szanton, is that the community is taking ownership and helping to shape the project.
Long-time Baltimore resident Regina Hammond and a few of her neighbors told the team they needed safer options for exercise. Together they hatched a plan to start a weekly neighborhood walking group.
“Some people walk other days too, now, as a result of meeting each other at the walking group,” Hammond says. A woman with depression joined the group and soon felt better. Another walker said he liked his neighborhood more after he discovered some new parks and an urban garden he’d never known about, despite living in the area for seven years.
The goal is to improve the health of individuals, says Szanton, and empower communities to create happier, healthier places to live.
"I think of what we’re building as like pipes in a water system,” Szanton said, “Where there’s a resource that's flowing to every household and that connects them to each other.”
This story comes from the health care podcast Tradeoffs. Dan Gorenstein is Tradeoffs' executive editor, and Leslie Walker is a senior reporter/producer for the show, where a version of this story first appeared. Subscribe to Tradeoffs' weekly newsletter to bring more reporting on health care in America to your inbox.
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