Community Partnerships in Neighborhood-Based Health Care: A Response to Diminishing Resources

Health care delivery has experienced accelerated change in the past three decades. The paradigm has shifted from acute inpatient care to care provided across a continuum of services, or an integrated system of health care. The focus moved from care for the individual patient to accountability for the health status of a defined population. Active quality management has been valued over retrospective quality review, and individual practice standards have given way to the development of practice protocols (Daniel & Hammer, 1994). The integrated delivery system of the 1990s has at its core the need to provide health care at the lowest level of service intensity. The base of this continuum is the primary care provider, supported by limited specialty care. It is from this base that the other services that are essential to the maintenance of health will be provided. The challenge to health care providers is to accomplish this mandate while managing the effect of the change to a cost-per-life reimbursement system. Downsizing and re-engineering have been the answer to a need to contain costs. The multiskilled worker must handle the work of several individuals. As the paradigm shift from an illness model to a wellness model continues, will the resources be shifted in time to accomplish expanded goals? Although the answer to this will certainly come from several quarters, the social work profession can make valuable contributions in the emerging scenario by going back to its roots in the community and refocusing on the larger picture. The experiences from a number of community-based initiatives with significant input from social work practice in their conception, design, and implementation at the Johns Hopkins Medical Institutions validate the value-adding potential of this macro-level approach in achieving expanded goals with diminishing resources. JOHNS HOPKINS AND HISTORIC EAST BALTIMORE The Johns Hopkins Hospital, the nucleus of the Johns Hopkins Medical Institutions, is a 1,036 licensed-bed facility located in the eastern section of Baltimore in the state of Maryland. Considered one of the world's preeminent health care institutions, it is known for its tertiary and specialty care. The hospital also serves as a major provider of health care for the poorest citizens of Baltimore. The community of which Hopkins is a part is plagued by unemployment, underemployment, violence, and crime. Neighborhood residents have the poorest health status of any Baltimore community. The historic East Baltimore community is defined by a geographical area that includes 23 census tracts, with a population of 79,691 residents according to the 1990 census. This community definition includes many different neighborhoods: 90 percent of the residents are African American; other ethnicities are on the decrease. The unemployment rate is 16 percent. More than 33 percent of the families have incomes below $10,000, and in many neighborhoods 80 percent of families live below poverty guidelines. More than one-half (52.7 percent) of East Baltimore residents have not completed high school. East Baltimore has the city's highest age-and sex-adjusted rates of illness and death from cardiovascular and cerebrovascular disease, diabetes, cancer, some pulmonary diseases, violence and substance abuse. East Baltimore's homicide rate is 4 percent, making it one of the "top 10" most violent communities in the country. Adolescent pregnancy in East Baltimore accounts for 15 percent of all births in East Baltimore. In many neighborhoods, 18 percent of all babies are at risk of low birthweight (Maternal and Child Health Science Consortium, 1995). JOHNS HOPKINS MEDICAL INSTITUTIONS AND THE COMMUNITY AS PARTNERS IN PROGRESS The Johns Hopkins Medical Institutions (JHMIs) have existed in the East Baltimore community for more than 100 years. Both the leadership of the community and the institutions approached the revitalization of the community as a joint venture. …