Neighbors Who Make House Calls
Relying on an intimate familiarity with their community and specialized training, home-grown health workers are improving lives in East Baltimore.
In the late morning summer swelter, Paige M. Bailey pounds on the white wooden door at 21 Decker Street, one of the few occupied homes in the narrow canyon of dilapidated row houses. The red or neon orange Xs on most doors mark the houses to be gutted and renovated.
A young boy in baggy shorts lets in Bailey. He goes off in search of his older brother. Bailey waits. She wears bright yellow rubber shoes and carries a pink stethoscope. "Johns Hopkins" is stitched in gold thread on one side of her navy blue medical scrubs, while the letters "CHW" and the caduceus symbol emblazon the shirt's other side.
A four-foot stuffed brown dog sits on a couch near the front window. The TV blares a Berenstain Bears cartoon. Without air conditioning, the row house is tropically humid and dizzyingly hot. Eighteen-year-old Bawnso Vonty enters the room, shyly greets Bailey and then leads her upstairs. The teen will translate for Bailey; his grandfather speaks Krahn, a West African language.
A 90-year-old Liberian refugee, Zarkly Vonty sits in a small back room on the second floor. He smiles and nods in Bailey's direction, though he has difficulty seeing her because of the cataracts that cloud his eyes. Bailey is not a doctor or a nurse. She is a community health worker (CHW), part of a Johns Hopkins Urban Health Institute team dedicated to improving the health of people in East Baltimore. Like the team's other CHWs, Bailey has had six weeks of training in physiology, medical terminology, first aid, conflict resolution and other skills. The training has helped her make a dramatic impact on Vonty's health. Before visits by Bailey and another CHW, Vonty didn't eat regularly, was dangerously thin, had high blood pressure and was mostly confined to bed. Initially, the CHWs brought him pureed food that he could eat with his poor teeth. Now, though still frail and near blind with cataracts, Vonty has gained weight, lowered his blood pressure, had successful prostate cancer surgery, and is being scheduled for dental and cataract surgery. "These are stellar impacts that would not have happened had we not been there," says Chris Gibbons, MD, MPH '97, associate director of the Johns Hopkins Urban Health Institute and leader of the seven community health workers on the team.
Near the end of her visit with Zarkly Vonty, Bailey learns that the grandfather hasn't been taking his medications recently.
His blood pressure might be a little high, Bailey warns. Petite with short hair, Bailey carries herself with confident grace. Born and bred in East Baltimore, she's comfortable joking with white construction workers or chatting up African-American mothers sitting on their stoop.
Bailey wraps a blood pressure cuff around Vonty's bicep. When it reads 134 over 77, she says, "Not bad. Not bad, actually." After she learns that the elder Vonty recently missed doctor appointments with his urologist and ophthalmologist, Bailey says she'll help reschedule those. A month earlier, when Vonty had the prostate cancer surgery, Bailey waited at the hospital for 14 hours until she could see him in the recovery room. "I had to look at him myself and make sure he was okay. You know what I mean?" she says.
CHWs like Bailey have long been a part of health programs in developing countries; and they have been part of interdisciplinary research at Hopkins into the prevention and treatment of chronic diseases for decades. Bloomberg School researchers and others hope that CHWs can help people with limited resources surmount the considerable barriers to care: medical insurance, transportation to the doctor's office, the physician's intimidating presence, not to mention the costs of doctor visits, treatments and prescription drugs.
"From the perspective of racial and ethnic minority populations in the U.S., you almost get the sense that many health care systems were built with an approach of 'If we build it, they will come,'" says Jean Ford, an Epidemiology associate professor. Instead, he argues that health care services need to take into account a population's demographic characteristics, its culture and its available resources.
Ford is launching a randomized, controlled trial to determine whether CHWs can help improve cancer detection and treatment among African-American seniors who are Medicare beneficiaries. (African Americans have the highest mortality rates in the U.S. for most cancers.) "The advantage of community health workers is that they know the community, they look like the community and they've experienced a lot of these barriers themselves," says Ford. "The idea is to use community health workers as a means for empowering people to take care of their health by educating them and supporting them to overcome those barriers."
In their previous lives, the CHWs with the Urban Health Institute project worked as teachers, nurse's assistants, school crossing guards or postal workers. Some have diabetes or high blood pressure. Some are recovering drug addicts. The CHWs may not know organic chemistry or how the peristaltic process works, but they do know the people of East Baltimore. They know who's not eating, who's not taking their prescription medications, whose blood pressure is up, who wants help getting off drugs, and who's holding back from their doctor important facts like they can't afford the medications prescribed for them. People confide secrets to CHWs that they would never tell their doctor or a nurse. "I've been in the place of some of these clients we're talking about. I'm here by the grace of God so we can have a healthier and better East Baltimore," says Barbara Johnson, an enthusiastic, older CHW known as "Miss Barbara."
When the CHWs hit the streets of East Baltimore each day, they knock on doors or chat with people on the sidewalk. CHWs use a health survey to quickly assess the needs of anyone who wants help. For those who lack health insurance, CHWs help them sign up for a Maryland state program called Primary Adult Care that covers outpatient visits and offers reduced cost or free prescription drugs. (They also direct people to housing assistance, jobs programs or detox clinics.) The CHWs, who are AmeriCorps volunteers and receive a $400 monthly stipend, follow up with their contacts, making sure they have the asthma inhalers or blood pressure medications or the doctor's appointments they need. Since the program started in March 2005, they have helped 800 individual patients.
On a Wednesday morning in mid-July, Gibbons meets with the team for their daily 9 a.m. community rounds in their office in a former printing plant. Gibbons moves briskly through the patient list. There's "Miss C," the ornery 82-year-old woman who previously had dumped all her prescription pills into a bag and occasionally scooped out a handful. A CHW helped her by organizing the medications in a 30-day pillbox and is now trying to help her get placed in an assisted living center. Then they discuss the young woman who was desperate for an asthma inhaler, the man with shooting sciatica pains, and the 70-something man who's had both legs amputated and lives alone on the second floor of a nearby row house. His recent blood pressure was sky-high, but he's missed an enrollment deadline for Medicare Part D, which covers prescription drugs. A CHW is working to get him a Social Security card so he can enroll in the program. As the meeting wraps up, Gibbons and his team savor a recent victory. A male patient with hypertension and diabetes has lost weight and reduced his blood pressure to 130 over 70. "That's absolutely astounding," says Gibbons, beaming.
Though he's been at Hopkins for 14 years, Gibbons ("Dr. G" to the team) says that he still has much to learn from the CHWs. When initial results from survey questions asked of new participants showed they relied almost equally on private doctors, clinics and the emergency room for health care needs, Gibbons was amazed. Conventional wisdom dictates that populations with low health insurance coverage turn to the ER first. "I said, this must be a mistake. I couldn't understand it," says Gibbons, an assistant professor of Health, Behavior and Society. "I asked the CHWs about it. They said it makes total sense. They said, 'Dr. G, look: Nobody likes to be hounded by bill collectors, and everybody around here knows that if you go the ER, you're going to be hounded the most. So if you have a choice, you go to the others first.' That blew me away. I've seen that written nowhere. I couldn't explain it, and my workers explained it to me in 30 seconds."
With intimate familiarity with the people of their community, CHWs offer the most promising means of bridging the chasm between Americans who need health care and the professionals who provide it, says Gibbons. "Tip O'Neill used to say, 'All politics is local.' I've come to really appreciate that all health care is local," he says. "If you don't know your local population really well, you're not likely to make a difference."