Results Summary

What was the research about?

Community-based organizations (CBOs) are nonprofit groups that work at the local level to improve life for people in need. CBOs can help people pay bills or find food, jobs, or places to live. CBOs can also help people with basic healthcare needs. Some doctors, hospital staff, or other healthcare professionals may not know about the services that CBOs offer to patients.

The research team wanted to learn if a program to link hospitals and clinics to CBOs could help keep patients in East and Southeast Baltimore, Maryland, from needing to go to the hospital or emergency room as often. The team compared patients who live near CBOs that were in this program with patients who live near CBOs that weren’t in this program.

What were the results?

After a year, the research team found no differences between patients who live near CBOs that were in the program and patients who live near CBOs that weren’t in the program. There were no differences in

  • How often patients went to emergency rooms or hospitals
  • How long patients stayed at hospitals if they were admitted
  • How often patients at hospitals or clinics were told about the services of CBOs
  • How often CBO clients were told about services at healthcare clinics

At the end of the program, staff members at inpatient and outpatient clinics in the study reported

  • Fewer barriers referring their patients to CBOs
  • More confidence in having the information they need about CBOs
  • More patient referrals to the CBOs that were in the program than to the CBOs that weren’t in the program

Who was in the study?

The study included 20 CBOs in low-income neighborhoods in East and Southeast Baltimore. The research team looked at healthcare records for 4,917 patients in the Johns Hopkins Health System. Patients lived in Baltimore and had many healthcare and service needs, such as trouble paying bills or finding a place to live.

What did the research team do?

The research team worked with CBOs and health professionals to create the program to improve how hospitals, clinics, and CBOs work together. The program included activities such as monthly meetings that involved all the CBOs in the program and meetings with Johns Hopkins Health System staff.

The research team assigned the CBOs, by chance, to one of two groups. One group was in the program; the other was not. Then, the research team looked at patient health records; the team grouped the patients’ records by which CBO was closest to their homes. The research team looked at patients’ health insurance billing information to see how many times patients went to an emergency room or hospital and how many days they stayed in the hospital if admitted. The research team compared patients who lived near CBOs that were in the program with patients who lived near CBOs that weren’t in the program.

The research team also interviewed people who used the services of the CBOs. The team asked people about the services that CBOs offered and how many other CBOs the patients knew of. The team also asked about the problems patients faced in the previous month, such as finding a job. The research team surveyed staff members at Johns Hopkins Health System before and after the program. The surveys included questions about barriers that staff members faced when referring patients to CBOs. The surveys also asked whether staff members had the information they needed about the CBOs.

What were the limits of the study?

The research team didn’t know if the patients visiting the hospital or clinics had ever been to their assigned CBOs, so the research team doesn’t know if going to the CBOs affected the study results. The number of CBOs in the study may have been too small to see if the program made a difference.

Future research could look at other ways to help teach patients about, and link patients to, the services in their communities.

How can people use the results?

Patients, doctors, and CBOs may be able to use the results from this study to work together to help people get the services they need to stay healthy. Teaching clinic staff members about CBOs may increase the number of patients the staff members refer to CBOs. However, making clinic staff aware of CBO services may not change how people use hospitals or emergency rooms.

Final Research Report

View this project's final research report.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer review process here.

In response to peer review, the PI made changes, including

  • Reorganizing and revising the report to make it more comprehensible to a wider audience
  • Providing more discussion about why some of the study’s outcomes were not achieved
  • Acknowledging that because the community-based organizations included in the study did not track patients, it was not possible to directly attribute patient outcomes to CBO exposures

Conflict of Interest Disclosures

Project Information

Albert Wu, MD, MPH
Johns Hopkins University
Reverse Innovation and Community Engagement to Improve Quality of Care and Patient Outcomes

Key Dates

May 2013
September 2017

Study Registration Information


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Last updated: January 25, 2023