Linking Community-Based Organizations with Each Other, and with Hospitals and Health Clinics, to Help Connect Patients with the Services They Need

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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.

Objective

To evaluate whether establishing links among community-based organizations (CBOs) and between CBOs and an academic health system reduces hospital and emergency department use among residents of East and Southeast Baltimore, Maryland

Study Design

The research team conducted a cluster randomized controlled trial to evaluate an intervention to link CBOs in East and Southeast Baltimore, Maryland, with the Johns Hopkins Health System (JHHS) inpatient and outpatient healthcare staff members. The research team worked with representatives from government agencies, JHHS, foundations, and local nonprofit organizations to develop the strategy for CBOs and JHHS to access and share resources.  

Researchers randomly assigned 20 CBOs that provide similar services to the intervention group or the control group. The CBOs in the intervention group participated in monthly meetings with all the intervention CBO partners, used a toolkit on a project website, and had access to a search engine to find local social and medical services. A research assistant volunteered at each CBO and acted as a liaison between the CBO and research team. Each intervention CBO partner also attended monthly meet-and-greet sessions with JHHS staff members. The control group CBOs did not participate in any of the intervention activities and provided services to their clients as usual.

Researchers assigned 4,917 high-risk JHHS patients as intervention or control patients. Researchers based the assignments on proximity of patients’ residences to intervention or control CBOs.

The primary outcome was healthcare use, measured using Medicare and Medicaid claims data and defined as the number of hospital and emergency department visits, as well as length of stay for JHHS patients. For secondary outcomes, the research team conducted baseline surveys and follow-up surveys 12 months later with:

• CBO staff members about their referrals of one or more clients to the healthcare system, receipt of one or more patient referrals from the healthcare system, levels of confidence in referring clients to other CBOs, frequency of communication with other CBOs, and number of referrals to CBOs in the previous month
• CBO clients regarding whether they received information about other CBOs, referrals to the healthcare system by CBO staff, or referrals to a CBO by a healthcare provider; surveys also assessed clients’ difficulties with finding a job, paying bills, getting transportation, getting food, or finding housing in the previous month
• JHHS inpatient and outpatient staff members regarding their perceived barriers to referring patients to community resources, referrals of patients to CBOs in the previous month, perceptions about how well healthcare organizations and community organizations work together, and levels of confidence in their knowledge about CBOs

The research team compared responses between the intervention and control groups and used difference-in-difference analyses to examine changes in responses to survey questions from baseline to follow-up.

Results

The research team found no significant differences between the intervention and control groups for healthcare use or for any outcomes measured via surveys with CBO clients and CBO staff members.

At follow-up, compared with the baseline period, JHHS staff were significantly more likely to refer a patient to an intervention CBO (3-percentage-point increase in inpatient staff referrals, p = 0.051, and 7-percentage-point increase in outpatient staff referrals, p = 0.027). JHHS outpatient staff members also reported a significant reduction in barriers to referring patients to CBOs related to a lack of available resources about CBOs (15 percentage points, p = 0.014) and up-to-date information about community resources (18 percentage points, p = 0.04). JHHS outpatient staff members reported increased confidence in knowledge about CBOs from baseline to follow-up (14 percentage points, p = 0.023).

Limitations

The research team was unable to track JHHS patients’ use of services at specific CBOs; therefore, it was not possible to relate CBO exposures to the outcomes. The team assigned patients to the intervention group or control group based on patient proximity to CBOs. The study included only 20 CBOs; the small sample size may have limited the researchers’ abilities to detect differences.

Conclusions and Relevance

The research team created a network of CBOs with links to JHHS that may have helped community members access health and social services. Although the study did not identify differences between the intervention and control groups for primary outcomes, JHHS staff members reported outcomes that suggest an increase in patient referrals to CBOs and a decrease in barriers to referring patients to CBOs.

Future Research Needs

Future research could explore how creating or strengthening links between CBOs and health networks can aid in improving the health of high-risk patients in urban settings.