Long emergency room wait times are unsafe and a problem across the country, but they are particularly bad in Maryland. After Washington, D.C., and Puerto Rico, we have the longest average wait time in the U.S., at four hours, seven minutes. A complaint of a nearly 12-hour wait was recently reported.
Long wait times are a direct result of our health care systems failing us. In Maryland, 6.5% of people don’t have health insurance and use the emergency department for non-urgent health care, while those with health insurance also encounter numerous barriers.
As a result, more people end up in our emergency rooms needing care too late and when they are too sick. Among our peer countries, Americans have the highest rates of death for treatable conditions, are the most likely to have multiple chronic conditions, have the lowest life expectancy and are the least likely to seek care. All that, and our country spends more on health care than any other developed nation.
Last month, a work group from the Maryland Hospital Association released a report detailing why emergency department wait times are so bad in our state, with suggestions to address the issue.
They identified the way forward as reforming prior authorization in hospitals and attaining sustainable funding for behavioral health initiatives. But those are patches. What we really need is to build a robust community health system. We need to shift away from expensive, inaccessible “sick care” and toward prevention and “whole-person care” that restores our optimal health when we do get sick. That way, emergency departments will be used for emergencies and not as a stopgap remedy when people lack preventive care or experience poor social conditions and barriers to quality primary care.
That’s the idea behind Neighborhood Nursing. It’s a groundbreaking initiative from the Johns Hopkins School of Nursing in partnership with schools of nursing at Coppin State University, Morgan State University and the University of Maryland. The program pairs a nurse and community health worker with every resident of a neighborhood to provide care block by block and family by family. Every resident, regardless of a person’s stage of life, health conditions, their insurance or insurance status.
For too long, primary care has been reserved for the people who show up at the provider’s office to receive it. But truly advanced primary care should facilitate access for all people, and include those who are homebound, homeless or otherwise unable to access care. That’s one revolutionary aspect of Neighborhood Nursing. The program meets people where they are — at home, at schools, at libraries and senior centers, or even virtually. That lowers the threshold for a person to access care and facilitates tailored treatment that is more likely to be effective.
Neighborhood Nursing represents a significant shift in health care delivery because it doesn’t just focus on treating illness, it aims to ensure optimal health and well-being. It gets to the root causes of health issues, which are largely driven by the social determinants of health — where we live, what we do and how we do it. Social determinants account for up to 80% of health outcomes, and Neighborhood Nursing connects residents with services to address housing, food, transportation and other related needs.
This model doesn’t replace traditional primary care. Rather, it acts as a crucial link, extending care to those who have poor access to it and removing barriers so that all residents can thrive.
Additionally, care is person-led. Nurses and community health workers work help people establish health goals and support them to achieve these goals through preventative measures, social support and improved overall wellbeing. By engaging individuals in their own health management and addressing social determinants of health, this model aims to reduce the total cost of care and reduce emergency room wait times and pressure on our health systems overall, while also empowering people to take control of their health. Critically, care teams can offer health education on appropriate use of emergency departments and provide non-emergency care that prevents inappropriate use.
More than a decade of evidence from other countries (such as Costa Rica’s community-oriented primary health care model) and pockets of innovation in the U.S. show that this model will improve key health indicators and substantially improve health equity. Specifically, it will reduce emergency department visits, hospital admissions and length of stay, while expanding access and utilization of primary care. This means higher vaccination rates and improved mental health, maternal health and chronic disease management, among other indicators.
The pilot phase of Neighborhood Nursing, launched in January 2024, focuses on two neighborhoods in Baltimore — Johnston Square and Sandtown-Winchester. They were selected based on existing infrastructure and community needs. Each pilot site includes a team of nurses and community health workers, serving residents of a few blocks and gradually expanding to reach more people over time.
The next phase will expand to rural communities, prioritizing regions Maryland has identified as areas to expand primary care. Critically, there are fewer than four primary care physicians for every 10,000 residents in Caroline, Garrett and Somerset counties, according to data from the Maryland Health Care Commission. In Baltimore — the jurisdiction with the highest ratio — there are only about 13 for every 10,000 people.
Alleviating long emergency department wait times will mean meeting people where they are and giving them greater control over their care. That kind of care, through means such as Neighborhood Nursing, would help us keep anyone from waiting too long or from being left behind.
Sarah Szanton is dean of the Johns Hopkins School of Nursing. Kim Dobson Sydnor is dean of the Morgan State University School of Community Health and Policy. Maija Anderson is chair of the Department of Nursing at the School of Community Health and Policy.
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