In an era when speed, efficiency and turnover have come to dominate the hospital psyche — just watch an episode of “The Pitt” — what role is left for human connection in our clinical toolbox?

More than you might imagine. Starting seven years ago, we started Together in Care, a program supported by Johns Hopkins Bayview Medical Center at Johns Hopkins that delivered social support to patients who suffered multiple health issues and hospitalizations. They provided food, engagement and conversation, home safety equipment and most importantly, confidence and trust. In other words, the goal was to promote health in addition to medicine.

This novel approach of social prescribing, or addressing non-medical determinants like isolation, kept 81 patients, who together had 100 days of collective ICU care in one year, out of the hospital for a full year. Building off this model, others in Baltimore have taken a major step further by engaging community members before they become patients.

In late 2023, Novartis, the Global Coalition on Aging, a network of Baltimore City senior centers and four local Baltimore churches led by Pastor Terris King, a former Medicare and Medicaid executive, created engAGE with Heart, a community-based program that brings together families, churches, senior centers and community partners to support heart health among their neighbors and congregations.

To a clinician, it made perfect sense. Why not work directly with people with an underlying condition that’s going untreated or an unhealthy lifestyle that’s bound to lead them to my emergency room one day?

Cardiovascular disease is the #1 cause of death for all Americans, for Black communities and for Baltimoreans. Health disparities are even worse, with Baltimore residents in certain predominantly Black neighborhoods living on average 20 years less than those in some predominantly white neighborhoods.

engAGE with Heart puts trust at the foundation of everything it does, enabling it to deepen its reach in the community in a way we in the hospital could never dream of. It achieves this by relying on Community Health Ambassadors, paid members of the community who have a deep understanding of local needs, culture, challenges and relationships.

These are the mothers, fathers, daughters, sons and friends in the pews every Sunday. Community Health Ambassadors operate in partnership with the conventional health system to refer at-risk people for care at the right time, before it’s too late.

Even more, starting in February of this year, engAGE with Heart and Together in Care came together to leverage the strength of both programs — caring for the communities and the patients. This extends its community-based model to care for discharged hospital patients enrolled in the program.

Too often, I see patients who are in the hospital in large part because of a social challenge — issues like loneliness, social isolation and food insecurity are common. Now, engAGE with Heart’s Community Health Ambassadors and congregations will regularly check in on these patients and help provide the human connection that we pioneered seven years ago and Pastor King has helped improve over the last two years.

For example, after a patient is discharged from the hospital, the program helps these patients find healthy meals for the week, helps them with smoking cessation, helps them schedule follow-up medical appointments, or even helps them comply with medical guidance, including taking their medicines.

So far, the combination has been a resounding success. Of the patients enrolled, they’ve reported a higher quality of life, have said they feel like part of a family, and most importantly, they feel cared for. To date, none of these patients have been re-hospitalized or seen an intensive care unit again.

A community’s health relies in part on social cohesion. That cohesion is rooted in purpose, engagement, culture and real, trusted relationships. Programs like engAGE with Heart and Together in Care are demonstrating the power of this community-driven approach to improve health outcomes, especially for our most vulnerable populations.

We must build on this success and grow this model across Maryland. By our existing medical infrastructure partnering with local faith networks, senior centers and other trusted community institutions, we can empower our community leaders and health professionals to reach people before they end up in the hospital.

Together, we can strengthen the social fabric of our neighborhoods and ensure all Marylanders have the support they need to live healthier, more fulfilling lives.

The time is now to invest in this community-based health care delivery model. Let’s commit the resources necessary to scale engAGE with Heart statewide. Our residents’ wellbeing — and the future health of our communities depends on it.

Dr. Panagis Galiatsatos, a Baltimore native, is an associate professor of medicine and oncology and the co-director of Medicine for the Greater Good at the Johns Hopkins University School of Medicine.