Sustaining Universal, Preventive-Centered Care Through Neighborhood Nursing

The fragmented multi-payer system in the United States creates powerful disincentives against the evidence-based interventions most likely to improve health and control costs: universal, prevention-centered care delivered where people live, work, and gather. When payer investments in prevention benefit competitors’ enrollees or generate community-wide returns that no single payer can capture, systematic underinvestment becomes rational economic behavior — even when prevention would be a “common good” that benefits everyone, including the health system. This problem is a often referred to as the common good dilemma.

But what if payment models rewarded community benefit? We are exploring this question through our work with Neighborhood Nursing, a geographically organized health and social care infrastructure designed to provide universal access to care services. Johns Hopkins University School of Nursing partnered with the University of Maryland School of Nursing and two nursing schools in historically Black universities, Morgan State University and Coppin State University, to develop the model. In this post, we describe the model’s service elements and potential payment pathways, recognizing that full realization of the approach will unfold over time.

What Is Neighborhood Nursing?

Neighborhood Nursing connects teams of nurses and community health workers with every person in a defined area, regardless of income and residency or insurance status. It delivers preventive (avert diseases or social problems), promotive (enhance and maintain good health and social well-being), and restorative (recover health or social functioning after an issue arises) services in people’s homes and community hubs.

Neighborhood Nursing is designed to include core services for everyone and specialized services to respond to specific population needs. Examples of core services include physical and mental health screening, chronic disease management, medication reconciliation, care transitions, linkage to primary and specialized care, and social needs and support navigation. Specialized services may include substance use support, maternal and newborn services, and pain management.

By serving everyone in a geographic area — not just specific payers’ enrollees — Neighborhood Nursing can align individual and collective interests. When a nurse helps someone manage diabetes or connects them to food resources, all payers with beneficiaries in that community benefit. But who pays? Through interviews with 21 health policy experts, providers, and payers across Maryland and beyond, we’ve mapped a “portfolio of payment possibilities” that reveals both opportunities and structural barriers. Our preliminary findings offer insights for any state seeking to finance prevention-oriented, equity-focused care models.

Potential Payment Pathways for Neighborhood Nursing

Leveraging existing state contracts. One immediate option involves contracts between a Neighborhood Nursing provider and primary care practices participating in existing enhanced payment programs. Maryland already offers several such programs — Advanced Primary Care Management (APCM), the Maryland Primary Care Program (MDPCP), and the new Primary Care AHEAD initiative — all of which pay practices for delivering services like care coordination, chronic disease management, and transitional care. Neighborhood Nursing could contract with these practices to deliver enhanced services on their behalf, receiving a share of the monthly payments, which could range from $15 to $107 per participant depending on complexity and program structure.

Tapping state population health funds. More promising opportunities emerge from state-level policy infrastructure such as a wellness fund, which creates stable, predictable funding for population health initiatives. Maryland’s Population Health Improvement Fund (PHIF), established under AHEAD and written into Maryland law, pools resources from state appropriations, hospital assessment rates, and interest earnings specifically to support interventions that advance the Statewide Health Improvement Plan. Those priorities — reducing chronic disease, improving behavioral health access, addressing health-related social needs — align precisely with Neighborhood Nursing’s service model.

CMS’ AHEAD, which Maryland and five other states are participating in, offers a unique opportunity to address our health system’s lack of collective accountability for population health. Other states can pursue similar alignment through all-payer claims databases that provide transparency across payers, shared quality metrics that create common definitions of success, and collaborative payment models that pool resources for common good interventions. The Ohio Health Care Plan and MiCare represent steps in this direction. The goal is moving from a system where each payer optimizes its own population to one where all stakeholders share responsibility for community health.

While state budgets across the country face significant fiscal pressures, strategic investments in prevention and universal wellness models represent not just a moral imperative but a fiscally sound approach to reducing future costs. Prevention-focused initiatives have consistently demonstrated strong returns on investment by averting more expensive interventions down the line and improving population health outcomes. Rather than viewing these programs as discretionary spending that can be deferred during tight budget cycles, policymakers should recognize them as essential infrastructure that can help states achieve long-term fiscal sustainability while addressing health inequities. One promising mechanism for ensuring stable, dedicated funding for such initiatives is the wellness trust model.

A wellness trust could be established through state legislation that allocates a dedicated pool of funds, raised from public and/or private sources, to finance community-based prevention strategies, reduce health disparities, and lower long-term medical costs. For example, the Massachusetts Community Health and Healthy Aging Funds was established via state law and regulation.

States can explore revenue sources like excise taxes on products that contribute to poor health and chronic disease (e.g., sodas, alcohol, tobacco products), penalties for corporate behaviors that harm community health (e.g., environmental regulatory violations; fraud, waste and abuse in the health system; opioid settlement funds), or portions of health care savings returned to prevention investment.

Other potential funding sources are the Rural Health Transformation Fund, 1115 waivers, and accountable care organizations (ACOs). Many states have beed awarded dedicated Rural Health Transformation Program funding to support states to strengthen rural communities by improving health care access, quality, and outcomes by transforming the health care delivery ecosystem. In Maryland, for example, the state is using a portion of these funds to expand and improve access to primary care, presenting an opportunity for Neighborhood Nursing. 

Similarly, Section 1115 Medicaid demonstration waivers provide states with flexibility to test innovative approaches to delivering and financing health care. States can use these waivers for upstream prevention initiatives, social needs interventions, and population health strategies. North Carolina used an 1115 Medicaid waiver to launch Healthy Opportunities Pilots that provide non-medical services like housing assistance, food and nutrition support, transportation, and interpersonal safety services to high-need Medicaid beneficiaries.

ACOs benefit financially from keeping people healthy and reducing unnecessary medical spending. ACOs can then allocate shared savings toward community wellness programs, chronic disease prevention, and partnerships with community-based organizations that address health-related social needs. In Minnesota, Hennepin Health partners with over 40 community-based organizations and hires community health workers to provide comprehensive care coordination and address social needs.

In Maryland, another state-level mechanism offers potential: the Outcomes-Based Credits program. The state can earn credits from the Centers for Medicare and Medicaid Services (CMS) for successfully managing and reducing chronic conditions like diabetes among Medicare enrollees. If Neighborhood Nursing’s diabetes management services — medication support, education, care coordination — reduce unnecessary ED utilization and hospitalizations, capturing a portion of those savings could create a sustainable financing loop. Yet, policy action would be need to create a regulatory mechanism to direct Outcomes-Based Credit savings to community programs outside the hospital system.

Other states and payers can participate in a similar outcomes-based payment approach via the voluntary CMS model, ACCESS (Advancing Chronic Care with Effective, Scalable Solutions). Like Maryland’s Outcomes-Based Credits program, ACCESS is Medicare-focused. However, CMS is also promoting alignment across Medicare Advantage, Medicaid, and commercial payers via a pledge for these payers to adopt the core principles of the model by Jan 1, 2028.   

From Paradox to Possibility

Our research to date confirms that no single payment pathway achieves the universality that equity-centered health systems require. States need to be creative and look to both existing programs, like alternative payment models, as well as establishing new funding sources such as a wellness trust to institutionalize common good investments.

With many Americans projected to lose coverage under recent federal legislation, the urgency for universally accessible care has never been greater. Universal models like Neighborhood Nursing can make community benefit a feature of the system rather than incidental. And they advance health equity by ensuring access doesn’t depend on insurance status, income level, or ability to navigate fragmented systems. When everyone in a geography can access preventive care, chronic disease management, and social needs support, everyone benefits — including every payer with risk in that community. The question isn’t whether we can afford to invest in universal, preventive care. It’s whether we can afford not to.

Acknowledgements

This work was supported by the Commonwealth Fund and the Johns Hopkins University Nexus Research Award. The authors thank the health policy experts, providers, and payers who generously shared their insights for this research.