Document text
Principal Investigator: Yvonne Commodore-Mensah
Organization: JOHNS HOPKINS UNIVERSITY
Fiscal Year: 2024
Award: $658,161
Funding agency: National Institute on Minority Health and Health Disparities
Project Summary/Abstract
Innovation in chronic disease management is urgently needed to effectively control hypertension (HTN) and
diabetes, conditions which affect millions of Americans. Uncontrolled HTN and diabetes cause cardiovascular
disease, stroke, chronic kidney disease (CKD), and premature death. However, these conditions are poorly
controlled despite the availability of effective and affordable therapy. A pressing priority is reducing disparities
in the management and control of chronic diseases and making primary care more convenient for underserved
populations. Black and Hispanic adults are disproportionately affected by HTN and diabetes than White adults.
They also experience more adverse social determinants of health, including a lack of access to reliable
transportation and fragmented access to primary care. Team-based care including community health workers
and pharmacists are “best practices” in improving HTN and diabetes control. Telehealth has become a
cornerstone of efforts to minimize disruptions in primary care and can be enhanced with remote patient
monitoring devices. The COVID-19 pandemic has spurred efforts to increase access to timely and appropriate
care through re-engineering primary care to be patient-centered and digitally-enabled. Sphygmo Home, a
remote patient telemonitoring solution that links with validated blood pressure (BP) and glucose monitoring
devices is a promising solution to improve patient's self-management of HTN and diabetes. We have designed
the LINKED-HEARTS Program, an innovative, theoretically derived, patient-centered, multi-level intervention
to address individual and community-level social determinants that affect chronic disease management. The
LINKED-HEARTS Program focuses on addressing structural issues of access and includes a self-measured
BP(SMBP) and blood glucose telemonitoring platform; team-based care including a pharmacist and community
health worker and provider-level interventions. Using a hybrid type I effectiveness-implementation design, our
proposed specific aims are 1) To compare the effect of the LINKED-HEARTS Program versus SMBP alone in
improving BP control (systolic BP<140/90 mm Hg) and improving patient-centered outcomes at 6 and 12 months,
in a cluster-randomized controlled trial of adults with uncontrolled HTN and either diabetes or CKD. 2) To use
the Pragmatic Robust Implementation and Sustainability Model (PRISM) to evaluate the reach, adoption,
maintenance of the LINKED-HEARTS program at 12 and 24 months post-randomization and explore contextual
factors that associated with adoption and maintenance of the program. We will enroll 600 adults, clustered in 16
practices including federally qualified healthcare centers. Through early and continued stakeholder engagement
with health system leaders, providers, patients, and our community, we seek to close the wide “know-do-gap”
and reduce chronic disease disparities. We also propose a comprehensive dissemination strategy to reach
critical audiences and achieve buy-in and policy change.
Terms: <21+ years old><Access to Care><Address><Adherence><Adoption><Adult><Adult Human><Affect><African American group><African American individual><African American people><African American population><African Americans><American><Apoplexy><Application Context><BP control><BP management><Behavioral><Biological><Black><Black race><Blood Glucose><Blood Pressure><Blood Pressure Monitors><Blood Sugar><Bluetooth><Brain Vascular Accident><COVID crisis><COVID epidemic><COVID pandemic><COVID-19 crisis><COVID-19 epidemic><COVID-19 era><COVID-19 global health crisis><COVID-19 global pandemic><COVID-19 health crisis><COVID-19 pandemic><COVID-19 period><COVID-19 public health crisis><COVID-19 years><Cardiovascular Diseases><Caring><Cerebral Stroke><Cerebrovascular Apoplexy><Cerebrovascular Stroke><Cessation of life><Chronic><Chronic Disease><Chronic Illness><Chronic Kidney Failure><Chronic Renal Disease><Chronic Renal Failure><Clinic><Clinical><Communities><Community Health Aides><Complex><Continuous Sphygmomanometers><Data><Death><Decrease disparity><Devices><Diabetes Mellitus><Disease Management><Disorder Management><Disparities><Disparity><Disparity population><Education><Educational aspects><Engineering><Enrollment><Ethnic Group><Ethnic People><Ethnic Population><Ethnic individual><Ethnicity People><Ethnicity Population><Evidence based practice guidelines><Glycohemoglobin A><Glycosylated hemoglobin A><Hb A1><Hb A1a+b><Hb A1c><HbA1><HbA1c><Health><Health Care Professional><Health Care Technology><Health Professional><Health Services Accessibility><Health Technology><Health behavior><Health system><Healthcare><Healthcare Technology><Healthcare professional><Hemoglobin A(1)><High Prevalence><Hispanic><Hispanic Populations><Hispanic group><Hispanic individual><Hispanic people><Hispanics><Home><Hybrids><Hypertension><Improve Access><Individual><Individuals from minority><Individuals of minority><Intervention><Intervention Strategies><Kidney Diseases><Latino Population><Latino group><Latino individual><Latino people><Latinos><Link><Lower disparity><Maintenance><Measures><Minority Groups><Minority People><Minority Population><Minority individual><Morbidity><Morbidity - disease rate><Nephropathy><Non-Hispanic><Nonhispanic><Not Hispanic or Latino><Organ><PRISM framework><PRISM model><Patient outcome><Patient-Centered Outcomes><Patient-Focused Outcomes><Patients><Persons><Pharmacists><Policies><Practical Robust Implementation and Sustainability Model><Pragmatic, Robust Implementation and Sustainability Model><Prevalence><Primary Care><Provider><Qualifying><Racial Group><Randomization trial><Randomized><Randomized, Controlled Trials><Renal Disease><SARS-CoV-2 epidemic><SARS-CoV-2 global health crisis><SARS-CoV-2 global pandemic><SARS-CoV-2 pandemic><SARS-coronavirus-2 epidemic><SARS-coronavirus-2 pandemic><Self Management><Severe Acute Respiratory Syndrome CoV 2 epidemic><Severe Acute Respiratory Syndrome CoV 2 pandemic><Severe acute respiratory syndrome coronavirus 2 epidemic><Severe acute respiratory syndrome coronavirus 2 pandemic><Soil><Stroke><System><Transportation><Underserved Population><Uninsured><Vascular Hypertensive Disease><Vascular Hypertensive Disorder><Visit><Work><access to health care><access to health services><access to healthcare><access to services><access to treatment><accessibility of health care><accessibility to health care><accessibility to health services><accessibility to healthcare><adulthood><availability of services><biologic><blood pressure control><blood pressure management><brain attack><cardiometabolic><cardiometabolism><cardiovascular disease risk><cardiovascular disorder><cardiovascular disorder risk><cardiovascular risk><cardiovascular risk factor><care access><care delivery><cerebral vascular accident><cerebrovascular accident><chronic disorder><chronic kidney disease><clinical decision-making><community health worker><contextual factors><coronavirus disease 2019 crisis><coronavirus disease 2019 epidemic><coronavirus disease 2019 global health crisis><coronavirus disease 2019 global pandemic><coronavirus disease 2019 health crisis><coronavirus disease 2019 pandemic><coronavirus disease 2019 public health crisis><coronavirus disease crisis><coronavirus disease epidemic><coronavirus disease pandemic><coronavirus disease-19 global pandemic><coronavirus disease-19 pandemic><design><designing><diabetes><diabetes control><diabetes mellitus control><diabetes risk><digital><disadvantaged group><disadvantaged individual><disadvantaged people><disadvantaged population><disadvantaged subgroup><disease disparity><disparate effect><disparate impact><disparate result><disparities across groups><disparity across subgroups><disparity among groups><disparity among subgroups><disparity between groups><disparity between subgroups><disparity in health><disparity reduction><dissemination strategy><effectiveness/implementation design><effectiveness/implementation hybrid design><empowerment><enroll><ethnic minority group><ethnic minority individual><ethnic minority people><ethnic minority population><ethnic subgroup><ethnicity group><evidence based guidelines><evidence based recommendations><experience><glucometer><glucose meter><glucose monitor><group disparity><group inequality><group inequity><health care><health care access><health care availability><health care service access><health care service availability><health disparity><health equity><health related behavior><health service access><health services availability><healthcare access><healthcare accessibility><healthcare availability><healthcare service access><healthcare service availability><hemoglobin A1c><high blood pressure><high risk><homes><hyperpiesia><hyperpiesis><hypertension control><hypertension management><hypertensive disease><hypertensive disorder><improved><inequalities among populations><inequalities between populations><inequalities in populations><inequality across populations><inequality among groups><inequality between groups><inequality in groups><inequitable effect><inequitable impact><inequitable outcome><inequities among populations><inequities between populations><inequities in populations><inequity across groups><inequity across populations><inequity between groups><inequity in groups><innovate><innovation><innovative><interventional strategy><kidney disorder><m-Health><mHealth><mitigate disparity><mobile health><monitoring device><mortality><outcome disparities><outcome inequality><outcome inequity><patient centered><patient monitoring device><patient oriented><patient oriented outcomes><population inequality><population inequity><premature><prematurity><prevent><preventing><primary care practice><primary outcome><programs><racial minority><racial minority group><racial minority individual><racial minority people><racial minority population><racial population><racial subgroup><randomisation><randomization><randomized control trial><randomized trial><randomly assigned><reduce disparity><reduction in disparity><remote health monitoring><remote patient monitoring><renal disorder><secondary outcome><service availability><severe acute respiratory syndrome coronavirus 2 global health crisis><severe acute respiratory syndrome coronavirus 2 global pandemic><social><social culture><social determinants><social health determinants><socio-cultural><sociocultural><sociodeterminant><stroked><strokes><subgroup disparity><team-based care><telehealth><telemonitoring><treatment access><under served group><under served individual><under served people><under served population><underserved group><underserved individual><underserved people><unequal effect><unequal group><unequal impact><unequal outcome><unequal population>