# A Cardiometabolic Health Program LINKED with Clinical-Community Support and Mobile HEAlth TelemonitoRing in Underserved PopulaTionS (LINKED-HEARTS PROGRAM)

> **NIH NIH P50** · JOHNS HOPKINS UNIVERSITY · 2021 · $702,093

## Abstract

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...

## Key facts

- **NIH application ID:** 10437338
- **Project number:** 1P50MD017348-01
- **Recipient organization:** JOHNS HOPKINS UNIVERSITY
- **Principal Investigator:** Yvonne Commodore-Mensah
- **Activity code:** P50 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $702,093
- **Award type:** 1
- **Project period:** 2021-09-24 → 2026-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10437338

## Citation

> US National Institutes of Health, RePORTER application 10437338, A Cardiometabolic Health Program LINKED with Clinical-Community Support and Mobile HEAlth TelemonitoRing in Underserved PopulaTionS (LINKED-HEARTS PROGRAM) (1P50MD017348-01). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10437338. Licensed CC0.

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