LINKED-HEARTS Program

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 can cause cardiovascular disease, stroke, chronic kidney disease (CKD), and premature death. Black and Hispanic adults are disproportionately affected by HTN and diabetes and experience more adverse social determinants of health, including a lack of access to reliable transportation and fragmented access to primary care. A pressing priority is to reduce disparities in the management and control of chronic diseases and make primary care more convenient for underserved populations.

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 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.

• use the Pragmatic Robust Implementation and Sustainability Model (PRISM) to evaluate the reach, adoption, and maintenance of the LINKED-HEARTS program at 12- and 24-months post-randomization and explore contextual factors associated with adoption and maintenance of the program.

We will enroll 600 adults, clustered in 16 practices. 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.

Yvonne Commodore-Mensah, PhD, MHS, RN
Principal Investigator
Serves as the contact PI and is responsible for communication with the funding agency (NIMHD) and the overall conduct of the study. Chairs the Technology and Team-Based Care Workgroup to oversee the development and deployment of the LINKED-HEARTS intervention. Oversees the research staff and practice training, data collection, analysis, and dissemination work with Dr. Himmelfarb.

Cheryl Dennison Himmelfarb, PhD, RN, ANP
Principal Investigator
As Co-Principal Investigator of the study, Dr. Himmelfarb is jointly responsible for the overall conduct of the trial. She jointly oversees the research staff and practice training, data collection, analysis, and dissemination work with Dr. Commodore-Mensah and leads study participants recruitment.

Jeffery Fink, MD, MS
Co-Investigator
Conducts research in the areas of chronic kidney disease, clinical epidemiology, and patient Safety. Stakeholder Advisory Committee member and provides direction and implementation of community engagement, stakeholder engagement, implementation science, and community health worker training. Attends meetings with MACCHE CORE and research team to ensure timely progress of LINKED HEARTS data dissemination.

Justin Echouffo Tcheugui, MD, PhD
Co-Investigator
Provides direction and implementation of community engagement, stakeholder engagement, implementation science, and community health worker training.

Kathryn “Kit” Carson, ScM
Co-Investigator
Leads data management efforts through the Centralized Data Core of the MACCHE and leads presentation to the data workgroup. Provides direction and implementation of community engagement, stakeholder engagement, implementation science, and community health worker training. Ensures timely progress of LINKED HEARTS Project data dissemination.

Wendy Bennett
Chief of Primary Care Clinical Innovation
JHCP

Marcee White
Chief Medical Officer
Total Healthcare Inc.

Megan Wojtko
SVP & Chief Clinical Officer
Choptank Community Health System Inc.

Christopher DeMarco
Chief Executive Officer
Greater Baden Medical Services

Raj Padwal
Co-founder
Mmhg Inc.

Peter Wood
Chief Operating Officer
Mmhg Inc.

Roger Clark
Community Chair
Institute for Clinical & Translational Research Community Research Advisory Council (C-RAC)

Rhonda Ford Chatmon
Vice President, Health Strategies Serving Baltimore & Greater Maryland
American Heart Association

Nora Hoban
Chief Executive Officer
Mid-Atlantic Association of Community Health Centers

Tiffany Scott
President
Maryland Community Health Worker Association
Vice Chair
Maryland Community Health Worker Advisory Committee

Monica Guerrero Vazquez
Executive Director
Center for Salud/Health and Opportunities for Latinos (Centro SQL)
Medical Director
JH Bayview Children’s Medical Practice

Keith Daye
Community Advocate

Lee Bone
Associate Professor
Bloomberg School of Public Health

Michelle Simmons
Community Advocate