Actively Recruiting

Phase Not Applicable
Age: 18Years +
All Genders
ID05321368

A Cardiometabolic Health Program Linked With Clinical-Community Support and Mobile Health Telemonitoring to Reduce Health Disparities

Led by Johns Hopkins University · Updated on 2025-10-09

425

Participants Needed

3

Research Sites

26 weeks

Total Duration

On this page

Sponsors

J

Johns Hopkins University

Lead Sponsor

N

National Institute on Minority Health and Health Disparities (NIMHD)

Collaborating Sponsor

AI-Summary

What this Trial Is About

Researchers are evaluating a program called LINKED-HEARTS aimed at improving health outcomes for adults with uncontrolled high blood pressure who also have type 2 diabetes or chronic kidney disease. This trial involves 600 adults receiving care at community health centers and compares usual care with an enhanced program that includes home blood pressure monitoring linked to telemonitoring technology and team-based support. The goal is to reduce blood pressure, lower blood sugar levels, and improve kidney function through integrated clinical and community support. The study has two groups: one receives enhanced usual care with home blood pressure monitors, and the other participates in the LINKED-HEARTS Program. Participants in the LINKED-HEARTS group will use the Omron 10 series blood pressure monitor with the Sphygmo telemonitoring app. They will also receive education and support from community health workers and telehealth visits with pharmacists who collaborate with providers to optimize medication. The enhanced usual care group also uses the blood pressure monitor with training but receives standard care from their primary doctors. Participants will measure and transmit blood pressure data using the telemonitoring app, and their health will be tracked over 12 months. Researchers will assess blood pressure control, changes in blood pressure readings, blood sugar levels, body mass index, kidney function, and quality of life. The study includes regular monitoring and support to help participants manage their chronic conditions. Total participation lasts at least one year, with outcome measurements at baseline, 12 months, and some quality of life assessments continuing to 24 months.

CONDITIONS

Brief Title

A Cardiometabolic Health Program Linked With Clinical-Community Support and Mobile Health Telemonitoring to Reduce Health Disparities

Who Can Participate

Age: 18Years +
All Genders

Eligibility Criteria

Eligible

You may qualify if you...

  • 18 years of age or older as of date of data extraction
  • Self-identify as non-Hispanic white, non-Hispanic Black/African American, and/or Hispanic
  • Diagnosed with hypertension with a systolic blood pressure of 140 mm Hg or higher at the most recent clinic visit
  • Diagnosed with diabetes or chronic kidney disease in addition to hypertension
  • Receives primary medical care at one of the participating health systems
  • Has a home address in Maryland or Washington, D.C.
Not Eligible

You will not qualify if you...

  • Younger than 18 years old
  • Diagnosis of end-stage renal disease treated with dialysis
  • Serious medical condition limiting life expectancy or requiring active management, such as cancer
  • Cognitive impairment or condition preventing participation in the intervention
  • Planning to leave the practice or move out of the geographic area within 24 months
  • No longer considers the practice site their location for primary care
  • Unwillingness to provide informed consent

AI-Screening

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Your Study Journey

Screening

Duration - 2 to 4 weeks

Participants are screened for eligibility to participate in the trial.

1 visit (in-person)

Outpatient Treatment

Duration - 12 months

Participants receive the LINKED-HEARTS Program including training on home blood pressure monitoring, use of a blood pressure telemonitoring app, education and counseling from Community Health Workers, and pharmacist telehealth visits to optimize medication therapy.

Regular telehealth and in-person visits with Community Health Workers and pharmacists throughout the program

Follow-up

Duration - Up to 12 additional months

Participants are monitored for health outcomes such as blood pressure control, diabetes management, and quality of life after completing the intervention.

Periodic assessments up to 24 months from baseline

Trial Site Locations

Total: 3 locations

1

Unity Health Care

Washington D.C., District of Columbia, United States, 20019

Actively Recruiting

2

Johns Hopkins Community Physicians

Baltimore, Maryland, United States, 21205

Actively Recruiting

3

Choptank Community Health Systems

Denton, Maryland, United States, 21629

Active, Not Recruiting

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Research Team

Y

Yvonne Commodore-Mensah, PhD, MSH

How is the study designed?

Study Type

INTERVENTIONAL

Masking

NONE

Allocation

RANDOMIZED

Model

PARALLEL

Primary Purpose

PREVENTION

Number of Arms

2

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Published Research Related To This Trial

Design and rationale of the cardiometabolic health program linked with community health workers and mobile health telemonitoring to reduce health disparities (LINKED-HEARTS) program.

Yvonne Commodore-Mensah, Yuling Chen, Oluwabunmi Ogungbe...

https://pubmed.ncbi.nlm.nih.gov/38759910