NEJM Catal Innov Care Deliv. 2026 Apr;7(4):CAT250130. doi: 10.1056/CAT.25.0130. Epub 2026 Mar 11.
ABSTRACT
In the United States, Black adults experience disproportionately high rates of hypertension and are nearly twice as likely to die due to a cardiovascular disease-related complication as white adults. These disparities are related to systemic barriers - including food, housing, and economic insecurity - that impede access to consistent, high-quality care. To address these structural inequities, the Indianapolis Health Equity, Access, Outreach, and Treatment Collaborative launched the Convenient Home Evaluation for Cardiovascular Health and Individual Tracking program in June 2023. It integrated home blood pressure monitoring, patient education, community health worker support, and virtual medication management to improve hypertension control among residents of high-risk Indianapolis neighborhoods. Adapted from the American Heart Association's "Check. Change. Control." model, the 4-month program was designed to help patients build the knowledge, skills, and support needed to manage their cardiovascular health. The program operated across six Indiana University (IU) Health primary care facilities strategically positioned near anchor communities selected based on high rates of cardiovascular disease, social vulnerability, and racial disparity. Participants received a free blood pressure cuff and training on accurate home measurement, along with automated text reminders and a 4-month educational curriculum covering hypertension basics, including nutrition, stress reduction, sleep, and physical activity. Through outreach and home visits, community health workers provided social support, assessed social determinants of health needs, and connected participants with additional resources. Community health workers escalated urgent cases to IU Health's social work team for rapid intervention, while IU Health pharmacists offered virtual support for participants with uncontrolled blood pressure. During the program's first 18 months, more than 60% of participants who completed the program achieved blood pressure control (blood pressure <140/90 mmHg), with average reductions of 7 mmHg systolic and 4 mmHg diastolic. Data on maintenance of blood pressure control were not collected beyond the 4-month period. In addition, data were not collected on how many referrals to community resources to address social needs resulted in services provided, though plans are under way to address that gap. Nevertheless, the authors' findings highlight the potential of the Convenient Home Evaluation for Cardiovascular Health and Individual Tracking (CHECK-IT) program as a scalable, community-centered model addressing both medical and social drivers of hypertension disparities.
PMID:42418541 | DOI:10.1056/CAT.25.0130