The University of Maryland School of Nursing’s (UMSON) Yolanda Ogbolu, PhD ’11, MS ’05, BSN ’04, CRNP-Neonatal, FNAP, FAAN, associate professor; chair, Department of Partnerships, Professional Education, and Practice; and co-director, Center for Health Equity and Outcomes Research, has been awarded a $2.4 million Pathways to Health Equity grant by the Maryland Community Health Resources Commission (CHRC) for a project that will address disparities in hypertension and social isolation in West Baltimore.

Yolanda Ogbolu

The project takes the form of the West Baltimore Reducing Isolation and Inequities in Cardiovascular Health (RICH) Collaborative, which seeks to achieve collective medical and social impact by bringing partner organizations together to advance common interventions for improving hypertension outcomes and social isolation.

UMSON is one of nine CHRC Pathways to Health Equity award grantees, which will be investing a total of $13.5 million in new resources in underserved communities across the state. The grant-funded projects will address health disparities, expand access to health services, and improve health outcomes with funding made available under the Maryland Health Equity Resource Act of 2021.

“I am excited about the West Baltimore RICH Collaborative because it seeks to break down fragmentations and silos in social and medical care to advance health equity,” Ogbolu said.

Ogbolu is the principal investigator on this grant, joined by co-investigators Shannon K. Idzik, DNP ’10, MS ’03, CRNP, FAANP, FAAN, UMSON associate professor and associate dean for the Doctor of Nursing Practice program; Kelly Doran, PhD ’11, MS ’08, RN, UMSON associate professor; and Charles C. Hong, MD, PhD, the Dr. Melvin Sharoky Professor of Medicine, director of cardiology research, and co-chief of cardiovascular medicine at the University of Maryland School of Medicine.

The project’s key objectives include establishing the collaborative using nurse-managed health centers, leveraging mobile health care, and enhancing care coordination through a community health worker model to decrease the number of patients with uncontrolled hypertension and to increase participation in social support groups. Specifically, the project seeks to:

• Reduce health disparities
• Improve health outcomes
• Increase access to primary care
• Promote primary and secondary preventive services
• Reduce costs and hospital admissions and readmissions

The RICH Collaborative is a multi-sector partnership across multiple community- and faith-based organizations, academia, and hospitals and hospital-related entities in Baltimore. Partner organizations working together to achieve the collaborative’s goals include:

• A Better Tomorrow Starts Today counseling agency
• Ascension St. Agnes Hospital
• Bon Secours Community Works
• Coppin State University Helene Fuld School of Nursing
• Druid Heights Community Development Corp.
• Lifebridge Health Grace Medical Center
• LIGHT Health & Wellness
• Ministers’ Conference Empowerment Center
• University of Maryland Medical Center (UMMC) Downtown and Midtown campuses
• University of Maryland School of Medicine Department of Cardiology
• University of Maryland School of Nursing
• University of Maryland, Baltimore (UMB) Community Engagement Center
• Two federally qualified health centers: Total Health Care and Chase Brexton

The organizations were selected based on opportunities to synergize and expand efforts to provide care and services to West Baltimore residents. “These organizations are passionate about their community and health equity, and we are set to start on a journey to collectively expand efforts to reduce cardiovascular disparities and social isolation in West Baltimore,” Ogbolu said.

Dana D. Farrakhan, DrPH, MHS, FACHE, senior vice president of strategy, community, and business development at UMMC, said the RICH Collaborative is critical in assisting West Baltimore’s health challenges.

“We are thrilled to be part of this grant that will help support our patients and community members after receiving inpatient care, by providing much-needed social and wellness support to address their multiple chronic conditions,” she said. “As an anchor institution, we seek to achieve health equity in West Baltimore with our partners and supporting our community members to achieve their highest quality of life.”

“Heart disease, the No. 1 cause of death worldwide, is a major driver of health disparities in America, but so much of it is preventable,” Hong added. “Social determinants of health play a huge role in defining how long and how well we live. Through this extraordinary multidisciplinary effort, we aim to improve the lives of our community by addressing specific barriers to health, such as social isolation felt by many in our neighborhoods.”

The RICH Collaborative will be implemented within ZIP codes 21201, 21217, 21223, and 21229, selected due to substantial racial inequities in cardiovascular health outcomes and social determinants of health. These communities have a rich and diverse history with strong and resilient people and community organizations that can resolve challenges if provided with appropriate resources and support, Ogbolu said. Evidence shows a significantly lower life expectancy for residents in West Baltimore neighborhoods when compared to wealthier communities, such as Roland Park, just a few miles away.

Beyond other social determinants of health, including unemployment and lack of access to transportation and technology, evidence shows that a lack of social connections also degrades cardiac health. While social isolation received increased attention during the pandemic, research shows that it had become a way of life in many marginalized communities, such as West Baltimore, even before the pandemic. Research has shown that social isolation is as dangerous as smoking and increases risk of cardiovascular challenges, including heart attacks and/or coronary artery disease, especially for middle-aged adults.

There is now compelling evidence suggesting that with effective, multidisciplinary, team-based, and culturally competent approaches, hypertension and disparities in cardiovascular outcomes can be reduced. Key interventions to be employed in the West Baltimore RICH Collaborative include:

• Addressing the social factors that impede health by linking individuals to social resources and a primary care physician
• Improving access to care through nurse-led clinics and mobile health services
• Leveraging expert community outreach workers to work closely with individuals to navigate needed health and social services

UMB, which is the home to UMSON, is anchored in the west side of Baltimore, along with the University of Maryland Medical Center. Both organizations are engaged as community partners to provide programs, services, support, training, and activities to advance the empowerment of their neighbors while strengthening the neighborhoods of West Baltimore.