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

Inclusion Criteria

• •1. 18 years of age as of date of data extraction,
• •2. Self-identify as non-Hispanic white, non-Hispanic Black/African American and/or Hispanic,
• •3. Diagnosis of Hypertension (HTN) defined by International Classification of Diseases, Tenth code (ICD-10 code) and elevated systolic blood pressure (SBP) measure (≥140 mm Hg) on their most recent clinic visit.
• •4. Diagnosis of diabetes or chronic kidney disease (both defined by ICD-10 code), in addition to HTN
• •5. Receives primary medical care at one of the participating health systems
• •6. Have a Maryland and D.C. home address