Meeting People Where They Are

One of the patients who sticks in the memory of Erica Spatz, MD, MHS, was a young father. On the surface, he had many of the characteristics associated with good health: a full-time job, steady income, health insurance, and a primary care provider. But beneath the surface, his dangerously high blood pressure went unchecked.

As is true for many in his situation, he found it difficult to take time away from family care and work to attend to multiple doctor visits, so he missed appointments with his primary care provider. The first time he landed in the hospital was for severe congestive heart failure; the second was for a massive stroke.

“This case got to me,” says Spatz, associate professor of cardiology and epidemiology at Yale School of Medicine (YSM). “Our approach to blood pressure management worked against him. Routine visits, missed work—all of it came at the expense of his time.”

According to the Centers for Disease Control and Prevention (CDC), nearly half of adults in the United States have high blood pressure, or hypertension, but only one in four has it under control. Rates of high blood pressure or hypertension have climbed steadily worldwide over the past two decades, fueled by a mix of sedentary lifestyles, diets high in processed foods, rising obesity, and high stress levels.

Left untreated, hypertension significantly increases the risk of heart attack, stroke, brain aneurysms, kidney failure, clogged arteries, and even dementia. “Regular screening is essential,” says Spatz. “So is moving beyond hospital walls and into the community.”

Community-based interventions have emerged as a powerful tool in the fight against hypertension. Health intervention programs rooted in trusted settings—churches, barbershops, and community centers—have been shown to improve blood pressure significantly, particularly in under-resourced populations. Promising outcomes from such programs have reinforced the urgency of the work that Spatz and her team at YSM focus on—eliminating disparities in blood pressure management through their Patient-Centered Outcomes Research Institute (PCORI) study called Pressure Check.

Spatz and her team started monitoring patients’ blood pressure remotely in 2018. The idea was to make appointments low-burden and focused on blood pressure in order to keep patients engaged over time. In just three months, Spatz and her colleagues observed that for many of their patients, blood pressure had come under control.

“Our patients loved this model of care because they felt like finally somebody was talking to them about the pills they were taking every day and addressing their concerns,” Spatz says. In 2023, the team took this model of care and moved it into the community, dubbing it Pressure Check.

Pressure Check presently spans four cities—Boston, Mass.; Norfolk, Va.; Houston, Texas; and New Haven, Conn.—each anchored by a major health system, and partnered with 10 community organizations ranging from churches and barbershops to pharmacies and neighborhood health centers. Each site runs regular screening events; once screened, individuals are enrolled in one of three treatment arms.

The first arm mirrors usual care with screenings, education, and referral back to a primary provider. The second delivers telehealth management with pharmacists and nurses who adjust medications remotely. The third combines the medical approach with community health worker support, addressing social factors—like food, housing, or transportation—that so often stand in the way of blood pressure treatment. “It’s really about testing the whole model of health care—not just the medicine, but the social support of it too,” Spatz says.

By building trust in community spaces, the program is reaching people who’ve avoided clinical settings for years. “There are people who don’t come in for care because they’re afraid of what we might find, or they don’t trust us, or they’ve had bad experiences,” Spatz says. At a Black fraternity alumni event held at a church, one man with high blood pressure who had resisted care for years finally agreed to try the Pressure Check model after health advocates connected with him. His blood pressure is now within a healthy range, and he has become an advocate spreading the word about Pressure Check. Spatz says many similar stories are emerging from the community screenings.

The program’s success is expanding beyond the study itself. Yale New Haven Health is launching a system-wide remote patient monitoring program for hypertension, diabetes, and heart failure based on Pressure Check’s model. The approach represents a fundamental shift—rather than waiting for patients to navigate their way into overcrowded clinics, the health care system is meeting them where they already are.

Not long after Pressure Check launched, Walter Kernan, MD, professor emeritus of medicine (general medicine) at YSM, and his colleagues reached out to Spatz. Their goal was to enable communities to provide evidence-based preventive brain and heart care to all their residents, starting with hypertension. The broader aim was to supplement the health system’s opportunistic method of prevention—which depends on an encounter with a health professional—with a more systematic approach that attempts to reach everyone proactively.

Kernan, along with Kevin Sheth, MD, professor of neurology and neurosurgery at YSM, regularly encountered young patients with devastating strokes and heart disease caused by unmanaged cardiovascular risks. “Both of us recognized that prevention holds huge opportunities to improve population health,” Kernan says. “Our current health system is simply not designed to bring standard high-quality preventive care to all adults who need it.”

Determined to achieve change, Kernan and Sheth aimed to create a model to improve health outcomes that could be easily disseminated and adopted by any community. Early in their work, they met with leaders in Derby, a city of around 12,000 people located in southwestern Connecticut. Derby’s population offered the ideal scale and diversity to develop and test an effective preventive strategy before broader implementation.

“The city of Derby recognized that unmanaged cardiovascular risk is a problem among its citizens,” Kernan says. “And they were willing to work with us.” That kicked off the project, dubbed PROSPER.

The group of physicians at YSM—including Kernan, Sheth, Spatz, Rachel Forman, MD, Daniel Sarpong, PhD, and others from the departments of neurology, sociology, and biostatistics—teamed up with Beth Comerford, MS (co-director of the Yale-Griffin Prevention Research Center); Todd Liu (executive vice president and chief operating officer of Griffin Health); and the city of Derby (current mayor Joseph DiMartino).

PROSPER has three core features. The first is engaging members of a community for hypertension awareness and diagnosis using marketing, sociology, and behavioral economics. The second draws on findings from highly developed health systems whose thorough patient registration and support, goal setting, and performance monitoring have resulted in markedly improved rates of hypertension control. “We want to bring this technology to bear on patients where they live and work,” Kernan says.

The third feature is rigorous assessment. PROSPER will rely on the American Heart Association’s stringent criteria to evaluate hypertension in enrolled participants by taking multiple blood pressure measurements rather than relying on a single reading, as blood pressure fluctuates throughout the day. Griffin Health, a hospital in Derby, has been one of the strongest collaborators in PROSPER. “It’s important for institutions deeply rooted in the community to partner with larger, more impactful organizations for better outreach,” says Liu.

The vision extends beyond Derby, Kernan says. If proven effective, a nonprofit structure would enable other cities to replicate the model, providing the necessary database, administrative roadmap, and tools to launch their own community-based hypertension programs. “Right now, PROSPER is a concept that needs to be proved,” says Kernan. “We’re in the early steps, but what we’re doing is based on an unequivocally important social need.”

That same urgency is driving another experiment at Yale in accessibility—one that puts the pharmacy itself on wheels.

In a parking lot in Waterbury, Conn., stands a 38-foot-long van painted with the words “Healthcare for Everyone.” Inside, its shelves are stocked with more than 400 classes of medications, including blood pressure pills, insulin, HIV prevention drugs, antibiotics, and vaccines. There’s a working pharmacy counter, a private exam room, and a clinician ready to see patients. Outside, community health workers fan out into nearby neighborhoods, offering blood pressure checks, glucose screenings, and quick HIV tests on the spot.

“We call it a mobile hub-and-spoke health care system,” says Sandra Ann Springer, MD, professor of medicine (infectious diseases) at YSM, who leads InMOTION, the first legal mobile retail pharmacy clinic in the United States.

Since its launch in late 2023, the unit has reached over 1,000 people across Connecticut. About half of them are unhoused, and many are uninsured. Most would have faced steep barriers to accessing care due to long waits at clinics, unaffordable co-pays, or pharmacies that don’t stock what they need. For some, their visit was lifesaving—a blood pressure diagnosis that headed off a stroke, or a refill of insulin that kept diabetes from spiralling out of control, Springer says.

The mobile unit now also serves Bridgeport, Hartford, New Haven, and Norwich, collaborating with the offices of mayors who recognized gaps in health care access in their communities. The team works with local agencies and the state department of public health to determine locations and schedules, focusing on areas where residents face barriers to accessing traditional brick-and-mortar health care facilities.

“People don’t always realize how innovative this is,” says Cynthia Frank, PhD, MBA, director of Springer’s lab, which is known as InSTRIDE (Integrating Substance Use Treatment Research with Infectious Disease for Everyone). “We’re creating a new kind of mobile health care delivery system—one that brings together the clinician, the pharmacy, and the community health workers out on the street.”

Trust, time, and access were barriers also on the minds of Yale medical students Rushabh H. Doshi, Pavan Khosla, and Kanhai S. Amin. They took inspiration from Pressure Check when they observed what Spatz was doing in barbershops, and wondered whether churches could serve in the same way.

Their model, recently outlined in an essay for the CDC, centers on an idea that’s both simple and sustainable—to train youth within church communities to become health ambassadors for their own congregations. Older youth teach younger ones. Teenagers learn about chronic diseases like hypertension and diabetes, then set up blood pressure screenings at weekly services. As the teens graduate and move on, they pass their knowledge to the next generation, creating a self-perpetuating cycle of health advocacy.

“It’s one of those rare win-win-win situations,” says Doshi. The youth will aim to gain leadership skills and health literacy; in return, the congregation will get regular screenings and health conversations that reduce stigma around medical care.

The team partnered with churches in New Haven, working closely with youth ministries to develop educational materials and train volunteers. They connected with the American Heart Association and New Haven’s Health Department for resources and support. Their main goal was to give communities the tools to sustain the program themselves. “The people get the evidence-based guidelines in an easy-to-understand format, and then they can adapt it for their communities,” says Khosla.

The team envisions the model leading to youth empowerment around chronic disease prevention while also creating weekly health check-ins for church members. “I think health is often stigmatized in many communities all around America,” says Khosla. “This project serves as a blueprint showing that by going into the community and opening up conversations about health, you can really start making change in terms of health care access.”