This grant builds on the success of the West Baltimore RICH Collaborative, an initiative supported by a $2.4 million Pathways for Health Equity Grant from MCHRC awarded two years ago. That effort focused on reducing social isolation and inequities in cardiovascular health in West Baltimore.

As with the original initiative, the new project, West Baltimore Reducing Inequities in Cardiovascular and Mental Health Collaborative-Stronger Together (RICH 2.0), in collaboration with community, faith-based, academic, and health care organizations aims to reduce cardiovascular health disparities, improve health outcomes, improve access to primary care, and reduce health care costs. This project extends into three additional ZIP codes in West Baltimore and expands beyond social isolation to other aspects of mental health.

The project is led by Yolanda Ogbolu, PhD ’11, MS ’05, BSN ’04, NNP, FNAP, FAAN, the Bill and Joanne Conway Dean of the University of Maryland School of Nursing, with support from Janette North-Kabore, MPH, and Asunta Johnson, MSHCM, project directors. 

Co-investigators on the project include: 

• Kelley Robinson PhD, CNM, CNE, assistant professor, UMSON
• William Mangana, DNP ’20, CRNP, FNP-C, assistant professor, UMSON
• Kelly Doran, PhD, RN, FAAN, associate professor and co-director, Biology and Behavior Across the Lifespan Organized Research Center, UMSON; director of health and wellness, University of Maryland, Baltimore (UMB) Community Engagement Center
• Abree Johnson, MS, MBA, director, pharmaceutical research computing, University of Maryland School of Pharmacy (UMSOP)
• Laundette Jones, PhD, MPH, associate professor, University of Maryland School of Medicine (UMSOM)
• Stacey Stephens, LCSW-C, clinical assistant professor, University of Maryland School of Social Work (UMSSW), director of B’More for Healthy Babies

“Collective power is needed to advance health equity and its impact on community health,” Ogbolu said. “The West Baltimore RICH Collaborative - Stronger Together not only aims to improve health outcomes but also demonstrates that multisectoral organizations can work together toward eliminating health disparities. I am proud to be partnering with trusted community organizations and health equity promoters that are committed to collaborating to improve cardiovascular and mental health and address the social determinants of health so that communities are stronger, safer, and healthier.”

The partner organizations composing West Baltimore RICH 2.0 include: 

• A Better Tomorrow Starts Today counseling agency
• American Heart Association
• Ascension Saint Agnes Hospital
• ATOSK Health Care Services, Inc.
• B’More for Healthy Babies
• The Community Builders, Inc.
• Coppin State University Helene Fuld School of Nursing
• Druid Heights Community Development Corporation
• LIGHT Health & Wellness Comprehensive Services, inc.
• Minister’s Conference Empowerment Center CDC
• Roberta’s House
• UMB Community Engagement Center
• UMSON
• UMSOP
• UMSSW
• UMSOM
• University of Maryland Medical Center (Downtown and Midtown)

West Baltimore RICH 2.0 will integrate activities and resources across these multiple organizations to improve mental (social isolation, stress, and anxiety) and cardiovascular outcomes and social determinants of health (SDOH), such as food, transportation, and economic security. Its goals are to reduce cardiovascular and mental health disparities, improve access to primary care, promote primary and secondary prevention services, and reduce health care costs for West Baltimore residents.

The program includes five strategic interventions:

1. a health equity collaborative
2. nurse-led clinics
3. self-monitored blood pressure programs and mobile health programs
4. primary and secondary events
5. a community outreach worker model to support and address social determinants of health.

Through the original West Baltimore RICH Collaborative, several UMSOM and UMSOP students worked with the initiative to gain skills and insight related to addressing SDOH barriers. Four community-based youth ambassadors were recruited to assist with community activities and learn about addressing complex community needs with wrap-around resources. 

Over the past 13 months, the West Baltimore RICH Collaborative and its partners have:

• engaged with 7,725 residents
• attended 546 mobile health events
• enrolled 2,001 participants into the program
• distributed 925 blood pressure cuffs
• established four nurse-led clinics at the UMB Community Engagement Center, Coppin State University, McCullough Homes public housing, and Family NP at Garwyn Medical Center
• provided health screenings to 1,124 participants, of whom 96% reported at least one SDOH need and received immediate resources.

Building on the success of the original project, West Baltimore RICH 2.0 will:

• expand partnerships with organizations to meet the need for mental health services and place-based care in senior housing facilities
• expand two mobile health programs for implementation in senior housing sites
• continue community outreach to address SDOH, with a central team at UMSON and additional support hired by and placed at partner sites
• maintain the nurse-led clinics
• measure community assets and strengths assessing perceptions of hope and their association with social isolation, mental distress, stress, and anxiety.

By the end of the five-year grant period in 2029, 4,000 additional individuals will have been served.