The Neighborhood Health Hub Model: Extending Primary Care into Medically Underserved Neighborhoods to Improve Health Equity

BACKGROUND: Limited research documents feasibility of deploying health coaches to extend primary care into medically underserved neighborhoods. AIM: To assess early experience implementing the Neighborhood Health Hub Model, an innovative, person-centered, place-based, neighborhood-level approach for providing convenient access to essential preventive services. SETTING: Memphis/Shelby County, Tennessee PARTICIPANTS: Adults seeking care from January 2022-June 2024 at Neighborhood Health Hub facilities. PROGRAM DESCRIPTION: Hubs are staffed by lay health coaches recruited from the community, trained in motivational interviewing, and supervised by a telehealth-connected health professional. Services include: 1) screening for obesity, hypertension, diabetes, and social determinants; 2) individual/group health coaching for chronic disease management; 3) referrals for medical, behavioral, and social needs. PROGRAM EVALUATION: A total of 1,252 clients were served, 1,151 received health coaching, and 383 (31%) participated in ≥ 2 coaching sessions, for a total of 3367 coaching sessions and 2,951 group visits. Average weight change with obesity was - 3.32 pounds (95% confidence interval [CI] - 5.72, - 0.92) and systolic blood pressure change with hypertension was - 15.17 mmHg (CI - 19.64, - 10.69). Higher number of health coaching sessions was significantly associated with greater weight loss. DISCUSSION: Dissemination of the Neighborhood Health Hub Model could improve health equity nationwide.