The model emerged from a stark arithmetic problem. University of Tennessee Health Science Center (UTHSC) researchers recognized that the number of primary care physicians available to serve Memphis’s medically underserved areas was simply insufficient, and that training and deploying enough physicians to meet the need was not feasible. At the same time, complications of obesity-associated chronic conditions — uncontrolled hypertension, diabetes, and their cardiovascular consequences — were identified by institutional and community leaders as a pressing public health emergency. In the target ZIP Codes, more than 50 percent of adult residents visit an emergency room one or more times per year, while fewer than 40 percent visit a primary care provider. The researchers concluded that if the system could not bring enough doctors to the neighborhood, it would have to bring the neighborhood into the care system — through a different kind of workforce.

That workforce is the community health worker, and specifically the health coach. Health coaches are typically members of the community who share similar ethnicity, cultural values, and lived experiences with the patients they serve, giving them a unique ability to provide culturally appropriate care. Extensive prior research, including the MODEL Study in Memphis and a New Mexico community health worker program that reduced emergency department and inpatient visits among high-need Medicaid enrollees, has demonstrated that these workers can improve control of multiple chronic illnesses. Yet few programs have systematically used community-based health coaches to deliver the Diabetes Prevention Program (DPP), diabetes self-management education (DSME), and other essential population health services, and pragmatic approaches for linking community-based self-management services with primary care — a connection envisioned by the Chronic Care Model — have remained largely lacking. The Neighborhood Health Hub Model was designed to fill precisely this gap in implementation science.

Technically, the model rests on three conceptual pillars. First, the Chronic Care Model provides a real-world framework for linking community-based self-management support with primary care, positioning hubs as a constituent part of primary care rather than a parallel outreach effort. Second, the social-ecological model recognizes that the social determinants embedded in neighborhood contexts — transportation, food access, economic stability — contribute most to human health and must be addressed directly. Third, the World Health Organization’s definition of health systems frames each neighborhood as embedded within a larger health system context, meaning hubs must coordinate bidirectionally with clinics, hospitals, and social services. The design also draws on evidence that neighborhood availability of primary care strongly predicts realized access, that is, actual primary care utilization. In line with Starfield’s four core domains of high-performing primary care, the hubs provide an accessible point of first contact, assist coordination through referrals, support continuity by encouraging follow-up with a regular provider, and contribute to comprehensiveness by delivering chronic condition screening and self-management services.

Hub placement was itself a technical exercise. The program used geographic information system (GIS) analysis to identify Memphis and Shelby County neighborhood locations with the highest prevalence of adult hypertension and adverse social determinants of health, the highest population density, and available public transportation, situated near partnering primary care providers and community health centers. Implementation began on January 1, 2022 with the opening of the UTHSC Health Hub–Uptown in North Memphis, followed by ShelbyCares on Third Health Hub in South Memphis in May 2023 and the Soulsville hub in January 2025. Practice collaboration agreements with a multisite community health center and a large safety-net provider established bidirectional referral pathways. Before full implementation, surveys and listening events in the target population demonstrated high levels of interest in personal health coaching and DSME services, and patients were engaged through community meetings, health fairs, flyers, media, and referrals from health systems and social service organizations.

Each hub is fully staffed by lay health coaches recruited from the community, trained and certified in motivational interviewing (MI)-based health coaching, and supervised by a telehealth-connected health professional affiliated with the university medical group. Motivational interviewing is a structured conversational technique that promotes engagement and behavioral change by eliciting the client’s own motivations rather than imposing advice. Services include screening for obesity, hypertension, diabetes, and social determinants of health; individual and group coaching sessions covering DPP, DSME, and chronic disease management; and referrals to primary and specialty care, behavioral health, and social services. Hubs also host cooking and fitness classes, health fairs, and community outreach activities, with coaches supporting weight loss, blood pressure control, glycemic control, and heart health by encouraging healthy eating, physical activity, medication adherence, and tobacco cessation. Crucially, hubs are designed to serve as primary healthcare providers of billable preventive services, distinguishing them from traditional community health education collaborations.

The evaluation data reveal both the reach and the engagement challenge of the model. From January 2022 through June 2024, 1,252 unique clients were served, of whom 1,151 received at least one individual health coaching session and 383 — 31 percent — received two or more, generating 2,216 follow-up sessions and an average of 5.8 sessions per engaged client. A total of 2,951 group sessions were attended by 513 clients, an average of 5.7 sessions per participant, with group activities featuring fitness (49.3 percent), diabetes education (20.3 percent), nutrition and cooking classes (18.7 percent), chronic disease management (7.4 percent), and tobacco cessation (2.6 percent). Among clients served, 733 — 58.5 percent — were screened for obesity, hypertension, and diabetes. Most clients were Black/African American (91.9 percent), female (62.7 percent), and uninsured (46.4 percent), with a mean age of 60.4 years. On intake, 29 percent reported not having a primary care provider, 58.7 percent met criteria for obesity, 52.8 percent for uncontrolled hypertension, and 33.8 percent for elevated blood sugar. No adverse events were reported.

The pre-post clinical outcomes are the headline finding. Among clients with obesity who completed at least one follow-up visit, average weight change was −3.32 pounds (95 percent confidence interval −5.72 to −0.92), and among those with overweight or obesity it was −2.82 pounds. Clients with elevated baseline systolic blood pressure of 140/90 mmHg or higher achieved an average systolic reduction of −15.17 mmHg (CI −19.64 to −10.69), with diastolic pressure falling by −7.05 mmHg among those with elevated diastolic values. Clients with baseline random blood glucose of 125 mg/dl or higher saw an average reduction of −40.04 mg/dl. Linear regression models demonstrated a statistically significant association between the number of health coaching visits and weight loss, with more visits linked to greater weight reduction. Notably, weight loss was achieved through an intentional emphasis of food as medicine for all clients, not limited to formal DPP participants, and improvements were not confined to any single program track.

Outcomes varied across hub locations, and the variation itself carries technical insight. Clients at the ShelbyCares on Third hub — the largest location — achieved greater weight loss than those at Uptown, likely due to stronger adherence to motivational interviewing–based coaching and greater availability of group exercise opportunities that fostered social support. The researchers’ previous work identified social support and trust of culturally congruent health coaches as key drivers of engagement, retention, and goal attainment, and the largest hub achieved higher attendance and group participation. Engagement pathways mattered enormously: clients recruited through general community events had very low follow-up rates, whereas those referred by a friend or specifically referred for health coaching by their primary care provider had the highest follow-up rates, consistent with prior literature showing higher engagement when preventive services are recommended by physicians. These findings highlight group-based health activities and integration into the traditional healthcare delivery system as essential components of the model’s effectiveness.

The study’s limitations are acknowledged candidly: the pre-post design is subject to selection bias, confounding, and other threats to internal validity, limiting causal inference, and the model’s unique Memphis setting limits broad generalizability, particularly to younger adults, who were largely absent from the client base. Nevertheless, positive patient experience, substantial targeted clinical improvements, and the strong dose-response association between coaching exposure and weight loss support intervention effectiveness. The economics are equally compelling. High rates of insurance coverage among clients, positive clinical changes, and low operational costs suggest potential for long-term sustainability through fee-for-service reimbursement and value-based payment. All UTHSC hub locations now use the Epic electronic health record to facilitate insurance billing, and negotiations with Tennessee Medicaid managed care organizations produced common reimbursement guidelines for services delivered by health coaches supervised by an approved billing provider, aligned with Medicare guidelines. Planned federal cuts to Medicaid could threaten this sustainability, and policy changes are needed to raise reimbursement for DPP and DSME services to sustainable levels. Program leaders are now working with health plans, regional health systems, and community health centers to expand locations and promote referrals from emergency departments, hospitals, and clinics for all individuals with obesity, uncontrolled hypertension, and uncontrolled diabetes. If the model scales, it could use health coaches to dramatically expand access to essential population health services for those with the greatest need, achieve major cost savings, and help Medicaid programs cut costs while improving outcomes — a potentially transformative prescription for the neighborhoods the American health system has long left behind.

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

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

Article References: Bailey, J. E., Ogunsanmi, D. O., Mahmud, S., Kabir, U. Y., Boykins, A. M., Butterworth, S. W., Mahmood, A., Hayes, B. L., Ozdenerol, E., Ballenger, F. M., & Surbhi, S. (2026). The Neighborhood Health Hub Model: Extending Primary Care into Medically Underserved Neighborhoods to Improve Health Equity. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10764-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10764-1

Keywords: Neighborhood, Health, Model, Extending, Primary, Care, Medically, Underserved, Neighborhoods, Improve, Equity, scientific research