Community Health Hubs
Idea Category: 2025 Ideas Challenge, Improving Quality of Life
2025 Ideas Challenge Entry
Many communities face high rates of chronic conditions like obesity, diabetes, and hypertension, which contribute to cardiovascular disease (CVD)—a leading cause of death. Low-income and medically underserved neighborhoods often have limited access to preventive care, resulting in higher emergency care use and disproportionate CVD impact on residents of color. The ShelbyCares initiative is a partnership between the county government and University of Tennessee Health Science Center (UTHSC) as an adoption of their Neighborhood Health Hub (NHH) Model, an innovative, person-centered, place-based, neighborhood-level approach to bring essential health services
The ShelbyCares brings free, neighborhood-based health services directly to these communities, including health screening for CVD risk factors, health coaching, cooking classes, diabetes management, tobacco cessation support, and referrals to primary care as needed. . Partnering with a local university health center, the program provides:
- Health screenings for chronic diseases and CVD risk factors.
- Culturally relevant health coaching and education.
- Nutrition and fitness programs, tobacco cessation support, and referrals to primary care.
Hubs are staffed by trained, community-based health coaches and strategically located in high-need neighborhoods. This approach empowers residents, reduces barriers to care, and improves both quality and length of life.
Impact or how it will be measured:
To measure the impact of the ShelbyCares initiative, UTHSC evaluated implementation of the NHH model in two high-need ZIP codes, which have high rates of obesity, hypertension, diabetes, and poor access to preventive care.
Between January 2022 and February 2025, two NHH sites had 13,199 total visits and served 2,030 unique clients:
- 1,432 received screenings for obesity, diabetes, and hypertension.
- 1,579 engaged in individual or group health coaching (78% engagement rate).
- Health improvements included an 18% drop in blood glucose, a 10% reduction in systolic blood pressure, a 6% reduction in diastolic blood pressure, and modest weight loss among obese clients.
Most participants were Black (94%), over 50 (67%), and female (60%). Additionally, qualitative feedback indicates improved mental wellbeing and reduced social isolation
The impact of ShelbyCares, in partnership with UTHSC, is measured through detailed engagement metrics, clinical outcome tracking, and health system integration efforts. The initiative demonstrates strong potential to improve chronic disease outcomes, reduce emergency care reliance, and build a sustainable, scalable model for preventive care delivery in MUAs.
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