An Innovative Place-Based, Neighborhood-Level Approach to Address Health Disparities in Medically Underserved Areas of Memphis, TN.

Little data demonstrates the feasibility of place-based, neighborhood-level care delivered by health coaches in medically underserved neighborhoods to expand access to essential primary care and address health disparities. This concurrent mixed-methods pilot study describes experience with the innovative Neighborhood Health Hub Program in Memphis, TN. Patient characteristics, including body mass index (BMI), blood glucose, blood pressure, and service utilization, were assessed. Key informant interviews and community meetings were conducted in an initial community listening period to guide program development. Patient experience with program services was assessed using semi-structured client interviews. In year 1, 355 year-one clients were outreached, 146 (41.1%) through community events, 149 (42%) walk-ins, 38 (10.7%) door-to-door communication, 34 (9.6%) telephone, and 9 (2.5%) referral. Of the 198 (56.1%) fully screened, mean age was 52.0 (± 15.9) years, 94.5% were African American, 55.8% female, and 32.7% without a primary care provider. Baseline blood pressure was uncontrolled (≥ 140/90) in 52.3%, BMI was ≥ 30 in 50%, and random plasma glucose was high (≥ 130 mg/dl) in 23.4%. The majority (68.3%) participated in individual health coaching. Sixty-eight group sessions had an average of 4 participants (range 1-13) and were focused on chronic illness management (39.7%), exercise (26.5%), or nutrition (25.0%). Major qualitative themes highlighted the importance of social barriers and social support for chronic condition management. Place-based, neighborhood-level care delivered by health coaches in medically underserved neighborhoods is a promising approach for extending primary care, expanding access to essential preventive and primary care, reducing health disparities, and improving patient outcomes.