Revolutionizing & Revitalizing Community Care: The MOMENTUM Hub 

​There is a significant opportunity to rethink, re-engineer, and ultimately redefine how North Nashville accesses essential services by moving beyond fragmented support toward a unified, community-led ecosystem designed specifically to address the upstream social drivers of health. The MOMENTUM Hub (Mobilizing Opportunity and Means for Economic, Neighborhood, and Thriving Unity, and Motivation) represents this shift, serving as a network "one-stop shops" designed to streamline access to health, housing, and economic opportunities.
 

The MOMENTUM Hub system alignment intervention builds on the strategic priorities developed by the Accelerated Accountable Strategic Sustainable Equity-centered Transformation (ASSET) Initiative and its multi-sector Board of Advisory Stewards. ASSET, like the MOMENTUM Hub, was also funded by the Systems Alignment Innovation Hub through funding from the Robert Wood Johnson Foundation's Systems for Action National Coordination Center. 
 

Establishing Research Foundations through Community Priorities: Futuring, Equity, and Trust
 

The MOMENTUM Hub maintains a fundamental commitment to the community, informed by the historical and contemporary experiences of North Nashville residents and supported by rigorous evaluative processes. To ensure sustained guiding community engagement and organizational accountability, the multi-sector Board of Advisory Stewards from the ASSET Initiative has been formally integrated into the Hub's governance structure.

 

Chris Callaway, a member of the Board of Advisory Stewards representing the Parkwood Neighborhood Association, noted that effective solutions must simultaneously address immediate crises and strategic future development, stating that initiatives must be sufficient "to stop the bleeding where [we] are now" while [proactively} "harness[ing] the future".

 

Testimonials from a diverse cohort of community stakeholders highlight the futuring, equity and trustbuilding underway through the MOMENTUM Hub. see below

 

The hub, community-driven,  also integrates a community-academic partnership between Community ConneXor and the Vanderbilt University School of Nursing with co-leads representing the community and research.  Research Lead James Muchira, PhD, emphasizes that the project focuses on how addressing social drivers—such as housing and economic stability—can directly improve health outcomes, particularly for those living with cardiovascular disease. "What makes MOMENTUM Hub especially promising is that the research is grounded in community priorities through co-design and shared governance," Dr. Muchira's notes. "We have an opportunity to generate evidence for a scalable model that strengthens connections between healthcare and community-based organizations while advancing health equity."  

 

From Fragmentation to "Unencumbered" Flow

The necessity for this model is underscored by decades of historical and persistent structural barriers facing the community. North Nashville, TN, a historically Black and under-resourced community, continues to experience longstanding structural inequities driven by discriminatory past policies, including redlining, disinvestment, and infrastructure decisions such as the construction of Interstate 40, which fractured social and economic networks and stripped generational wealth.

 

Today, residents face persistent disparities in poverty, chronic disease, and housing instability now fueled by the unprecedented growth of Nashville that is further aggravating the longstanding issues. Fragmented health, housing, food, and social service systems operate in silos, leading to inefficient referrals, weak accountability, and barriers to care that reproduce inequities. In this time of policy shifts, institutional instability, and declining trust, this project is designed to meet this moment by generating policy-relevant, actionable evidence to support the adoption and dissemination of a replicable community-governed, cross-sector care coordination model scaling the enabling technology of WellSky Community Services.  The community care  hub model shows promise for cross-sector service coordination, yet a critical gap persists: the lack of community-governed, accountable infrastructure to ensure residents receive the services they need in a timely and coordinated way.  The MOMENTUM Hub, the first installment in a community care hub model. 

 

The Hub addresses these "invisible" barriers through:

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• Unified Entry Points: Existing organizations elevated to “no wrong door”  community entry points with select standardized intake tools, processes, and metrics supported by shared enabling communication technology ensure residents like "Abbyh," a mother needing food assistance and job training, only have to share her story once. (MOMENTUM Hub Case Study)

• Real-Time Coordination: The enabling digital platform facilitates immediate referrals and ensures providers work together to track progress.

• Community Stewardship: Continuous performance improvement with a standing collaborative stewardship shared governance framework integrated into the Hub remains accountable to the neighborhood it serves
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The MOMENTUM Hub  infrastructure buildout is divided into three major periods,

 

• Hub 1.0: Focuses on CBO network development and establishing the enabling technology foundations for communication and coordination.

• Hub 2.0: Continues the focus on technology buildout and workflow refinements within the CBO network, adding a community facing dashboard, and exploring optimizing the integrated NPH Resource Directory and minimum integration points with health care payors. Continues the focus on technology buildout and workflow refinements within the CBO network, adding a community-facing dashboard, and exploring optimizing the integrated NPH Resource Directory..

• Hub 3.0: Expansion of  CBOs in the network, and pilot to connect the CBO network to healthcare providers.

 

To date, Hub 1.0 model co-design has included:

 

• Prototype co-design meetings held in 2025 with a group of twenty organizations primarily representing upstream SDOH service providers but including other sectors,  that identified critical priorities such as  multi-level trust, data privacy and security related to data sharing, measurement of longitudinal impact, and minimizing disruption to existing CBO workflows.

 

Community co-lead Vickie Harris described the above co-design sessions as non-negotiable work of refining the technology-enabled CBO network model  as mapping how to "meet the CBOs where they are and build out their capacity and capabilities to be an effective no wrong door point of entry."

 

• Individual meetings were held with six organizations expressing an interest in participating in the MOMEHUM Hub pilot, with technology-focused discovery sessions completed followed by tailored configurations and previews with feedback loops for each.

 

System infrastructure building milestones positioning for Hub 3.0 network Social Return on Investment (SROI) casemaking:

 

Standardization:

• One validated upstream SDOH screening across the network

• Adoption of the  USDA six-question food insecurity screening by food pantry sites
   

Systems Alignment

• Upstream SDOH domain metrics related to food insecurity, housing instability, and workforce and training  aligned with the 2026-2028 Metro Davidson County Community Health Improvement Plan, creating the throughline for future measuring of longitudinal impact at client, organization and network level that can inform the CHIP from the the client

• Network performance metrics aligned, in part, with TennCare (Tennessee Medicaid closed loop referral metrics)

• Integration of the Nashville Public Health Department’s Community Resource Directory into the Hub’s technology platform 

 

Five North Nashville Organizations  Leading Transformational Change

 

Five North Nashville community-based organizations, all indisputable community “assets” in the area of upstream social service delivery, representing multiple upstream SDOH domains (not just one), have signed on to participate in the MOMENTUM Hub pilot that kicked off May 1st. 

 

• Black Mental Health Village

• Healing Minds and Souls

• Inspiritus

• Pathways Kitchen

• Rebuilding Together Nashville

 

A Blueprint for the Future

This ASSET  initiative’s MOMENTUM Hub  is more than a service delivery project; it is a foundational step toward a resilient future. As Katina Beard, CEO of Matthew Walker Community Health Center, observed during the ASSET Initiative’s strategic planning phases that led to the MOMENTUM Hub, "North Nashville has everything it needs". The MOMENTUM Hub simply provides the infrastructure to harness those existing strengths.

 

Community co-lead and Community ConneXor CEO, Vickie Harris, aligns with Beard’s assessment but highlights the intricate challenge of re-engineering how we leverage local strengths. She notes that existing assets were often designed to address singular upstream social drivers, even though residents navigate the complex intersection of multiple social needs. Harris explains that this restructuring must confront entrenched power dynamics and traditional funding mechanisms that often preserve the status quo. To ensure both fidelity and long-term sustainability, she emphasizes that a commitment to continuous performance improvement must be hardwired into the MOMENTUM Hub’s architecture. This collaborative stewardship ensures all stakeholders remain collectively accountable to the community's evolving needs, using the Aligning Sectors for Health framework  as a vital guide along with a Five (5) Whys tool as cornerstones to prevent a return to fragmented service delivery.  

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About Community ConneXor

Community ConneXor is a North Nashville-based organization focused on building equity-centered systems and solutions that empower residents and dismantle the barriers that have long limited access to opportunity, health and well-being. Established in 2012, the mission of the organization is to serve communities by delivering innovative sustainable solutions that connect, improve and transform how social and health care agencies together deliver holistic, person-centric care and services.  Community ConneXor leverages a digital platform and strategic partnerships for collaboration, access, and activation—bridging gaps in health, education, workforce, housing, and social support by aligning civic, nonprofit, and private sector stakeholders around shared goals to strengthen local ecosystems to drive equitable outcomes, sustainable community health improvement and coordinated impact. Learn more at www.CommunityConneXor.org or contact Vickie W. Harris @ vharris@communityconnexor.com. 
 

About Vanderbilt School of Nursing 

Founded in 1908, Vanderbilt University School of Nursing (VUSN) is a nationally recognized leader in nursing education, research, and practice. As part of Vanderbilt University, a private R1 research institution located in Nashville, Tennessee, VUSN offers a range of graduate-level programs, including the Master of Nursing (MN), Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), and PhD in Nursing Science. The school is committed to advancing health equity and well-being through scientific discovery, innovation, evidence-based care, and lifelong learning. For more information, visit nursing.vanderbilt.edu or contact Dr. James Muchira @james.muchira@vanderbilt.edu