Smoketown Family Wellness Center

What would you do with an extra 10 years to live?

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Founding Story: Share a story about a key experience or spark that helps the network understand why this project got started or a story about how you became inspired about the potential for this project to succeed.

As a pediatrician, I hear many questions from parents. Questions about sleep, tantrums, friends, safety, nutrition, learning, discipline, behavior. There is an innate understanding that children need more than their vaccines to be healthy. All parents have hopes and dreams for their child. The role of pediatrician provides a wonderful perspective to partner with parents to allow them to reach their own potential to be the best parent they can and want to be. Our model will bring those dreams into reach for families that might not otherwise have the resources that they need to raise healthy children. The concept for the Center began to take shape while working with the Louisville Metro Department of Health and Wellness to create a community health improvement plan as part of the Healthy Louisville 2020 initiative. Rather than try to manage disease or to change bad habits, we need to look upstream to establish good habits from the beginning of life, to make healthy choices not only available, but easy and to empower parents with the tools they need to raise their children to be healthy in mind, body and spirit.

Which categories describe you? (the answer will not be public)

  • White (for example: German, Irish, English, Italian, Polish, French, Caucasian)

If you chose to self-identify your race, ethnicity, or origin, please share here: (the answer will not be public)


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Location: Where is your organization headquartered? [State]

  • Kentucky

Location: Where is your organization headquartered? [City]


Location: Where is your project primarily creating impact? [State]

  • Kentucky

Location: Where is your project primarily creating impact? [City]


Problem: What problem is this project trying to address?

The US spent $3 trillion on healthcare in 2014, 75% on the management of chronic disease. Yet our health outcomes remain below average. Smoketown has the highest rate of death attributed to poverty in the city. Six in ten children live in poverty, growing up without enough basic resources, decreasing their chances to succeed in school and increasing the chances of developing chronic conditions. Children in Smoketown have limited access to a wide range of resources as basic as education, food, and safety. Our model will move care upstream to provide primary prevention of chronic diseases that begin in childhood. Our goal is to create a healthcare system that works to maintain wellness instead of manage disease.

The Smoketown Family Wellness Center (SFWC) has a dream that every child will grow up healthy, living up to their potential regardless of the neighborhood where they live. Smoketown has the highest rate of death attributed to poverty in our city. Six in ten children live in poverty, growing up without basic resources, decreasing their chance to succeed in school and increasing the chance of developing chronic conditions.

The SFWC model of healthcare delivery will move care upstream to provide primary prevention of diseases that begin in childhood. We will empower parents with the tools they need to raise their children to be healthy in mind, body and spirit. In this way, they become health experts themselves, spreading their knowledge to family, friends and neighbors to create a culture of health and wellness.

Services will include:

  • Well Care

SWFC’s well care services will include comprehensive pediatric care.  SFWC will offer group well visits that will enable parents and children to act as support systems for other parents and children as they face challenges.  Hours will be flexible based on the need in the community.

  • Sick Care

SFWC will offer same day sick visits as well as access for medical advice by phone. On-call services will be provided 24 hours a day, seven days a week.   SFWC will also provide diagnosis as well as ongoing management of asthma and ADHD.

  • Family Coaching

A “Family Coach” will be vital to SFWC and will meet with each family with strengths-based approach.  The Family Coach will be a trained, licensed social worker who will evaluate the status of each family: housing, food security, physical health and safety, Adverse Childhood Experiences (ACEs), and mental health disease. They will be a vital part of the team to maintain health and wellness in our community. Rather than waiting to connect with families once there is a problem, the coach will work with families routinely to help establish good habits and to promote the importance of social determinants as vital to our health. This service will normalize the inclusion of social determinants of health and healthy lifestyles in maintaining wellness. Families will be supported in navigating the rough spots in day to day living and parenting. 

  • Parent coaching and support groups

Parenting classes will provide a basic understanding of child development to guide caregivers to develop a positive, responsive relationship to promote wellbeing and to protect against the effects of toxic stress. They will be offered for each age group.

  • Mental Health Services

SFWC will partner with skilled mental health providers to provide step up care when necessary. As the Center grows, these services will be offered on site.

  • Healthy Eating

All SFWC team members will have a working knowledge of the benefits of healthy eating. We will partner with the Department of Public Health and Wellness, WIC, and local food organizations to provide resources. We anticipate having a Fresh Stop (a fresh local food pop-up) within the Center to provide fresh food access. SFWC will be built around a teaching kitchen, focusing on simple, fast food preparation and encouraging the family meal as an important factor in raising healthy, successful children. 

  • Active Living

In addition to encouraging active play and lifestyles, SFWC will partner with exercise coaches and facilitators to offer a variety of classes to families based on the interests of the community. Partners include the YMCA, Heuser Health, Hope by Hope Performance LLC and independent teachers.

  • Financial Literacy

Finances are an important part of life. SFWC will offer financial empowerment classes through certification from Louisville Metro Department of Community Resources and The Center for Nonprofit Excellence’s Community Financial Empowerment certification.

  • Family Literacy

Education and health are closely tied. Supporting parents to promote literacy across a lifetime is an important part of health.  SFWC support the city’s cradle to career education path. Providing access to books will help prepare children for school and provide important resources for parenting and health. SFWC will begin with its own Little Free Library and partner with the Louisville Free Public Library to promote further opportunities for literacy.

  • Stress Management

Managing stress is a vital part of wellbeing. SFWC will partner with existing programs of mindfulness, exercise, music therapy and other modalities for both children and adults. Developing social emotional intelligence will be a focus. Stress management will be modeled by SFWC staff in day to day encounters with children, families and other staff.

  • Dental Education

Partner with local Pediatric Dental providers to provide dental education. Good dental hygiene will be taught and fluoride varnishes will be applied as a part of routine care.

  • Smoking Cessation

SFWC will partner with the Department for Public Health and Wellness to provide smoking cessation through the evidence-based Cooper Clayton method.

  • Tracking results

The nation is looking for new models of healthcare delivery. By providing integrated primary prevention and healthy lifestyle support in a community-based setting, SFWC will deliver measurable results and serve as a replicable model for healthcare in other neighborhoods.  Research will track not only traditional health outcomes such as vaccination rates, emergency department visits and successful management of asthma and attention deficit disorder, but also educational and socio-economic outcomes. Outcomes will help guide shifting insurance reimbursement to value-based care.

Is your model focused on any of the following traditionally underserved communities?

  • Communities of color
  • Low-income communities

Does your model work within any of the following sectors?

  • Child and Family Services
  • Community Development and Empowerment
  • Education
  • Mental Health
  • Other

If you chose "other," please share the sector you work within here:

Children's Health Care

Year Founded


Project Stage

  • Idea (poised to launch)

Example: Walk the network through a specific example of what happens when a person or group engages with your solution.

From the minute you walk into our center, you will see the difference. You enter into a large community room that can be used for fitness, parenting or financial literacy classes, after school tutoring or a fresh stop market. There is a kitchen that can be used for kids cafe or cooking classes for the family, a little library to support literacy and success in school. The medical exam rooms are tucked away in the back. Collaboration is vital to this project. Based on the needs of the families, we will partner with existing organizations, bringing them together to build upon the success of each, weaving the fabric of a healthy community.

Impact: What was the impact of your work last year? Please also describe the projected future impact for the coming years.

Our Center is currently in the visioning and planning stages. As a new model for healthcare delivery, outcomes are vital for the success of the project. With the understanding of what makes up health: physical environment, clinical care, lifestyles and socio-economic factors, we need models to address all components to improve health outcomes. We will collect traditional health metrics such as vaccination rates, ED visits, asthma management, BMI, and screening for ACEs. We will look at educational outcomes such as kindergarden readiness, suspensions, reading and math scores, graduation rates. Socioeconomic outcomes will include income, safety, incarceration, housing and employment. Our model provides true primary prevention to establish health in families that will ultimately improve the health of individuals and create a culture of health. Our model is scalable to other communities.

Organization Type

  • nonprofit/NGO/citizen sector

Annual Budget

  • $500k - $1m

Financial Sustainability Plan: What is your solution’s plan to ensure financial sustainability?

Reimbursements from Medicaid and private insurance will cover medical services. We are seeking funding for facility renovation and the remainder of operating expenses. As data proves the impact of integrating clinical care with healthy lifestyle support, we hope for improved reimbursement for these expanded services. The return on investment in improved health and decreased spending on chronic disease management will change health care delivery.

Unique Value Proposition: How else is this problem being addressed? Are there other organizations working in the same field, and how does your project differ from these other approaches?

Many organizations focus on a single area of need, yet multi-prong approaches expand the reach. Lifestyle practice has found a niche, generally targeting individuals with diabetes or heart disease. While effective, we need to look upstream, to invest in the primary prevention of chronic diseases that begin in childhood - with lifestyles, exposure to adverse childhood experiences (ACEs) and socio-economic factors. SFWC will incorporate all aspects of health into the community-based setting, addressing clinical care, healthy lifestyles and social determinants of health.

Reflect on the Field and its Future: Stepping outside of your project, what do you see as the most important or promising shifts that can advance children’s wellbeing?

Recognition of adverse childhood experiences as the root of not only mental and behavioral health problems but also heart disease, cancer and diabetes. By identifying and addressing these pervasive problems, we will make a significant improvement in mental and physical health of individuals and communities. There is a recognition that one size does not fit all - for learning, discipline, health or families. When parents, teachers, health care providers team together to support a child and allow for individualization, many more children can be successful in their own right.

Source: How did you hear about the Children’s Wellbeing Challenge? (the answer will not be public)

  • Email

Referral: If you discovered the Challenge thanks to an organization or person other than Ashoka, who was it? (the answer will not be public)

RWJF newsletter

Program Design Clarity

Smoketown is Louisville’s first African American neighborhood. Once a thriving community, it now suffers from years of poverty, unemployment and crime. Health issues remain a problem. Six in ten children start kindergarten not ready to learn, decreasing their chance to succeed in school and beyond. We will provide medical services, family coaching, improve access to healthy foods, exercise and health education, as well as to connect children with someone to believe in them. The staff, community partners and community members will deliver services in the heart of the neighborhood.

Community Leadership

Our Community Advisory Board meets monthly as we create the vision and to guide the services that will be offered once we open our doors. Their participation is vital to the success of the Center. The Family Coaching model will allow for families to identify their own needs and guide their path to wellbeing and ultimately become leaders in building a culture of health. This is a dynamic model and we hope to build upon community voices as we grow.

Age of Children Impacted

  • Pregnancy - 0
  • 0-1.5
  • 1.5 -3
  • 3 - 5
  • 6 - 12
  • 12+

Spread Strategies

Our vision is to empower parents to raise children who are healthy in mind, body and spirit. By assembling resources, families are surrounded by community support to create a culture of wellness. The family becomes the expert and the change agent. We offer an innovative solution to improve wellness that is resonating with like-minded organizations, is strengthened by partnership and is scalable to communities locally and nationally.

Reflect on how your work helps children to thrive. How are you cultivating children’s sense of self, belonging, and purpose through your model?

Starting at birth to provide families with support will create a strong foundation for children’s sense of value. Supportive relationships with adults will provide a stable footing for growth. A multi-generational and cross-sectional approach will create a sense of worth and belonging in their community. By establishing healthy lifestyles early in life, children can succeed in school, and maintain mental and physical health across their lifespan.

Leadership Story

It is an to honor to be a pediatrician. Families share their hopes, dreams and fears. Caregivers fundamentally want what is best for their child, but may not have the resources - knowledge, support, access - to help their child succeed. Over 20 years of working in healthcare (and 16 years as a parent) have made it clear families need more than 20-minute well visits to meet the health needs of their children. We must work in partnership with families and the community to provide resources to raise children who are healthy in mind, body and spirit.

What awards or honors has the project received? (Optional)

Children's Wellbeing Pioneer Leadership Louisville Bingham Fellow 2016. Smoketown Family Wellness Center was chosen as a project with a goal to launch the Center in early 2017.

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