City Health Works
MISSION: City Health Works creates healthier, stronger neighborhoods through health coaching and care coordination delivered by locally hired health coaches. We improve outcomes and reduce spending among patients struggling with preventable chronic illnesses who are not successfully managing their condition(s) through traditional, clinic-based services alone.
ABOUT US: City Health Works launched in 2013 in Harlem, NY to prove that a neighborhood-based layer of care that partners with health care providers while operating in the neighborhood can improve health while reducing avoidable spending. By hiring coaches from the same neighborhood as the people they serve, they have a unique ability to build trust with patients, making City Health Works a valuable bridge between the patient and clinics.
The majority of activities required to manage the daily realities of living with chronic conditions take place at home, not at the doctor’s office. Yet for most clinicians, the focus of care does not consider the home situations of patients with chronic conditions. City Health Works extends the reach of overburdened clinics by serving as vital eyes and ears to clinicians while providing extra support to individuals and their households.
EVIDENCE-BASED SOLUTION : One conversation at a time, we help patients build confidence in their ability to live healthier lives, while strengthening their communication and trust with the doctor's office. In home or community settings, our teams of locally hired Health Coaches provide personalized health coaching and care coordination to help patients achieve realistic health goals, access the right care at the right time, and prevent crises. Patients learn to solve their health problems more effectively.
Our coaching programs are evidence-based and largely developed through academic medical partnerships.
We recruit and train individuals from the community with strong empathic listening skills and personal experiences of overcoming health struggles. We implement rigorous, ongoing learning & performance review processes.
 WHO WE SERVE: People living with multiple chronic illnesses and the stressors of poverty.
 HEALTH COACHING AND CARE COORDINATION
Most patients are referred from a primary care clinic, while some are referred from a hospital or community setting. During the first 3 months, City Health Works’ coaches provide intensive, home-based health coaching on a weekly basis. Throughout the year, City Health Works helps patients navigate medical and social services and connects patients to the right medical care in a timely way to prevent crises.