City Health Works Bridges the Gap to Healthier Lives

by Cameron St. Germain

Part of the Food Policy Community Spotlight Series

What they do: The City Health Works Care Team serves as vital eyes and ears to clinicians, and Health Coaches support individuals for whom traditional clinic care alone is insufficient. Our value-driven approach leads to better health outcomes, better quality care, and lower costs for the system. City Health Works was founded in East Harlem to support the increasingly overtaxed healthcare system by hiring and training local, clinician-supervised community health workers to act as health coaches. City Health Works, a partner to many large private and public health systems in the region, is a pioneer in the growing trend of community care. The organization operates on the premise that using coaches and care teams that are from the neighborhoods they serve has the greatest potential for patient success, and makes sound economic sense.

How they do it: Coaches help low-income residents of Harlem and Upper Manhattan who are at high risk for diet-related chronic disease better navigate daily self-management by providing motivational interviewing-based health coaching, support and education on navigating medical and social services, referrals and accompaniment to appointments and resources as well as coordination with clinical and non-clinical services and providers.


City Health Works bridges the gap between the doctor’s office and the everyday lives of patients diagnosed with life-threatening chronic illnesses.

The majority of activities required to manage the day-to-day realities of living with chronic illnesses take place in the home. For most clinicians, the home is a black box. City Health Works extends the reach of overburdened clinics by serving as vital eyes and ears to clinicians and providing extra support to those who need it most. Our value-driven approach leads to better health outcomes, better quality care, and lower costs for the system.”

Latest project/campaign: Currently, City Health Works provides health coaching for diabetes, hypertension, asthma, and congestive heart failure. Additional chronic conditions such as chronic obstructive pulmonary disease, chronic kidney disease, fall prevention, and co-morbid depression will be added in the coming years. City Health Works is currently involved in multiple evaluations of their service to assess its impact on outcomes and cost. As the recipient of the Janice Nittoli Fellowship, City Health Works is working with the Urban Institute in 2017 to apply its operational learnings to inform policy. Finally, City Health Works is transitioning to an earned revenue model through contracting with public payers and hospitals in the area.

Major Funding: Primary philanthropic supporters include the Robert Wood Johnson Foundation, Robin Hood Foundation, the Draper Richard Kaplan Foundation, PCORI, and the Astrazenica Foundation.

Profit/nonprofit: Nonprofit

Annual Budget: N/A

Interesting fact about how they are working to positively affect the food system: City Health Works reports that 50% of the patients they serve have benefited from early detection of potentially severe medical issues, and that 78% have seen a decrease in their A1C values. The A1C is a blood test that provides information about a person’s average blood-glucose levels over a period of months.



  • 127th West 127th Street, Suite 2027
  • New York, NY 10027

Core Programs:

  • Health coaching
  • Coordination of care and enhanced primary care
  • Improved disease management
  • Adult preventative care
  • Social/mental health evaluation and referrals

Number of staff: 16

Number of volunteers: N/A

Areas Served:

  • Bronx
  • Manhattan

Year Started: 2012

Executive Director/Founder: Manmeet Kaur

Contact Information:

(646) 684-4601

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