City Health Works

City Health Works
Organization Name:
City Health Works
Primary Address 1:
127 West 127th Street
Primary Address 2:
Suite 207
Primary Address City:
New York
Primary Address State:
Primary Address Zip:
Long Organization Description:

As a bridge and trusted partner to clinicians and patients, City Health Works extends the reach of clinics and strengthens the abilities of patients with chronic illnesses to achieve better health. The majority of activities required to manage the day-to-day realities of living with chronic illnesses take place in the home, which is a black box for most clinicians. 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.

Organization Website Address:
Organization Phone Number:
(646) 684-4601
Director, Manager or CEO (First Name):
Manmeet Kaur
Interesting Fact About the Organization:
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.
Community members (approx.):
Number of staff/employees:
Year Started:
Major Funders:
Primary philanthropic supporters include the Robert Wood Johnson Foundation, Robin Hood Foundation, the Draper Richard Kaplan Foundation, PCORI, Astrazenica Foundation
Organization Type:
Anti-Hunger Organization, Community Advocacy, Management of diet-related diseases
About the Organization:
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. 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, 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.
Latest Project:
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.
Areas Served:
Bronx, Manhattan
Core Programs:
Health coaching, Coordination of care and enhanced primary care, Improved disease management, Adult preventative care, Social/mental health evaluation and referrals
Major Issues:
Advocacy-Community, Chronic Disease (e.g., Diabetes), Socioeconomic Health Disparities, Workforce Development
Hours of Operation:
9AM-5PM Monday-Friday
We have and or use Social Media?:
Yes, we do have social media (twitter, Facebook, etc…)
Frequently used hashtags 1:
#watchuswork, #dowhatworks, #CHW, #healthjustice, #dignity, #socialjustice
Frequently used hashtags 2:
#socialneeds, #socialsupport, #healthreform, #Harlem
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