Partner Spotlight Series: City Health Works Partner Spotlight Series: City Health Works

Partner Spotlight Detail

Partner Spotlight Series: City Health Works

City Health Works staff from left to right: Camilo Matos (Health Coach); Manmeet Kaur (Executive Director) Tenisha Dewindt (Health Coach); Anita Hernandez (Health Coach); Marisillis Tejeda (Health Coach); Destini Belton (Health Coach); Leny Rivera (Health Coach); Stacie Gutierrez (Health Coach); David Strefling (Health Coach Supervisor); Jamillah Hoy-Rosas (Director of Health Coaching) ; Elsa Haag (Operations Analyst).

City Health Works, Community-Based Organization Collaborating with Hospitals

Inspired by community health solutions from across Africa, Manmeet Kaur adapted a global health model and brought it to Harlem.

During her time in South Africa, she witnessed the unique impact community health workers play in improving the health of individuals with chronic conditions. This inspired Manmeet to launch City Health Works, an organization focused on leveraging the power of peers by training and hiring local individuals to serve as Health Coaches. “A key strength of locally hired Health Coaches is that they have shared life experiences and can quickly build trust in their communities,” remarked Manmeet.

Working within the Local Community

The core of their organization is made up of a team of health coaches, who are trained and supervised by a clinician. These coaches are longtime residents of the neighborhoods they serve. Most have personally experienced some of the same challenges and concerns faced by patients, making them uniquely qualified to serve as bridges to the health care system.

“We hire people who are from the neighborhood, train them to help their peers better manage their health, navigate the complicated healthcare system and utilize the resources available in the community. We have a powerful ability to work closely with patients, primary care teams, and social service providers. Together, we work to achieve population health goals, reduce healthcare spending, and create more resilient neighborhoods, explained Jamillah Hoy-Rosas, Director of Health Coaching and Clinical Partnerships.

Jamillah, a Registered Dietitian & Certified Diabetes Educator, is the architect behind the training program used with the coaches and the self-management education curricula used with clients. “Our health coaching model is grounded in Motivational Interviewing, designed to help clients increase their internal motivation to adopt realistic, culturally-appropriate lifestyle changes to improve their health.” The program uses evidence-based curriculum elements from the American Association of Diabetes Educators (AADE), the American Heart Association (AHA), the American Lung Association (ALA) & the National Institute of Digestive and Diabetes and Kidney Disorders (NIDDK).

“I have learned so much about diabetes, high blood pressure and asthma and in turn it’s helped me with my own health and allowed me to help my family and friends living with chronic illnesses,” said one of the first health coaches hired, Leny Rivera.

With this experience and understanding, each coach meets with their clients at their homes or in various community settings. Together, they go through a flexible curriculum, tailored to the individual needs of each person. They discuss self-management strategies to empower clients to achieve successful health outcomes and stay out of the hospital.

When teaching medication reconciliation and adherence, patients are asked to take out all of their medications. Coaches check expiration dates and dosage instructions, help patients understand the purpose for each of their medications and identify whether or these medications are being taken as prescribed.

“We help identify barriers to medication adherence and address them. If Pharmacy A can’t deliver medication or has too high of a co-pay, the coaches help patients find a pharmacy that delivers and work with them and their providers to find ways they can afford their meds” said Jamillah.

The coaches are always available to their clients by phone to provide social support and answer any questions they may have. “I like getting to know people and helping them overcome barriers that aren’t just clinical. They may need help filling out an application for food stamps, finding a senior center or talking to their landlord about repairs needed in their apartment to improve their asthma, we can help with that” said Health Coach Destini Belton.

Working Closely with Hospitals

City Health Works recognizes that it can have the greatest impact in the home if it is closely connected to the primary care clinic and hospitals to ensure its efforts are aligned with the provider. “The coaches serve as eyes and ears for the health system in the community. With unique insight into the homes and lives of clients, our Health Coaches and Care Team help bridge the gap between doctors and patients. For one in every two clients, we identified and escalated a medical, medication or mental health issue that was otherwise unknown, before it became a crisis. Through this collaboration, we jointly ensure patients get the right care at the right time,” remarked Manmeet.

The organization uses two referral processes. One is a community-based approach in which the health coaches lead health education workshops at partner community organizations, senior centers, and recreation centers. Patients, who sign up for City Health Works’ services in these settings, work with the City Health Works staff to connect with their primary care provider.

The second is a population health based approach where Mount Sinai Hospital generates a list of target patients and providers make referrals based on eligibility. City Health Works reviews complex cases and sends progress reports and medical alerts directly to referring providers. “Keeping the lines of communication open is essential to our success with our clinical partners”, says Health Coach Supervisor David Strefling.

Clinical supervisors also have secure read-only access to medical records for patients who have provided consent. This keeps the City Health Works team informed of their patients’ health information and outcomes over time.

“We help identify barriers to medication adherence and address them. If Pharmacy A can’t deliver medication or has too high of a co-pay, the coaches help patients find a pharmacy that delivers and work with them and their providers to find ways they can afford their meds” said Jamillah.

Sharing Information

“We would really love to see shared care plans. We’re doing all of this work trying to integrate services, but we still can’t see what happens when patients visit other clinical partners or CBOs. A centralized location to share data and speak the same language would really help improve continuity of care,” said Manmeet.

City Health Works is an active member of the Workforce and Clinical Quality and Clinical Executive Committees, projects 2ai, 3bi, 3ci (where they serve as co-lead), 4bii, and the Care Coordination Cross Functional Workgroup.

“DSRIP brings community based partners to the table so they are a part of an integrated patient experience,” said Manmeet. “It is trying to connect the community as a bridge for patients; this is a link that would benefit everyone. We are proud to be a part of this effort”

For more information about City Health Works, please visit: