City Health Works

City Health Works City Health Works is a New York City–based nonprofit organization focused on chronic disease management and peer-based health coaching for underserved populations. Founded in 2008, the organization operates in partnership with local hospitals, community health centers, and social service agencies to deliver culturally tailored interventions. Its model draws from public health practice, community organizing, and primary care innovation to address conditions such as diabetes, hypertension, and asthma.

History

City Health Works was established in 2008 in New York City by Hope Lewis with early collaboration from partners including New York Presbyterian Hospital, Columbia University, Mount Sinai Health System, and community stakeholders from neighborhoods such as Harlem, Bronx, and Brooklyn. Early pilot programs were influenced by evidence from initiatives like the Chronic Care Model, the Community Health Worker movement, and randomized trials such as the Diabetes Prevention Program. Over the 2010s the organization expanded programming in coordination with municipal efforts led by the New York City Department of Health and Mental Hygiene and initiatives associated with the Affordable Care Act, while engaging funders including the Robert Wood Johnson Foundation and CommonSpirit Health affiliates. City Health Works has adapted approaches used by Partners In Health, Fenway Health, Kaiser Permanente, and global community health programs spearheaded by institutions like Harvard Medical School and Johns Hopkins University.

Mission and Model

The stated mission emphasizes improving health outcomes for people with chronic conditions through peer health coaches recruited from communities served by institutions such as Montefiore Medical Center, NYU Langone Health, and BronxCare Health System. The model integrates elements of the Patient-Centered Medical Home concept, task-shifting approaches from World Health Organization guidelines, and motivational strategies similar to those developed at Motivational Interviewing Network of Trainers and research from RAND Corporation. Coaches work alongside clinicians from clinics affiliated with Weill Cornell Medicine and behavioral teams informed by work at Columbia University Mailman School of Public Health and Yale School of Medicine. Training draws on curricula influenced by CDC programs and competency frameworks from American Public Health Association and National Association of Community Health Centers.

Programs and Services

Programs include peer health coach services for conditions such as diabetes, hypertension, and asthma delivered in neighborhoods served by Harlem Hospital Center, Kings County Hospital Center, and federally qualified health centers linked with Community Health Center Network (NYC). Services encompass individualized coaching, group education modeled on Stanford Chronic Disease Self-Management Program, home visits inspired by Visiting Nurse Service of New York practices, and care coordination with referral networks like Department for the Aging (New York City), New York Foundling, and CityHarvest. City Health Works pilots workplace wellness collaborations with employers such as Mount Sinai Health System and engages in school-based outreach connecting to initiatives like New York City Department of Education health programs. Digital adaptations reference tools produced by IBM Watson Health, Microsoft HealthVault, and academic digital health research at Massachusetts Institute of Technology and University of California, San Francisco.

Partnerships and Funding

The organization maintains partnerships with healthcare systems including NewYork-Presbyterian Hospital, Montefiore Medical Center, NYU Langone Health, and public health entities such as the New York City Department of Health and Mental Hygiene and the NYC Health + Hospitals network. Funding sources have included philanthropic foundations like the Robert Wood Johnson Foundation, Ford Foundation, The Commonwealth Fund, corporate grants from entities like Google.org and Citi Foundation, and government contracts associated with Centers for Medicare & Medicaid Services demonstrations and state Medicaid initiatives overseen by the New York State Department of Health. Academic collaborations have involved Columbia University, Weill Cornell Medicine, Mount Sinai Icahn School of Medicine, and evaluation partners such as RAND Corporation and Johns Hopkins Bloomberg School of Public Health.

Impact and Evaluation

Impact assessments reference improvements in metrics commonly tracked by health services researchers at Agency for Healthcare Research and Quality, including reductions in emergency department utilization noted in comparative analyses with cohorts from New York City Health and Hospitals Corporation clinics. Evaluations draw on methods from Centers for Disease Control and Prevention program evaluation guidance and employ quantitative approaches used by National Institutes of Health–funded studies and qualitative frameworks from Urban Institute work on community interventions. Outcomes reported in partnership publications with institutions such as Columbia University Mailman School of Public Health and Weill Cornell Medicine include better self-reported medication adherence, improved glycemic control comparable to findings from the Diabetes Control and Complications Trial literature, and enhanced patient engagement similar to results observed in Patient Activation Measure research. External recognition has included invites to present at convenings hosted by Institute for Healthcare Improvement, Association of American Medical Colleges, and briefings for policymakers at New York City Hall.

Category:Non-profit organizations based in New York City