City Health Works Scales Health Coaching Model with $2 Million Grant from the Helmsley Charitable Trust

City Health Works will prepare to grow their network to serve more people with chronic disease in communities throughout New York City

New York, NY ­— City Health Works announced today a new $2 million grant from The Leona M. and Harry B. Helmsley Charitable Trust to help the Harlem-based organization expand their network of health coaches and clinicians to serve the needs of more New Yorkers city-wide.

City Health Works bridges the gap between the doctor’s office and the everyday lives of patients diagnosed with life-threatening chronic illnesses. In home or community settings, locally-hired Health Coaches provide personalized coaching and care coordination through one-on-one sessions and phone calls. Coaches use an evidence-based curriculum and motivational interviewing to educate clients about their conditions and give them strategies to improve their nutrition, medication adherence, physical activity, stress management, and communication with primary care providers. Founded in 2013, City Health Works currently serves 400 patients in East Harlem with diabetes, asthma, hypertension, and congestive heart failure.

“The daily realities of living with chronic conditions take place at home, not the doctor’s office,” said City Health Works executive director Manmeet Kaur. “If we can reduce the barriers to finding the right healthcare solutions for patients then we can redefine what it requires for individuals to attain better health and significantly improve our system.”

Currently 50% of healthcare spending in the U.S. is spent on 5% of the population and 80% of health is determined by socioeconomic and behavioral factors. City Health Works’ value-driven approach has a proven track record of better health outcomes, better quality of care, and lower costs for the system. A study of City Health Works patients with uncontrolled diabetes conducted by Mount Sinai found that:

Insurers spent $600 less per month on healthcare costs after ten weeks of coaching, and $900 less per month by their fifth month; and

83% of diabetes patients decreased their average blood sugar levels during the course of the program, compared to 62% enrolled in other diabetes self-management programs led by certified diabetes educators, and 44% of patients dropped their average blood sugar levels below target.

“City Health Works’ model is proving that we can cut costs for payers, providers, and patients, while improving the experience and quality of care,” says Tracy Perrizo of the Helmsley Charitable Trust. “This is a very promising, high-value, low-cost model that meets people where they are. This grant aligns perfectly with Helmsley’s portfolio of investing in grantees that make it possible for people to have greater access to the care and support they need to live healthier lives.”  

City Health Works coaches are hired from the neighborhoods where they work, helping them understand the specific needs of their members more fully than clinicians meeting with them in primary care settings. City Health Works’ custom software enables their neighborhood-based workforce to collect data, analyze cases, generate reports, and make smarter decisions in real-time while creating a better flow of information to primary care and social service providers.

“Without the clinician’s eyes being able to see what goes on in the home, without being able to provide the constant reinforcement that patients need to master chronic illness self-management ­- it’s a broad set of skills,” said Alex Federman, director of research in the division of general internal medicine at the Icahn School of Medicine at Mount Sinai. “This is really one of the great features of working with an organization like City Health Works, is you have an organization where somebody goes into the home. They have eyes on the home, and there’s so much tremendous value in that to a clinician.”

“The strength of this model is in its workforce development and its training, and its clinical backup as well as the workflows they develop with the clinical teams,” said Theresa Soriano, senior vice president of care transitions and population health at Mount Sinai St. Luke’s Hospital.

About City Health Works

Launched in 2013 in Harlem, NY, City Health Works creates healthier, stronger neighborhoods through health coaching and care coordination delivered by locally hired health coaches who are equipped with our custom, mobile software. We partner with clinicians and insurers to 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 the Helmsley Charitable Trust

The Leona M. and Harry B. Helmsley Charitable Trust aspires to improve lives by supporting exceptional efforts in the U.S. and around the world in health and select place-based initiatives. Since beginning its active grantmaking in 2008, Helmsley has committed more than $2 billion for a wide range of charitable purposes. For more information, please visit helmsleytrust.org.