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

BPC Report: Rightsizing Rural Healthcare in America Demands National Attention

Washington, DC—While there are renewed efforts to revive rural America, its residents continue to face greater disparities and barriers to quality healthcare than their urban counterparts and should not be disenfranchised from national policy discussions. Today, the Bipartisan Policy Center releases a new report which highlights the challenges of healthcare delivery in rural areas of the Upper Midwest and identifies key areas for reform that could apply nationally to all rural communities.

The report, Reinventing Rural Healthcare: A Case Study of Seven Upper Midwest States, was created over a six-month period in collaboration with the Center for Outcomes Research and Education (CORE). It includes insight from nearly 100 national thought leaders and healthcare providers in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming on the current state of rural healthcare, and the strategies and tools needed to deliver high-quality, high-value care to rural and frontier areas of these states.

Centers for Disease Control and Prevention data show that 46 million Americans living in rural areas are at a greater risk of dying from heart disease, cancer, chronic lower respiratory disease, and stroke than their urban counterparts. Rural residents also have higher rates of obesity, tobacco and opioid use, and suicide than those living in urban areas.

“In order to address healthcare in rural America, federal laws should better align to meet the unique needs of rural areas of our country,” said G. William Hoagland, BPC senior vice president. “The 115th Congress has introduced numerous bills that address rural healthcare, but acted upon individually, they are piecemeal and take a siloed approach to improving access and delivery and that will not solve this problem.”

BPC’s survey of the seven Upper Midwest states identified four specific policy areas for developing recommendations:

1) Rightsizing Healthcare Services to Fit Community Needs. Recognizing not every community needs a Critical Access Hospital (CAH), communities should adjust services to better suit the needs of the local area. In an effort to prevent closures, CAHs should be allowed to provide more primary care and prevention-focused services.

2) Creating Rural Funding Mechanisms. Given small population sizes, growing healthcare needs, and demographic trends, rural areas need alternative Medicare and Medicaid reimbursement metrics and payment mechanisms that allow for value-based alternative payment models and innovation. Appropriate reimbursement mechanisms for telemedicine should also be examined to accommodate the virtual provider and the on-site provider or host hospital.

3) Building and Supporting the Primary Care Physician Workforce. New workforce models should be examined in collaboration with universities and residency programs to expose providers to rural environments and telemedicine, and reserve placements in medical programs for rural residents. Alternative providers such as nurse practitioners and physician assistants can fill vital primary care roles in rural communities.

4) Expanding Telemedicine Services. Telemedicine is a promising way to connect patients with providers and create a peer network for rural providers that will improve recruitment and retention. However, it must be supported by adequate broadband services and reimbursement. Rural health systems need to provide health professionals with the necessary tools and technology to offer this type of quality care to their patients.

“This report serves as a critical snapshot of the healthcare challenges and opportunities for reform in rural communities across America, said Walter Panzirer, a trustee at the Helmsley Charitable Trust. “Strengthening the financial viability of the rural healthcare system and providing an injection of innovation and technology to these underserved communities is imperative.”

“Rightsizing America’s rural healthcare system will require bipartisan action from Congress,” said Anand Parekh, BPC chief medical advisor. “Tackling the barriers to delivering quality and efficient healthcare to rural America is long overdue.”

This work was funded through a grant from The Leona M. and Harry B. Helmsley Charitable Trust. 



Joann Donnellan, Bipartisan Policy Center,, 703-966-1990.

Laura Fahey, Helmsley Charitable Trust,, 212-953-2814.

T1D Program Defines Clinically Meaningful Outcomes

In partnership with other members of the T1D Outcomes Program Steering Committee, Helmsley has jointly come to a consensus in defining and standardizing meaningful type 1 diabetes (T1D) outcomes other than hemoglobin HbA1c (A1c), which is an average of blood glucose levels over a three-month period. Although A1c remains an important measure, its limitation as an average means it does not capture the entire picture of glycemic control, particularly around day-to-day variability in blood-glucose levels. The statement, published in Diabetes Care, a journal of the American Diabetes Association, defines additional clinically meaningful T1D outcomes beyond A1c such as hypoglycemia, time in range, hyperglycemia, and diabetic ketoacidosis (DKA).

The intended impact of these outcome definitions and standardizations is to encourage regulatory agencies and payors to consider the bigger picture of glycemic control when evaluating new diabetes treatments and technology. The consensus statement was developed over the course of two years and incorporates diverse perspectives from persons living with T1D and their caregivers, clinical experts, industry, Advisory Committees representing researchers, and clinical evidence.

Led by grantee JDRF International, the fellow T1D stakeholders represented in the Steering Committee also include: the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, the Pediatric Endocrine Society, and the T1D Exchange.

Read the joint announcement at and the Diabetes Care article at

State Policy Framework Outlines Path to STEM Opportunities for Underserved Students

Achieving the Dream and Jobs for the Future released the Middle-Skill STEM State Policy Framework this week, outlining five key recommendations for how states can improve academic and career pathways for historically underserved students.

Recent research has shown a large number of STEM jobs require less than a Bachelor’s degree. This critical fact of today’s workforce underscores the role that community colleges can play in launching many more individuals to high-paying, quality careers in STEM fields. Such “middle-skill” STEM jobs represent an unprecedented opportunity for the historically underserved students who disproportionately enroll at community colleges.

The framework’s recommendations are based on the STEM Regional Collaboratives, a yearlong multi-state initiative funded by the Trust to identify effective, concrete ways in which state policy can help community colleges build middle-skill STEM career opportunities for students and meet the high demand of local labor markets.

Read the Middle-Skill STEM State Policy Framework at

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