Health Coaching & Care Coordination for those who need it most.
City Health Works bridges the gap between the doctor's office and the everyday lives of patients diagnosed with life-threatening chronic illnesses.
The majority of activities required to manage the day-to-day realities of living with chronic illnesses take place in the home. For most clinicians, the home is a black box. City Health Works extends the reach of overburdened clinics by serving as vital eyes and ears to clinicians and providing extra support to those who need it most. Our value-driven approach leads to better health outcomes, better quality care, and lower costs for the system.
One conversation at a time, we help patients build confidence in their ability to live healthier lives, while strengthening their communication and trust with the doctor's office. In home or community settings, our teams of locally hired Health Coaches provide personalized health coaching and care coordination to help patients achieve realistic health goals and access the right care at the right time.
We target populations who struggle with multiple chronic illnesses and stressors such as poverty and isolation. Currently, we provide coaching for Diabetes, Hypertension, & Asthma. Additional health conditions are being added (i.e. Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, etc.)
With shared life experience, our locally hired Health Coaches have a unique ability to build trusting relationships. They are all long-time residents of the neighborhoods we serve and most have personally experienced and overcome some of the very same challenges faced by patients.
We are proving that providing extra support to those who need it most saves lives, while also saving money.
For 1 out of every 2 patients, we identified a medical issue that was otherwise unknown to the medical provider, before it became a crisis.
It has impacted my life tremendously. My A1C has decreased to 7.1, and not only has my health changed, but my attitude over all. My children have noticed how I'm more pleasant. I've learned so much about how to change my diet and now I'm teaching what I learned to my family members who have been diagnosed with pre-diabetes.
My patient and I tried tweaking her med regimen, changing her diet, got her daughter and family on board - but nothing really clicked. But then I got her enrolled in CHW and it did click: we watched her A1C drop like never before. Getting this patient and her family connected to a CHW Coach made all of their hard work come together to make a real difference in her health.
Dr. Joseph Truglio | Mount Sinai Health System
Every clinic is unique. We approach each partnership by first learning about each clinic's needs, operations and existing services to ensure that we fill the right gaps.
We help shift the center of healthcare from hospitals to the places where people live, work, play and age.
I have been on a journey to enhance my own health and fitness and it has improved all areas of my life. I joined City Health Works so that I can help others on their journey. Improving the health of people in my community can improve all areas of my community, which will be helpful for us all.
FAVORITE FOOD: Avocado & Mango
FAVORITE PLACE IN EAST HARLEM: Jefferson Park
I joined City Health Works to learn more about chronic illness prevention and to teach others. Chronic illnesses such as hypertension, asthma, diabetes and cardiovascular disease are prominent throughout inner city communities. As an East Harlem resident I take pride in addressing these issues full force.
FAVORITE FOOD: Baked Chicken
FAVORITE PLACE IN EAST HARLEM: FDR Pier
Concerned with the diet related diseases that plague East Harlem, I joined City Health Works to be a part of a neighbor helping neighbor support system. As a Health Coach, I offer support to our clients through empathizing, educating and empowering East Harlem residents to reach goals for better, healthier lives.
FAVORITE FOOD: Salads - a rainbow of nutrition!
FAVORITE PLACE IN EAST HARLEM: Museum of the City of New York
I love the fact that City Health Works is helping the community to take charge of their health. Our communities are in need of an organization that cares about us. I joined City Health Works because I want to help motivate women and men to meet their health goals so that they can be healthier people who can then lead healthier lives.
FAVORITE FOOD: Tacos
FAVORITE PLACE IN EAST HARLEM: West Harlem Pier
My experiences and struggles with health and fitness are personal and working as a Health Coach, is an opportunity to jump-start a career that links my passions. I want to make wellness and healthy lifestyle approaches contagious! And this is why I work at City Health Works!
FAVORITE FOOD: Watermelon
FAVORITE PLACE IN EAST HARLEM: Central Park
I love the East Harlem/ El Barrio Community and I want to see every one achieve their fullest potential but all too often, the lack of knowledge about nutrition and exercise leads to poor choices. I know my community can make better decisions around these issues and I hope to facilitate positive changes.
FAVORITE FOOD: Broil beef with beans & dry cheese
FAVORITE PLACE IN EAST HARLEM: Little Sisters of the Assumption Family Health Services
I believe healthier communities produce stronger nations. That's why I left my career in finance and joined City Health Works. I wanted to be part of the process of bringing hope to those in need in the East Harlem Community, through self-management health education, social support and motivation. One small goal at a time.
FAVORITE FOOD: Japanese Nabeyaki Udon
FAVORITE PLACE IN EAST HARLEM: Central Park
Manmeet Kaur founded City Health Works in 2012 to create a business case for the integration of local health coaches into the U.S healthcare system. Prior, she was an advisor to the One Million Community Health Worker Campaign and worked on community health and workforce initiatives in South Africa (Mamelani Projects), India (LabourNet) and NYC (the Brennan Center for Justice). In her time abroad Manmeet saw the potential for reverse innovation from lower cost health systems when applied to the U.S.
Manmeet's work has been featured in PBS Newshour, The Economist, NPR, Generations, the New England Journal of Medicine, the Commonwealth Fund, the NY Daily News, the Brookings Institution, NationSwell, and more. She earned an MBA from Columbia University and a BA from Barnard College. Manmeet is currently a Janice Nittoli Practitioner Fellow at the Urban Institute and a Draper Richard Kaplan Social Entrepreneur; she has formerly served as a PopTech Social Innovation Fellow, a GLG Social Impact Fellow, and a Third Millennium Human Rights Fellow. She serves on the Board of the Sikh Coalition, a civil rights organization, and as an Advisory Board Member to the Sikh Family Center. Manmeet was born and raised in New York; she lives in New York with her husband, mother and two energetic sons.
Sabine has worked in healthcare operations and management for the past 12 years. She has spent the majority of her career in primary care improvement, and is passionate about wellness promotion and health education. Sabine’s vested interest in nutrition and wellness is largely driven by the values she and her family share - to continually increase their knowledge about how to prevent disease and manage chronic illness. She is honored to join an organization that is increasing access to health education and empowering individuals to take ownership of their health.
Sabine has worked with Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs), instituted and lead performance improvement (PI) initiatives, and has built and managed PI teams. Prior to joining City Health Works, Sabine managed the operations of care coordination and telehealth programs at the Visiting Nurse Association Health Group of NJ. She directed Montefiore Medical Center’s Patient Centered Medical Home initiative, which focused on transforming outpatient practices to team-based models of care and on training care teams on how to use data to drive improvement. Prior to that she worked at Montefiore on an HIV access to care improvement initiative, and oversaw the performance improvement and research components of the grant-funded program, and at Kaiser Permanente as a performance improvement consultant.
In her role as Regional Director of Harlem, Sabine oversees City Health Works’ first regional team and helps design the scale-up pathway towards creating locally led teams in new geographies.
Sabine enjoys mentoring young students who aspire to become public health and health administration professionals. She actively volunteers with youth development programs and with her alumni associations.
Sabine holds a Master of Science degree in Health Policy & Management from the Harvard School of Public Health, and a Bachelors of Arts in Biology from Wesleyan University.
Jamillah Hoy-Rosas is a Registered Dietitian and Certified Diabetes Educator, who has worked in the fields of nutrition and public health for over 12 years. Jamillah received her B.A. in Biological Basis of Behavior from the University of Pennsylvania and completed her RD and Master's Degree in Public Health Nutrition at New York University. Jamillah specializes in health coaching, adult education, motivational interviewing, care coordination and medical nutrition therapy for diabetes, obesity and heart disease.
She is trained as a Lifestyle Coach for the National Diabetes Prevention Program, as a U.S. Diabetes Conversation Map Program Facilitator and as a Asthma Care Specialist.
In her role as Director of Health Coaching & Clinical Partnerships at City Health Works, she is responsible for overall program design and evaluation. She has oversight in the hiring, training and supervision of coaching staff who provide self-management strategies and motivational coaching to adults living with chronic illnesses. She manages clinic partnerships for the organization including special projects and grants and serves as the primary contact for the care teams at partnering health systems, pharmacies and clinics. Jamillah is active in social justice and volunteer work for under-represented and vulnerable populations.
David Strefling, MPH, RD, CDE is responsible for day-to-day supervising, training and continuous education of health coaches. David worked directly with lay health workers in Africa while in the Peace Corps, where he learned first hand the important role community health workers play in improving the health of their community. After this experience he focused on nutritional care for HIV/AIDS patients at a large non-profit organization in New York City.
David is a Certified Diabetes Educator and received his Masters of Public Health degree at the University of Massachusetts and B.S. in dietetics at Michigan State University.
Elsa Haag is passionate about creating more equitable systems in the U.S. and believes that addressing the social determinants of health and providing effective comprehensive health care are essential parts of that process.
Elsa joined City Health Works in 2014. She works on policy, research and communications in support of CHW's innovative payment and delivery model for population health. She also works with CHW's health system partners on program evaluations and conducts research to improve CHW services. In her previous role at CHW as Operations Analyst, Elsa worked to design, develop and implement CHW's custom care coordination software to support health coaches and care managers in program delivery and supported quality improvement efforts through data and program monitoring.
Before coming to City Health Works, Elsa worked at the Institute for Public Health Innovation on their community health worker program, Positive Pathways, and interned at the Environmental Protection Agency in the Office of Children's Health Protection. As Convener of the Public Health Club at Earlham College, Elsa led coordination of blood drives, created a tobacco cessation course students take for credit, and developed an internship program at the EPA, among other things. Elsa was a volunteer Emergency Medical Technician at the Wheaton Volunteer Rescue Squad for seven year in high school and college. She received a B.A. with Honors in Neuroscience from Earlham College. Elsa was born and raised in Silver Spring, MD.
Monique provides administrative and operations support to the City health Works team. Monique has worked at nonprofits in Florida and New York as a Case Manager and Program Coordinator, providing support to individuals in need of childcare, employment and housing assistance. She received a BS in Social Work from the University of Central Florida.
During her 10 years in the nonprofit sector, Monique has become a strong advocate for providing clients with the best possible care and attention. She is committed to nonprofit sector service work, and has a deep appreciation for how nonprofits seek to improve quality of life for individuals, one program at a time. In her spare time, Monique enjoys museums, politics, and picnics.
Hyacinth Reid is a results-oriented leader providing financial, operational, and infrastructure administration success in diverse industries for over 30 years. Hyacinth received her BS with honors in accounting from St. John’s University. Hyacinth is highly skilled in process improvement, staff development, financial management, budget management, and forecasting.
Before joining Your Part-Time Controller in 2012, she was an external auditor at PriceWaterhouseCoopers, LLP for over 6 years and served in the capacity of controllership at various organizations including 10 years at Christian Brother’s investment Services. City Health Works is one of her clients where she is the Finance Officer.
In her role as an associate at Your Part-Time Controller, she serves as a strategic advisor to Executive Directors/Presidents for several non-profit organizations and has oversight in training and supervising her YPTC clients, monthly financial closing and leading audit processes. She has proven to be a resourceful change agent adept at identifying inefficiencies and delivering quick, cost-effective solutions. Her vast experience allows her to be big picture oriented but attuned to detail. Her collaborative nature and excellent communication skills have fostered strong working relationships with all levels of management and staff at her clients.