About Us

City Health Works integrates teams of local Health Coaches into clinics and social service providers to support population health management in local neighborhoods.

A Systems Approach to Population Health


City Health Works enables vulnerable populations struggling with multiple chronic illnesses to live healthier, happier lives and access the right care at the right time.

What We Do

Inspired by community health worker innovations from across the globe, City Health Works scales teams of locally hired individuals to support their peers in achieving better health. We help health systems improve how care is delivered while reducing avoidable costs & creating jobs. We launched operations in Harlem, NY in late 2013.

Target Population

We provide extra support to those who need the most help.
We primarily target the elderly who struggle with multiple chronic illnesses, depression, physical limitations and the stress of poverty.

The Opportunity

People who need the most support also cost the most – 50% of our healthcare spending is on just 5% of the population.

Some of the reasons why individuals who need extra support cost more are:

  • Most of the people we serve struggle to communicate with clinicians because they can’t speak English or know how to identify symptoms until they become a crisis.
  • The health system pays for volume, not value. It doesn’t pay for the time clinicians spend trying to make sure patients understand how to eat or take their meds.
  • The majority of activities required to manage the day-to-day reality of living with chronic illnesses take place in the home. For most clinicians, the home a black box.
Our Services

We improve the health of low-income individuals struggling with uncontrolled chronic diseases by giving each individual the personalized tools and support they need to make healthful choices at home and when speaking with their doctors.

  • Personalized Health Coaching: We strengthen the ability of individuals to manage their lifestyle and medical care through setting realistic goals.
  • Enhancing primary care: We escalate urgent and routine medical, psychological and social needs to ensure access to the right care, from the right person, at the right time.
  • Addressing social and economic needs: We address diverse barriers, such as depression, food insecurity & social isolation.
Systems Approach

We built a systems approach that amplifies the reach of clinics and strengthens the abilities of patients. The four main components are:

  • Local Workforce: With shared life experiences and a desire to help their own neighbors, our locally hired Health Coaches have a powerful ability to motivate and support their peers. We invest in the skills, tools and clinical oversight to ensure high-performance.
  • Primary care integration: With unique insight into the homes and lives of our patients, our Health Coaches serve as vital eyes and ears for the doctors.
  • Supportive Technology: Our proprietary software helps clinics and health coaches collect data and make smarter decisions.
  • Quality Improvement: We continually monitor operations and implement efforts to make sure our processes get better.

City Health Works is proving that providing extra support to those who need the most help not only saves money, but it also saves lives.

Leadership + Operations

Governance Board