Using Communities to Bolster Health

City Health Works employs community members to care for their neighbors coping with chronic illnesses, resulting in healthier, more engaged neighborhoods.

Based in Harlem, City Health Works scales teams of locally hired individuals to support their peers in managing chronic illnesses such as diabetes, hypertension, and asthma. The organization’s health coaches do not have medical backgrounds, but are trained and supervised by clinicians to work with highrisk patients after they have visited their medical provider. They provide simple yet crucial services in this underserved community, such as making sure people know why and how to take their medicine and advising them in culturally and linguistically appropriate ways about how to eat more healthfully, be more active, and cope with stress, depression, and anxiety.
While they are equipped with the skills and clinical oversight needed to ensure quality care, the transformative element of City Health Works’ health coaches is their deep embeddedness in the community. This innovative model has allowed the organization to simultaneously improve health outcomes, create jobs, and foster community engagement.

Relevance of solution

Healthcare cost the USA $3 trillion in 2014, amounting to 17.5% of its GDP.1 Despite this astronomical spending, most daily activities required to manage chronic illnesses take place in a person’s community and home, rather than the hospital. City Health Works bridges this gap by training community members to help their neighbors manage their chronic illnesses, improving health outcomes and bolstering community engagement.

Triple Bottom Line


Avoiding hospital visits by managing care locally also avoids using energy for tests, procedures, and producing unnecessary medical waste.


Personalized health services help manage stresses of poverty, food insecurity, and social isolation that can arise when living with chronic diseases in a disadvantaged neighborhood.


Being an active part of the community allows coaches to spot health problems before they become serious enough to require a clinic visit, thus preventing unnecessary spending.


  1. Centers for Disease Control and Prevention. “Health Expenditures.” (2016.)