Health care providers are trained to solve patients’ acute care needs, like repairing a snapped tendon or treating a bacterial infection. Yet providers have little accountability for helping patients attain or maintain good health outside the doctor’s office.

“Clinicians like me, we’re not trained to do that,” said Jacob Reider, chief executive officer of the Alliance for Better Health, at a recent convening at the Urban Institute. “You step on a rusty nail, I know what to do. We’re not trained to really understand where [patients] are and help them chart their own course toward better health.”

Manmeet Kaur, the inaugural recipient of Urban’s Janice Nittoli Practitioner Fellowship, started Harlem-based City Health Works in 2013 to address an urgent lack of successful chronic disease care management by lifting up a previously untapped workforce from within the community. The organization quickly attracted attention from across the health care and social service sectors, and Kaur began exploring how to expand the program’s reach and impact.

City Health Works changes the lives of its clients, but it could help solve a bigger problem in the US health care system.

The American health system needs holistic innovations

Outside hospital walls, patients are ill equipped to understand and abide by complex care regimens for chronic diseases like diabetes, hypertension, chronic heart failure, and asthma. The number of Americans facing these illnesses is growing at an alarming rate. In 2014, 60 percent of Americans had at least one chronic condition, which now accounts for more than 85 percent of our total US health expenditures.

If we could even marginally move the needle on chronic care management, we could see significant cost savings and drastic improvements in people’s quality of life.

That’s where models like City Health Works come in. Hiring directly from the community, the organization trains health coaches, supervised by clinicians, to teach clients to self-manage their conditions, navigate the health care system, and connect with social services. Often, these patients have been failed by our traditional health care system and struggle with additional stressors like food insecurity, unsafe housing, and caregiving responsibilities.

By hiring coaches who live in the neighborhood, speak the language, and understand cultural norms, City Health Works builds trust and respect within the community. “We do really well with the people who are struggling the most and who have not been able to be helped by the medical system as it currently stands,” noted Jamillah Hoy-Rosas, chief health officer at City Health Works.

The approach is working. After a few months of coaching, clients referred from primary care make life-altering changes to their diets, physical activity, and adherence to prescribed medication. Preliminary data show that 78 percent of clients with diabetes saw a reduction in their A1C levels, and 80 percent of clients with asthma experienced improvement in their self-reported asthma control.

For half its clients, City Health Works identified a medical issue that was otherwise unknown to the medical provider before it became a crisis. Those positive outcomes also add up to savings. By week 10 of the program, early data show an average $600 drop in spending per member each month.

Providers and payers are taking notice

Theresa Soriano, senior vice president for care transitions and population health at Mount Sinai St. Luke’s Hospital, praised City Health Works’ evidence-based curriculum for coaches, the focus on local workforce development, and a commitment to collaborate with clinical partners.

Melissa Cohen, vice president for payment innovation strategy at Anthem, also noted the rise of value-based payment and holding providers accountable for cost and quality outcomes. “This is one of the tools that the provider community is using to get those results,” she said.

City Health Works is helping transform the culture of our health care system. Health coaches are being more fully embraced as valuable team members, and clinicians are starting to recognize their responsibility to better equip patients with the resources, tools, and knowledge they need to manage chronic conditions.

Laudy Aron, codirector of Urban’s cross-center initiative on the social determinants of health, emphasized that “this is about high-touch, low-tech care. This is about patient care that is patient and caring.”

In a conversation with Joanne Kenen, executive editor of health care at Politico, former secretary of the US Department of Health and Human Services Kathleen Sebelius reminded us that health is not health care. Our goal should really be working to keep people out of the hospital.

“Most of health is determined not by an interaction by the health care system but what happens outside the system,” she said. “Health has to be everybody’s job. Until it is, we’re going to keep repeating all of these mistakes.”

The Urban Institute’s Nittoli Fellowship team is grateful for a tremendous year of learning and partnership with Manmeet Kaur and City Health Works. We can’t wait to see how City Health Works will grow and expand its health coaching model to empower patients in Harlem and beyond.