Manmeet Kaur is the executive director and founder of the Harlem-based community health organization City Health Works, which helps create healthier, stronger neighborhoods in Upper Manhattan through health coaching, care coordination, and reduced health care spending.

Kaur was selected as the inaugural recipient of the Janice Nittoli Practitioner Fellowship. Funded by the Rockefeller Foundation, the fellowship was created with the help of the foundation’s then-president Judy Rodin to honor a former colleague. The fellowship is awarded to practitioners working directly with communities to alleviate inequities. Fellows partner with Urban Institute senior researchers to advance their work through evidence-based solutions.

We hope that the fellowship will bridge the gap between research and action by integrating practitioners into the research cycle to produce real and timely results that elevate and inform evidence-based policymaking.

Kaur recently spoke with me about how she plans to leverage the Nittoli Fellowship to support her organization and its goal of building a healthier community through a holistic approach to health care.

How do you plan to apply the Nittoli Fellowship in supporting City Health Works?

City Health Works’ primary workforce is composed of health coaches, who function as community health workers. Our coaches meet with patients in their home 12 times over the first three months. In these one-on-one sessions, coaches teach patients self-management skills, reconcile the patient’s medications, and address barriers to adherence. They also train patients in leading a healthy lifestyle, including lessons on portion size, exercise, and how to afford healthy food on a meager budget.

We were able to develop and test this unique model over the past four years with support from the Robert Wood Johnson Foundation.

By interacting with patients directly, City Health Works has gained rich insights on their needs and the needs of the health care system. I’m excited to use the Nittoli Fellowship to learn how to better use these insights to support our mission to change current dominant norms regarding the role of health care.

The fellowship is an excellent opportunity to support our goal of moving the health care ecosystem away from being reactive and toward being responsive and, ultimately, proactive.

What do you mean by a “proactive” health care system?

There’s currently a gap in our health care system between a patient’s visit to the doctor’s office and what happens after that patient returns home. Managing complex medical and social needs is challenging, especially for older adults struggling with multiple chronic illnesses and poverty. Fifty percent of health care spending is on 5 percent of the population. Yet, 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.

The system is designed to treat symptoms and crises and focuses less on preventive care that keeps patients healthy and reduces their medical expenses.

Patients also often lack the knowledge they need to manage their health, and doctors often don’t have the time to fully explain to patients what to expect from their condition or treatment.

Other approaches to improving community health have been more classroom oriented and require patients to absorb lots of information in a single sitting. Our personal approach helps ensure a patient’s treatment is properly aligned with their goals and needs and helps patients learn. For most patients, this is the first time they get the proper knowledge, capability, and confidence to self-manage.

We also build huge amounts of trust with the patients we serve and use this to elevate their voices in communicating what their health issues are, to train them in seeking help from the right places, and to present their issues to providers and clinics.

How can the Nittoli Fellowship help ensure City Health Works is achieving this big mission?

We’re currently involved in collecting data with our partner hospitals and clinics to look at City Health Works’ effect on clinical outcomes and changes in patients’ use of the hospital. Once we get more complete access to that data, I’m excited to dive deeper into it and learn from it with the help of Urban Institute’s researchers. Tapping into the Urban Institute’s knowledge of the realm of data analytics will be very rewarding.

I’m also eager to produce case studies in a more rigorous way that helps tell stories alongside the data. Given that this is a new approach to care, there’s a lot that the data can’t fully communicate about how our approach is changing things for patients, clinicians, and the overall health care system.

Can you share one such story from City Health Works?

We’ve found that one out of two people we’ve helped through City Health Works has identified a medical, medication, or mental health issue that wasn’t previously known to their clinicians.

For example, one of our elderly patients had been making frequent trips to the emergency room for falling down. It turns out she was falling because she was living in an overcrowded public housing unit and she was sleeping on a broken sofa.

Our health coaches found that this patient’s insurance covers the cost of a new bed. After advocating to the insurance company, we secured a new bed for her and thereby reduced her medical expenses and her reliance on emergency care.

Documenting case studies like this one in a systematic way is one thing I’m excited to accomplish through the Nittoli Fellowship.