City Health Works (CHW)


EHHOP has a partnership with City Health Works, a community organization that provides health coaches to patients with diabetes. These coaches will make home visits and phone calls, following patients for one year to improve diabetes management.

CHW Consent Forms (En/Sp)

Patient Eligibility:

1) A1C ≥ 8.0 (taken within the past month)

2) Resident of East Harlem/ Harlem (area codes: 10026, 10027, 10029, 10030, 10035, 10037) OR able to travel to East Harlem/ Harlem regularly to meet health coach. (At least 10 out of 12 sessions in the first 12 weeks should be in person. After the first 12 weeks, more of the sessions, which tend to be biweekly or monthly, can be over the phone.)

3) Interest in having a City Health Works health coach

Exclusion Criteria: Advanced dementia, complicated or severe mental illness, gestational diabetes, cancer treatment, end-stage disease, active alcohol or substance use disorder.

Senior Clinician and Teaching Senior

Access to Care Team

Community Referrals Manager will coordinate the referral. ACT Case Managers do not need to see the patient.


Cost to EHHOP Patient: Free.

Wait Time

Patient will be assigned a City Health Works health coach who will contact the patient directly after the patient's consent form has been received.


Community Referrals Manager: Allie Dembar