Name: Jamillah Hoy-Rosas, MPH, RD, CDE
Title: Chief Health Officer
Organization: City Health Works
Mission: City Health Works bridges the gap between the doctor's office and the everyday lives of patients by hiring community health workers to provide health coaching, disease management education, and care coordination services to people living with life-threatening chronic illnesses.
Why did you choose to become a diabetes educator?
At the time, I was the director of the WIC Program at Betances Health Center and working with pregnant women diagnosed with gestational diabetes. I learned that they had a high likelihood of progressing to type 2 diabetes in the postnatal period. I pursued the certified diabetes educator credential (CDE) to learn about how to prevent the development of type 2 diabetes in my pregnant clients and to help those already diagnosed with gestational diabetes. I was already certified as a lactation counselor, so this complemented my work with pregnant and breastfeeding women.
As Chief Health Officer at City Health Works, what makes your job structure unique?
Because we are a young organization, my work is constantly evolving and it is exciting to see the concrete progress we have made over the past 5 years. I am responsible for the design of the educational curriculum we use with clients as well as the hiring, training, and supervision of the care team. It is unusual for registered dietitians (RDs) to be afforded these types of high-level roles within healthcare institutions. We are often thought of as the “diet” people, when in fact RDs and especially RD CDEs are also experts in adult education, health promotion, and behavior change — skills that I use every day. I also oversee all clinical collaborations with partnering health systems, pharmacies, clinics, community-based organizations, and foundations.
Do you feel like your current program is an example of a new model of care? How might it evolve over the next 5 years?
The City Health Works coaching model is a unique health care delivery model because we combine both health coaching and care coordination with the goal of building client capacity to self-manage their chronic condition(s) over extended periods of time. Over the next five years, our services will expand to other geographies in New York City and New York State. In addition, we will continue to develop and implement evidence-based coaching programs for additional needs, such as maternal health.
Our experience adapting the AADE framework for other disease areas highlights a demand for similar evidence-based services for other chronic diseases
What is the most rewarding aspect of your job?
It is rewarding to know that every single day our neighborhood-based care team is improving the health and lives of those enrolled in our program. One of the principles of finding joy and fulfillment in life is knowing that your work has purpose and impact. One conversation at a time, we are enabling people and neighborhoods to become healthier. That’s very powerful. This work also aligns with my lifelong focus on advancing social justice for low-income communities of color.
What do you see as the biggest challenge facing diabetes educators today?
Diabetes educators have to really think outside the box when seeking opportunities that may not have traditionally been their area of expertise. Diabetes educators are well suited to be leaders in the healthcare industry, managers, and collaborators at the highest levels. They are also well suited for chronic disease self-management work for conditions other than diabetes — many of the principles are the same. At City Health Works, we have refined the coaching program for clients with diabetes and adapted the curriculum to work for patients diagnosed with hypertension, asthma, and congestive heart failure. We quickly learned that the foundations of the diabetes program, drawn largely from AADE guidelines, remained applicable for these additional conditions. City Health Works is achieving early positive outcomes, improving client satisfaction and clinical outcomes, and reducing the total cost of care. Our experience adapting the AADE framework for other disease areas highlights a demand for similar evidence-based services for other chronic diseases.
How has being an AADE member helped you treat patients?
City Health Works has benefited greatly from the practice documents (position statements and practice documents) from AADE. The practice paper on the use of community health workers in diabetes management and prevention was a guiding light as we were building this model and thinking of how it could be successful. City Health Works health coaches (community health workers with a minimum of a GED) receive upfront and ongoing training from RD/CDE clinician supervisors as part of an interdisciplinary, multi-level team. We first developed coaching for clients with diabetes, modeling the program and curriculum from the AADE7 Self-Care Behaviors™ framework and incorporating specific training in motivational interviewing, adult education, and Ed Wagner’s Chronic Care Model. All our coaches are certified as AADE Diabetes Paraprofessionals (Level 1) and work individually with patients in the community using a structured, but flexible curriculum.
Describe your best experience with AADE.
I try to go to AADE’s Annual Conference every year. I am the Chair of the AADE’s Community of Interest on Diversity. I have presented a poster or done a presentation on City Health Works’ model, impact, and outcomes on many different occasions. I always have a wonderful time. This year, I am presenting a poster on the use of community health workers for medication adherence. Medication reconciliation is a key role of our health coaches because they can be the eyes and ears for doctors into the lives of their patients. Health coaches learn to identify and troubleshoot medication management and adherence challenges with their clients that may not be easily detected by periodic primary care visits or pharmacy consultation.
What are some of your interests outside of diabetes education?
I live in Brooklyn and work in Harlem, so I have a long commute. One of my favorite things to do on that commute is to read books and novels. I particularly love time management books, romance novels and science fiction. I also listen to various TED talks daily and podcasts. My passion is girl empowerment. I ran a Girl Scout troop in Brooklyn for many years and am very active with several girl leadership organizations. I also sit on the parent association and board of trustees at my children’s school and am very involved in my church community.
Based on your experience, what advice would you give to aspiring Diabetes Educators?
I would tell them to think outside the box and go for positions that may not seem like they are in their area of expertise. This way they can have the opportunity to grow and learn in different roles.