North Coast Health


Chronic Illness Management

NCH provides coordinated, patient-centered care to underserved patients with chronic disease. Through this program patients receive care that improves their quality of life and improves or stabilizes their overall health.

Neighborhood Family Practice


Promotion of Healthy Lifestyles to Prevent Chronic Illness

A wellness coordinator assists patients who may be overweight and suffering from chronic disease, such as diabetes, hypertension and depression, in adopting healthy behaviors. This program fills an ongoing need for patients and families at NFP by providing healthy lifestyle counseling, linking to outside resources, and utilizing health promotion interventions to promote physical activity and nutrition.

Magnolia Clubhouse


Psychiatric Rehabilitation

Magnolia Clubhouse provides clients with serious mental illness and health issues the chance to receive care under one roof. Clients are involved in all levels of managing the house, which provides opportunities to recover from illness through work training, medical care, socialization and other wellness activities.

Lutheran Metropolitan Ministry


Adult Guardianship Services

AGS provides comprehensive guardianship services, including chronic disease care management and access to health care, to vulnerable adults (adults with dementia and adults with severe mental illness) in Cuyahoga County. Trained staff and volunteer guardians serve as advocates and surrogate decision-makers.

Joseph’s Home


Medical Respite Care

Medical respite is short-term residential care that allows homeless individuals the opportunity to rest in a safe environment while accessing medical care and other supportive services after they have had major medical care. This helps significantly reduce over-utilization of hospital emergency rooms, and helps homeless individuals stabilize their medical conditions while assessing barriers to permanent housing.

Hunger Network of Greater Cleveland


Stay Well

Stay Well provides additional holistic services at food pantries, beyond simply giving food. Services include health screenings; one-on-one wellness coaching to address personal health concerns; medication compliance counseling; assistance enrolling in and navigating Medicaid and SNAP; wellness education on nutrition, healthy cooking, dental health, medication use and mental health; and referrals to primary care physicians and for dental, vision and mental health care.

Eliza Bryant Village


High-Risk Seniors Community Program

The high-risk seniors community program helps frail elderly by providing services and programs to support their independence. The program aims to improve quality of life and health outcomes, delay or prevent seniors from being institutionalized, support caregivers, and provide health promotions and interventions to assist seniors aging in place.

Centers for Families and Children


Chronic Care Population Health Team

The chronic care population health team’s goal is to enhance the primary care team’s ability to manage more complex, chronically ill patients and use the team approach to improve clinical outcomes.

Care Alliance Health Center


Chronic Care Coordination Program

Care Alliance and FrontLine Service provide complimentary, integrated physical and behavioral health care for Cleveland’s most disenfranchised, vulnerable residents. Care is provided at health centers; through the new mobile clinic at the permanent supportive housing complexes; and more traditional shelter and street outreach including shelters, drop-in centers and abandoned buildings.

Better Health Partnership


Clinic to Community Linkage

The program will refer adults with uncontrolled hypertension and children with asthma and/or overweight/obesity issues to community resources for healthy eating, active living and improved asthma control, as well as other needed social services to assist with basic needs.