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A year around the Cityblock

Guest post from Iyah Romm, Co-Founder and CEO, Cityblock Health

It’s been 12 months since we started on our journey to radically improve the health of urban communities — here’s where we’ve been, and which streets we’ll cross next.

In October 2017, we announced the launch of Cityblock, a novel company building a scalable, technology-driven system to deliver personalized health and social care to low-income neighborhoods — block by block, one trusting relationship at a time. We partner with provider organizations, health plans, and community-based organizations to ensure that the members we care for receive high-quality, personalized care that enables good health. And we’ve built all-new technology capabilities to support our model, connect people with the information they need, and create a path for scale across communities. The past 12 months have been all about bringing this vision to reality.

First, an example of what Cityblock care is like for our members:

It’s 4 p.m. on a Tuesday. Patricia and Ron* are in their Brooklyn apartment, a pile of mail and forms strewn across their kitchen table. Patricia, who lives with schizophrenia, is a few weeks out from her most recent psychiatric hospitalization. Several days ago, she was discharged from a transitional outpatient clinic because she missed several appointments, a result of not having transportation to the clinic. Like millions of other low-income families, the couple is mired in a constant and stressful struggle to stay on top of their appointments, to manage dozens of medications, and to decipher the mountains of paperwork from the doctors’ offices and social services agencies they rely upon for support. Until recently, they lacked a trusted advocate to help them navigate it all.

Erica*, one of Cityblock’s Community Health Partners, knocks on their door. She sits with Patricia and Ron for two hours, discussing the couple’s concerns. The conversation ranges from their medical history and Patricia’s challenges in finding the right combination of medications to the couple’s struggle to stretch a fixed income to cover living expenses. Erica records their answers to her questions and notes their concerns in Cityblock’s online platform, Commons. As the three of them look at the screen, a comprehensive picture of Patricia’s and Ron’s goals, needs, and challenges begins to emerge.

Together, they discuss where to begin. The challenges seem insurmountable to Patricia and Ron. Erica asks the couple about their health and life goals, what matters most to them and why, and shares her perspective along the way. She engages in care planning, incorporating Patricia and Ron’s priorities and goals for their health with insights generated by Commons. The outcome is a collaboratively-developed, personalized Member Action Plan that helps them work with Cityblock’s care teams to achieve their shared goals. Patricia and Ron tell Erica they’re grateful that someone is finally listening to them. For the first time, they have a plan that addresses the challenges they face and reflects their perspective.

In the days that follow, Erica introduces the couple to their full Cityblock care team. A physician trained in complex care, a psychiatrist, a therapist, and a nurse are all available to support Erica, Patricia, and Ron. Erica coordinates in-home mental health and medical care and arranges rides to Patricia’s specialist appointments thanks to Cityblock’s partnership with a ride-sharing company. She uses Commons to work with Patricia and Ron to define and regularly update their concerns and goals. Changes in their individual needs are documented dynamically and drive action for both the care team and each member. Erica also initiates services with local community-based organizations that she knows will provide high-quality services and resources specific to their needs, including home-delivery of medically tailored meals. Erica stays in close contact with Patricia and Ron in-person and via telephone and SMS — using whatever modality suits them the best.

We’ve made this vision a reality — this is Cityblock Health.

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