The Cityblock Health team celebrating our one-year anniversary outside of our Dumbo, Brooklyn office!

A year around the Cityblock

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.

Cityblock Health
Cityblock Health
Published in
10 min readOct 18, 2018

Iyah Romm, Co-Founder and CEO, Cityblock Health

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.

Our approach to care is inspired by the individuals and communities we serve — including those who access Medicaid, are dually eligible for Medicaid and Medicare, and others living in underserved neighborhoods. While holding firm to our social justice roots, our ways of being and working are characterized by the creativity, collaboration, and mutual learning emerging from uniting world-class technologists, healthcare providers, social workers, and operators to deliver a radically different experience of care for our members.

Since we launched last October with the support of Sidewalk Labs (an Alphabet Company), we moved to Brooklyn to be closer to the first community we would serve. We then raised over $20 million in Series A funding from leading investors to continue to grow our team, develop our technology platform, and launch our organization. Soon after, we united with EmblemHealth, New York’s largest not-for-profit health plan. Our partnership enables us to reach individuals in New York City neighborhoods facing high poverty rates and accompanying social challenges — issues like housing instability, unemployment, food insecurity, insufficient childcare, loneliness, and fragmented social supports.

At Cityblock, we refer to those we serve as “members,” not “patients,” an intentional part of welcoming them into our community of care, reflecting our partnership with them — and fostering a sense of belonging in that community. We hire and train providers who embody a member-first philosophy and empower them to deliver care the right way, without the constraint of a 15-minute visit or a fee-for-service imperative. Together with EmblemHealth, we have set out to reach and engage our Cityblock members in comprehensive medical, behavioral health, and social services that improve their overall health and well-being.

Each of our members is assigned a Community Health Partner, their ally on their journey to improved health.

How did we build this reality?

In July, we opened the doors to our first Neighborhood Hub in Crown Heights, Brooklyn. We are co-located within an AdvantageCare Physicians New York practice, where many of our members already receive primary care. The proximity facilitates coordination between Cityblock care teams and members’ existing PCPs. But in our model, primary healthcare extends beyond the doctor’s office. Our care teams flex out from the Hub, meeting and engaging with members on their terms — in coffee shops, community centers, their homes and other locations — whenever and wherever is most convenient for them.

Our Community Health Partners (CHPs), typically hired from the communities we serve, are selected for empathy, respectful listening skills, trustworthiness, tenacity — and for their deep commitment to advocacy. CHPs partner with members and their families to create and manage a plan uniquely tailored to each individual’s needs. Our approach prioritizes these relationships and ensures that the medical, behavioral, and social factors that determine health outcomes are treated as equally essential in supporting each Cityblock member.

Our custom-built community care platform, Commons, enables high-touch, integrated, and personalized care.

In parallel, we launched our community care platform, Commons, which we built to address four major gaps in technology infrastructure for community-based care:

  1. 360° view of individual health: Commons is designed to provide a comprehensive view of the diverse factors that impact and impede members’ health. Commons ingests and renders data from diverse sources including medical and pharmacy claims, electronic health records, health information exchanges, and community data sources. This information is combined with rich structured data on behavioral health and social needs, collected through direct interactions with members, and made actionable through decision-support and workflow tools.
  2. Inclusive care planning: For individuals with complex needs, healthcare often results in complicated, disorganized medication and treatment plans — with missing records, gaps, and contradictions. With Commons, care planning reflects a member’s needs and strengths and incorporates real-time clinical decision support and evidence-based protocols. The resulting individualized Member Action Plan focuses on goals and tasks directly relevant to the member’s lived reality.
  3. Multiple, integrated modalities of care delivery: Commons enables omni-channel engagement with members, leveraging built-in secure SMS functionality, video-visiting, printable tools, and the platform itself to meet members where they are — in person or virtually, in the community or in the home, according to their preferences.
  4. Design that supports end users: Healthcare providers are typically well-acquainted with cumbersome tools that disrupt, rather than enhance, communication and workflows. We designed Commons with the goal of providing a seamless experience for care teams. Commons enables communication and coordination — resulting in improved care planning and, ultimately, driving better outcomes.
Our belief that “health is local” inspires how we deliver care to low-income neighborhoods.

What have we learned so far?

Effective care starts with understanding and addressing social challenges. From the outset, we believed that Cityblock’s care delivery and technology products had to be designed to drive trust, accountability, and engagement. Since we launched our Neighborhood Hub, we’ve learned a tremendous amount from seeing these products in action as we interact with our members daily. That Commons and Member Action Plans from Day One reflect the issues that matter most to our members — access to food, stable housing, and transportation services foremost among them — helps to swiftly build trust and credibility with members. For the first time, their care teams are focused on what matters most to them, instead of what matters most to the healthcare system. Coordinating the array of services necessary to be responsive to the multitude of diverse needs of our members requires tight partnerships, like the one we’ve formed with Coordinated Behavioral Care, and new tools to enable communication and coordination. Importantly, we’ve also observed that social needs follow economic scarcity, not insurance status, and find significant need for work on the social determinants of health across all our members, irrespective of insurance type.

Our technology must seamlessly support and empower care teams. We’ve methodically begun to retool the entire community-based provider technology stack, with Commons built specifically for value-based care. Freedom from traditional fee-for-service care means our providers focus entirely on improving the way care is delivered, not the back-end complexities. We refine our platform daily to serve our users better and tailor-fit product features to the neighborhoods we serve. And, as is to be expected, there are a whole host of key assumptions we made and functionalities we built that weren’t quite right — so we’ve become good at hearing feedback, analyzing data, and iterating quickly.

Building a company with strong technology roots demands pioneering new ways of work, not just shipping product. We’re stripping ineffective administration, arcane business process, and inadequate tools out of the system, and reorienting it entirely. To do this well, we brought together experts from tech companies and from healthcare. Every day at Cityblock, technologists who have shipped and scaled products at companies such as Google, Uber, and Compass work side-by-side with exceptional clinicians and care providers. Together, they’ve learned to be fluent in product management and clinical languages, collaborating to build technology that enables our care teams to best support each of our members.

We believe “health is local,” and we hew closely to that mindset as we grow. From the outset, we dedicated significant time to learning about the neighborhoods where our members live. As we grow, we’ll continue to deepen our understanding of the communities we operate in, building networks of community-based organizations and integrating members into our co-design process. We’ll continue to hire members of our care teams from the community, as we see those individuals and members as the true experts on their neighborhoods. We’ll codify learnings from each community in our technology, building the right communication systems and processes to support care teams and our members’ diverse needs.

Our growing team of technologists, clinicians, and operators work side-by-side to build healthier communities.

What’s ahead for Cityblock Health?

One thing is certain — we have a lot of work to do. Understanding and building to meet the needs of distinct communities and engaging each member in the right care takes time. There are no shortcuts.

As 2019 approaches, we look forward to delivering care to more members in new communities. In parallel, we’ll continue to grow our tech-enabled care capabilities and deepen integrations with existing community providers. From Commons, we’ll launch capabilities to customize content and platform logic for each community we enter. We’ll introduce tools to make Commons more accessible for our on-the-go users and deepen process automation to extend our care teams’ ability to provide excellent member care. In the next year, we’ll continue to listen, learn, partner, and earn our members’ trust so that we may have the opportunity to support them in reaching their health and well-being goals.

There are millions of people in communities all around the country who have too often been let down by the very system intended to support their care needs. People deserve better. We aim to scale to as many of these communities as we can and to build tools that can be leveraged well beyond our walls. We know this is a major undertaking, but we’re confident that our approach will enable us to help lead the charge into value-based care at the community level.

We can’t do this alone. We’re growing fast and need the help of compassionate and dedicated people who believe, as we do, in the convergence of trust and technology to create a better way of caring for people. Join us, partner with us: together, we will build healthier communities —block by block, one trusting relationship at a time.

*The stories in this post reflect a composite of member experiences and references no specific individual. We use pseudonyms for all member and staff names to respect the privacy of our members and their trusting relationships with the Cityblock team.