Showing Up For Our Members Wherever They Are

A look at how we are leveraging virtual services and in-home escalation to “Be All In” for our members during COVID-19

Toyin Ajayi, Co-founder and Chief Health Officer
Kyle Bailey, Manager of Nursing, Brooklyn
Bay Gross, Co-founder and Head of Product
Elizabeth McCormick, Associate Medical Director, Brooklyn
Kyle Talcott, Head of National Operations

Back in January, pre-COVID-19, we launched a new set of company values: Put Members First, Be All In, Bring Your Whole Self, Aim for Understanding, and Lean into Discomfort.

In a post from Iyah and Toyin on April 16th, we discussed what the COVID-19 crisis means for Cityblock and the work we’re doing, anchored within one of our core values: “Put Members First.”

Over the coming weeks, we’ll share more on our response to COVID-19 and how our values are driving our work to provide care for marginalized communities. Today, we’ll explain what “Be All In” means to us and how we are showing up for our members when it matters most.

In a pre-COVID world, Cityblock approached transforming community health by providing comprehensive medical, behavioral, and social care to people who have been left behind in the healthcare system.

Our focus on engagement has been anchored around the importance of building and sustaining longitudinal trusted relationships between our members and their Cityblock care team — and most of this trust was brokered in-person: in our members’ homes, in local coffee shops, community centers, or our own neighborhood hubs. In fact, pre-COVID, more than 70% of our care was delivered face-to-face. Technology made that care better but didn’t replace significant in-person interactions.

Then COVID hit, and our ways of interacting shifted almost overnight. As individuals and companies learned to connect, collaborate, and co-work virtually, we recognized that in order to continue to meet our members’ needs at a time when they needed us the most, we would have to very quickly shift to be much more reliant on virtual care delivery. And importantly, unlike many other care delivery organizations facing similar challenges, the unique and complex needs of our members made this transition no easy feat.

We accelerated our virtual services offerings.

Our members represent a segment of the population that faces a very high risk of serious illness — and even death — if they contract COVID-19. As the virus became increasingly prevalent in our communities, we recognized that the most important thing we could do to help safeguard the health and wellbeing of our members and our care teams was to limit in-person contacts as much as possible. We had to help our members get the care they needed, when they needed it, without risking exposing them to an infection that could potentially be life-threatening, including the risk of such infection inadvertently being carried by one of our well-intentioned care teams. We also believed that virtual care works for a lot of what we do.

In the wake of the COVID-19 outbreak, we saw a massive expansion of telehealth services targeted at individual consumers, largely tailored to higher-income, commercially-insured populations. At the same time, primary care practices that traditionally care for underserved communities were struggling to keep their doors open, unable to pivot quickly enough to new ways of maintaining fee-for-service revenues.

In this moment, as always, we observed that new technologies and investments preferentially target those with relative privilege, leaving behind lower-income and marginalized populations.

We recognized that virtual care, if deployed carefully and thoughtfully, would be a powerful tool to ensure equity of access to essential health services for underserved communities.

But to do so, we would have to think very differently than the mainstream about how we offer care to our members that preserves trust and longitudinal engagement and meets them where they are.

More than 90% of all of our member contacts are now virtual — facilitated by video, phone, or SMS.

Telephone

As the shift away from in-person care delivery occurred, we pushed to explore and leverage the benefits of telephone, while also understanding its limitations. We found that for many of our members and our staff, the telephone quickly became their primary and preferred means of interaction and engagement with friends, family, and care providers. After all, the telephone is ubiquitous and familiar for most. Our inbound telephone volume increased by approximately 33% in the weeks following the stay at home order in NYC.

We proactively reached out to all of our highest-risk members by telephone and hosted large community-wide conference calls to replicate that “drop-in” feeling of our physical hubs. We worked to develop scripts and tools to support our clinical and non-clinical team members in telephonic triage and escalation. And we trusted that the strength of the existing relationships that our Community Health Partners had built with their members would ensure that our members would continue to feel cared for, supported, and heard — even through the telephone.

But we also knew that we couldn’t stop there. There’s a good body of evidence that telephonic care coordination alone simply does not work for high-risk individuals. And many of our members were experiencing respiratory and other acute symptoms that would benefit from a visual and often in-person examination. So, in parallel, we invested heavily in scaling our video-visiting capabilities.

Video

Over the past few weeks since the COVID-19 outbreak, we have seen our video encounters increase by 150x — driven by a clear increase in demand for ways to connect with and clinically care for our members while maintaining social distance as much as possible.

The use-cases for video encounters at Cityblock are clear and compelling:

• For Community Health Partners, who are experts at building and maintaining trust with our members through personal connection and proximity, video can help ensure that our members feel truly seen and also provides visibility into their physical and social environments.
• For Nurse Care Managers and Pharmacists, the ability to visualize and coach members as they check their own vital signs, administer an inhaler treatment, or unpack the contents of the medicine cabinet is crucial in ensuring understanding.
• For Nurses, Advanced Practice Clinicians, and Physicians triaging members with acute or acute-on-chronic needs, “laying eyes” on the member — observing their work of breathing, directly examining the wound or the rash they’re complaining of, assessing cognition and mobility — is an essential component of effective and safe clinical evaluation. And in particular, with the increase in members experiencing respiratory symptoms and the complex and myriad clinical manifestations of COVID-19, we need all the tools at our disposal to ensure we are embarking on the right diagnosis and the right next steps for our members.
• For our Behavioral Health teams, video has enabled clinicians to meet members where they are, including sometimes curled up in bed under the covers, to read and react to physical cues as well as verbal ones, and to break through so much of the loneliness and isolation that many of our members experience.

In order to deliver these experiences, our IT and product teams have had to partner even more closely with our field-based teams, helping to offer tools to problem-solve challenges like figuring out how to video conference when a member does not have a computer and only has a cell phone; or ensuring that our technology choices enable group video calling between multiple remote providers and one member at the same time — a hallmark of our collaborative model. We’ve also stretched our platform and vendors to quickly support small-group therapy classes and move our successful community events online.

Ultimately the devil is in the details when unlocking these new tele modalities. How can we work across product, engineering, IT, and clinical services to ensure a seamless experience for our members and staff? Scheduling, authentication flows, digital waiting rooms, wireless bandwidth, and basic web literacy all must come together. We’ve leaned heavily on our early adopter clinicians and most enthusiastic members to blaze a trail here for the rest of our organization and community to follow.

SMS

Finally, we continued to use SMS as an important modality that has always been central within our model. 46% of inbound inquiries are already being received through SMS. We anticipate that as we continue to work with our members in this way, the use of SMS could as much as double.

24/7 access

Even pre-COVID, 20% of inbound contact from members happened after business hours. Now, during the COVID crisis, when they develop symptoms (whether of COVID or not), our members and their families are even more reluctant than before to go to the ER or urgent care. They need real-time evaluation and guidance to help make these critical decisions. And, like many of us, they are also experiencing fear, anxiety, and challenges with sleep. In order to truly meet our members’ needs, we had to be ready to respond with clinical, social, and behavioral health support 24/7.

To do this, we leveraged our Virtual Hub — headquartered out of North Carolina and expanding into our local communities — fully equipped with Community Health Partners, RNs, Behavioral Health Specialists, Psychiatrists, and Primary Care Physicians to ensure that we have around-the-clock clinical and social supports for our members.

We took advantage of the relaxation of state licensure requirements to cross-cover our markets so that care team members from geographies that had not yet been hard-hit by COVID would be able to support their colleagues in New York. And while other providers have been forced to downsize their clinical staff, we have grown and are continuing to look to bring on passionate, values-aligned clinicians to join our team. (If you know someone who might be a fit, please send them to our careers page.)

The landscape of Digital Health has changed forever. We have demonstrated that it is possible to engage a high-risk, marginalized population effectively with digital care modalities. As the reality of the next weeks and months unfolds, it will become increasingly clear that things will not simply revert to the way they used to be. Our members will continue to be high-risk for COVID-19 and other infections. We will continue to show up for our members by being available to them through whatever modality they choose.

So we are investing heavily in accelerating our virtual care offerings. Over the coming months, we’ll be launching improved features and functionality around bulk-messaging campaigns and automated member check-ins. We’ll be expanding our video offerings to support not just member and provider conversations, but also more nuanced group sessions and team-based encounters. And we’ll be launching our first member-facing mobile app, unlocking 24/7 digital access to our model and on-demand triage.

We intensified our in-home escalation platform.

As powerful as we have found virtual care to be for our population, we also recognized that many members had needs that could not be met virtually.

Through our virtual encounters, Cityblock care team members were able to identify members who needed urgent hands-on clinical services in order to effectively diagnose and treat acute issues.

But sending these members to the emergency department or to urgent care was more dangerous than ever, and we could see and hear from our members that the physical risks of exposure to COVID-19 during prolonged wait times in our local acute care facilities, as well as the psychosocial reality of being alone and unaccompanied by family, made going to the hospital an even more daunting and undesirable option than usual.

It became clear that keeping our members safe at home would require us to rapidly enhance and scale our urgent in-home clinical response capabilities.

Leveraging our technology tools, scrappy startup DNA, and the clinical experience of our field-based teams, we designed, staffed, and launched a Community Rapid Response program within a couple of weeks — and not a moment too soon. Our Community Rapid Response team of paramedics and virtual physicians specially trained and equipped with tools to evaluate and treat acutely unwell members in their homes hit the ground running just as the COVID outbreak in Brooklyn hit its peak.

During our first week of operations, the team was called to urgently evaluate Cityblock members with a range of needs, including an elderly gentleman living alone whose homecare nurse had stopped coming to visit since the pandemic. He was experiencing severe shortness of breath as a result of worsening heart failure. We were called to evaluate another member with a urinary tract infection that had resulted in dehydration and dangerously high blood sugar levels. And yet another member struggling with dementia who had recently fallen. And, of course, numerous members with COVID-19 infections, struggling to manage a range of symptoms — all hoping to avoid a hospitalization.

Cityblock Community Rapid Response paramedics arrive in our members’ homes clad head to toe in personal protective equipment (PPE) often mere minutes after being dispatched. They are equipped with the tools and skills to comprehensively assess members’ vital signs and physical symptoms, obtain labs and an EKG, administer IV fluids, antibiotics, and other crucial medications, and connect members virtually to an on-call emergency medicine or primary care doctor. The team takes the time to communicate, explain, and ensure careful follow-up for members who need it, providing an experience that ensures members’ needs truly are met — all within the safety and comfort of their homes.

In the weeks since the program launched, Cityblock’s Community Rapid Response paramedics have fit right in alongside our existing team of nurses, advanced practice clinicians, and physicians who continue to show up for our members with the most complex needs in their homes. Every day of the week, our care team members are among the few individuals out in the streets of Brooklyn, dropping off portable oxygen monitors and thermometers for those with respiratory symptoms, caring for chronic wounds, collecting urine specimens and drawing labs, checking vital signs and making medication recommendations, in addition to evaluating and managing urgent needs. We are truly meeting our members where they are.

We’ve seen roles flip across teams. Previously our Community Health Partners, the community care team members who hold primary relationships with our members, were predominantly in homes while our clinical teams provided central support. Now our doctors and nurses are going into homes daily, while our CHPs are building and maintaining trusted relationships by phone, text, and video.

With this ambulatory intensive care level of care, we are able to meet a large range of our members’ clinical needs in the home.

We will continue to learn from our teams and our members.

We are constantly learning how to provide better care, and we are guided by our value to Be All In. Every day, our teams identify new challenges — and then they work to quickly stand up solutions to make sure we can provide the level of care our members deserve.

In Cityblock’s next post, our colleagues on the front lines of care delivery will discuss important initiatives they’ve created to help us Be All In for our members during this unprecedented time.