The Crisis Within the Crisis: Putting our Members First

Because when disaster strikes, people who have historically been oppressed will always suffer more. That’s why we’re here.

Toyin Ajayi and Iyah Romm, Co-Founders, Cityblock Health

We’re about one month into the COVID-19 crisis. A month of unprecedented tears, fear, pride, unfathomable courage, and deepening rage. We’ll never be the same again. This post is a look at what it’s meant for a care provider with a mission to radically improve the health of marginalized communities. Over the next few weeks, we’ll share our stories, experiences, and tools and resources that we’ve built to respond to COVID-19. We hope these can benefit our communities.

We are in the middle of what’s likely to be the peak of the pandemic in Brooklyn — home not just to the two of us, but also to Cityblock’s headquarters, our first community Hubs, the majority of our team, and many thousands of our members.

At Cityblock, we deliver personalized health services to marginalized communities. We are trying to reduce disparities and rebuild trust between healthcare providers, social services organizations, and marginalized groups. Our mission has never been more important.

You haven’t heard much from us over the last month because we’ve been focused on safeguarding the health and wellbeing of communities hardest-hit by COVID, and by the sequelae of systemic health inequities. This is a moment that we could never have anticipated — but yet, at the same time, one we are built for — our clinical and technical capabilities combined with our experience providing care to a truly underserved population has never been more needed.

Our teams have spent the past 30+ days innovating in incredible ways: clinical teams meeting the huge increase in demand for vital in-home care for very sick, frail members; care teams adjusting to virtual modalities; tech teams advancing our capabilities to rapidly identify those at the highest risk of death and serious illness and escalate, track, and coordinate their care. We’ve had a singular focus: to keep our members safe and supported in the community.

What has this month meant for Cityblock?

COVID-19 has crippled the world. It’s challenged our nation. And it has disproportionately challenged Cityblock’s communities. It has also only increased the imperative for us to serve. Because COVID-19 reveals the deep fractures of our society, the inequity of our social and health safety net, and the need for a radical transformation of community health, it lays bare the very reasons that we built Cityblock.

More than anything, the last month has been defined by our commitment to show up for our members in a time of unprecedented need and to meet them where they are, to make sure care is always personal, available, and trust-based.

Here’s what we’re seeing:

Social distancing is beyond challenging, perhaps unfeasible, in communities like ours.

When we’re talking about a disease that is transmitted by close contact with sick people — for which the number one thing you can do to prevent getting infected is to isolate yourself — we are going to see a higher rate of infection in our members’ communities.

At a time when so many other New Yorkers have retreated to their comfortable homes out of the City, shifted to online shopping and home delivery, and adapted to new, remote ways of earning income, our members don’t have any of these luxuries.

Many of our members are forced to leave their homes daily, spending hours on public transportation to arrive at custodial and service jobs (including in healthcare) that they must continue to work in order to put food on the table. They are essential workers for our society to function. Others still lack stable housing. For those members, the price of a roof over one’s head frequently includes sharing sleeping spaces, bathrooms, and utensils with a rotating cast of strangers.

The most fortunate among our members live in multi-generational households, or with non-nuclear family members, typically in very small spaces. They must balance their own risk of infection against their dependency on others — home care workers, neighbors, and relatives — for their daily needs of food, personal care, and physical safety.

We must remember: Physical distancing is a privilege, not a responsibility. For our members, the public health and personal health steps they ought to take frequently come into direct conflict with their economic and practical survival.

Existing inequities in our society become magnified in situations of distress and duress.

The known risk factors (things like diabetes, hypertension, coronary disease, and end-stage kidney disease) are more prevalent in low income and communities of color because they have lacked access to primary care, effective management, education, and health insurance.

These are the folks that are going to get sick and die. What’s more, the very protocols health systems are using to triage who receives access to life-saving treatments in response to this crisis discriminate against those with greater baseline burdens of disease. In a race to save lives, we’ve structurally prioritized white communities.

Prior to the COVID-19 outbreak, our borough of Brooklyn, and in particular Central Brooklyn, where the majority of our New York members reside, already had one of the highest mortality rates in the state, the highest food insecurity rate in the city, and even within the Borough, a 10-year life expectancy gap between the wealthiest and least wealthy residents.

Our healthcare and public health institutions, already stretched and underinvested in, were struggling to provide quality and accessible services to the community. This, in large part, is why we chose to launch our first hubs in Central Brooklyn.

In this pandemic, we see the direct outcome of systematic underinvestment and undertreatment for communities of color. And what’s worse, we see Americans, including many visible, powerful leaders, emerging from the woodwork to deny racism and to victim blame. People of color, lower-income communities, and folks with limited English proficiency are not responsible for disparities. Racism and structural violence are.

For these reasons, and so many others, is it any surprise that people of color, particularly Black and Latinx, are proving to be 3–6 times more likely to die from COVID-19? Moreover, other marginalized communities, disproportionately included among our members, including people with significant physical disabilities, folks with significant behavioral health needs, and people who are LGBTQIA+, are also far more likely to be at risk of COVID-related morbidity and mortality.

The health and social systems that were already taxed and strained are even more overwhelmed by COVID-19 — and that residents in those communities are further underserved.

Despite the currently popularized tropes, this disease is not a “common equalizer,” and that notion must be killed. Because when disaster strikes, people who have historically been marginalized will always suffer more. It’s why we have to show up for our members at this moment more than ever.

The outbreak is further eroding already low baseline trust in healthcare. Our members have seen the worst of the worst. So many have experienced the loss of life and the morbidity of COVID-19 personally.

At a time when hospitals are, for good reasons, refusing to allow patients to be accompanied by family members during their acute stay, and when it is not uncommon for patients to be transported to the hospital in significant distress, the deep historical mistrust that our communities have had in the healthcare system becomes all the more intensified. And stories abound of people who are legitimately sick calling 911 only to be told to stay home instead by emergency responders.

Quite simply, our members are even more afraid to engage with healthcare providers than ever before. They see the data around racial and ethnic disparities in infections and mortality due to COVID, and they know — as we do — that their fears are well-founded.

Those with significant disabilities, who at baseline experience worse outcomes and lower levels of trust in the healthcare system, have also expressed fears to us that they are being ignored; that their care will be rationed.

Stories matter here. It took our breath away, recently, when a long-standing friend and colleague, someone with a significant disability, reminded us of their fear that someone — a healthcare worker — would come to take their ventilator for a younger person. Do we believe that healthcare would actually come to that? No. But the fear is real.

And so they would otherwise suffer at home, often in silence, feeling the judgment and neglect that has so long been broader society’s response to the disparities in outcomes that these communities face. They know that their lives in so many ways throughout history have been treated as disposable by society.

This means that talking with members — and talking to them frequently — has never been more important.

We need our members to know there is someone on their side. And we need to be in touch with them frequently, often daily, on their medical, behavioral, and social needs. It’s the most important thing we can do to keep our communities safe. Even when the world feels like it’s falling apart, we make people feel safe. And heard.

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” — Maya Angelou

So we’ve looked to our teams to innovate and stand up new ways to communicate with and provide services to our members. In the last weeks, we’ve seen a 250% increase in text message and telephonic communication and a 10x increase in video visiting.

While these experiences of the telehealth boom are consistent with many other providers, they bust myths head-on that lower-income communities are not interested in telehealth or that they don’t have access to cell phones. Many of our members far prefer to text than even to video visit or call — in fact, just shy of half of our member interactions at baseline are by SMS.

We’ve connected with many of our members daily — whether with a reassuring text message, an urgent video session, or even an in-home clinical visit when a member’s needs warranted a physician, nurse practitioner, or paramedic.

In the last four weeks alone, we’ve had encounters with 60% of our members — that’s an astronomically high figure for a care delivery organization. Many of our members call to check in, just making sure that we’re here for them; and a kind word, or willingness to listen, to creatively problem solve, and to make sure that they feel heard goes a very long way.

“My care team is a blessing to me in this time.” — Cityblock Member

But building and maintaining trust is only the building block for the radical change we imagine. Over the last weeks, we’ve built new social care services to meet our members where they are, launched net new clinical programs, and expanded our member base significantly to meet community demand for services to help keep folks safely in their communities.

And importantly, learning from New York, we have been able to get ahead of the curve in the other markets in which we work, working closely with our partners to prepare for the impacts of COVID-related illnesses on a broader scale.

What can you expect from Cityblock going forward?

We will stay focused on our members. We will work as hard as we can to care for them — and rapidly scale our ability to serve more people in need and better support our teams and partners.

But we know there are so many other communities who do not have anywhere to turn. And we know caregivers and providers are understaffed and underfunded. So we’ve asked our teams to discuss initiatives and publish the resources they have been developing over the last weeks.

This will include how we:

• Leveraged our data science and actuarial teams to rapidly better understand who was most at-risk for COVID-related illness
• Built simple outreach tools and scripts to reach every one of our highest risk members in the first two weeks
• Accelerated our virtual services offerings built specifically for lower-income communities
• Intensified and scaled our in-home clinical escalation platform
• Launched new social care initiatives most relevant to our members today
• Developed resources to support our care teams, who themselves are getting sick, and are scared
• Are thinking about how COVID shapes the next 12–18 months of care delivery for vulnerable communities
• Are positioning what comes next for Cityblock, for value-based care, and for omnichannel, place-based care

Of course, as we learn more about what new initiatives are making the biggest differences, and as we develop resources that might help others, we will continue to publish them here.

We started Cityblock with an audacious goal serving of 10 million people by 2030. We’re early in our march to radically transform the health of communities, block by block. Our mission and that goal are never more important than today. To our members, to communities that have been systematically ignored and disenfranchised. We see you. We stand in solidarity with you.

And if you’re a community organizer trying to bring about local change, or a health plan provider, or government leader, we can help, please shout. We’re here. We’re focused. And we’re not stopping until all communities have the care they need.

As has become something of a mantra on the Block:

Onward.