Population Care

This N.Y. “startup” clinic tackles health's social determinants

Cityblock Health is a startup company that uses high-tech tools to deliver personalized, high-touch care to low-income residents with multiple health concerns.

Practicing medicine in this way may also be a “prophylaxis against physician burnout,” Cityblock Chief Health Officer and co-founder Toyin Ajayi, MD, told a gathering at the AMA’s Chicago headquarters.

“I love my job; I love being a doctor,” Dr. Ajayi said. “I’m excited to get up and go to work each day—and many of my fellow physicians are not.”

Cityblock was launched in 2017 as a spinout of Sidewalk Labs, which is a subsidiary of Google’s parent company, Alphabet. Within four months, Cityblock had raised more than $23 million in investment funding. It was also one of the first companies to receive an investment from Town Hall Ventures, a venture capital firm led by Andy Slavitt, former acting administrator of the Centers for Medicare & Medicaid Services.

“We need to stop investing in the third Fitbit for the 50-year-old upper-class person and start innovating for people who have common diseases and conditions, but live in communities with low access to care,” Slavitt, a 2017 recipient of the AMA’s Dr. Nathan Davis Award for Outstanding Government Service, told CNBC.

The AMA is improving the health of the nation by confronting the increasing chronic disease burden. The AMA is committed to helping America achieve no new preventable cases of type 2 diabetes, all adults meeting their blood pressure goals, and an end to the opioid epidemic.

Back at Cityblock, the model includes integrated primary and behavioral health care combined with social services to meet the complex needs of patients that may be further complicated by substance-use disorders, poverty and unresolved issues stemming from traumas either witnessed or experienced.

“The traditional health system fails to meet their needs, and we see it in ED [emergency department] visits and disparities in key outcomes of health and well-being,” Dr. Ajayi said.

Dr. Ajayi described how a patient’s death inspired her to practice differently.

The patient, in her 40s with two children, was someone traditionally labeled as “noncompliant.” She was struggling with substance-use disorder, severe and persistent asthma, and was in and out of the hospital or emergency department in a “constant revolving cycle.”

By “traditional measures of quality,” the staff did a good job with this patient, Dr. Ajayi said. They did all the right things, such as dutifully making recommended follow-up calls, but still failed to meet her needs.

“What could we have done differently?” Dr. Ajayi wondered. She reviewed the patient’s chart and found that she received fragmented care from 20 different physicians in the last year of her life. She also learned that no one addressed the woman’s sleep troubles, which stemmed from the trauma of deep personal losses early on in life.

Dr. Ajayi began to question how she approached her practice of medicine, given the challenges she faced in delivering high-quality care to her patients within the constraints of a system that wasn’t set up for success. These challenges include trying to solve four major health issues in a 15-minute visit or writing a $400 monthly prescription without realizing the sacrifices it might take for patients to afford that medicine.

Emphasizing health over health care

A realization came that there needed to be accountability for health—not just the delivery of health care services.

“What does it look like to scrap it all and build from scratch?” Dr. Ajayi asked.

She found out by discovering a “community of like-minded people” who went about designing a new primary care infrastructure for a high-risk population.

The patient is in the middle, surrounded by a team who meets patients’ needs using new communication tools. To achieve this, Cityblock created a new health care job as a critical part of their care teams.

Cityblock hires and trains nonclinical “community health partners.” They are people, often from the neighborhoods Cityblock serves, who meet with patients in their homes. These partners may not always have an advanced degree, but they possess empathy, tenacity and strong listening skills.

“Patients,” by the way, are now “members.” And, instead of clinics and offices, Cityblock operates from “neighborhood hubs” that are located next to public transportation and include free internet and common spaces that provide room for classes, family counseling, and social events.

In April 2018, Cityblock partnered with the nonprofit health plan EmblemHealth to reach members facing complex health and social needs in New York neighborhoods. In mid-2018, Cityblock opened its first hub, co-located with AdvantageCare Physicians, an EmblemHealth-affiliated multispecialty practice in Brooklyn.

Common connection for data

Cityblock’s technology platform is named Commons. It enables Cityblock’s on-the-go care teams to see each member’s health and social needs and goals, and to coordinate their care. Cityblock also has technology to support telehealth services such as texting and videoconferencing with patients.

The platform is also used to manage “member action plans” and prioritize next steps using data from electronic health records, health information exchanges, claims and other sources.

The technology is also being used to build a body of practical decision-support evidence.

This could include helping patients determine the three most important things someone with multiple health concerns must do to stabilize their conditions. For example, a person may present with chronic obstructive pulmonary disease and schizophrenia. They may also be homeless—so they cannot use medication that requires refrigeration.

Decision support should answer the question, “What works for a person who looks like this?” Dr. Ajayi said.