The Cityblock Neighborhood Hub is nestled between a Dunkin Donuts on a busy stretch of Eastern Parkway in Crown Heights, Brooklyn. Inside, it’s an oasis. The décor is soothing and minimalist: blue leather couches, ferns, and paintings by local artists. To the right of the waiting room is a childcare space furnished with a bright red bean bag chair and a carpet decorated with cartoon animals.
Right now, there are two people in the waiting area: an older man with a beard and a younger woman. Behind the reception desk, three Cityblock employees answer calls. There is a sense of constant motion, but without the usual accompanying anxiety. Unlike an urgent care clinic, for example, it doesn’t feel transactional, like you’re waiting for a service to be rendered in the minimum time.
Members—a term Cityblock uses in lieu of “patients” for those in their community of care—come in for a variety of reasons. Many of them aren’t acute issues that need immediate attention. The Neighborhood Hub is a place that people can visit before they’re sick; some visit for help with the day-to-day management of a chronic illness. Rather than being prescriptive or dictatorial, Cityblock wants to make healthcare fit into the lives of their members.
Three miles away, at an office in Dumbo, Brooklyn, about half of Cityblock’s growing 150-person team works to support Cityblock’s members and their healthcare providers. The Manhattan Bridge looms outside the tall windows of the company’s brightly lit office, which, like the Hub, has a quiet hum of activity: teams huddle around desks, groups meet in glass-walled rooms around the perimeter of the office. A long wooden table separates the kitchen from the office, where employees gather for communal lunch.
Here, Cityblock’s employees work to answer a seemingly simple question, one that belies a complex network of opaque policies: How do you make healthcare work for everyone?
— Brennan Moore, Director of Product Engineering
Iyah Romm and Dr. Toyin Ajayi, Cityblock’s co-founders and its CEO and Chief Health Officer, respectively, believe that health is the issue of our lifetime. Indeed, it’s hard to overstate just how inequitable the US healthcare system is.
As of May of 2018, 15 percent of Americans did not have health insurance, according to a Commonwealth Fund tracking survey. From 2008 to 2018, premiums for family coverage increased by 55 percent, outpacing wage growth. A 2014 study from the CDC found that almost 900,000 Americans die prematurely from the five leading causes of death, but that 20 percent to 40 percent of the deaths from each cause could be preventable.
A 2017 study published in the Journal of Primary Care & Community Health found that socioeconomic status affects individual health outcomes as well as the quality of healthcare they receive: people with lower socioeconomic status are more likely to have worse self-reported health, lower life expectancy, and suffer from more chronic medical issues than the wealthy. The study also found that physicians were less likely to perceive their lower-income patients as “intelligent, independent, responsible, or rational,” and that they consider them “less likely to comply with medical advice and return for follow-up visits.”
That’s a huge problem.
Cityblock, which was incubated in Alphabet’s Sidewalk Labs and spun out on its own in October 2017, wants to change this, focusing on bringing better care to people living in lower-income neighborhoods, including those who access Medicaid or are dually eligible for Medicaid and Medicare. They want to address the underlying social and economic factors—such as lack of transportation, limited food access, even loneliness—that acutely impact health, but are often left out of traditional healthcare models.
“The first thing to acknowledge is that the healthcare system itself can be re-traumatizing, so we need to stop that first,” says Ajayi as she reclines on a blue couch. “What does it mean to have trauma-informed spaces, to use language that is supportive and empowering of people, to ask consent in everything that we do, and to partner with our members in crafting their own care plan? That is itself really important.”
Ajayi sits next to Romm, who is wearing striped blue socks sans shoes. Romm was 22 years old when he suffered a traumatic brain injury that left him legally blind for three years. In a fragmented and chaotic healthcare system, he found himself having to navigate the bureaucracy of the traditional healthcare system while also recovering from a debilitating injury.
Ajayi and Romm, who previously worked together at nonprofit healthcare organization Commonwealth Care Alliance, designed Cityblock around two initiatives to address the failings of the US healthcare system. The first is the creation of Neighborhood Hubs, the home base in the Cityblock model. At these local clinics, a wide variety of medical professionals work with members. These sites offer a new paradigm of care: each member is assigned a Community Health Partner, someone who has been hired from the neighborhoods surrounding the Hub. They serve as an advocate, counselor, a social worker, and a personal healthcare docent, and meet with members both at the Hub and beyond it, in the spaces where members live their lives.
The second initiative is Commons, a platform designed to enable teams to deliver better care to Cityblock’s members. Community Health Partners use the system to input real time information on members and organize tasks, as well as communicate with their care teams—their squad of doctors, nurses, behavioral health specialists, psychiatrists—and to work together to develop a personalized program of care called a Member Action Plan. The Member Action Plan doesn’t only address an acute health issue, but its underlying factors as well—and, crucially, reflects the member’s priorities for both their health and their everyday life.
If a member needs food stamps to maintain a healthier diet, their Community Health Partner will get the application, help fill out the paperwork, send it in, and follow up on their behalf. If a member needs transportation to get to an appointment or a meeting, their Community Health Partner will arrange a ride to the Hub. If a member is unable to travel, their Community Health Partner will visit them at home or set up a video chat with a doctor.
“[Commons] itself fundamentally flipped [the standard model] on its head, in that, in a traditional healthcare technology platform, the medical would be most important and then you’d have some behavioral health stuff over there as an add-on, and the social stuff would sit over here in a different ecosystem,” says Romm.
People would then have to navigate a number of other systems to access social and behavioral health services. But Cityblock brings all those care areas together, uniting seemingly disparate concerns—the medical, social, and psychological factors that impact health—in one platform. By providing holistic healthcare, Cityblock believes they can address the system’s inequities.
Brennan Moore, Director of Product Engineering, considers learning about the lives and needs of members essential to his work. Because the communities with which he works understand what they need, he says, it’s just a matter of making resources accessible. Their feedback goes right into the technology he develops, and he can see how immediately it helps Cityblock’s members.
“The teams use Commons every day, and it’s transformed how they provide care to these very high needs members,” he says. “Coming from the somewhat anonymous world of consumer tech to this area—where there’s such a deep connection with our members, our team, and the impact we’re having—can be a very emotional process.”
Cityblock partnered with EmblemHealth in 2018, and their first and, for the moment, only Neighborhood Hub is embedded in one of the nonprofit insurer’s sites in Crown Heights. They also share the building with an AdvantageCare Physicians New York practice, where many of their members already receive primary care. When I entered, Community Health Partner Kellie Foxx-Gonzalez was having an informal meeting with a member, discussing the next steps in their Member Action Plan.
According to Theresa Coffin, one of Cityblock’s clinical operations leaders, one member comes into the Hub just to have a cup of tea and relax when she feels anxious. This is the ambiance Cityblock hopes to create: the Hub isn’t just where you go to see a doctor, but also a multipurpose space, always available to its community.
Cityblock’s providers include physicians, nurse practitioners, physician assistants, behavioral health specialists, and psychiatrists, who work together to deliver coordinated care. This manifests physically: at the Hub, for example, doctors and psychiatrists are across the hall, so members can access medical care and meet with a behavioral health specialist all at once. It’s a model that goes beyond diagnosis. The physical proximity of each member’s healthcare providers makes it easier to find holistic solutions to many-sided problems. But it’s really the Community Health Partners who are the driving force in Cityblock’s care teams—they are the members’ advocates, ensuring that they have the support they need.
Nworah Ayogu, the Medical Director at the Crown Heights Hub and an early member of the Cityblock team, is running late to speak with me; he was called into a video meeting with a nurse calling from the home of a member. At the Hub, he serves as a physician—but before attending medical school, he worked as a community organizer and founded a technology healthcare startup in South Africa. As we sit at small circular table in a meeting room at the Hub, he describes Cityblock’s work with vibrancy and enthusiasm.
“DNA is double stranded, right?” he says, twisting his fingers into the shape of a double helix. “That’s us. Our tech and healthcare are wrapping as a double strand, because there are ways in which the tech portions have come into the way we do things in healthcare...and healthcare is very person-focused, so the product team has taken some of our member focus into the way they do things.”
“I like to look at medicine as capacity building. What we are doing is a means; it’s not the end,” he said. “My job is to remove a health barrier so that you can live a fulfilled life: play with your children, play basketball, make music, do art, whatever it is. That’s the end. What we do is the means.”