I started my journey as a practicing doc in a commuinty health center and as a hospitalist in a safety net hospital, and then transitioned to working at a health plan that exclusively focuses on people who are dually eligible for Medicare and Medicaid. For folks who are not deep in this space, that’s about 10% of the total population that tends to have the most significant physical health and mental health needs as well as an experience of living in poverty, and qualifying for Medicaid. These are folks who tend to drive 50-60% of total medical spend, because their health care needs are so complex. Most of them are driven to the hospital as their usual source of care or as a last resort because they lack the type of access to the type of primary care and community-based services that Cityblock offers.

 

So, my career has been really focused in the space, and over the last five years I had this incredible opportunity to co-found Cityblock, along with some really incredible folks, with the idea that we could scale this model to reach many more people, with a real focus on individuals who are marginalized and people living in poverty.

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JL: One thing you said to me I think is a great starting point – the framework you described highlighting primary care, behavioral, and social care as well. Part of the work that we do is trying to articulate that the intention behind implementation matters a great deal. Tell me a little bit about that framework and the intention that underlies the delivery model and the strategies that Cityblock Health has.

 

TA: I think the intention is a very simple one. It comes from recognition that it is both possible and in fact fundamentally necessary to deliver more cost effective, more high value services in the health care system by taking better care of people, and in delivering care in ways that respect them and dignify them, and that meet their needs.

 

The thing I love about the work that we do and the space that we operate in, it is imperative actually that we do right by patients – by “members” as we call them at Cityblock – by meeting them where they are, by building trust relationships with them, by engaging them in care experiences that are affirming, by solving not just their physical health and their diagnoses, but also their mental health and social needs.

 

If we do that, then we deliver economic value to the health care system. And so our business model is inextricably tied with doing what I know to be right and best for the population whom we serve. That intentionality around starting with the member and focusing on putting them first and centering their needs, and delivering a holistic experience of care and its translation through a very well thought out logical model into our business objectives, ensures that we are building with intention.

 

We’re not a company that says we are going to change the world by starting with cash pay only, fee-for-service, focus on commercially insured folks. None of which is a bad thing per se, but none of which has been demonstrated to actually impact those who need it the most in our health care system – folks struggling with the confluence of poverty and social, and mental health, and physical health complexity. We are actually built for purpose for that population, built for purpose with a business model that aligns with our mission and our clinical model, ensuring that intentionally carries all the way through the business and through the experience that our members have.

 

JL: You highlighted person or member centered are. My understanding is that Cityblock Health works on care plans for its members. Tell me about the idea of care plans, and how it accounts for social context and where people work and live? What do those care plans look like?

 

TA: We call them Member Action Plans, and the focus is on first understanding holistically the needs of the member that we’re serving. That’s recognizing you may have hemoglobin A1C of 11, you may have a diagnosis of chronic kidney disease, you may have a most recent echocardiogram that shows that you have heart failure.

 

That’s only one very small part of your entire lived experience. Until we understand the totality of that, we need to understand where you sleep at night, whether you’re lonesome, whether you have trusted relationships, whether you experienced a childhood of trauma, whether your biggest issue on a daily basis is figuring out where you’ll get enough food to feed your family – until we understand all of those things, we actually cannot get to that hemoglobin A1C of 11. We can’t prevent that heart attack or that stroke by getting you on different or better medications because there’s so many other things that complicate your experience of every day health and well-being that we must understand and address.

 

Historically the nuance of all the factors that I described gets buried in a social work note, often, and often it happens once. When a person is admitted to the hospital and the clinical team says, we can’t figure out why this person doesn’t take their medicines, we’re going to consult social work. And rightly so, the social worker on the team historically would take a very detailed social history and would document the richness of and the complexity of this person’s daily experience. All of which are real clues as to why they may be struggling, why they may not take their medications as prescribed, why they may not follow up with their cardiologist or nephrologist.

 

But those clues get buried. They’re siloed; they’re not considered as important as the medications that get prescribed at the regular follow-up visit when they get there, or as the discharge summary that indicates all of the medical needs that have been addressed in the hospitalization.

 

What we’re seeking to do is to really surface all of that richness, and put it in the members voice, make sure that we understand that matters to them. Because I learned very early in my career as a physician that I can’t as a doctor want a clinical outcome for a patient more than they want it for themself. And in contrary to a lot of judgement, bias-laced, implicit beliefs about people who struggle with their health care needs, they want things for themselves.

 

My patients want things for themselves, they want health, they want wealth, they want to be around for their grandchildren, they want to see another milestone.

 

They may express it differently than we may in the health care sense. We may say we want to see their A1C to be less than 8, because that’s how we get a quality bonus. They may say I want to walk down the aisle with my daughter and give her a way at her wedding in December. Those are two very different goals expressed. But the one that matters the most, is the one that the person I am working with holds to be the most important. And because we know that health is so critical to our overall sense of well-being, they’re connected. And to get way from the frame of putting them in opposition to each other – the doctors want this from my patient, the patient wants something else, therefore we’re at odds – we can actually align them in a shared action plan where the care team and the member commit to goals that they hold in common, and we work against those goals together.

 

They include non-medical goals because so many of those non-medical goals are critical antecedents to the medical goals. And the recognition that your health is so much more than the diagnoses and the prescriptions that we actually have to talk about every step along that framework and along that chain of events that enables you to take the medicine and benefit from it, that’s what we encapsulate in the Member Action Plans. That real shared plan of care, that shared document is a really important grounding tool that enables us all to speak from the same basis of understanding of what matters to members.

 

JL: Tell me about how – as these documents come up and you re-engage clinicians who may not be used to seeing goals articulated that way – that’s been like. How have clinicians responded to that, seeing the goals framed a different way?

 

TA: I think a lot of the clinicians that we work with, we know this to be true in our gut. When I talk to fellow physicians at other practices, I ask them often to just recall that patient, and everyone has one of those patients. If you’re in primary care it is the person who, when you come into the clinic for the morning, you see their name on the schedule for the day, your heart sinks just a little bit, despite yourself.

 

Because one of two things will happen. Either they will not show up to their appointment and you’ll spend the rest of the afternoon wondering are they ok? Are they in the ER and I just don’t know it yet? Are they passed out somewhere on a street corner unsafe? Are they ever going to come back to me? I’m not sure, because I know that what happens to them outside of the times when I see them in the office is often so vast and often so dangerous that I’m not even sure if they’re ok.

 

Or they will come to the appointment and you will be either late for the rest of your visits because you’ll spend so much time working through all the things that matter to them. Or you’ll rush through your time and be nagged by the guilt of knowing that you didn’t even scratch the surface of what mattered to them when they came in that day.

 

You’re almost set up to fail for that person. And we know it to be true because of the ways in which, as human beings, we recognize when a patient comes in and they avert their eyes when they meet us, or appear disheveled, or you can smell the alcohol on them, or you can tell that they are not taking their medications regularly, or you can see that they have been in the emergency room four or five times since the last time you saw them – that all is not well. And that the tools to solve that thing go far beyond your prescription pad and far beyond what you can do in a 10-minute office visit, in a typical primary care appointment.

 

And when you ask clinicians, physicians, advanced care practice clinicians, nurse care managers seeing these patients regularly in the community setting, they will tell you all the things they know their members/patients need. They will tell you because they care and because they’re intuitive and because we’re trained to understand these things. But what they will also tell you is that they’re not equipped and enabled to actually solve those problems.

 

So to see encapsulated in a Member Action Plan, all of the things we knew and didn’t know, the things we intuited but had never had time to really dig into, surfaced up for a person with a very clear accountable person and action against each one of those goals, for many clinicians is such a relief. It’s: I don’t have to carry it on my own, I don’t have to ignore or try to lean in to a problem that I’m not equipped to solve; either one feels unfulfilling. And most importantly, because I really do believe that we all go into this into this work for all of the right reasons, I have just that much more confidence that this patient in front of me will get what they need. And that they may ultimately have the tools to live a healthier life.

 

JL: This issue of bridging health care often requires bridging health care and community-based organizations, and other people and groups. This is often said, and in my opinion, easier said than done. How does Cityblock Health think and approach that, and what are some of the learnings you’ve had from that work?

 

TA: I think there’s a few. First, we are in this new chapter of our dialogue around what people often call social determinants of health. That is now more mainstream than it has ever been. And yet, I think we would all agree that the evidence based around what social interventions yield what return on investment from a health care dollars perspective is still really nascent.

 

A lot of the interventions more broadly, frankly, are very broad-based applications of relatively low impact social interventions across a large population of folks, because it helps us all feel like we’re doing a thing, right? We’re screening for x or y, we are referring people who say they are food insecure to a food pantry. That has never been proven to work meaningfully. It may for the scattered individual, and certainly it helps us as health care workers feel like we’ve done something. But the real work in this chapter for us, collectively, is to start to apply the level of rigor that we would apply for any other intervention across social determinants.

 

The first thing is to recognize this is not a one size fits all modality. What I see many folks do is sort of the equivalent of saying every person with diabetes who comes into your office gets the exact same dose of metformin and the exact same prescription for dietary interventions, irrespective of their circumstances, kidney function, or hemoglobin A1C. We wouldn’t do that. And when we think about social factors and social interventions, we probably should think about it the same way.

 

Housing is a great example, the spectrum of interventions are as vast as the difference between diet and exercise, metformin, and three times daily insulin is for diabetes. We could pay to house a person in an emergency respite housing unit. We could engage somebody in a Housing First program where they get very, very clear support around getting housed and mental health and wrap around supports in that housing unit. We could refer a person to a housing agency where they would then get put on a list for Section 8 waivers. We could provide a person with two-night stay in a hotel in the middle of a pandemic. We could give someone a cab voucher to a shelter.

 

All of these are housing interventions. There’s a dose and a dependency associated with each of those interventions that should be appropriately titrated to the patient and to their clinical complexity and to their needs. That level of nuance is something that we’re collectively just starting to understand and build the evidence around. We’re really excited to be contributing to that but recognizing that this is still very nascent.

 

As we address and intervene around this, you have to start with an understanding. We can’t solve things we don’t understand. So, we’ve really invested very heavily at Cityblock in building, what we call, a 360 view of our members. Making sure that we fully understand not just their physical health and behavior health needs, but also the rest of their social needs. Because until you understand them and the interplay between them, you can’t start to intervene.

 

We’ve built heuristic models. So again there’s not randomized control trials underpinning a whole bunch of these interventions, but there’s a lot of really good common sense. As an example, if I’m caring for somebody who struggles with chronic kidney disease and they are now at the stage where they require three times a week dialysis, and they are marginally housed (not sleeping on the streets per se, but couch surfing and spending time with friends and family, and maybe their address has changed five, six, or seven times in the last four months), that person is inherently more vulnerable to their marginal housing than if they had the same housing situation but didn’t require three times a week dialysis (if their kidney disease was slightly less advanced and they were able to be managed with medications alone).

 

I should think about the person whose very daily existence depends on them being able to get to a facility to receive a lifesaving treatment, as very different from that person who perhaps we have little bit more time and tools that we can use. Starting to build out that nuance and understanding about where we might apply different levers for different people as it pertains to social determinants (housing is one example of many) is a really important next step in building the evidence base and building our experience base around how we do this work. You can get at that in lots of different ways, but recognizing the interplay between them is really important.

 

The same goes for folks who struggle with mental health challenges, you get into these vicious cycles. If you have diabetes and you are experiencing physical manifestations of that, you’ve got numbness and pins and needles in your toes and feet, and you find it hard to walk and do your daily activities, you’re also more likely to be depressed. If you’re taking certain medications they’re more likely to make your mood low. We can just see those cycles and we’ve got to understand those interplays in order to start to intervene around social needs as well as behavioral health and physical health needs. That’s a big part of the work that we’re doing.