Behavioral and social care have never been more important to staying healthy

How our company value to “Be All In” drives the type of behavioral and social services we deliver during COVID-19 and beyond.

Ari Rosner, Head of Social Care
Juliana Ekong, Associate Chief Health Officer

In a post from our co-founders Iyah and Toyin on April 16th, we discussed what the COVID-19 crisis had meant so far for Cityblock and our members.

This post is part of a series about our response to COVID-19 and how our work has been guided by our company values: Put Members First, Be All In, Bring Your Whole Self, Aim for Understanding, and Lean into Discomfort.

Today, we explore how our value of Be All In has guided us as we develop additional member initiatives in response to COVID-19.

Our colleagues recently discussed how Cityblock has escalated virtual services and intensified our in-home escalation to deliver medical care when and where our members need it.

Cityblock was founded with a mission to address the social determinants of health because we know that staying healthy requires more than access to medical care. Improving health outcomes and minimizing the inequities in healthcare requires having access to things like nutritious food and the ability to safely care for yourself and others.

Well before the COVID-19 pandemic hit, providing social and behavioral health services to our members was core to our integrated care model. And during a pandemic, our members’ needs for those services increased at the same rate as their medical needs.

We hope that by sharing our interventions and programming described below, more providers can deliver comprehensive care to the communities that need it most.

First, make sure you’re getting the right interventions to the right people.

In March, as the cases in Brooklyn were rising rapidly and New York City hospital systems were struggling to keep up, we were focused on making sure our members were able to stay safe at home.

We needed to keep them out of the hospital, minimize their exposure, and help them quarantine safely. However, many of our members don’t have a support network readily available, or their regularly used supports would put them at risk of exposure. We wanted to help fill this gap by proactively outreaching all of our members at risk (even if they weren’t reaching out to us asking for help) and addressing their most pressing needs.

We created a COVID-19 screening tool for our teams to use while engaging with members that assessed needs related to food access, housing instability, access to medication/medical supplies, social support, interruption of home care services, transportation to urgent clinical needs, and screening questions around depression and anxiety. The tool also assessed for COVID-19 exposure, symptoms, and follow up. Implementing standard questions allowed us to collect consistent data across our member population.

The combination of this tool in our digital platform, and an algorithm created by our data and clinical teams to identify our members who were at high risk of hospitalization or complication if contracting COVID-19, allowed us to prioritize outreach to our highest risk members. Our care team members started outreaching these members using the tool we developed. We quickly learned that there was a critical need for support around food, housing, medication/other supply delivery, and general anxiety/difficulty coping. We immediately built programs to respond.

Design programs to meet members’ needs.

Access to food over the last few months has been difficult for all of us. This was especially stressful for our members who couldn’t get to the grocery store safely, didn’t have a network to assist them, were experiencing financial hardship due to recent changes in household income, and/or needed to stay isolated to minimize exposure.

There were many community resources that were initially available, but they quickly tapped out, had long waits, or didn’t have delivery capabilities.

We developed a volunteer food delivery program that included Cityblock employees as well as a network of existing volunteers in Brooklyn. With the help of these volunteers, we have been able to pack and deliver both shelf-stable groceries and fresh produce to more than 70 members for a total of 285 deliveries over the last three months.

Not only did these deliveries allow our most vulnerable members to stay home, but they also allowed our symptomatic members and those with lab-confirmed results to effectively quarantine themselves. Zero of our previously undiagnosed vulnerable members enrolled in the food delivery program have become sick with COVID-19.

We also launched a high-risk housing program. If a member does not have a stable place to stay, lives in an overcrowded home, or in a congregate setting, they are at an increased risk of being exposed or exposing others to COVID-19.

To ensure our members’ health and safety, we developed this program to place members in short-term housing. In addition to decreasing their COVID-19 risk, we were able to reduce the number of shelter stays and cut down the time to placement in permanent housing.

For example, one of our members had between 5 and 10 emergency department (ED) visits per month prior to us placing her in a hotel. Since she has been there, she has not had any emergency room visits. This has been the longest stretch without an ED visit since we’re known her.

Several other members in this program have used the time in stable housing to work with their Cityblock Community Health Partner to gather the appropriate paperwork, complete applications, and refer to the appropriate housing units/settings.

Our high-risk courier program was developed for similar reasons and utilized our internal volunteer program to ensure our members had the supplies that they needed.

Our volunteers delivered needed medication, cleaning supplies, paperwork for applications, and medical supplies for home monitoring such as blood pressure cuffs, pulse oximeters, and thermometers.

These programs were leveraged for our other markets, and as the situation in Brooklyn stabilized, community coalitions were developed and the city and other resources started to come together. This has allowed our programs to become more sustainable over time and strengthened our partnerships in the community.

Make sure your members know you’re there for them — even if it has to be virtually.

With our members isolated in their homes, and many expressing symptoms of anxiety and difficulty coping, we developed care team-driven virtual programs to create community and reduce stress.

These included sessions on insomnia, tai chi, salsa dancing, chair Zumba, and nutrition classes. We also offered support groups around anxiety, as well as individual sessions with a counselor for short term support. Our community forums allow our members space to ask questions, help one another, and request information about resources.

Lastly, trust your teams who are closest to the work as they best understand these members’ on-going needs

Empowering our care teams to conceptualize and launch new programming is how we will continue to most effectively and efficiently reach and engage our members. Our care teams build relationships with our members based on trust and respect — and know the needs of our members best.

We will continue to show up for our members by delivering personalized care and services. We are available to them not only in their homes and communities but also 24/7 via the phone, video calls, and over text. Through our data-driven approach, we strive to ensure that the right members are receiving the right resources at the right time.