Radically different care for a healthier life.

Iyah Romm

Problem Tech Solves

Cityblock Health is a transformative, value-based healthcare provider for Medicaid and lower-income Medicare beneficiaries in vulnerable and underserved communities. Traditionally thought of as difficult and/or costly to engage, patients within these populations often face multiple barriers to accessing the services they need, and many have had poor experiences with the healthcare system in the past. Current care models don’t fully address all of the contributing factors that may be affecting a patient’s health, including things like access to food, legal issues and housing. Additionally, much of the existing technology today doesn’t allow for the level of coordination and care needed to improve health outcomes, drive down costs and fully address the complex health needs of this population. The current system is failing them. Cityblock Health partners with community-based organizations, health plans, and expert providers to build trust with patients and deliver medical care, behavioral health, and social services virtually, in-home, and via community-based care clinics. These integrated care teams, made up of physicians, behavioral health specialists, social workers, care navigators and more, use custom built tools to meet individuals where they are. For patients, the holistic, tech-enabled coordination ensures that their health needs are fully identified and addressed, with less opportunities for gaps in care.

Tech Brief

Cityblock Health’s approach combines the power of expert providers, technology and data to offer personalized, comprehensive medical, behavioral health, and social care to some of the nation’s most vulnerable populations. This expert coordination of care and services is enabled by Commons, Cityblock’s proprietary care management platform. Commons enables members of the care team from different disciplines, including social workers and behavioral health specialists, to record notes, tag each other with messages, and share takeaways from virtual visits or text messages with patients. With Commons, providers are able to document issues clearly, troubleshoot quickly, and make care recommendations with a holistic understanding of the patient. Cityblock also pairs community outreach, local clinics and virtual care with a software core that surfaces medical and social care issues, identifying potential gaps in care before they spiral into larger, more costly issues. With this approach, data from Cityblock's first member cohort pointed to a 15% reduction in emergency room visits and a 20% reduction in in-patient hospital stays. Cityblock currently sees around 70% member engagement compared to the health plan average of 5-7% member engagement and receives average NPS scores of over 85, compared to the provider average of 15. While delivering these outcomes, Cityblock is experiencing 3x year-over-year revenue growth.

Tech Differentiators

While there have been several primary care-focused initiatives popping up over the last several years, Cityblock Health’s tech-enabled solution is one of the few that specifically targets the unique challenges facing the Medicaid population. Many providers find it difficult to engage Medicaid patients, largely due to the myriad of social factors affecting the health of these individuals. Medicaid members are more likely than other groups to move addresses often, and are more likely to be homeless. They are more likely to live in primary care deserts, where quality healthcare is hard to come by, and more likely to face barriers to care such as lack of transportation, childcare or flexibility in work hours. Cityblock’s interdisciplinary model, enabled by its care coordination technology, is built around addressing the root of these issues. Cityblock providers prioritize spending more time with patients, rather than having to rush through appointments to general higher volumes, as in the traditional model where doctors are paid per visit. This business model is the value-based care model in which providers are paid based on patient outcomes. By bringing together primary care, behavioral health care, and social services under one value-based care model, Cityblock is able to provide high-quality care for the whole person at lower costs.


In July 2017, the Cityblock team took to the streets of New York City in search of their first member. They knocked on doors of the names they had been given by a payer partner, and two days into the search, they found their first member. He was in his eighties, living in the basement of his family's home in east New York. He was blind, did not have any of his medication, and hadn't seen a healthcare provider in years. The Cityblock team did a three hour comprehensive assessment in his basement that same day. He immediately signed up with Cityblock and was able to get the care he needed.

Why Us

For far too long, the U.S. healthcare system has worked for those who can afford to pay for their care, leaving everyone else behind. Cityblock is out to change this, to flip the paradigm of healthcare delivery in this country.

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