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How Cityblock Health's Integrated Equity Model Works

Analysis  |  By Laura Beerman  
   January 30, 2023

CEO Dr. Toyin Ajayi details how her approach delivers innovation for patients and payers: "You just prove it."

"For us, it's very emphatic. We are a healthcare provider."

So answered Cityblock Health co-founder and CEO Dr. Toyin Ajayi in an exclusive interview with HealthLeaders that kicked off with the question: Where does Cityblock operate in the healthcare delivery system?

This in a conversation that included payer partnership models and the company's mission to "radically improve the health of marginalized communities at scale," Ajayi continued.

"Cityblock is in the community, providing primary care, behavioral health services, and social care. We are technology enabled and rely very much on data, analytics, and decision-support tools to provide care in a multimodal way: at the right time, in the right place."

Cityblock offers this care via clinical and non-clinical providers who deliver largely home-based care. The company's aforementioned tools help identify need, meet need, escalate response based on a member's situation, and pivot between virtual and in-person care.

Cityblock's integrated care model

"We focus on folks who struggle with the combination of low income and the clinical, social, and behavioral challenges that layer on to that, as well as disabilities. Making their lives is our sweet spot," the CEO said.

For example, Cityblock improved 2022 utilization as just reported in its Equity In Action analysis, including:

  • 20% of ER visits prevented for members seen by the Mobile Integrated Care team
  • 15% fewer ER visits in Washington, D.C. for members engaged in the Advanced Behavioral Health program

The company's social care services play an important role.

"Social care as a concept is something that we did a lot of work to pioneer in many ways, describing what it looks like to encompass trusted, longitudinal relationships and close gaps," Ajayi said.

"We can't address mental health without addressing physical health, and we can't address either without considering social drivers and social contexts. There's a recognition that care models that carve out mental health may allow expertise and specialization in nuanced provider contracting, they don't align with the ways that human beings actually experience life."

"COVID forced us to relearn lessons we should have known already," Ajayi continued. "When you not only have silos, but also trauma that is particularly concentrated in low-income communities and communities of color, you create the perfect circumstances for it becoming no one's problem with people falling directly through the cracks."

"The majority of what we do is in the community"

Ajayi describes Cityblock's model as progressive and tech-enabled to manage high-risk members, of which:

  • 89% are either Medicaid or dual-eligible
  • 85% experience two or more chronic conditions
  • 47% have behavioral health needs
  • 62% have specific social needs

Cityblock's approach and health plan partnerships have yielded results. From Equity In Action, the company reports 90% patient engagement with mature dual-eligible cohorts.

Across all populations, Ajayi stated: "Frequently, as many as 50% of the highest-risk people in a population cohort haven't seen a PCP in 12 months. And that's not because they aren't attributed to one. They have somebody's name on their insurance card."

"But if they're also trying to figure out where they're going to sleep at night or if they can't afford transportation or don't have a cell phone to manage appointments and get to their care—it's no surprise that these folks are falling through the cracks," she said.

"We know who those folks are. And we task our Cityblock teams with finding them. It's a high-intensity, boots-on-the-ground model that leverages team members who live in the communities we serve."

"They can really engender the trust that is necessary to pull people back into the healthcare system and allow us the privilege of serving them," she noted.

How Cityblock chooses markets and partners

In 2022, Cityblock began serving more members after expanding to Indiana in a partnership with MDWise, which Ajayi describes as the state's second-largest Medicaid MCO.

"They share our values," she said. "We launched with them in Indianapolis and Fort Wayne to serve about 10,000 Medicaid members.

Delivering on Medicaid innovation in general is also a priority.

"There's been a real trend there," Ajayi said. "States aren't just saying, 'We want you to manage the population. Here's the rate book.' They're saying, 'We want you to innovate.'"

That includes closing health equity gaps, being accountable for quality metrics, and creating value-based provider relationships."

Ajayi added: "States want plans to move the ship toward value. Cityblock acts as both a primary care provider in their networks and as a care coordination partner for members."

To meet payer needs, Ajayi noted that Cityblock pursues:

  • Specific populations in need and in states with Medicaid MCOs
  • Plans that want to partner beyond managing medical spend and medical loss ratios
  • Deeper, broader collaborations in existing markets
  • Expansion to roughly two new markets per year

"One of the things that is so important to us about building this business is that there is a scalable, sustainable model that can really have an impact for people."

Changing the narrative

This impact involves people who haven't been served well by the healthcare system or regularly included in its innovations.

"There are a lot of myths about the way the economics can and can't work, all of which pose barriers. But today, more people are thinking about these populations, and we played a role in helping that happen. If you're going to launch a healthcare business today, you better be thinking about how what you're doing applies to those most in need—the most systemically marginalized among us.

"We need to continue to push that it's possible. It's our moral imperative. It's a moment in time where we as innovators are not looking at the data and seeing that brown people and people with disabilities are the most disadvantaged over and over again. I want that to not be the story anymore. That requires everybody pulling together to change that."

Ajayi added: "Ultimately, the proof is in the pudding. When we deliver, and as we continue to scale this business, we belie any of the other fallacies and narratives. You just prove it. That's what gets me really excited about this."

“When you not only have silos, but also trauma that is particularly concentrated in low-income communities and communities of color, you create the perfect circumstances for it becoming no one's problem with people falling directly through the cracks.”

Laura Beerman is a contributing writer for HealthLeaders.


Cityblock Health takes on big challenges: delivering integrated physical, mental, and social needs care for the most vulnerable patients.

Through data and analytics shared with payers, the company identifies and meets needs—pivoting care approaches across clinical and non-clinical teams.

CEO Toyin Ajayi's goal is to change the equity economics narrative through data and results.

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