The Rise of Home-Based LTSS and Cityblock’s Unique Approach

“Bringing services into the home allows us to gain a deeper understanding of our members’ environments, proactively identify unmet clinical and social determinants of health, and intervene earlier in their care journey,” explains Libby Graves, Cityblock’s senior vice president of regional markets and market vice president for Massachusetts. “With the increasing number of dually eligible members – individuals often grappling with age-related challenges, disabilities, multiple chronic conditions, and poverty – the home becomes an even more critical point of access.”

Founded in 2017, Cityblock Health has rapidly emerged as a tech-enabled provider focused on delivering medical, behavioral health, and social services to marginalized communities. Serving over 100,000 members and partnering with numerous Medicaid health plans and health systems, the company aims to create a holistic, integrated care experience. As Dr. Kameron Matthews, Cityblock’s former chief health officer, articulated, the vision is to establish a one-stop shop for in-home primary care, ultimately improving health outcomes and reducing overall costs.

What sets Cityblock’s LTSS program apart is its willingness to assume financial risk for both LTSS and medical expenditures. This incentivizes substantial investment in LTSS, with the expectation of reducing reliance on more expensive medical interventions and achieving better patient outcomes. The company’s integrated, interdisciplinary team plays a crucial role in “right-sizing” LTSS, tailoring support to individual needs. For instance, primary care providers can facilitate medication delivery through pre-packaged pharmacy services, potentially accelerating a patient’s transition away from intensive Visiting Nurse Association care.

Home- and community-based services (HCBS) currently account for over 60% of all LTSS spending in the United States. As Cityblock expands its LTSS capabilities, the home is positioned as the central hub for care delivery. However, access to care remains a significant hurdle for many dually eligible individuals, who often face challenges related to housing instability, food insecurity, and transportation limitations. These factors further emphasize the importance of bringing care directly to them.

Cityblock’s rollout across its expanded footprint is informed by lessons learned from its successful Massachusetts LTSS program. Key takeaways include the importance of proactive in-home visits to connect members with services *before* a crisis occurs, and a deep understanding of the local care landscape to ensure seamless integration with primary care, behavioral health support, and specialist care.

“Long-term services and supports are absolutely critical, yet they are frequently overlooked in care coordination efforts,” Graves emphasizes.

Did You Know? The number of Americans aged 65 and older is projected to nearly double by 2060, significantly increasing the demand for long-term care services.

Beyond simply providing services, Cityblock is actively addressing the social determinants of health that often exacerbate health disparities. By understanding the unique challenges faced by each member, the company can connect them with resources to address issues like food insecurity and housing instability, fostering a more holistic approach to well-being.

What role will technology play in further enhancing the delivery of in-home LTSS? And how can providers effectively address the workforce challenges inherent in expanding these services?

Frequently Asked Questions About Cityblock Health’s LTSS Expansion