Transition of Care RN (Mobile Integrated Care) at Cityblock Health
Cityblock Health is the first tech-driven provider for communities with complex needs—bringing better care to where it’s needed most, block by block. Founded in 2017 on the premise that “health is local” and based in Brooklyn, we are backed by Alphabet’s Sidewalk Labs along with some of the top healthcare investors in the country.
Our mission is to improve the health of underserved communities. Importantly, our solutions are designed specifically for Medicaid and lower-income Medicare beneficiaries, and we meet our members where they are, bringing care into the home and neighborhoods through our community-based care teams and Virtual Care offerings.
In close collaboration with community-based organizations, local providers, and leading health plans, we are reorganizing the health system to focus on what matters to our members. Equipped with world-class, custom care delivery technology, we deliver personalized primary care, behavioral health, and social services to deliver a radically better experience of care for every member and community we serve.
Over the next year, we’ll grow quickly to bring better care to many more members and their communities. To do this, we need people who, like us, believe that everyone should have good care for what matters to them, in their community.
Our work is grounded in a belief in the power of a diverse community. To close gaps in care and advance equity in the communities we serve, we have to start with making our own team diverse and inclusive. Our ways of working are characterized by creativity, collaboration, and mutual learning that comes from bringing together a community from diverse backgrounds and perspectives. We strive to ensure that every person on the Cityblock team, and every Cityblock member, feels supported and included as a part of our community.
- Aim for Understanding
- Be All In
- Bring Your Whole Self
- Lean Into Discomfort
- Put Members First
About our Team:
We employ a field-based, home-based care model and are committed to meeting members where they are--in their homes, in their community, and in our Hubs. You will go above and beyond to connect with Cityblock members in a non-judgmental, respectful and empathic manner, to meet their needs, and to provide feedback to the system as a whole as we strive to do better every day.
About the Role:
As a Transitions of Care RN, you will coordinate with the member, their case manager, and the internal Cityblock care teams to ensure a safe transition from the health care setting to their home, and that they do not return to the hospital. This includes connecting with the member at the healthcare setting, connecting with the member in their home, and ensuring the member has what they need to be able to stay safe and at home.
More specifically, you will be part of a new Transitions of Care team led by the Director of Care Transitions that will be accountable for managing the post-discharge and readmissions processed in all of Cityblock Markets. This team will manage members post-discharge for a 30-day period and respond in real-time to readmissions that occur.
- You will work in a radically different model of healthcare
- Expect collaboration, shared making, and partnership across clinical and non-clinical care team members, including in partnership with the Readmissions RN.
- You will maintain a fluctuating panel shared with the Readmissions RN of anywhere between 30-250 members as they cycle through the 30-day post-discharge period, depending on the volume of admissions and readmissions
- Own the end-to-end readmission prevention process post-admission; this includes, but is not limited to:
- Monitor our internal HIE alert system to quickly outreach to members admitted or readmitted to the hospital or facility
- Telephonic and in-person outreach to the member and their case managers post-hospitalization, ER visit, or Skilled Nursing stay to conduct a comprehensive assessment that includes medical, behavioral, pharmaceutical, and social needs to improve health and reduce the risk of readmission
- Assist hospital staff in creating the discharge plan that will address identified needs and barriers to support a smooth recovery; assess if the member can be discharged. Confirm Consent with the member every step of the way
- Timely Contact Post Discharge:
- Assess the member’s knowledge of their clinical condition and provide education and self-management guidance based on the member’s unique learning style
- Conduct virtual in-home visits or dispatch our Community Rapid Response team to assess safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
- Proactive Mitigation:
- Weekly follow up by the Readmissions Reduction Team with the member consistently for 30 days post-discharge to prevent readmission
- Ensure that the member successfully has a visit with either their PCP or a Cityblock provider post-discharge
- Coordinate care by serving as the member’s advocate with our internal care teams, the attending physician and case manager, and the member’s family
- Return to ED Outreach:
- Respond to return to ED HIE ping within a timely manner in attempts to avoid admission
- Warm Handoff of Members to Long-Term Cityblock Care Team:
- Within the 30-day post d/c period fully enroll members to Cityblock Health
- Comfortable reaching out to new unknown people and following leads to make contact with members
- Leverage strong time management skills to make impactful judgment calls on member care and balance with daily team meetings and skill-building workshops
- Utilize our custom-built care facilitation platform, Commons, and the market’s EMR to collect data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources
Requirements for the Role:
- You have experience with patient navigation, management, or any kind of direct service provision
- You have a passion for working within the community you are a part of or have been a part of in the past
- Hold a Valid RN License
- Experience in transitions of care management, both in-person and virtual
- Demonstrate the ability to affect change, and have been effective in helping a member or patient adopt to new habits, or change behaviors
- You are flexible, team-oriented, and willing to wear many hats
- Work a full-time 40 hour week, Monday-Friday 9 am to 5 pm ET
- Your work may take you outside of normal business hours as urgent member needs arise
- You are experienced in the documentation of member action plans, care planning, care coordination and have excellent writing skills
- You excel at empathy and human interactions and want to improve the health of individuals and whole communities
- You are an independent self-starter and a strategic thinker who is eager to learn, improve, and grow
- You are excited about how technology can support your work and help drive the ongoing evaluation toward new, better, care
How We Define Success:
- Manage the end-to-end transition of the care process to ensure that the members stay safely at home and do not re-admit into a healthcare setting
- Utilize critical thinking skills and excellent communication skills to manage complex clinical issues leveraging assessment skills and protocols
- Meet evolving monthly and quarterly targets for visits with Cityblock members, in both clinic and home setting
- Engage in target setting for new clinical initiatives and managing those targets
- Collaboration with existing care team members
Nice to Have, But Not Required:
- Experience working with individuals with mental health and substance use diagnoses.
- Training in motivational interviewing, behavioral activation therapy, or problem-solving treatment.
- Direct familiarity with clinical settings.
What We’d Like From You:
- A resume and/or LinkedIn profile
- A short cover letter, please!
Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.
We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means.
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