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 Transition of Care Nurse, 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 meeting with the member at the healthcare setting, reconciling medications, meeting 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 Readmission Reduction Team that will be accountable for managing the post-discharge and readmissions processed. 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-decision making, and partnership across clinical and non-clinical care team members, including in partnership with the Readmissions Community Health Partner.
- You will maintain a fluctuating panel shared with the Readmissions Community Health Partner of anywhere between 30-120 members as they cycle through the 30-day post-discharge period, depending on the volume of admissions and readmissions
- 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
- 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
- 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
- Schedule in-home visit to assess safety and risks and implement evidence-based interventions and protocols for complex chronic conditions
- Assist members with medication reconciliation, medication administration & medication management
- Proactive Mitigation:
- Weekly follow up by the Transitions of Care 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 member to Cityblock Health
Requirements for the Role:
- Active, unrestricted Registered Nurse license in the state in which you are seeking employment with Cityblock
- You have 3+ years of experience as a Transition of Care Nurse or Post-discharge work.
- Your day-to-day will be a combination of virtual visits and telephonic visits.
- Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members
- Experience managing a panel of members
- Experience in transitions of care management, both in-person and virtual
- Experience as an active participant in continuous quality improvement projects within a provider setting
- Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), assessment, and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression.
- Demonstrate the ability to affect change, and have been effective in helping a member or patient adopt new habits or change behaviors
- Excited about how technology can support your work and help drive the ongoing evaluation toward new and better care
- Independent self-starter, a leader, and a strategic thinker who is excited about the big picture of whole community health, and the ongoing evaluation and iteration of our care model
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
- Ensure that all member’s medications are accurate and follow prescriber’s orders
- 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 coordinating multi-disciplinary care for members with multiple complex medical and social conditions
- Experiencing caring for individuals with criminal justice involvement
- Experience in hospice, acute care, and/or care management
- Bachelor’s degree preferred
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.