MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.


Title and Organization


Address 2



ZIP/Postal Code

Email Address

Phone Number

Alina Schnake–Mahl

Evaluation Specialist, Cityblock Health

55 Washington st







Q2 Please describe your company or organizations overall goals and mission.

Cityblock was founded in 2017 on the basis of a simple idea: that cities should be healthy places to live – for everyone. Our mission is to radically improve the health of urban communities, one block at a time. We aspire to be at the leading edge of arming the mainstream healthcare system with new tools and a new approach to caring for underserved urban populations, by delivering hyper–local, personalized care, at scale. Cityblock is partnering with community–based organizations, health plans, and provider organizations to reconfigure the delivery of health and social services. We do this by reorganizing the health system to focus on what matters to our members. We deliver personalized primary care, behavioral health, and social services through a network of neighborhood hubs with deep community–based partnerships and world–class technology.

Q3 Please indicate which category your organization falls under.

Health Care Provider

Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Cityblock Health is a new type of care delivery company built for low–income urban populations with complex needs (Medicaid, Dual Eligible, and low–income Medicare beneficiaries). These high–need and high–cost populations–who have been largely ignored by commercial innovation–require care that can flex in non–traditional ways to address their extremely varied and often non–medical needs. They require a model that puts the social determinants of health first, rooted in approaches that build trust and engagement. At Cityblock, we learn from and augment proven interventions and wrap them into a new care model that we call Personalized Social Care, designed specifically for our target population, featuring deeply integrated behavioral health and social service delivery capabilities. We will take on the financial risk (and incentive) of addressing the physical, behavioral health and social challenges that underpin good health, by employing value–based contracts. In support of this mission, we are deploying multidisciplinary teams of home–and community–based care workers armed with a novel and purpose–built set of digital tools that facilitate collaboration between care teams, social services providers, and members and their caregivers –whether a sibling or neighbor –as appropriate. We will open community–based care centers that provide clinical care, as well as integrate the delivery of social services, and more broadly anchor our presence in the community as physical places where members, caregivers, and local organizations can engage and address challenges in the community and social context.

Our care model employs evidence based screenings, and augments existing screenings using our custom–built care facilitation platform called Commons. Commons helps care teams better understand our members and their communities, build and maintain relationships at scale, work together with members toward shared goals, and drive action and accountability simultaneously. Building on successful models such as the medical–legal Partnership and HealthLeads, we partner with local Community Based Organizations (CBO´s) andsocial service providers to address the social, economic, environmental, and educational needs of our members. Cityblock adds to these models by directly integrating with existing CBOs to ensure that our members´ socialneeds are met, ranging from transportation to connectivity, and layering these social need referrals with delivery of high–touch care as needed, where needed, and when needed, including in–home and after–hours.

We are opening our first care center in Crown Heights in the summer of 2018, in partnership with EmblemHealth, and over time, we plan to grow this partnership across New York. Our purpose–built technology, a highly–leveraged field staff, and sophisticated risk modeling make scaling our model at national scale possible. We aspire to become a national market–leader in value–based care for urban populations with complex health needs.

Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.


Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)

Social and Community Context,

Health and Health Care,

Neighborhood and Environment

Q7 I give the Department of Health the right to share the information submitted in this application publicly (for example: on the DOH website). I understand that there is no monetary reward/reimbursement for my submission or for attending the summit should my innovation be selected.

I consent to have my innovation shared