Cityblock Health

Affiliate Manager

• manages a member panel to support care coordination and social care for high-complexity members
• conducts assessments and screening instruments
• collaborates with psychiatrists, RNs, and Behavioral Health Specialists for case review and care planning
• meets with members in the community as needed
• utilizes care facilitation, electronic health record, and scheduling platforms as needed

Behavioral Health Community Health Partner

Pharmacist

• Provide Comprehensive Medication Management (CMM) in collaboration with hub-based and virtual clinical care teams and provide other pharmacist support services as needed.
• Contribute in the development of a medication management action plan to achieve member self-management goals and clinical outcomes, with measurable parameters and timeline for monitoring and follow-up.
• Communicate and work collaboratively with Cityblock and external providers belonging to member care team to ensure all clinical interventions and encounters are aligned with medication-related goals, and conduct ongoing assessments and refinements to care plan necessary to promote goal attainment.
• Provide direct support to clinical team members for all general drug information, dosing, interaction/adverse effect avoidance questions or member-specific needs.
• Participate in staff education through presentation of medication management in-services, development of educational tools for clinical and non-clinical team members, and training/coaching/facilitating all roles on consistent maintenance of a member’s best possible medication list care management platform, Commons, as well as post-discharge med reconciliation process for providers.
• Help develop medication management and disease state-specific clinical pathways/protocols, with the eventual goal of transitioning to collaborative practice agreements (CPA) with Cityblock physicians, permitting pharmacist to perform member assessments, order laboratory tests, and initiate or adjust medications per protocol to improve the efficiency and effectiveness of team-based care.

Ambulatory Care Clinical Pharmacist – OH, MI, IL

• Meets with members in the community (home, short-term nursing facility shelter, hospital) as needed, including as an extension of the care team
• Cares for members, identifying and addressing their barriers to and social influences on optimal health.
• Coordinates care for a case load of members, identifying and addressing their barriers to and social influences on optimal health.

Community Health Partner

Ambulatory Care Clinical Pharmacist

Manager

• Manages a panel of clinically complex members to support impactable clinical programs
• Collaborates with members to create a care plan and oversees progress
• Coordinates closely with the integrated Cityblock Care Team as well as external providers
• Conducts regular clinical visits and follow-ups per clinical program guidelines
• Supports members in achieving their care plan goals through coordinated care efforts

RN, Care Manager

• Engage and receive members from engagement and care teams
• Describe program expectations and goals to members
• Complete assessment and screening instruments following protocols
• Collaborate with RN Care Manager to determine need for member placement in a different program
• Partner with the RN Care Manager to develop members’ care plans
• Incorporate quality opportunities in care plans
• Support members in achieving their care plan goals
• Bring preliminary goals and identified resources to members to address social and care coordination needs
• Participate in case conferences
• Provide ongoing check-ins with members to follow-up on care coordination needs and care plan progress
• Activate members around preventative care topics and goal progress
• Provide routine non-clinical education on preventative care topics to members
• Meet with members in the community as needed for non-clinical needs
• Complete screenings for emerging needs
• Support loop closure on internal referrals

Community Health Partner – MD

Medical Director

• Develops and implements cost of care initiatives based on segmentation and other population health drivers
• Partners with Cityblock’s Data and Analytics and Population Health teams to understand and map solutions to address drivers of utilization
• Leads clinical quality improvement initiatives that may span multiple locations
• Decreases unnecessary hospitalizations, emergency room visits, and unnecessary speciality referrals
• Participates in case conferences to bring a psychiatric lens to member care
• Supports care team in developing members’ care plans when behavioral health interventions apply
• Guides clinical team on complex clinical cases
• Conducts psychiatric evaluations for members referred to BH or identified through segmentation
• Conducts visits for medication bridging for any member
• Prescribes, as clinically indicated, psychiatric medications
• Completes comprehensive, compliant diagnosis capture
• Works with members until they are stabilized in the community
• Supports members in achieving their behavioral health care plan goals