AI Bolsters Cityblock Health’s LTSS Expansion

Cityblock Health, whose whole-person care model involves value-based contracts integrated across medical, behavioral health and social care, is now expanding into Long-Term Services and Supports (LTSS) in all 11 states where it is operating. Company President Mike Roaldi recently spoke with Healthcare Innovation about the expansion and some of the ways AI is helping clinical staff and care managers streamline assessments and is supporting data-driven clinical decision-making.

LTSS encompasses a range of health and personal care services for individuals who need help with daily functional activities due to chronic illnesses or disabilities. They are utilized by 8 million Medicaid enrollees, over half of whom are also dually enrolled in Medicare.

Cityblock notes that these enrollees account for over $400 billion of spend on LTSS, of which $284 billion is spent on home- and community-based services. On average, Medicaid enrollees who use LTSS have healthcare spending that is eight times higher than enrollees who do not use these services. 

Roaldi, who joined Cityblock after holding several roles at United Healthcare in the Medicaid and dual-eligible business, spoke about how Cityblock’s approach integrates LTSS care planning and coordination with a member’s total care experience.

Healthcare Innovation: Cityblock has been growing quite a bit in the past few years, hasn't it? What are some of the factors allowing it to flourish? Are there things about its model that has allowed it to scale up. Is the whole-person care approach gaining more traction?

Roaldi: I think first thing is just execution. We have built a very sophisticated operating model — sophisticated or on our side, but simple for the members — so we can deliver on key things that are valuable to health plans. First and foremost, being able to engage members — actually go out and find them, many of whom are largely unengaged with the health system, but then to deliver the right care, in the right place, at the right time. I think we're unique in that regard. I think a lot of existing primary care is trying to add those capabilities to traditional practices, whereas we were specially designed to do this. 

The second, I would say, is the changing policy environment, including, for instance, what states are doing with dually eligible members and trying to integrate that benefit, as well, as some of the changes coming out of the public health emergency. Having a value-based provider that's actually able to reach those members and move the needle on quality and total cost of care is just more valuable than ever to plans.

HCI: We’re going to talk about Long-Term Services and Supports. Do you think there are some misconceptions about this area or things people aren't aware of in terms of the impact that it has on the healthcare ecosystem?

Roaldi: In the industry, I think there's widespread recognition of the importance of it. I think to people not in healthcare, it is very surprising that those services are covered. They're surprised to hear that somebody can get home modifications or durable medical equipment or a personal care attendant at home. And they are certainly surprised at the magnitude of what we are spending and delivering as a country. But then when you explain to them how much it can help with keeping people living independently, it makes a lot of sense, and I find that people respond really positively and see the value of it.

HCI: I think when you talk about the dually eligible and how that's handled between state Medicaid programs and Medicare, most people probably don't understand that either. It gets very complicated.

Roaldi: I think it took me two years of being at United Healthcare to get a pretty good idea of how a D-SNP [Dual Eligible Special Needs Plan] works. And I don't know that I'll ever fully grasp all the implications.

HCI: Cityblock announced it's going to expand the LTSS solutions that it has operated in Massachusetts and some coordinated services in a couple other states. So how many states will this service be offered in? 

Roaldi: We're in 11 states and we're looking to grow to more. There are varying levels of LTSS benefit in each state. Ohio and Massachusetts are the two places where there's the most significant benefit. But we're going to bring this capability to all states where there is an LTSS benefit in that existing footprint and then hope to grow as well.

HCI: Did Massachusetts provide an opportunity for Cityblock to learn what works in this space?  Were there some lessons learned in that market that you can use as you expand? 

Roaldi: Yes. We have had a contract with One Care in Massachusetts for a very long time. Actually our CEO, Toyin Ajayi, was the chief medical officer of one of the plans there. So to some degree, I would say the genesis of the Cityblock model was her experience working with Massachusetts duals. 

We have served the Massachusetts market for over five years and used a lot of what we learned from serving those very complex members to inform this effort. It's an integrated product. They have the LTSS benefit combined with the Medicare benefit. So we can manage the entire person in that construct and can coordinate with their LTSS care managers to ensure that there's synchronization between their primary care and their LTSS services to make sure those those two things are informing each other. The LTSS benefit is informed by what their medical diagnoses are and their activities of daily living that inform their LTSS benefit are also part of their primary care plan.

HCI: Your press release about this says that sometimes legacy LTSS solutions are disconnected and engage via phone or virtual modalities and focus on adjusting care plans at the margins. How is Cityblock’s approach different?

Roaldi: Oftentimes, especially in those markets where the benefit isn't integrated, you have an LTSS care manager who might be doing an assessment and determining how many hours are necessary for that person or what benefits they need based on that assessment. That is certainly helpful and important, but it's a limited view compared to what we can do.

First of all, we are proactively engaging these people on an ongoing basis and establishing a level of trust and dialog with them. Second, we have primary care providers. In some cases we are the attributed primary care provider. In other cases, we just provide a supplement to their attributed primary care provider. 

We also have what we refer to as our mobile integrated care team, which is a team of EMTs that can go into a home, where necessary, when there's urgent or emergent needs, or even sometimes if the member just needs a test done or a long-acting injectable, and we have behavioral health clinicians. So instead of just having an LTSS care manager do an assessment that might tell them what the activities of daily living are, we have the data from all of those different components of our model, informing us not just about home- and community-based service, but also: how does that home- and community-based service interact with what your primary care physician is seeing and what your personal care attendant has observed in the home? With all of that, you get a much more holistic view of what the person needs. You can identify the services they need earlier, and you can coordinate them much better. It's different because it's part of this larger care model, instead of more siloed or isolated.

HCI: Is there a role that AI and Cityblock’s tech platform can play in supporting the caregivers and streamlining administrative burden in this process?

Roaldi: Yes, there are a few different components of that. One is reducing the administrative time, as you mentioned. That’s very important for both clinical staff and care managers. There’s really a shortage of personnel for these services, so the more we can cut down on administrative time, the more those caregivers serving members can focus their time on actual service delivery instead of administrative burden. Ambient listening can help fill out assessments and help with documentation. We also have a continuous learning model identifying the highest member needs. Traditionally, most plans and providers have used algorithmic risk stratification to put people in certain risk categories. This new model involves AI learning the biggest need or likely need or potential acute event on an individual basis, which is valuable in informing what the care plan should be. It is much more precise than that traditional algorithmic risk stratification. We also are increasingly interested in in allowing members to interact with an AI tool if it's helpful to them for information about their care plan.

HCI: Are there things happening on the regulatory front from CMS that Cityblock is interested in? New alternative payment models that you're looking at? Or things happening at the state level?

Roaldi: From a state policy perspective, we're very interested in the integration of the duals benefit, because we can deploy this holistic model.

We also participate in the Advanced Medical Home program in North Carolina. We are definitely keeping an eye on some of the new models coming out of CMS. I'd say at this point, we don't have enough detail to make a decision. 

HCI: Like the LEAD Model?

Roaldi: Yes, and the ACCESS model. But we're in the process of assessing that. One thing we never want to do is sacrifice the fidelity of our model, which was specifically designed to serve this population. We're always assessing the benefits and drawbacks of models, but we are never going to move away from what we think is going to deliver the best patient care.