A Healthcare System that Heals - Dr. Toyin Ajayi, Chief Health Officer of Cityblock Health

SHIV GAGLANI:Hi, I'm SHIV GAGLANI. Today, on Raise the Line, I'm happy to be joined by Dr. Toyin Ajayi. Dr. Ajayi is Chief Health Officer and one of the co-founders of Cityblock Health, which is a New York based health and social services company that serves low-income Medicaid populations. She's also a board-certified family physician and continues to practice primary care and hospital medicine with the focus on patients with chronic, complex and end of life needs. Dr. Ajayi, thanks so much for taking the time to be with us today. 

DR. TOYIN AJAYI: Thanks for having me. 

SHIV GAGLANI: Can you start by telling us a little bit more about yourself and what led to your interest in healthcare and then family medicine?

DR. TOYIN AJAYI: Sure. I grew up in East Africa, in Kenya, and experienced very early on the massive disparities in health outcomes and social outcomes based on income, based on a whole host of kind of externalities around me. I grew up at the height of the HIV-AIDS epidemic and saw firsthand from the very beginning the impact that health and social policy can have on people's outcomes, so my entire childhood was really steeped in the notion of social justice and the idea of service. 

For me, medicine was a really natural extension of my interest in science, my interest in research and evidence, as well as the real desire to have a tangible impact on people around me. In fact, I made family medicine as a way to really gain as broad a skill set as I could have and be able to focus on a lot of the things that I’ve found that I continue to love about practicing medicine…sitting with people, meeting with them, meeting them where they are, understanding what they need and helping to build trusted relationships.

SHIV GAGLANI: That's great. I actually didn't know about the East African connection. I actually was born in Namibia. I lived in South Africa, and that's where I got my own interest in healthcare. My dad is a general physician, and following him at the hospital he used to help supervise is what got me interested in pursuing a career in healthcare. It's one thing to become a physician and practice as you do. It's another thing to start one of the most innovative healthcare companies out there, Cityblock. Can you tell us a bit about your role in co-founding Cityblock and where the idea came from?

DR. TOYIN AJAYI: Sure. In retrospect, I certainly never intended to become an entrepreneur, but I've always been a fixer. I've always liked to build systems and solve problems. I sort of have a bias to action and to try to figure out what the root cause of an issue is and just sort of to dive in and fix it. I like to learn new things by doing them so over the course of my adult life, I built things -- organizations, campaigns during the HIV epidemic, a nonprofit in Sierra Leone which I helped to co-lead and run prior to coming back to the U.S. for medical residency.

I didn't know that there was a thing that allowed you to do that in healthcare, but I found myself practicing in Boston doing my residency in a community health center. I found myself practicing as a hospitalist and started to bump up against the ways in which the system was broken, to my perspective. There were so many structural issues that prevented me from providing the type of care that I wanted to provide to the patients that I loved to care for -- the folks with the most complex needs, people struggling with mental health challenges and addiction and social issues, people approaching the end-of-life, who had deep, deep-seated mistrust for the healthcare system and such a gap in the services that they needed. 

I found myself with two choices. I was either to practice in a community health center serving the population I wanted to serve but doing it in a way that just felt so alien to my core values --like a series of ten-minute office visits without the types of resources that I needed, without the real space to meet people really where they were and build those trusted relationships over time or in the hospital. I was working as a hospitalist as well, where again, I was getting to spend time with people and really, really to have the type of impact often at the end-of-life and on the types of courses of disease that I really wanted to touch, but I was seeing people come in and out over and over and over again for things I knew we could do differently. 

I think what sort of led me almost inadvertently down the road of entrepreneurship was that I felt myself becoming more alienated from the work I was doing. I felt a widening chasm between my values and the things that filled me up and the things that had driven me to medicine and the day-to-day work and the things that I needed to do to be successful. I was becoming a really good doctor by the standards of seeing lots of patients. I could write my notes. I could move my way through any EHR as quickly as possible, but I was much less fulfilled, and it felt like something was broken. I was less in touch with my patients and with myself, and a lot of my colleagues I see in practice often tend to sort of think it's them. 

They work harder, or they cut back their hours, or they call it burnout or what have you. I, for some reason, just knew in my gut that the system was broken. It wasn't me. I was a really good, smart person working my tail off, and I wasn't making an impact for my patients, but I was sure that it wasn't me. It was the system that is broken. That led me down a journey of starting to learn how we got the healthcare system that we have, follow the dollars, try to understand how we pay for healthcare and therefore how we get the outcomes that I was seeing, starting to understand the interplay between those root causes, structural factors in our society, in our community, how we fund social services, how we perpetuate racist policies, how does that show up in the outcomes that I was seeing and then started to ask how I could chip away at some of those things over time. 

That led me to value-based care, first through a health plan -- Commonwealth Care Alliance in Massachusetts -- where I finally got to think about a holistic investment in changing outcomes for a population of folks, and then over time, led me to think about what it would look like to do this at national scale at Cityblock. That was the sort of the origin of our vision for Cityblock.

SHIV GAGLANI: I know there's a lot of innovation around primary care, Medicare Advantage plans, and whatnot. One thing that differentiates Cityblock is that you primarily serve low-income Medicaid populations. Can you tell us a bit about some of the innovations that you all have pushed forward at Cityblock and what makes the model work the way it does?

DR. TOYIN AJAYI: Absolutely. Medicaid is such an important program in providing access to health insurance and health benefits for people who are lower income across the country and has long been an area that really is ripe for disruption, for innovation in terms of being able to have an impact on the health and the health outcomes of millions of people who are struggling not only with medical needs but also with the cycle of poverty.  So we knew from the outset that just from a mission and a values perspective, Medicaid was going to be such an important part of the business that we sought to build. 

From my experiences as a clinician and as an operational leader in organizations that served primarily a similar population -- including folks who are duly eligible for Medicare and Medicaid -- there were a couple of core features that I knew that we needed to build from the outset. The first is a recognition that behavioral health needs pervade throughout our population in general, but there are significant access issues and supply issues around behavioral health services, in those communities in particular that had in many instances the greatest needs, so we built our care model with full integration of behavioral health with physical health as a core central tenet and that included ensuring a point of service, “no wrong door” care for people with serious mental illness, folks who are struggling with addiction, as well as for people who are struggling with the sequelae of trauma. 

When you think about what it feels like to have grown up in some of the most impoverished communities in our country -- having lack of access to a whole host of even basic social services, having experienced significant childhood trauma and social disruption -- those challenges pervade throughout your life. The healthcare system can either perpetuate trauma, which it very frequently does for these patients by treating people disrespectfully, by being inaccessible, by being patriarchal and disrespectful, by being untrustworthy and not following up, or we can actually provide care that is respectful, that's trust-based, that's relationship-based, that seeks to affirm the autonomy of the people we're serving and partnering with them and also seeks to understand where they're coming from. That is really a core component of our model. It pervades how we resource our care teams and the types of programs we focus on. It's directly manifested in our ability to engage the population that we're serving and to work with them to incent behavior change. That's one piece.

The second piece that we really innovated around in order to serve the Medicaid population is on the data and technology side, particularly around analytics. What you'll know, I'm sure, and your listeners will know, is that there's a proliferation of technology tools and data and analytic tools aiming to create insights into population health, specifically targeted in particular at populations that have a significant burden of physical health needs, chronic conditions, medication issues where the signal and the tooling sits on top of data that are readily available in healthcare. 

A lot of these technologies and a lot of these data analytics platforms basically draw from data that are available in the electronic medical record, data that are available through healthcare claims, data that are available from pharmacy records and use that to try to generate a sense of who's high risk and who's not high risk, who's likely to go to the hospital, who needs a certain type of case management intervention and who doesn't. But what we know in the Medicaid population, in particular, is that there is a whole host of other factors that drive risk in Medicaid that aren't visible in structured data and typically structured data sources.

Whether a person has a place to sleep at night is a far more important predictor of whether they're going to end up in the hospital than their medications on their medication list. Whether a person has strong and longitudinal and trusted relationships with family members or with a healthcare provider, that is a massive, massive predictor of whether or not they're going to be stable through readmission, a risk period, or whether they'll come right back into the hospital. Most of the tools out in the market lack that kind of data and lack those kinds of insights that are really targeted towards understanding the full 360-degree view of a patient and of their community and of their risk factors. So, we started to build custom technology tools that really, really take into account the full view of the member and the individual patient's experience through a combination of the typical health data sources, as well as a significant investment in pulling in behavioral health data, and then finally creating a trust-based framework that allows people to share their social data with us because factors like “Do you have enough food to eat?”, those are really hard questions to ask a person if they don't trust you. 

They're really hard questions to infer the answers to without actually getting proximate to the patients that you're serving, so we sought out to actually gather that data from our members and use it to inform an analytical engine that helps us better predict the impact and impactability of individual members at various journeys, at various points across their journey so that we can target our clinical teams and our interventions effectively to improving their outcomes. Then finally, we think about the importance of omnichannel access any time, any place, anywhere, really meeting people where they are, because we recognize that the traditional healthcare model relies very heavily on bricks and mortar. 

Even some of the most innovative practices that are focused on Medicare Advantage, a big part of their model is getting people to the clinic in order to access care from doctors and nurses, and others on the care team. We recognize that, particularly for folks in the Medicaid population, they may not have access to transportation or the ability to take time off from work in the middle of the day to come to a doctor's office appointment or child care to cover them when they come in or frankly, the desire to prioritize one hour or a two-hour trip to the doctor's office over all of the other things that they're solving for in their social lives. So it became even more important to make sure that our clinical model was truly able to meet people wherever they were, so the majority of our care is community-based. It's in people's homes. It's meeting them in the Dunkin Donuts. It's accompanying them to other appointments. 

We use asynchronous communication via text messaging, our app, inbound phone calls, outbound phone calls, emails, every way that we can to get connected and stay connected with people and to make sure that they know that they can access us any time that they want or need, and that extends all the way through to being able to provide high-intensity clinical services in people's homes. We do a tremendous amount of clinical home visiting, as well as bringing people into the clinic when they choose to come. They may choose to come for a whole host of reasons other than just clinical care, really creating a community-based setting. 

SHIV GAGLANI: That sounds very comprehensive, and clearly, you guys have thought through all the issues -- trust-based care, value-based care. I'd love to hear what the size and scope are right now of Cityblock? Do you have any results that you'd be able to share as to how the model is working?

DR. TOYIN AJAYI: Yes, absolutely. We've been in operation for about three years. We launched our first market in Brooklyn, New York, where I actually live, in the summer of 2018, and we are now live in four markets. We have practices, and we have members that we serve in New York, Connecticut, Massachusetts, and Washington, D.C. We serve tens of thousands of members across all of those populations focused on folks with complex and chronic needs in the physical health and behavior health in the social space. 

We're starting to see outcomes. We're starting to see that our first cohorts of members are demonstrating significant reductions in acute hospitalizations since their engagement with Cityblock. We're starting to see reductions in the total cost of care. We have a net promoter score, which is sort of our measure for patient satisfaction, that is in the 90s, which is really quite a tremendous feat in healthcare. We're reaching engagement rates in orders of magnitude greater than has typically been thought to be possible in these types of populations. We're able to find people, connect with them, build trust with them, understand what's going on for them, and then drive interventions that improve their overall health and well-being and reduce their hospitalizations, in particular ambulatory care, sensitive inpatient admissions -- so the types of hospitalizations that could be averted by effective and comprehensive community based-care.

SHIV GAGLANI: That's fantastic traction and progress so far. Obviously, you've scaled quite a bit in three years…four different markets, many covered lives. COVID has thrown a curveball in many areas of healthcare, in many areas of life, and also the issues that have been exposed around racial injustice, which have been there, but this year has certainly been a banner year for awareness around it. I would love to hear how both crises or both issues have affected your operations at Cityblock and what do you think are some of the lasting changes from both for Cityblock and healthcare in general?

DR. TOYIN AJAYI: It's so fresh and hard to prognosticate, I think, in some instances, although there are some things that I think are obvious that we can start to point to. I think we’re still grappling with the fallout and the consequences of COVID, particularly in communities like the communities we serve, folks with complex needs, folks living in lower-income communities, communities of color. We knew very early on as the pandemic started to roll through the United States that our members would be among the most vulnerable, so we worked incredibly hard to identify who of all of our members are at the highest risk to make sure that we did outreach to them, to make sure that we were asking very specific and targeted questions around how we could help keep them safe and their family safe during this period and to make sure that they had all the resources that they needed, such as a 90-day supply of prescriptions. “Is there enough food? Do you have emergency contact information? Do you have PPE? Do you know what the signs and symptoms of COVID are to watch out for?” 

We did a tremendous amount of work just covering and reaching out to our members. Where we are fortunate is because of our structure -- our value-based care model that makes sure we receive funding from the health plan partners that we contract with to maintain support and care delivery to our members irrespective of modality -- meant that we were able very quickly to pivot even further towards virtual care and to ensure that we were not only maintaining but actually increasing our engagement with our members and also that we were able to spin up very novel and innovative ways of reaching people and meeting their needs. 

For us, what that meant with COVID was that we were seeing our members more frequently than we had done before. We were seeing people using video visits, and of course, with our regular other asynchronous telehealth modalities, we were also seeing people in their homes deploying highly trained, highly responsive clinical teams of paramedics and nurses and doctors and nurse practitioners into people's homes in full PPE to provide the kind of clinical evaluation and treatment that folks needed. We're providing rapid initiation of substance use disorder treatment if needed. We were doing all of the things of our model in whatever domain, whatever modalities we needed to in order to meet their needs. 

We were also partnering in innovative ways with community-based organizations to make sure that our members with social needs were well cared for, including creating a program to help put people in hotels if they were unable to socially isolate or they needed a place to recuperate with COVID symptoms and they had no home. I do hope a lasting sequela of COVID will be that value-based care models are more resilient at times like this when a pandemic means that our traditional model of care delivery -- which is dependent on people leaving their homes, perhaps getting on public transportation, coming to a doctor's office, sitting in a waiting room with a whole bunch of other humans in order to receive care -- that is not the most resilient way to resource a healthcare system. Because what it's meant for so many other primary care providers is that they've struggled to keep their doors open and they're struggling with liquidity issues, and they're struggling to just maintain their clinical service availability and access because the fee-for-service model of care was not responsive. It was too brittle to respond to the needs of the community at a time like this. That, I think, will be lasting for us and for many others in this space. 

How does this relate to this sort of newfound, heightened recognition of structural racism and its effects and impacts and driving massive disparities in health outcomes, particularly for communities of color? I think that COVID was just yet another example, another illustration of how much work our society as a whole has yet to do to reckon with the history of racism and the legacy of racial injustice. It happened at a moment in time where we couldn't take our eyes off of it. It happened in a moment in time that happened to just coalesce with yet another murder of an unarmed black person. For once, it felt like, and is feeling like, we have a moment of national attention on this crisis and we’re starting to see, we hope, some real movement to addressing this. 

What does this mean for us as a company that is rooted in community care, that is rooted in caring for communities with complex needs, communities that are in every single way you look at it struggling with the sequelae of injustice and disparities? It means a continuation of the work we've been doing. It means continuing to pour fuel on the fire that we have had as a company about making sure that we are an anti-racist company, building policies and processes, language norms, ways of being that interrogate our biases from top to bottom, that make sure that we are creating an inclusive environment for our team members, that our team members feel empowered, feel supported, feel included, feel heard and feel able to treat our members and patients that we serve with the same dignity, the same inclusion and the same respect that they themselves are receiving within the company. 

I do believe that your insides reflect your outsides, so ensuring that we focused on company culture, even at a time when we're all remote, because it is so critical. Our people are our greatest asset. They're the folks who do the work on our behalf with our members who need this work so desperately, and then we've been really public about making commitments and affirmations and making sure that our voice is heard in an advocacy space as we do whatever we can to advocate on behalf of our members, many of whom are suffering and living through the exact same injustices and barriers that we have seen play out on the national stage.

SHIV GAGLANI: That's fascinating and super comprehensive, and one thing that clearly resonates is that long-term, value-based medicine is going to be really important to deal with potential future pandemics or shocks to the system. Then also, how are we recruiting, training, empowering our healthcare professionals and staff because there's a lot of people behind the scenes who are contributing to the $4 trillion healthcare industry who we have to figure out how to train in ways that make them capable of not only providing value-based medicine but community-based, trust-based, as you mentioned.

I know we’re coming up on time. I have two final questions for you. The first is, given that you are a physician and entrepreneur…we have many students and early career health professionals in our audience. What is your advice to them about meeting the challenges of COVID and just the national moment we're facing and approaching their career in healthcare?

DR. TOYIN AJAYI: I think this is a tremendously challenging time to be a learner and to be early in your career. I have so much empathy and gratitude for all of the early-career health professionals who are out there doing the work for whom this is their first taste of medicine. What a crisis and what a tragedy it's been. So my advice is to take care of yourselves. We learn early and we build early skills and muscles and rituals that we hope will sustain us through the rest of our career. I think it's different for everyone. For me, some of the keys have been assembling a really trusted group of confidants and colleagues. Mine are my dearest friends from residency. We still talk frequently, particularly when we're going through a collective moment like we are, with so many of us on the front lines of taking care of people struggling with COVID. 

Have people around you that you can be fully real and fully open and honest with where you can share vulnerabilities and you can problem solve and who understand your personal theses for why you are in healthcare, why you are a physician and can support you through the journey. Then also build self-care rituals and routines that will sustain you even during the hardest times. These are things that you will hold sacrosanct, if it's your five minutes of meditation or your 30-minute workout every day, or your early to bed and eight hours of sleep. Build in those routines and hold fast to them because it is so easy for the work to seep into everything, and it's so easy to lose yourself if that happens. Those would be my words of advice.

SHIV GAGLANI: I couldn't agree more, and it's certainly a topic that's come up consistently on our Raise the Line podcast. It’s all about improving healthcare capacity, getting more people into the front lines delivering healthcare, but that only works if they stay.  

It reminds me of one of our other Raise the Line guests, Arianna Huffington. She's made a whole career at Thrive Global on how we improve people, not just healthcare professionals, but people's resilience and help them thrive in the workplace? My last question for you is, is there anything else you'd like our audience to know about Cityblock, about you, about the future of healthcare? We'd love to give you an open mic.

DR. TOYIN AJAYI: I would like people to know that the factors that drive health outcomes for people go far beyond the organ systems, the diseases that we spent so much time learning to name, to measure and to treat. If you have any hope of accompanying and supporting and perhaps steering individuals and communities towards better health, you have to fully understand them. That means sitting for a minute and putting down the stethoscope and putting away the otoscope, stop staring at the X-Ray, close the computer screen and actually look the human being in the eyes and understand what matters to them and what's going on for them. That is not a luxury. It's not a “nice to have”, it's not quote-unquote bedside manner. It is actually the work. It's a fundamental input. I think I describe that in the way that we describe even our data model. It's a fundamental input to making sure that we can understand and therefore engage and therefore intervene and therefore support on the path to better health.

SHIV GAGLANI: Totally. I couldn't agree more. Dr. Ajayi, I really want to thank you not only for taking the time to be with us today but for the innovation you're pioneering over at Cityblock. I wish you all the success as you try to scale that beyond the four markets that you're in.

DR. TOYIN AJAYI: Thank you.

SHIV GAGLANI: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line since we're all in this together. Take care.