Within 90 days of becoming a member, the Cityblock Care Coordination team will reach out to you to schedule an in-person appointment for your health needs assessment. Your assessment will be completed in person, or telephonically at your request, by a registered nurse. After the assessment is complete, your care manager will work with you to create an individualized care plan.
Your care manager will then coordinate your care team by working with you and all of your health care providers. Your care team may include your medical care providers (such as a primary care provider or a mental health or substance use counselor), pharmacy professionals and social care managers. Your care team may also include advocates, family members, caregivers, friends, mentors and/or peer supports.
Based on your health needs assessment, your care manager will also help you connect with and coordinate any additional nonmedical resources you may need such as nonmedical transportation.