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Hospital to home

Our 1-on-1 support helps ease the transition from hospital to home, so members can focus on the important part: getting healthy.
Image of a senior member sitting on a hospital bed wearing a patterned patient gown while looking at the camera.

Extended support after the hospital

Our care starts before you leave the hospital, followed by weekly check-ins and in-home visits if needed. Whatever our members need to settle into their daily lives without returning to the hospital.

Image of a senior member in a hospital gown sitting on a bed and using her smartphone in a hospital room.

Caregivers who go beyond

Our specialized nurses support members every step of the way. They’ll schedule follow-up visits, organize meds, and even connect members to resources like childcare or food delivery.

Image of a community health partner showing a laptop to an older man wearing glasses as he signs paper documents.

Around-the-clock urgent care line*

Our goal is to help members avoid unnecessary hospital visits. That’s why our urgent care teams are on standby over the phone 24/7 to give clinical care and guidance. Plus, they’ll set up a video visit or come to you if needed.

Image of a nurse in blue scrubs taking a member's blood pressure using a manual cuff and stethoscope.

What to expect

Our hospital to home program removes the guesswork of “what happens next”—giving our members a clear view of their recovery.

  • We’ll call you

    Pick up the phone or call us 833-904-2273 (TTY:711) 24 hours a day, 7 days a week. 

  • Meet your 1-on-1 nurse

    They’ll help create a plan for your health.

  • Weekly follow-ups

    For visits, meds, or help getting set up at home.

  • Continuing care

    For ongoing support from your team of providers.

Specialized 1-on-1 support

I’m Tammy, a nurse who knows what it means to be in your corner. I believe listening to our members makes a big difference in their healthcare. The first thing I do is call and talk with members to understand their health goals. From there, I can help with tasks like setting up food delivery or picking up their meds. I’m here to support and advocate for members as they recover and heal.

Image of a nurse care manager wearing a black Cityblock t-shirt that reads "Empathy is my superpower."

Reducing emergency room visits

Our hospital to home program provides a 360-view of a patient’s health following an ED event. We collaborate with our members’ external providers to fill in the gaps—allowing members to adhere to their health plans.

How we work with providers

“It’s hard to find somebody that really, really cares that much.”

Noah credits his Cityblock nurse for giving him the confidence to undergo a critical surgery.** He says she’d visit him in the hospital, explain and answer his questions, and help set-up appointments for his recovery. Overtime he began to trust her. After his surgery, Noah says he’s healthier, happier, and thankful for Cityblock.

Image of an older member with a goatee wearing a blue vest, standing outdoors with trees in the background.

*In-home urgent care services are provided where permitted by law and, as required, facilitated by and/or with advanced practice practitioners and/or physicians. Please call 911 for life threatening emergencies.

**Member’s name has been changed, and a stock image of a model has been used for the individual’s privacy.

There is no change to your health plan benefits when you join Cityblock Health. All medical services are provided by licensed physicians and health care practitioners employed by Cityblock Medical Practice, P.A. Cityblock Health, Inc. provides management and administrative services to Cityblock Medical Practices.

The services described are care management services that are part of Cityblock Medical Practices that focus on navigating and coordinating members’ ongoing health needs and goals.