Office-based primary care physicians often can’t keep up with and serve all the medical, social, pharmaceutical, nutritional, and behavioral health needs of older adults with multiple chronic conditions. That can contribute to these patients experiencing a high rate of hospitalization and emergency department (ED) visits, increasing costs and reducing patients’ health and quality of life.
Landmark Health was formed in 2013 as a for-profit company to bring comprehensive care to the homes of patients with multiple chronic conditions. Landmark contracts mostly with Medicare Advantage plans to serve Medicare enrollees and a smaller number of low-income and disabled people who are dually eligible for Medicare and Medicaid. Landmark and the health plans use the company’s algorithm to select enrollees based on their current health status, number of chronic conditions, and potential cost savings. Nearly 10 percent of a plan’s enrollees usually meet the criteria. Landmark also contracts with other provider organizations, such as risk-contracted primary care physician practices, to serve their patients. Under those contracts, Landmark assumes financial risk for hospital stays and ED visits and other costs incurred by its enrollees.
The company has about 500 employed medical providers and 50 behavioral health providers serving 176,000 patients in 18 states. They are organized and located in neighborhood pods to serve patients in particular geographic areas. In addition, the company’s provider-staffed 24/7 call center handles more than 6,500 inbound phone calls per week.
Landmark patients on average are 77 years old and have eight to nine chronic conditions. Forty percent have two or more behavioral health conditions, 40 percent have advanced renal disease, and 40 percent have 12 or more prescribed medications.
Landmark’s providers ― physicians, nurse practitioners, and physician assistants ― visit patients in their homes at least six to 12 times a year, with 12 to 24 additional check-in calls, to address a broad range of medical, urgent care, behavioral health, social, economic, and palliative care needs.
The care team also includes behavioral health nurse practitioners, social workers, palliative care practitioners, dietitians, nurse care managers, as well as unlicensed health care “ambassadors,” who help with light social work and care coordination needs and make sure patients don’t miss appointments.
“We want to help our patients live well and die well, according to their goals,” said Anthony Zizza, MD, Landmark’s senior medical director. “As a geriatrician, I love providing more care while decreasing the total cost of care.”
For instance, Carissa Foley, a Landmark nurse practitioner based in New Hampshire, recently visited a new patient at home and discovered he was suffering a crisis with his chronic obstructive pulmonary disease. His oxygen concentrator had failed and he hadn’t been taking his medications properly. Over three straight days, Foley administered intravenous steroids and a nebulizer treatment, ordered lab tests, and performed an in-home chest X-ray that showed he had pneumonia.
She also made an urgent referral to bring in a social worker and a home health aide, and asked his primary care physician to monitor the man, who also suffers from congestive heart failure.
“He’s much much better, and he’s able to get up and walk,” said Foley, who said the patient’s goal is to get healthy enough so he can resume going to the beach. “Without Landmark, that gentleman would have been in the hospital within 24 hours for acute respiratory failure.”
Landmark staff reach out to eligible patients to explain the program and ask them to enroll, typically at no cost to the patient. Staff also work with the patients’ regular primary care physicians to encourage patients to participate. About 75 percent of eligible patients sign up, and fewer than one percent disenroll, Zizza said.
Landmark providers work closely with the regular primary care physicians, essentially serving as the geriatric specialist in the home. “I have primary care physicians who love this program,” Foley said. “They read my notes. They don’t see what’s in the fridge, the empty beer cans, the falling-down house. They feel I am their eyes and ears in the patient’s home. And we can address some of those issues with our social work team and dietitians.”
Early on during the COVID-19 pandemic, Landmark for a short time switched to telephone and video visits, developing its own secure video app. But the staff resumed home visits within six weeks, and 85 to 90 percent of visits now are done in-person.
Zizza said home visits have been key in spotting patients’ social isolation and depression, need for food delivery, and other issues during the pandemic. “There’s no substitute for seeing patients in their homes,” he said. “Those are things you often can’t tell by phone.”
Landmark claims that its program has reduced hospital admissions for its enrolled population by 15 to 25 percent. It also says it reduces medical costs during the last 12 months of its patients’ lives by 20 percent. In addition, the company says its services are associated with a 26 percent decline in mortality for patients within 12 months of their enrolling in the program.
“We’re not just saying we’ll decrease costs,” Zizza said. “We’re doing this by having patients living longer and healthier.”
In February 2021, Mathematica reported on Landmark’s outcomes in working with two California Medicaid managed care plans ― Inland Empire Health Plan, serving high-cost Medicaid enrollees, and the Health Plan of San Mateo, serving enrollees dually eligible for Medicare and Medicaid.
The study found that Landmark’s program was associated with decreases in hospitalizations and ED visits particularly for patients with behavioral health conditions, increases in primary care visits, and a greater probability of primary care follow-up after discharge from the hospital or skilled nursing facility.
Demonstrating value to primary care physicians is key.
Some primary care physicians initially may be resistant to their patients enrolling in Landmark because they think it may reduce in-office visits for which they receive fee-for-service payment, Foley said. “But oftentimes, they eventually realize that what they can do for patients who can’t get into the office is limited, and that the patient is suffering.”
In some cases, Landmark providers visiting the patient’s home set up a video visit with the regular primary care doctor so the doctor can observe the home visit. “That’s worked out fantastically well,” she said.
It’s important to constantly seek improvements in the care model.
Zizza said Landmark is always looking at how it can enhance its services, including its scheduling system, driving routes to patients’ homes, triage call center, and data analytics tools for understanding patients on a population health level.
In addition, the company focuses on how it can optimize the quality of care it delivers, which helps improve Healthcare Effectiveness Data and Information Set (HEDIS) quality scores for its partner health plans and can boost their reimbursement rates.
Helping patients make decisions about care at the end-of-life is a critical part of the job.
By building a strong relationship with patients, Landmark staff are able to help them identify their goals and values about how they can optimize their quality of life during their final months, including by bringing in palliative care specialists.
Foley recalls a patient in her 80s with severe heart problems and end-stage kidney disease who initially said she wanted all possible medical treatments to keep her alive. But it turned out it was actually her family members who wanted that. Foley helped her develop a plan to forego outpatient dialysis and instead bring in hospice services so she could enjoy her remaining time with her family and her dog and watch the Red Sox beat the Yankees one more time. She recently died at home.
“For many of these patients, their goals aren’t always to pursue any and all treatments,” Foley said. “We get to know what’s important to them and help them accomplish their goals. That’s really nice.”
Thank you to Anthony Zizza and Carissa Foley for helping to inform this profile.
* Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986.
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