When Landmark Health and Blue Shield of California teamed up a year ago on a joint home-based care program, the goal was to improve access to services for the insurer’s most vulnerable members. Since then, the collaboration has yielded more than 15,000 home visits for medical, behavioral and social support services, as well as urgent and post-discharge care.
The fast-paced scale of the program serves as a template for other home-based care providers and insurers, especially as Medicare Advantage (MA) becomes more flexible and focused on social determinants of health.
Blue Shield of California and subsidiary Care1st Health Plan officially began collaborating with Landmark Health on the program — designed to provide “the 21st-century version of house calls” for sick, frail and chronically ill members — in April 2018.
Individuals are eligible to receive services under the program if they have five or more specific chronic conditions, such as hypertension, chronic kidney disease or diabetes.
Founded in 2013, Huntington Beach, California-based Landmark Health is one of the largest risk-based provider groups in the United States, caring exclusively for complex, chronic populations. In general, the company works by sending physicians, nurse practitioners and physician assistants into the homes of its patients to keep them healthy and out of the hospital, operating alongside regular primary care providers.
“When we are sick, we oftentimes don’t want to leave our home,” Malaika Stoll, senior regional medical director at Blue Shield of California, told Home Health Care News. “We’ve made such great medical strides since the time of doctor home visits with a black bag in hand, but this is one thing that we have lost throughout time. We wanted to bring this back, especially since access to care is a challenge for those with multiple chronic conditions.”
Besides handling the in-home patient care portion of the partnership, Landmark also provides 24/7 telephone support services for eligible members.
“Our motto really is about bringing care and a team-based, holistic approach to patients wherever they are,” Dr. Michael Le, co-founder and chief medical officer of Landmark, told HHCN. “We are a mobile medical group that employs doctors, nurse practitioners and also behavioral health staff, psychiatrists, [psychiatric nurse practioners], social workers, and then a full team of nurse care managers, pharmacists and dietitians, all with the goal of [providing] comprehensive, 24/7 interventional care to the patients home.”
Delivering the right care
Landmark and its medical teams carry out house calls across 13 states. Apart from its U.S. operations, Landmark also has an international office in Bengaluru, India.
On its side, Blue Shield of California uses data-driven algorithms to identify members who qualify for the program with Landmark. Once the insurer finds an eligible member, it then invites them to enroll.
Landmark likewise boasts risk-stratification capabilities.
“There is a point algorithm, where we take into consideration certain chronic diseases, debilitating conditions and frailty indicators,” Dr. Le said. “This develops a point scale. And then on this point scale, patients who qualify for the program become eligible for the Landmark services.”
The Blue Shield-Landmark program was initially rolled out for eligible members enrolled in select Medicare plans, but it was promptly expanded to also include those with Blue Shield individual and employer-sponsored health plans, as well as Care1st Medi-Cal and Cal MediConnect plans.
About 92% of participating members are enrolled in a Medicare, MediCal or Cal MediConnect plan offered by Blue Shield or Blue Shield Promise. The average age of program participants is 72, with the most common chronic condition being hypertension.
About 55% of program participants have depression, further highlighting the need for behavioral services in the home.
San Francisco-based Blue Shield of California is a not-for-profit, independent member of the Blue Shield Association, serving more than 4 million members and generating more than $20 billion in annual revenue.
Since its launch last year, more than 3,500 members have enrolled in Blue Shield of California and Landmark’s home-based care program.
It’s still too early in the program to present concrete numbers on emergency room and re-hospitalization reduction rates, the companies say. Broadly, though, the program utilizes the same high-touch, proven method Landmark has historically used with its patients. Landmark patients reportedly see a 39% reduction in ER visits in the first six months of engagement, according to the company.
A “touch” is defined as a combination of in-person home visits and telephone calls by Landmark’s office-based staff.
“We have touch frequencies with the patient,” Dr. Le said. “The typical patient is going to have a little over 2 touches per month. We also stratify, so for our patients with the highest acuity, patients who are at risk of being admitted within the next three days, those patients are receiving between 3.8 to 4 touches per month.”
While the program differs from the typical care of a home health provider by placing its area of focus on physician-led longitudinal and interventional care, it often leverages home health through Blue Shield of California’s network of home health providers, according to Dr. Le.
“We may start the first dose of antibiotics [or] we may do some initial assessment of a wound, but it’s not the best use of our providers’ time to continue to come out three times a week to be doing wound care or other infusion therapies,” he said. “We do some of the same things as home health to stabilize the patients, but then we leverage home health to continue to a lot of the ongoing treatment for patients.”
Overall, Blue Shield of California believes that its home-based care program falls in line with recent steps federal policymakers have taken to better care for complex and chronically ill Americans, Stoll said.
Landmark co-founder and former CEO Adam Boehler currently leads the Center for Medicare & Medicaid Innovation (CMMI).
“I think that the spirit of what we are doing is absolutely aligned with what CMS is trying to do in terms of evolving their policies,” she said. “In a value-based world, we are looking for the best outcomes. We are not looking to pay for the process — we are looking to pay for the outcome. We all believe that we will get a better outcome with these complex members if we can meet them where they are and provide them care in the home.”