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This Doctor comes to you – How one medical group is disrupting healthcare

Landmark Health is blending house calls with technology and innovative payment models to improve outcomes for patients with multiple chronic conditions

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There’s little debate our health care system struggles to provide the great care for the most vulnerable patients – especially the frail elderly population. Healthcare costs for a subset of these patients with multiple chronic conditions (MCCs) continues to balloon due to repeat, avoidable emergency room visits and extended hospital stays. Today MCC patients with six or more chronic conditions represent about 14% of the Medicare population but are responsible for nearly 50% of Medicare medical spending.

Dotty is an 84-year-old woman who lives alone in the Worcester area. She has a great group of girlfriends who she enjoys venturing around town and on occasion to Foxwoods Casino. However, over the past two years Dotty has struggled to keep up her normal rhythm – her life has been overtaken by over 30 trips to the hospital due to challenges managing her COPD and other chronic conditions. Dotty is worried that she may not make another trip to Foxwoods Casino and more importantly she is worried she may be in the hospital for her nephew’s upcoming wedding.

Five years ago, Landmark Health was founded on the premise that our “Dotty’s” deserve better. Most people know a Dotty, it might be a parent, grandparent, or family friend – someone who has struggled to get the appropriate care they deserve as they age. To tackle this challenge, Landmark pioneered a new model of care for patients with multiple complex chronic conditions. By combining a home-based medical model, innovative technologies and analytics, and risk-based financial arrangements, Landmark has been able to dramatically improve the outcomes and reduce unnecessary medical cost of patients with six or more MCCs allowing them to live longer, more meaningful lives, in their communities.

Today Landmark is bringing this model to nearly 80,000 patients in risk-bearing arrangements representing around $2 billion of annual medical spend. In Massachusetts, they provide care to over 4,000 patients and are expanding rapidly in New England.

Chris Johnson, Vice President and General Manager at Landmark Health’s Massachusetts market

The core of Landmark’s model is to bring care to the patient. Many patients with MCC struggle with the burden of traveling to their healthcare providers and unnecessary emergency and hospital admissions are not only expensive but also potentially dangerous to these patients. Given these barriers, Landmark decided their medical group would be mobile, instead of clinics with four walls their providers drive cars with four wheels and conduct visits with patients in their homes. Sitting with patients and their families at their kitchen table over hour long appointments allows the Landmark team to understand patient goals of care and design care plans that will help them achieve those goals. “We let the patients set their goals of care – they tell us what will make their lives meaningful and we figure out how to help them achieve those goals,” said Chris Johnson, Vice President and General Manager at Landmark Health’s Massachusetts market.

When Dotty first met her Landmark provider, she had two goals: she wanted to rejoin her girlfriends for their regular trips to Foxwoods Casino and most importantly she wanted to attend her nephew’s wedding in a few months’ time. She was nervous that neither would be possible if she continued to end up in the hospital.

The Landmark medical model relies on more than just physicians and nurse practitioners who see patients in the home. The Landmark care team is truly interdisciplinary consisting of nurse care managers, clinical care coordinators, healthcare ambassadors, social workers, behavioral health clinicians, pharmacists, and nutritionists. Working together, the interdisciplinary care team is not only able to address the medical needs of the patient but also many of the psycho-social determinants that can lead to poor patient outcomes. For instance, providers complete home safety checks, do pantry checks and assess patients living in their own space. Providers also evaluate the patient’s personal support network, and medication competency, and Landmark’s social workers and healthcare ambassadors connect patients to the appropriate community resources.

The Landmark team focuses on building strong relationships with a patient’s PCP and specialist providers to extend care into their home and beyond the normal business hours of healthcare – Landmark providers are on call 24/7 for urgent house calls. Landmark supports patients post-discharge, after hours, in between office visits, and in urgent situations. They complement PCP’s to create unparalleled health-care access wherever the patient resides and whenever they need it.

Dotty’s Landmark care team was able to stabilize her health, educate her on how to properly use her medications and nebulizers, and was available to her 24 hours day for any urgent conditions that arose. One day the provider even helped Dotty assemble a book shelf she was having trouble with. Since her journey with Landmark began a year ago, Dotty has had only a single visit to the ER. She is seeing her girlfriends more often, has made a couple visits to Foxwoods Casino, and even attended her beloved nephew’s wedding – claiming it to be the Wedding of the Century.

To care for patients with MCCs, Landmark’s providers evaluate many patient data variables: medication, diet, routine, home safety, social support and more. Landmark’s proprietary electronic medical record (EMR) allows providers to focus on patient care in the home while risk adjustments, quality metrics and other streamlined systems run on the backend. “We’ve created an innovative model of assuming risk for our patients and developed the custom technologies we needed for out-of-office-based primary care,” said Johnson. “It makes for better patient experiences and lets our providers practice medicine.”

For the model to work, Landmark looks for innovative partners who can enter true risk-sharing agreements. Medicare Advantage plans are a frequent partner for Landmark and the company also has strong partnerships with dual eligible, Medicaid, and commercial plans and some progressive risk-bearing medical groups and health systems. Landmark has confidence in their ability to deliver results and therefore look for partners willing to let them share in the risk. “We believe the key to the success of our clinical model is the alignment of financial incentives. We want to benefit only when our patients and partners do as well.,” said Johnson. “We are excited as we talk to additional partners across New England who share our vision to dramatically improve the quality of care for patients with multiple chronic conditions.”

Combing the clinical model, technology and analytics, and risk-based partnerships has allowed Landmark to deliver impressive results, patients are incredibly satisfied with Landmark giving the organization a net promoter score of over 90 for three years in a row.  Beyond the quality of care, Landmark has been able to deliver incredible financial results to their plan partners. On average they have been able to reduce overall hospital admissions by 30% while ensuring more comprehensive diagnostic exams that have led to risk adjustment capture rates in excess of 120% in the first year of operations.

Having seen their first patient only three and a half years ago, Landmark has already made quite an impact. We are excited to see what they have in store for us over the next couple years.


  1. Femiint says:

    Great to read .. thanks for sharing

  2. Mohammed says:

    Dont see much different from home visiting doctor, many business already combine home visit with sesnor technology.

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