Harvard Pilgrim Health Care and in-home medical care company Landmark Health have entered into an agreement to offer a new care coordination program for chronically ill Medicare Advantage members with complex health and social needs.
The Landmark program brings care to high-need patients where they live, treating the whole patient with a dedicated focus on long-term outcomes. Their physicians and advanced practice providers, dubbed Complexivists, bring medical, behavioral and palliative care to patients through routine and urgent house call visits.
These providers are supported by a local multidisciplinary team -- including behavioral health clinicians, pharmacists, nurses, social workers and dietitians -- who provide education, support and care over the phone and in the home.
WHAT'S THE IMPACT
A key driver of patient health outcomes is a high level of coordination with patients' regular doctors, specialists and caregivers, as well as community services. Landmark's in-home care is supplemental and designed for those with complex health needs due to multiple chronic conditions such as diabetes, heart disease, lung disease and cancer.
The collaborative, holistic approach to care is driving real results for Landmark's patients nationally, the company said in a statement -- including a 28 percent decrease in hospitalizations and a 39 percent reduction in emergency room visits.
The program is voluntary and offered at no cost to eligible Harvard Pilgrim Health Care Medicare Advantage members who have multiple chronic conditions, and live in the Massachusetts counties of Middlesex, Worcester, Suffolk, Norfolk, Essex, Bristol and Plymouth.
ON THE RECORD
"In collaboration with Landmark Health, Harvard Pilgrim will further advance its whole person, complex care coordination services for members with special healthcare needs and guide them to better health outcomes," said Michael Carson, president and CEO of Harvard Pilgrim Health Care. "Harvard Pilgrim understands that one size does not fit all when it comes to helping members with complex care conditions. Landmark's proactive care coordination augments Harvard Pilgrim's multifaceted efforts to bring high-quality care directly to where it best benefits its members."
"House calls give our providers quality time with patients to develop relationships, trust and insights inside the home that allow us to tailor proactive care to their unique health situations," said Dr. Michael Le, Chief Medical Officer and co-founder at Landmark. "Landmark is excited to deepen our roots and serve more patients in Massachusetts."