Teaming Up to Transform Care in the Safety Net

With a knock on the front door of a home in suburban San Bernardino, Dr. Michael Le and two nurse practitioners from Landmark Health recently launched an important initiative to improve care of complex, chronically ill patients. Waiting inside was their first California patient, a fragile 61-year-old woman with congestive heart failure who in three anxious years has endured a heart attack, cardiac surgery, multiple strokes, and bouts of depression. The knock on the door was a gift to that patient — and a valuable opportunity to road-test a new model of care for enrollees in California’s Medicaid program, known as Medi-Cal, and California’s dual-eligible program, known as Cal MediConnect.

The woman complained that some of her doctors were too busy or too uninterested to answer important questions about her care. For 90 minutes, Dr. Le and the nurses talked to the woman, answered her questions, gave her a thorough medical exam, reviewed every bottle in her medicine cabinet, and explained in detail how to head off emergency room visits. On Day One, Dr. Le said, Landmark’s 24/7 home care concept was validated by her overwhelming gratitude. “You could see that a big weight was lifted now that she has a team to back her,” Dr. Le said. “She said, ‘This is a godsend and just what I needed — someone to take the time to listen to me and take me seriously and address all the issues I have, not just one or two.’ We give patients time and show them respect and not let them feel like we have one foot out the door for the next patient.”

Landmark is the most recent company we have added to the CHCF Innovation Fund portfolio. Landmark is a provider group that partners with health plans to deliver responsive, high-intensity, home-based medical care to health plans’ most complex members. It currently offers care to more than 45,000 patients nationwide, and this California project is its first effort to expand to serve Medicaid enrollees. Landmark’s ongoing, integrated care has been proven to keep costs down and patients healthy, and the company has demonstrated success in improving access and quality of care with a high degree of patient satisfaction.


Landmark providers partner with community providers and deliver in-home services that focus on each patient’s medical, behavioral, and social needs. Landmark’s operating platform integrates into the health plan’s information technology infrastructure to facilitate clinical data exchange. Its providers receive palliative care training in order to focus on end-of-life planning and to establish advance directives. Landmark’s model turns the current fee-for-service paradigm on its head by assuming financial risk for their patient population.

This project is yet another example of markets being transformed by innovation. Systems in place for decades or longer are being overhauled for efficiency, expediency, and for the future. Most market disruption thus far has been about convenience and commerce — in transportation, food delivery, and instant communication. The health care delivery system represents a growing and largely untapped market that is primed for disruption, particularly for the costliest chronically ill patients covered by Medi-Cal.

Making Life Better for Vulnerable Patients

Because we think this model of care will dramatically improve the quality of life for medically vulnerable patients and their families, CHCF plans to invest up to $1.2 million over two years in support of efforts by Landmark and others to tailor services to California’s safety-net population. Dr. Le, chief medical officer and a cofounder of Landmark, is spearheading the launch of this care for Inland Empire Health Plan, which plans to extend the service to hundreds of Medicaid and dual-eligible enrollees in Riverside and San Bernardino Counties.

Because of expanded eligibility under the Affordable Care Act (ACA), California now leads the US in Medicaid beneficiaries. In 2011, there were 7.6 million enrolled in Medi-Cal, and today there are more than 12 million. A very small number of patients drive the majority of medical costs in California. In 2011, only 1% of patients accounted for 36% of Medicaid expenditures. These patients have high costs and very high needs; they tend to be dual-eligible high users of medical services and have multiple physical chronic health conditions, sometimes complicated by substance use and homelessness. Medi-Cal’s managed care plans have strong moral, financial, and regulatory incentives to improve care for these so-called super-users, and the plans are looking for solutions to effectively and efficiently address these users’ complex health and social problems.

Traditional health care delivery systems are not well organized to meet the challenges of these enrollees. Medical and behavioral health services are often provided via separate systems that do not coordinate clinical assessment, care planning, or care delivery. Access to care requires that patients arrange multiple appointments in different locations and travel to where the providers are. When a crisis occurs, many of these chronically ill patients end up accessing care where it’s the most inefficient and the costliest, such as the emergency department, often with poorer outcomes. Our hope is that Landmark’s groundbreaking work will provide the incentive for others to look for ways to innovate in the health care delivery system for California’s growing safety-net population. Dr. Le, who was a fellow in the Institute for Physician Leadership at the University of California, San Francisco, shares that vision.

“I grew up watching this kind of medicine,” said Le. “My dad was a small-town physician in Massachusetts, and I always thought it was very Norman Rockwell-ish. It’s rewarding to be able to practice medicine like my dad did and see that this is the model of the future. We need to bring the care, the services, and the teams to the patient who can’t come to us. I hope this is transformational — providing concierge-level home care for patients who need it most.”

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