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Health System Partners With Home-Based Medical Services Provider

Analysis  |  By Christopher Cheney  
   September 07, 2021

Southwestern Health Resources is working with Landmark Health to boost the care of medically complex patients.

Dallas-based Southwestern Health Resources (SWHR) has established a partnership with a provider of home-based medical services to improve the care of medically complex patients.

Medically complex patients such as older patients with multiple chronic conditions are a driver of medical service utilization, including hospital admissions and emergency department visits. Introducing medical services in the home can drive down utilization rates and improve clinical outcomes.

A key element of SWHR's partnership with Landmark Health is the ability to boost care management in between office visits with medically complex patients, says Pamela Sullivan, MD, chief clinical officer at the Huntington Beach, California home-based medical services provider.

"At Landmark, we have a very comprehensive approach to geriatric and chronically ill patients, which is hard to do when you are managing a large population of patients. So, we focus on this group, and we are very proactive. We look at social determinants of health. We also have a robust predictive analytics team that analyzes our patients, and we know when a patient is likely to get admitted to a hospital or have other needs. So, we can target patients and focus on making sure they get the right touches from the right care providers at the right time to make sure that we decrease hospitalizations," she says.

Landmark also works with SWHR to refine individual care plans for medically complex patients, Sullivan says.

"When we go into the home, we can spend a lot more time with the patient than a SWHR provider can spend with the patient in the office. By seeing each individual patient's needs and using our predictive analytics, that helps us to come up with a care plan that not only meets the patient's goals and wishes, but also puts a family member at ease or a caretaker at ease. We have multiple touch points with social workers and providers going into the home along with a nurse calling and following up, or a pharmacist consulting with the team. Then we can coordinate that care with the care managers in the PCP offices or the primary care physicians," she says.

The partnership with Landmark is expected to reduce total cost of care for SWHR's medically complex patients, says Jason Fish, MD, senior vice president and CMO of the health system. "If you manage complex patients well, you absolutely will cut waste and you should see a decrease in total cost of care."

The partnership should help address physician burnout, he says. "With a busy practice that has 2,000 to 2,500 patients and a set of complex patients, this partnership serves to reduce the risk of burnout among our providers. With complex patients, we now know Landmark is looking at these patients between visits and communicating back to the PCP. For those complex patients, it is a breath of fresh air knowing that we now have a greater opportunity to manage them."

The partnership also improves transitions of care, Sullivan says. "If you are a primary care provider and you see a patient in the office who has congestive heart failure or pneumonia, and you are concerned about how the patient is going to do if you send them home, we can provide safe care in the home. The PCP can contact us, and we can be in the home that same day or the next day and coordinate care. We can keep the patient out of the hospital."

Landmark helps to keep patients in their homes and out of hospitals and emergency departments, she says.

"When you talk about our group of patients, they are patients who want to stay in their homes. Sometimes, they are afraid to share some things or have us in their homes because they do not want to be forced out of their homes to other living situations. Once they learn that we are a trusted partner and that we are going to work with their PCPs, they realize that our goals are their goals. They realize that we are not trying to displace them and that we are working to get them community resources so that they can live in their homes. We can make the quality of life better in their homes," she says.

Measuring the partnership's impact

The effects of the partnership will be measured with several metrics, Fish says.

"The impact involves a few things. From the patient's view, if the goal here is to improve the quality of life and reduce unnecessary care, then you measure that through traditional utilization measures such as ED utilization, acute admissions, readmissions, and patient satisfaction. You measure by patient engagement—are patients continuing the engagement or are they discontinuing engagement?" he says.

SWHR also will measure the partnership through its providers, Fish says. "Are they satisfied? Do they like the partnership? Do they think the partnership is adding value? We do routine questionnaires with our providers to ascertain that information."

Lastly, the health system will measure the medical-economic impact of the partnership, he says. "You should see one of two things. You should see that your total cost of care comes down because you have engaged the appropriate service lines in a way that reduces waste and improves outcomes. Or you could see improved clinical outcomes and somewhat increased costs because you have engaged patients who were at risk, and it takes more services to care for them. In the short term, you may see a little increase in costs; but in the long term, you will see costs decrease."

Related: Finding Untapped Potential in the Home-Based Medical Care Market

Christopher Cheney is the CMO editor at HealthLeaders.


Medically complex patients such as older patients with multiple chronic conditions are a driver of medical service utilization, including hospital admissions.

This partnership features home-based medical visits with medically complex patients between office visits with primary care providers.

The partnership is expected to reduce total cost of care.

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