#PNN_House Call

A comprehensive home-based care program for Blue Shield of California members with five or more specific chronic illnesses has been widely embraced in its first 12 months. The program, in collaboration with Landmark, uses data-driven algorithms to identify members qualified to receive community-based, physician-led care in plan members' homes so they can better manage multiple complex health issues such as kidney and heart diseases, diabetes, hypertension and depression.

More than 3,500 members have enrolled in the program since it launched a year ago. Those members used Landmark's 24/7 access to care, and received more than 15,000 home visits for medical, behavioral and social support services as well as urgent and post-discharge care.

"I feel alive again!" said Larry Johnson, 92, a World War II veteran, who lives in Los Angeles County. After visits and treatments from Landmark providers, Johnson said his dehydration disappeared, and his sleep and appetite improved. He has gained weight and feels increasingly healthier and happier, following a long recovery from a stroke.

The Landmark service is available at no additional cost for eligible members of Blue Shield of California and its subsidiary Blue Shield of California Promise Health Plan. Landmark medical professionals do not replace a member's primary care physician or specialists; they work collaboratively with members' physicians to reinforce the doctor's in-office care plan.

"We are heartened to see so many of our members who can benefit most participate in this program, which delivers the right care at the right time and in the right setting – their home, at any hour of the day," said Terry Gilliland, MD, Blue Shield's chief health officer. "The enrollment of eligible members has outpaced our first-year expectations, and we are delivering on our goal to help members with multiple chronic illnesses improve their quality of life by better managing their conditions."

How the program works

Blue Shield uses data-driven algorithms to identify members who qualify for the Landmark program, then invites them to enroll through letters and phone calls. Primary care physicians of eligible members are also notified about the program.

"I'm sold on Landmark because I can get treatment when I want it. Usually a Landmark provider can get to my house within two hours," said Ted Tomasegovich, a 70-year-old retired engineer in Sacramento County.

Key findings in the program's first year:

  • 92% of the participating members are enrolled in a Medicare, MediCal or Cal MediConnect plan offered by Blue Shield or Blue Shield Promise; the rest are Blue Shield's commercial health plan members.

  • Average age of program participants is 72.

  • Top 10 chronic conditions addressed:

    • Hypertension 99%
    • Chronic Kidney Disease 76%
    • Diabetes 69%
    • Peripheral Vascular Disease 66%
    • Coronary Heart Disease 65%
    • Pulmonary Disease 62%
    • Depression 55%
    • Heart Failure 53%
    • Atrial Fibrillation 37%
    • Cerebral Vascular Disease 27%
  • 15,550 home visits were made by a Landmark provider.

  • 33,317 phone contacts were made by a Landmark provider.

Blue Shield's Landmark program is currently available in Orange County, as well as in Los Angeles, Sacramento, San Diego, Riverside, San Bernardino, San Mateo, San Francisco and Santa Clara.

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