Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients . We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
The Care Advocate (CA) is responsible, as part of the care team, for the overall patient Care Management process. The CA works with the care team to provide , guidance and support for the patient care plan as developed through clinician, and allied clinical support evaluation and physical risk assessment completed by a Landmark provider.
The CA gathers information by telephonic interactions with patients. This information is used and helps guide treatment and care decisions of the team and also identifies services and vendors for needed care while navigating patient benefit plans. The A works collaboratively with a multidisciplinary team of PCP, specialists, Behavioral Health clinicians, midlevel practitioners, pharmacist, nutritionist social worker and the patient, family and/or caregiver as they provide supportive care to enrolled patients.
The CA ensures that medical services are managed in the most effective and appropriate health care setting according to the patient’s medical condition.