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.
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 Nurse Care Manager (CM) Manager is responsible, as part of the care team, for the overall patient Care Management process. The CM provides oversight, guidance and support for the member care plan as developed through clinician, CM and allied clinical support evaluation and physical risk assessment.
The CM uses nursing assessment and evaluation skills to help guide treatment and care decisions of the team and also identifies services and vendors for needed care while navigating patient benefit plans. The CM works collaboratively with a multidisciplinary team of PCP, specialists, Behavioral Health clinicians, midlevel practitioners, pharmacist, nutritionist and Social Worker and the member, family and/or caregiver as they provide supportive care to enrolled members.
The CM ensures that medical services are managed in the most effective and appropriate health care setting according to the member’s medical condition. The CM is responsible for developing and implementing a plan of care appropriate to the member’s clinical condition and psycho/social needs to maximize his/her level of functioning and establishing and maintaining communications with the responsible party of the member.
Certificates, Licenses, Registrations: