Landmark Health and Southwestern Health Resources (SWHR) have formed a new value-based care partnership designed to serve older adults with complex medical needs. As part of the collaboration, Landmark and SWHR will offer “interdisciplinary medical care” in the home setting.

Founded in 2014, the Huntington Beach, California-based Landmark is a multidisciplinary mobile medical group that delivers comprehensive in-home medical care to “the sickest and frailest” patient populations. The company’s physician-led teams work alongside patients’ existing health care providers in 17 states and dozens of metropolitan areas.

Meanwhile, SWHR is a clinically integrated network of 29 hospitals and over 5,500 providers. The network coordinates care for hundreds of thousands of patients across 17 counties in North Texas.

By teaming up with Landmark in the new value-based care partnership, SWHR will be able to provide longitudinal, interdisciplinary medical care to about 10,000 patients. The Texas-based organization is no stranger to value-based models, as it runs one of the most successful Next Generation ACO programs in the country.

“Their accountable care organization (ACO) is one of the best, if not the best, performing ACOs in the country,” Dr. Michael Le, Landmark’s co-founder and chief medical officer, told Home Health Care News.

Over the last three years for shared savings, SWHR’s Next Gen ACO reduced Medicare expenses by more than $120 million. Beyond those numbers, though, Landmark saw a partner in SWHR because of the organization’s reputation and alignment in values.

“They have a strong and similarly mission-driven clinical culture that really focuses on putting patient care first,” Le said.

While Landmark isn’t itself an ACO, it is one of the 51 direct-contracting entities (DCEs) approved by the U.S. Centers for Medicare & Medicaid Services (CMS) for 2021.

Through the Landmark-SWHR partnership, high-risk patients will be assigned a physician or nurse practitioner. Depending on patients’ health needs, they may also be assigned a psychiatrist, social worker, pharmacist or dietician.

“It’s very high-touch,” Le said. “Patients probably are being touched, on average, two times a month or even more, especially for the most acute or highest-risk patients.”

As part of the initiative, Landmark uses a points-based algorithm that measures chronic conditions. Participating patients who are treated typically have anywhere between six to eight “chronic condition points.”

The initiative is interventional and procedural in nature, Le said. This means Landmark and SWHR can draw blood, provide IVs and do wound care in the home setting — and that’s just the start.

“[We provide] a lot of services that normally would be done in an ER or urgent care to treat and stabilize patients in the comfort of their homes,” Le said. “This is available to patients 24/7.”

While Le believes there are similarities between this initiative and hospital-at-home programs, which are seeing a recent surge in popularity, he noted that there are some key differences.

“It is similar to hospital-at-home, in that there are a lot of procedures that can be done in the home,” he said. “Now in contrast to hospital-at-home, our patients don’t need to meet criteria for in-patient admission. We’re trying to get upstream a little bit by catching these patients before they would get to a point where they would formally meet criteria and need hospitalization.”

Another key difference: Landmark and SWHR’s initiative doesn’t center on remote patient monitoring.

“Landmark will reach those patients who need greater support with in-home medical visits – these can augment the already excellent care our community of physicians provide,” Dr. Sanjay Doddamani, chief physician executive and COO of SWHR, said in a statement. “This kind of innovative care delivery extends our mission to ensure that people living with chronic conditions have an opportunity to receive the best medical care in the comfort of their homes.”

For Landmark, this recent initiative falls in line with its overall mission of filling in care gaps that are created when patients are unable to receive traditional health care.

“At the very sickest end of the population, there are so many patients who are falling through the cracks, just because of mobility challenges, just because of the short time that is available in an office-based appointment,” Le said. “Our mission is to bring as much of this care as possible to our [patients] because there is so much need out there.”

Caring for patients in the home has taken on even more importance during the COVID-19 pandemic.

At a time when the risk of infection is high, it’s imperative to keep patients safe and in their homes, according to Le.