Carol DeVol, COO and Co-Founder of Landmark Health

Landmark Health provides home-based care to the chronically ill. Founded in 2013, Landmark’s care model combines a longitudinal multidisciplinary team with 24/7 urgent visits. Headquarted in California, Landmark has risk-bearing deals with Medicare Advantage, Medicaid, and commercial plans in 15 states. Pulse writer Jeremy Rubel sat down with COO and Co-Founder Carol DeVol to talk more about Landmark and her experiences.

The Pulse: What drove you to co-found Landmark?

Carol DeVol: There is no country in the world that has a better acute care system than the United States. But that system does not do the best job caring for the chronically ill and too many chronically ill are forced to rely on it. Patients with multiple chronic conditions often require 35+ minute appointments, but primary care physician (PCP) offices may not be set up for long visits. PCPs do hero’s work in our country, particularly now. But they are not set up for the care needed by the most frail, chronically ill. Moreover, patients struggle to access primary care on a timely basis. Frequently, a person with a chronic illness has an exacerbation that goes from 0 to 100 in a matter of hours. Even if the PCP can see the patient the next day, the patient might be in the ER by 8pm that same night because her condition can deteriorate that quickly.

The founders of Landmark believed there was a better way to care for the frail, chronically ill. This population is well served by longitudinal care delivered in the home by a multidisciplinary team. We designed a system of care to respond more quickly to treat exacerbations and to avoid ER visits.

The Pulse: 25% of Landmark’s house visits are made on an urgent basis. How do you manage the operational challenge of rapid clinician deployment at scale?

CD: We have improved our ability to respond urgently over time. When Landmark first started, the longitudinal provider left unscheduled flex time to respond that same day. As we’ve matured, we created specialists called “urgentivists” who solely focus on responding to urgent visits.

We also developed a 24/7 call center that we call “Landmark First”. Clinical staff of physicians, nurse practitioners, and physician assistants triage inbound patient calls. We do not have to deploy an urgentivist if the need can be managed telephonically. Through our call center, we can connect a patient with a provider on the phone within 3 – 5 minutes. With our scale and focus, we can provide this type of responsiveness which is difficult for an office-based practice to do.

The Pulse: Landmark boasts a 39% reduction in ER visits compared to a control group. What is the key driver of these successful results for Landmark’s care model?

CD: Landmark’s outcomes are due to its combination of longitudinal proactive care and its ability to respond urgently. Imagine a patient with 5 or 6 chronic conditions. With longitudinal care, the patient will have fewer exacerbations. Then, if there is an exacerbation, our urgentivists provide care within 60 or 90 minutes to prevent an ER visit. The two sides of the model work hand in glove.

The Pulse: In the last 18 months, Landmark has nearly doubled its patient population, now serving over 100 thousand patients in 15 states. As COO, what are the key operational challenges to expanding into a new market?

CD: Landmark deploys an implementation team of operators and clinicians to launch a new market. First, they secure office space, recruit new employees, and coordinate with health plans. Second, there is a clinical delta team composed of nurse care managers, physicians, and nurse practitioners. They interview new clinical employees, train them on our clinical model, and perform clinical work side-by-side with those they just hired. Third, the new market implementation team meets with local community providers. We want to collaborate with providers to explain how we complement their work. A lot of community providers ultimately become referral sources because they understand the value that Landmark brings to their patient population. Our Landmark First clinical call center is another advantage when we enter a new market because we already have after hours and triage resources ready to go.

The Pulse: During this pandemic, how does Landmark make patients feel comfortable with a clinician entering their home?

CD: First and foremost, clinicians need to have PPE. We worked diligently to expand our inventory. We also make sure that when our providers go inside a home, the patient and their family/caregivers wear a surgical mask for source control.

In the first 2-3 weeks of the pandemic, we pivoted hard and quickly to telemedicine. That said, telemedicine is not a cure all for our frail elderly population. We quickly pivoted back to 80-90% in-person visits once we had sufficient PPE and could safely re-enter homes. Now, we are at about 60-70% in-person visits given heightened caution due to the recent surge in cases. Although we seek to leverage telemedicine and conduct visits via video if we can, we have built comfort with patients with in-home visits based-on our safety protocols.

The Pulse: What has Landmark discovered about how to effectively use telehealth for an older patient population with complexities like hearing loss, vision impairment, or dementia?

CD: If there is not a caregiver in the home who can facilitate, it may not be possible. Telehealth is a tool in the toolbox, and it will not fully replace the face-to-face visit, especially for this patient population with multiple chronic illnesses. We deploy ambassadors who train the family or the patient over the phone or over video on how to get set up with telehealth.

The Pulse: If you take the long view of the history of American health care, house calls were once common. In the 1940’s house calls comprised 40% of doctor visits and today they’re less than 2%. In your view, what explains why house calls fell out of favor and why do you believe they are poised for a comeback now?

CD: House calls fell out of favor because they were no longer economically efficient. Physicians are higher cost labor, so it makes sense for physicians to stay in one location and see more patients. Provider offices gained new technologies that cannot be transported easily. And there’s efficiency when multiple providers are in one setting. The patient can see a PCP and then the phlebotomist down the hall in a single visit. An office is more efficient for most patients and house calls should not completely replace that.

House calls are seeing a resurgence because companies like Landmark have recognized that they are more efficient in certain cases. If you can provide longitudinal care and 24/7 urgent visits that reduce ER visits and nursing facility stays, then you can reduce costs and deliver a higher quality experience for the patient. For the vulnerable population with multiple chronic conditions, the effectiveness of house calls makes it the best way to deliver care.

The Pulse: Where do you see Landmark headed next?

CD: We were selected to participate in the CMMI (Center for Medicare and Medicaid Innovation) direct contracting demonstration. Right now, all our business is with health plans, but most Medicare beneficiaries still are on a fee-for-service model. We are excited to expand our reach to this new population.

We also just signed an agreement with a large risk-bearing provider group in the Bay Area. We expect to see growth signing deals with larger provider groups and systems that receive global capitations. In addition to these new avenues, we expect to continue to grow our footprint by signing up new health plans, especially in the traditional Medicare Advantage space. We now have relationships with multiple payers in many of our markets. We want to continue to add more density in our existing geographies because it creates a virtuous economic cycle.