Landmark Health Improves Post-Discharge Visit Completions by 250% With Real-Time Care Intelligence™

Across its various locations, Landmark found one common challenge in their care delivery model: delayed data on patients’ care events. Landmark has an effective polychronic care model, but on average it took two to three years to engage half of its patients under management. Typically, the Landmark staff depended on their affiliated health plans and provider organizations for information on patients’ care events, but these organizations relied on surrounding hospitals for information on members’ admissions, discharges and transfers (ADTs). As a result, Landmark at times did not find out about patients’ care events until 8-10 days after they occurred, if at all.

With such delayed information, the Landmark team could not make timely and proactive outreach to patients during pivotal care moments, such as after discharging from the hospital, emergency department or post-acute facility. Consequently, Landmark could not ensure that post-discharge follow-ups were scheduled within 7 days, nor that patients were following post-discharge care instructions or receiving necessary medications and support. This often led to patients returning to the hospital for care and presented challenges for Landmark to ensure readmission rates remained low.

Landmark initially partnered with Bamboo Health to support across its New England locations. The team soon saw the value of efficient post-discharge follow-up workflows with data readily available in Pings™.  The team experienced freed up time and resources now that they no longer had to chase down patient locations by calling facilities or the patients directly. As a result, the Pings solution was launched across five additional states: North Carolina, Ohio, Kansas, Missouri and Texas.

The Landmark team leverages Bamboo Health’s Pings product for real-time notifications on patients’ care events, which are received via SMS, email and on the Pings web application. The team also uses the Pings solution’s Saved Filters, Exports, COVID-19 Flag, Readmission Risk Flag and 3-Day Waiver Flag features. To date, 170+ Landmark users leverage the platform, including care coordinators, nurses, physicians and pharmacists.

Since using Bamboo Health’s real-time data, Landmark has been able to:

• Receive real-time visibility into members’ care events to monitor members post-discharge from acute and post-acute care settings.
• Improve their post-discharge visit completion rate by 250% over one quarter in markets using Pings.
• Free up time and resources by having real-time patient location data available from Pings, versus calling facilities or the patients directly to gather such information.
• Improve member engagement to prevent unnecessary admissions and readmissions.
• Connect with difficult-to-reach and previously non-engaged members to schedule follow-up appointments, re-enroll them in Landmark services and improve participation with Landmark’s care.
• Support its health plan clients in succeeding under value-based care and quality initiatives by improving member engagement and readmission rates.

Landmark Health is one of the nation’s leading risk-based medical groups that delivers at-home, value-based care to high-risk patients across 17 states. Through its employed groups of physician-led practices, Landmark’s team of doctors, nurses, nurse practitioners and physician assistants deliver 24/7, medical, behavioral health, palliative care and social services to 130,000+ patients, specifically those that are high-risk and faced with multiple chronic conditions. Additionally, Landmark partners with health plans and risk-based provider organizations to help manage care and deliver services to their most high-risk,  vulnerable member populations. Through its multi-faceted approach, Landmark is able to ensure that high-quality care outcomes are continuously delivered to at-risk patients while supporting health plans and other managed care organizations responsible for total cost of care to succeed under their value-based and quality care initiatives.

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.