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Blue Shield of California and Landmark, an in-home senior care company, are using data analytics to drive care for the health plan’s most vulnerable population.

The results of the analytics initiative are exceeding expectations for the San Francisco-based insurer. At the end of the first year of the partnership with Landmark, BSC reports the duo enrolled 3,500 more eligible members, completed more than 15,500 home visits and made 33,317 phone contacts.

Ninety-two percent of the BSC participating members are enrolled in a Medicare, MediCal or the Cal MediConnect plan offered by Blue Shield or Blue Shield Promise, with the rest being members of Blue Shield’s commercial health plan. The average age of a program participant is 72.

“We are heartened to see so many of our members who can benefit most participate in this program, which delivers the right care at the right time and in the right setting—their home, at any hour of the day,” says Terry Gilliland, MD, BSC’s chief health officer. “The enrollment of eligible members has outpaced our first-year expectations, and we are delivering on our goal to help members with multiple chronic illnesses improve their quality of life by better managing their conditions.”

Ananth Ramkrishnan, chief technology officer at Landmark Health, says the company’s diagnosis-based algorithm enables it to identify an appropriate risk population where utilization is driven largely by chronic disease, and on which Landmark has had a proven impact on utilization and patient outcomes.

“Landmark uses advanced analytics and stratification based on claims data and physician assessments of acuity to appropriately align house call providers with the highest risk patients,” Ramkrishnan says.

Ananth Ramkrishnan

In addition to the data analytics, Landmark custom built an offline electronic medical records system designed to meet the unique needs of mobile providers who may not have immediate access to Internet or WIFI while treating a patient in their place of residence, Ramkrishnan adds.

Landmark’s EMR—called Ubiquity—enables offline documentation during a home visit, longitudinal management of patients based on clinical conditions and is used by all members of the Landmark team to support team-based collaboration. Ubiquity “drives longitudinal health outcomes for patients and also enables clinical documentation exchange with community providers,” he says.

The top 10 chronic conditions BSC and Landmark addressed in the program’s first year included: hypertension (99 percent); chronic kidney disease (76 percent); diabetes (69 percent); peripheral vascular disease (66 percent); coronary heart disease (65 percent); pulmonary disease (62 percent); depression (55 percent); heart failure (53 percent); atrial fibrillation (37 percent); and cerebral vascular disease (27 percent), BSC says.

According to Paige O’Connell, senior program manager at BSC, before the Blue Shield/Landmark care-collaboration program, Blue Shield of California and Blue Shield Promise members had to rely on making an appointment with their primary care physicians or specialists.

“If they could not get a timely or urgent appointment or needed urgent care in the middle of the night, they may have gone to the emergency room or found themselves being readmitted to the hospital after being recently discharged,” she says. “Now they have other options that complement the care they receive from their regular medical providers. We hear many anecdotes from patients that they have been able to avoid the ER or hospital readmissions because of their access to Landmark providers.”

Landmark estimates about 20 percent of chronically ill patients currently experience a gap in the care they are receiving, which can be addressed through medical care, support and education provided in the home.

The Landmark service is available at no additional cost for eligible members of BSC and its subsidiary Blue Shield of California Promise Health Plan. Landmark medical professionals do not replace a member’s primary care physician or specialists, but instead work collaboratively with members’ physicians to reinforce the doctor’s in-office care plan, O’Connell says. Primary care physicians of eligible members are also notified about the program.

“While many health insurers have done in-home care coordination programs, they can often struggle with enrolling and engaging members,” says Matthew Yi, BSC’s senior director of communications. “Blue Shield’s program with Landmark sets an example of how to be successful.”


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