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My grandmother lived just outside Boston since 1944, in the same house where she raised her five sons. As she got older it became harder to stay. While it may have eased everyone else’s mind for her to go to a nursing home, it was not at all what she wanted.
Ultimately, she was able to pass away at home a few years ago. What it involved was not extraordinary: a social worker’s level of support to coordinate care and transportation to her doctor’s offices. It’s remarkable that these cost-effective interventions still aren’t prioritized over the status quo of systems and facility-based care delivery in Massachusetts, even after the years have pointed to the dire need for alternatives.
Ranked one of the top three states by the Commonwealth Fund and the second healthiest state by the United Health Foundation, Massachusetts established itself as one of the highest performing health care systems in the country in 2017.
But cost and health disparities continued to be a major hurdle. As many as 1 in 4 residents reported going without needed medical or dental care due to cost. Emergency department, hospital outpatient and acute care, and hospital use were above national averages, contributing to high costs and ranking the state 37th in preventable hospitalizations. The Massachusetts Health Policy Commission passed a statewide target for sustainable growth in health care spending: 3.6% for the first five years, then 3.1% for 2018. Unfortunately, since that benchmark was established, health care spending averaged 3.59% annually.
It was in this environment that our stories collided — Landmark’s, Massachusetts’ and mine — as I was asked to launch the home-based integrated care model’s entrance into the state, where I’ve lived all my life. Already established in New York, California, Washington and Oregon, Landmark brought an interdisciplinary care team consisting of social workers, behavioral health providers, clinical pharmacists and nurse care managers into the home to provide true preventive care and address social determinants of health. We started in Boston negotiating at-risk, value-based contracts with local health plans.
Our patients average six to eight visits annually from their Landmark physician or advance practice provider. And when urgent care issues arise, we’re on call 24/7 to triage and avoid unnecessary hospital visits. This alternative model intrigued me, as my grandmother’s struggles were top-of-mind. What surprised me the most, though, was that no one else was doing it.
From 2018 to 2019, Massachusetts healthcare spending growth was 4.3%. The Massachusetts Health Policy Commission’s efforts to control spending included limiting sites that can bill as hospital outpatient departments and implementing site-neutral payments, in an effort to counter the ripple effects of health systems buying physician’s practices. Landmark grew throughout Greater Boston in the ultimate site-neutral location: a patient’s home. By tailoring care to the individual patient’s daily habits, we improved outcomes at lower costs.
In 2020, as many as 17% of Medicare beneficiaries have five or more chronic conditions and at least two million Medicare beneficiaries are completely homebound, with little access to care in the home. And as a result, over the course of the pandemic, the perception of where and how people age dramatically changed — for good reason. Home is where the daily act of health care happens for our patients, who average 77 years old with more than eight chronic conditions and over 12 medications. Landmark’s results speak for themselves: a 26% reduction in mortality rates and a 20% reduction in medical costs in the last 12 months. Sending clinicians into the home isn’t cheap, but a 25% reduction in hospital admissions shows that our model pays for itself over the course of a year.
It took a public health emergency to show that orienting a system around acute care delivery puts far too much pressure on one end of the system. And with all of its reputation for health reform and innovation, the large health systems in Massachusetts are swimming downstream. We can change the trajectory of what it means to age in the United States. We’ve had the solution all along. Right here, at home.
Chris Johnson is CEO of Landmark Health.
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