The Blue Shield/Landmark Program
Landmark is a comprehensive home-based care program for Blue Shield of California members with five or more specific chronic illnesses has been widely embraced in its first 12 months. The program uses data-driven algorithms to identify members qualified to receive community-based, physician-led care in plan members’ homes so they can better manage multiple complex health issues such as kidney and heart diseases, diabetes, hypertension, and depression.
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.
More than 3,500 members have enrolled in the program since it launched a year ago. Those members used Landmark’s 24/7 access to care, and received more than 15,000 home visits for medical, behavioral, and social support services as well as urgent and post-discharge care.
The Landmark service is available at no additional cost for eligible members of Blue Shield of California and its subsidiary Blue Shield of California Promise Health Plan. Landmark medical professionals do not replace a member’s primary care physician or specialists; they work collaboratively with members’ physicians to reinforce the doctor’s in-office care plan.
Top 10 Chronic Conditions Addressed
| Hypertension | 99 % |
| Chronic kidney disease | 76% |
| Diabetes | 69% |
| Peripheral vascular disease | 66% |
| Coronary heart disease | 65% |
| Pulmonary disease | 62% |
| Depression | 55% |
| Heart failure | 53% |
| Atrial fibrillation | 37% |
| Cerebral vascular disease | 27% |
- 15,550 home visits by a Landmark provider
- 33,317 phone contacts by a Landmark provider
Who are the Enrollees?
- 92 percent of the participating members are enrolled in a Medicare, MediCal or Cal MediConnect plan offered by Blue Shield or Blue Shield Promise; the rest are Blue Shield’s commercial health plan members.
- Average age of program participant is 72.
- Many have multiple chronic illnesses to manage; for example, 99% of the population has hypertension, 76% has chronic kidney disease and 69% has diabetes.
- The home health interventions also target behavioral health needs that are common in this population.
Connecting Care Between Payer and Provider
Blue Shield uses data-driven algorithms to identify members who qualify for the Landmark program, then invites them to enroll through letters and phone calls. Primary care physicians of eligible members are also notified about the program.
Landmark’s EMR 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. The EMR “drives longitudinal health outcomes for patients and also enables clinical documentation exchange with community providers.
Blue Shield’s Landmark program is currently available in the following counties: Los Angeles, Orange, Sacramento, San Diego, Riverside, San Bernardino, San Mateo, San Francisco and Santa Clara.
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