August 20, 2018

The Value of a Multidisciplinary Care Team

Not all medical problems can be solved at physician offices alone.

Mental Health Issues Increase Hospitalizations
Gene, a 75-year-old man with multiple chronic conditions, struggled with his health, but not simply due to his physical condition. Gene’s wife had died a year earlier, and his grief and loneliness was causing him anxiety. He sometimes confused his sudden panic attacks with heart attacks. Each time his anxiety grew uncomfortable, Gene called the emergency room (ER), where he was admitted due to his other chronic conditions.

Many patients’ medical issues are complex, multifactorial, and cannot be addressed purely within a medical context. In a study by the Kaiser Family Foundation, 18% of frequent ER users have a mental health condition, compared to only 6% of the study population. While ERs can treat the symptoms that the patient is experiencing, they do not typically have the capacity to deal with the underlying mental health issue that drove the 911 call.

Medication Compliance Challenges Are Often Unreported
Carol, age 65, didn’t purchase the medications her primary care physician (PCP) prescribed for her COPD following a hospital stay. She couldn’t afford her prescriptions—but didn’t admit this to her doctor. The doctor had no way of knowing that Carol was not taking her medications. When her condition worsened, she ended up back in the hospital.

According to the Commonwealth Fund in 2007, 23% of survey respondents in the US reported not filling out prescriptions or skipping doses due to the cost of the medication.

Living Conditions Cannot Be Evaluated by PCPs
At 80 years old, Jerry had difficulty walking due to an advanced arthritis condition. But his home was littered with objects he could easily trip on due to his hoarding. His doctor was aware of his frailty, but couldn’t have predicted that Jerry would trip on a box in his hallway and break his hip. This fall was preventable—and it threatened his ability to continue living independently at home.

ER visits linked to falls are rising as the overall population ages, according to California Healthline. Simple home safety interventions can address fall risks. Fall risk factors can be difficult for an office-based clinician to assess.

Why Landmark’s Multidisciplinary Model Works
The importance of having a strong understanding of the patient’s comprehensive health picture and living situation is clear—including all clinical conditions, mental health status, and psycho-social and environmental factors. Home visits allow for longer, in-home conversations that build trust with patients and caregivers, and can help Landmark unearth the root causes of their complex health.  The multidisciplinary teams at Landmark Health then tackle these issues with expertise and tools not always available to physician offices.

Landmark Health offers a range of specialized roles for in-home evaluation and treatment. Landmark’s multidisciplinary team can reinforce and amplify the care the patient receives from their primary care physician.

Landmark Health’s Specialized Roles
Our multidisciplinary team can address the unique needs of each individual patient. For example, for a patient such as Gene, Landmark might use the clinical expertise of the following:

 Nurse Care Manager
A Nurse Care Manager can answer Gene’s call and coach him over the phone on breathing and relaxation techniques. They can also educate him on the differences in symptoms between panic and cardiac episodes, and on managing his multiple chronic conditions over time.

A Landmark Urgentivist could perform urgent in-home visits for Gene, to assess and treat him at home, rather than Gene immediately calling the ER.

  Social Worker
A Landmark social worker may visit Gene regularly to fully assess and address his psycho-social risk factors and needs.

 Psychiatric Nurse Practitioner
A psychiatric nurse practitioner could prescribe medication and ensure appropriate support to deal with Gene’s anxiety and panic attacks.

For a patient such as Carol, who has difficulty following her medication regimen, Landmark offers specialists such as:

 Physician, Nurse Practitioner, or Physician Assistant
Landmark physicians, nurse practitioners and physician assistants can see things in the home that are not apparent during an in-office visit. These providers perform a thorough medication reconciliation in the home, where they can physically hold and see the pill bottles. They have time to talk with patients, which makes patients more likely to share information about their financial situation.

For Carol, a Landmark pharmacist can help identify lower-cost medication substitutes with similar clinical impact. Pharmacists can also ensure the safe and effective use of medication, using medication reconciliation, assessment of optimal drug product selection, dosage regimen design, as well as providing effective administration and drug therapy monitoring services.

  Nurse Care Manager
Landmark nurse care managers would collaborate with Carol’s primary care physician and specialists such as her pulmonologist to discuss a health regimen to which Carol can adhere long-term, avoiding further hospitalizations.

For Jerry, Landmark would offer a social worker to assist with his living conditions, as well as the following:

 Nurse Practitioner
Landmark providers, including nurse practitioners, regularly conduct fall risk assessments as part of routine visits and can conduct home safety assessments to point out potential fall risks to patients like Jerry.

 Care Coordinator
A Landmark care coordinator would work to help order Jerry the necessary medical equipment to support him in his home after his broken hip, such as walkers, grab bars, or a modified toilet.

A Landmark ambassador might work with Jerry in his home and over the phone to build a lasting relationship with him and educate him on how best to use Landmark’s services. The ambassador would also conduct structured surveys with Jerry, to further understand his needs, which would be shared with the full multidisciplinary team.

Reinforcing the Primary Care Providers’ Care Plan
Landmark’s multidisciplinary team can uncover and root out issues that may not come up in the office, and use the advantage of being in the home to intervene when necessary. This collaborative and high-touch approach helps Landmark deliver strong results, including high patient satisfaction, reduced hospitalizations, and better quality of life. Learn more.


The information provided herein is intended for your general knowledge only and is not a substitute for professional medical advice or treatment for specific medical conditions. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition.