Chronic disease causes major limitations in daily living for more than one of every ten Americans and substantially increases the risk of mental disorders. Without treatment, chronic depressive disorders are expected to be second only to heart disease in the global burden of disease. The interconnection between these two areas has important implications for both chronic disease management and the treatment of mental illness which requires a holistic approach to care.

Landmark’s behavioral health team consists of board-certified psychiatrists, behavioral health advanced practice providers, social workers, and care coordinators. Together through our comprehensive approach to care, our behavioral health providers identify and treat physical and mental needs in the home.

Through home visits, Landmark providers glean an intimate understanding of social determinants of health many times unseen in the PCP office. All notes, including screening, diagnoses and treatment information, are relayed back to the PCP ensuring highly integrated and collaborative care.

“Over time, I realized that people do care about me. Now my Landmark Psychiatric NP comes about every month, because I don’t want to get depressed again. Anytime I want, I can call my Landmark Psychiatric NP.” – Michael, Landmark patient

In addition to urgent and preventative in-home care offered by our physician-led team, Landmark offers eligible patients 24/7 access to interdisciplinary support, including behavioral health, for crisis evaluation and management and treatment of behavioral health issues such as:

• Adjustment disorders
• Depression
• Anxiety
• Cognitive impairment including dementia
• Substance use disorders

Types of in-home behavioral health services

Landmark behavioral health providers perform psychopharmacological evaluations to assess actions, effects, and psychoactive drugs in the context of the patient’s physical and mental health and make recommendations to PCPs regarding psychotropic medication management. They use tools like the Mini-Cog to assess cognitive function and decision-making-mental capacity and collaborate with PCPs if further neurological testing is recommended. Landmark providers also support patients in the home through the use of motivational interviewing and brief supportive counseling with expertise in empathy and listening.

Patients are typically referred to a Landmark behavioral health provider by other members of the interdisciplinary team. Services may also be requested directly by the PCP for members in the Landmark cohort.

Case Study: Mrs. Summer

Mrs. Summer is a 78-year-old female with a history of COPD, CAD, lung cancer, depression, anxiety, and PTSD. She lives in a one-level condominium and is the caretaker for her husband who has a history of a recent TBI. She has not driven in several years and has not seen her PCP or any specialists in over 1 year due to significant agoraphobia. She was taking Alprazolam 5mg per day as it was the only medication that “worked” for her. She was in danger of having this medication discontinued as she was not able to get to the office for follow up.

Mrs. Summer was seen in her home initially by the Landmark medical provider. During that assessment, a depression screen was performed along with medication reconciliation. As a result of a positive depression screen, and with Mrs. Summer’s permission, a referral was made to the behavioral health team to evaluate the psychopharmacologic and social issues that were impacting Mrs. Summer’s medical stability.

The behavioral health nurse practitioner (BHNP) was scheduled, and the evaluation was completed. A referral was made to the Landmark social work team to assist with transportation and community supports. The BHNP communicated with the PCP to discuss psychopharmacologic recommendations and a plan was agreed upon. The BHNP continued to see Mrs. Summer in her home and provided communication to the PCP around her progress.

Eventually, with the behavioral health, social work, and medical team support, Mrs. Summer was able to resume her appointments with her PCP, specialists, make the transition to outpatient mental health services and even go back to church and have lunch with family members!

She states, “If it weren’t for your program, I wouldn’t have made it!”