Episode #134: A New Standard of Care: Comprehensive, Concierge-like Home-based Care for Seniors with Complex Chronic Conditions – with Michael Le MD, Co-founder of Landmark Health & Chief Medical Officer of Optum Home & Community


Our topic today is nothing less than a new standard of care for a vulnerable segment of the population that has been subjected to highly fragmented, uncoordinated and grossly inadequate medical care. For those of us who have experience with older parents as well as for physicians and other providers of care – you understand how challenging, frustrating and heartbreaking this situation can be.

Dr. Michael Le, and his colleagues at Landmark Health and Optum’s Home & Community division, have spent decades developing and deploying a remarkably humanistic alternative approach to care for this vulnerable population.  He outlines for us a comprehensive, concierge-like, premier home-based care ecosystem for frail seniors and those with complex chronic conditions.
Dr. Michael Le is the Chief Medical Officer of Optum Home & Community, as well as the Co-founder & Chief Medical Officer of Landmark Health. He has spent the majority of his career serving high-acuity, frail patients through the development and implementation of innovative care models.  Prior to Landmark, Dr. Le served as the Chief Medical Officer of Fidelis SeniorCare, a Medicare Advantage Special Needs Plan.  Before that, he was the Senior Medical Officer at CareMore, a Medicare Advantage plan where he ran high-risk clinical programs. Prior to CareMore, Dr. Le was a Regional Lead Hospitalist at HealthCare Partners, a risk-bearing medical group, where he was the physician lead for the company’s

high-risk Ambulatory Case Management program. Dr. Le received his MD at UCLA and completed his residency in internal medicine at Cedars-Sinai. 

In this interview, we’ll hear:

  1. The profound problem and tremendous gap in the American healthcare delivery system that Landmark is solving.
  2. The various types of home-based care that Landmark offers to frail elderly individuals and seniors with complex chronic conditions.
  3. The remarkable outcomes that Landmark has achieved for patients, providers and payers.
  4. Where Landmark is going next and some insights into Optum’s Home & Community division.

There are some many wonderful aspects to the healthcare approach Dr. Le and his colleagues have created at Landmark Health and are now incorporating as part of Optum’s Home & Community division. The core team is a pod composed of a physician, a NP or PA, a nurse care manager, and a health ambassador/health coach.  Surrounding this core team is another team of a pharmacist, a psychiatrist and a social worker.  And even beyond that, there is another team of specialists in urgent and emergent care that can be deployed for more complex testing and procedures in the home.  It’s nothing less than an entire ecosystem of high quality, comprehensive clinical care that can be delivered in patients’ home – 24/7!  

Another key differentiator of this new standard of care is that it’s equally focused on the social and behavioral aspects of medical care.  In fact, Michael shares with us that over 50% of the calls they receive from patients and family members have to do with psychosocial factors, the social determinants of health and palliative care needs.  What I found remarkable is that Landmark trains every one of its providers and team members in a specially designed program around how to discuss and deliver excellent Palliative Care. It’s clear from listening to Michael that they not only talk the talk around Palliative Care and outstandingly respectful and dignified end of life care – they walk the walk.  It’s heartwarming to hear how intentionally caring Landmark is in this domain.

The proof, of course, is in the pudding and Landmark’s outcomes are remarkable. A 20 plus percentage reduction in hospital admissions; a 20 – 30% improvement in the Medical Loss Ratio; a 43% reduction in emergent dialysis starts. The statistic or outcome that really gripped me was the 26% reduction in mortality.  This is astounding – and it really speaks to the holistic care that the Landmark team provides, and their approach to dealing with the real barriers to care in real time.  

When you listen to Dr. Michael Le speak, you hear a physician who grew up watching his father practice medicine in a small town, carrying a black bag and doing home visits.  Michael and his Landmark colleagues have brought the best of the past into the present, and propelled that care into the future with a high tech, high touch holistic approach to care that delivers hospital and ED quality care in the comfort, convenience and safety of the patients home.  This type of care would be welcome by all of us, but it’s especially needed and appreciated by those elder patients who are suffering with complex and chronic conditions – issues such as dementia, frailty, and end stage chronic diseases. 

Landmark Health was acquired by Optum Health and Dr. Le could have easily retired.  But instead he has joined Optum Home & Community and launched a whole new chapter in his career and a whole new chapter in the field of home-based care.  As he puts it,The vision at Optum Home & Community is to break down silos and improve collaboration – to give patients a seamless care experience across their entire continuum of needs”.  He and his colleagues at Optum have united numerous companies under the umbrella of home-based care, and their goal is to scale it across the country.  It’s a breath-takingly bold and brilliant vision – and one that will contribute to improving the care for some of the most needy and vulnerable seniors.  I have so much respect and admiration for Dr. Michael Le and his colleagues.  We need more leaders like this in healthcare: focused on what truly matters and what truly makes a difference in patients’ lives – in all of our lives!

Until Next Time,
Be Well

Zeev Neuwirth, MD