URMBT program

Program expansion

Key elements

Success stories

T.S.*

A 66 year-old, male, T.S. had a left-sided stroke about one year ago. He spent four months in a coma and required feeding tubes, ventilation and tracheostomy. He also has high blood pressure and high cholesterol. T.S. has recovered significantly, but continues to have memory difficulties, minimal right-sided weakness and dyskinesia. Part of Landmark’s treatment plan is to work with T.S. and his care team to address intermittent dizziness and low blood pressure, and coordinate medications and care with his primary care provider and specialists. Landmark reports T.S. is healthy and stable. He told Landmark he hasn’t had any episodes of dizziness or falls since working with Landmark.

B.C.*

B.C. is an 87-year-old female who lives with adult children in the same house, though she provides more care for them than they do for her. She contacted Landmark after receiving a flyer introducing her to the program and decided to call because she didn’t want to go to the emergency department. She was suffering from bladder infection and had been treated by her primary care provider with antibiotics but was not improving as quickly as she hoped. Landmark visited BC on back-to-back days. During the initial visit, it was determined that B.C. had been prescribed antibiotics days before but hadn’t been taking them as directed. She was evaluated for signs of worsening infection, such as sepsis or kidney involvement, but no additional concerning symptoms were found. B.C. called the next day due to unusual nausea and vomiting. During the second visit, she was treated with anti-nausea medication. Urinalysis was completed in-home. A Landmark physician contacted BC’s primary care provider for a physician-to-physician discussion regarding the treatment plan. Urinalysis showed her bladder infection was improving and that continued treatment following the current course of antibiotics was appropriate. B.C. was contacted by Landmark several times over the following days to monitor progress and avert an unnecessary ER visit.

F.J.*

F.J. is a is a 72-year-old male who is non-compliant with his medication regimen and complains of shortness of breath. He has Type 2 diabetes, which requires insulin, hypertension, chronic obstructive pulmonary disorder and morbid obesity. F.J. said his goal is to get “back to a normal routine without shortness of breath.” In December 2021, he was discharged from the hospital and treated by several specialists who had prescribed two inhalers. F.J. said he didn’t know how to take his medication — and why it was needed — and that he didn’t like them because they didn’t make him feel any better. He was using an over-the-counter nasal spray and mist instead. Landmark discussed F.J.’s plan of care with the multidisciplinary care team and determined that a nurse care manager would follow up with a call to him in two weeks to continue education and support. Landmark provided F.J. with extensive education about his medical conditions, specialists and the importance of using his medications as prescribed. “I see all of these doctors and they are all doing different things,” F.J. said. “Marcia (from Landmark) came in and I got more education from her than all these specialists! She put it in layman’s terms and I was able to understand everything for once. I am very appreciative of the Landmark team, the education and the time spent with them. I am looking forward to the next visit.”