Post-Acute Care Pilot 

HPSM’s Post-Acute Care Pilot (PACP) promotes recovery and helps prevent relapse for members transitioning out of skilled nursing facilities and long-term care settings. HPSM is partnering with Landmark Health providers to care for our members in this pilot. The PACP has three main goals: 

1. Increase coordination between care settings, especially for our most complex members who are eligible for home-based care 
2. Reduce readmissions to the hospital 
3. Invest in additional post-acute care capacity 

How the Post-Acute Care Pilot works 

• Eligibility All HPSM members who have CareAdvantage or Medi-Cal only (with no other health coverage) are eligible for the PACP. 
• Availability The PACP is currently offered at six facilities: Burlingame Long-Term Care, Millbrae Skilled Care, Peninsula Post-Acute, Providence San Bruno, St. Francis Heights and St. Francis Pavilion.
• Credentials Landmark’s provider team currently consists of Dr. David Portier and Laurensia Widyastami, a nurse practitioner. Both have extensive training and experience caring for the elderly. Dr. Portier is a member of the Society for Post-Acute and Long-Term Medicine (PALTC), and is a certified medical director through that organization. 
• Participation All new admissions to the six participating facilities will be assigned to Dr. Portier, as will any long-term care residents whose care complexity qualifies them for the HomeAdvantage program. Members may choose to opt out of the PACP if they wish to be seen by a different provider. 
• Duration Post-acute care begins with the member’s arrival at a nursing facility. Post-discharge, Landmark providers visit the member at their home for 45 days to check in on their health and provide home-based care as needed. 
• Care Coordination Hospital discharge staff, care coaches and post-acute facility administrators continue coordinating with the member’s assigned PCP. 
• Quality Assurance HPSM medical directors maintain clinical quality oversight of the PACP, including monitoring quality measures and reviewing clinical concerns. 

For more information, call Provider Services at 650-616-2106.