The Blog to Transform Advanced Care
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The Mission of Partners in Care Foundation (Partners) is to align social care and health care to address the social determinants of health and equity disparities affecting diverse, under-served and vulnerable populations. Partners is a nationally recognized leader in developing innovative home and community-based approaches to health promotion, chronic disease management and addressing health disparities. With a current annual budget of more than $20 million and 204 employees across five locations throughout Southern California, we provide non-medical home and community-based services, self-management education, medication safety screening, and outreach and care coordination for more than 25,000 individuals annually. This number is rapidly expanding.
Partners is accredited in complex care management by the National Committee for Quality Assurance (NCQA) and was the second community-based organization in the country to achieve this status. We focus on improving chronic disease self-management, identifying, and resolving dangerous medication errors, preventing falls, averting costly hospitalizations, and preventing premature nursing home placement through care coordination. We are intent on helping people care for themselves in their home rather than in an institutional setting. And we continue to actively expand regional workforce development initiatives to address the rapidly growing need for workforce to effectively impact social determinants in-home.
Grounded in an extensive history of creating, testing, adapting, and disseminating evidence-based models of care, Partners also builds capacity to integrate health and social care by advising health systems on redesign to include Social Determinants of Health and bring training programs to qualify new groups to expand services to vulnerable and aging populations. Our overriding goal is to promote the best possible health and quality of life for those most in need through enhanced self-care, special supports, and access to key health-impacting resources.
All of Partners’ programs serve diverse, low-income populations across the age spectrum, with older adults representing the majority of those we serve. Most of our programs are offered in Los Angeles County with these exceptions: Short-Term Services are offered through regional partners and reach participants across California; MSSP also offers programs in Kern County and Santa Barbara; Health Homes also reaches Inland Empire and San Diego.
Summary of Programs and Services
Our main programs fall into three categories:
Community Wellness: Partners conducts evidence-based workshops for low-income participants with challenging chronic health conditions such as diabetes, heart disease, arthritis, or chronic pain. Workshops are typically six 2.5-hour weekly sessions. Participants learn to set realistic personal health goals and gain skills to better manage their emotions, health impacting behaviors, and their healthcare. Workshops are held across the county, with a concentration in areas of greatest poverty. These programs are led by specially trained peer leaders.
Long-Term Services and Supports: Partners operates three Medi-Cal nursing-home/ER-diversion programs: 1) Multipurpose Senior Services Program (MSSP) – Partners is the largest MSSP provider in California. We design, implement, and monitor customized care plans for very low-income frail seniors to help avoid placement in a nursing home and ensure a dignified and safe aging experience in their own home; 2) Home and Community-Based Alternatives (HCBA) Waiver – This program maximizes community living for highly disabled children and adults. Partners provides care coordination and oversees complex in-home support services; and 3) Health Homes program – People in this program have complex social and medical needs and severe chronic conditions, are frequent ER users, and many are homeless. Our role is to identify, engage, help to establish a medical home, and provide ongoing social care management.
Short Term In-Home Services: Under contract with health plans and hospital systems, our health coaches and social workers work closely with individuals to improve management of their chronic conditions at home. Participants are typically newly released from the hospital or nursing home, which is a time of maximum risk for medication errors, falls, or worsening health. A primary outcome of these in-home services is to help people stabilize, resulting in a much better transition experience and substantial reduction in hospital readmissions. These services are available directly from Partners staff in Southern California, or through the Partners at Home network elsewhere in the state
In addition to our three main program categories, Partners also provides highly specialized services to organizations in California and throughout the country.
HomeMeds: This is a powerful in-home, risk screening assessment tool. Non-clinical and in-home care providers both in California and across the United States utilize this evidence-based tool to identify potential patient medication-related hazards. It consists of an in-home medication review and intervention that includes a computerized risk assessment and alert process, plus a pharmacist review and recommendation for medication adjustments. It is valuable for patient readmission reduction, health self-management, care transitions, and caregiver support.
Workforce Development: Partners’ strong focus on workforce development is essential to equip the service field with qualified personnel to deliver new models of care. Workforce initiatives include developing and disseminating curriculum to train Community Health Workers and an initiative to expand the supply of MSWs to serve increasing numbers of older adults. Multiple training programs help equip other agencies and work groups with specific skills to deliver a range of specialized programs targeting key health risk factors benefitting from self-management.
Engagement Center: The ability to reach and begin working with clients is a crucial part of Partners success in providing services. Making connections with individuals often starts with our state-of-the-art Engagement Center and its talented staff, which not only supports Partners, but is contracted with Health Plans throughout the country to aid in effectively and efficiently reaching their members.
Partners was drawn to C-TAC because as a Community Based Organization that is mission driven to improve health care systems our values align and complement each other. C-TAC policies surrounding health equity, community support, caregivers, workforce development and care models are among our main priorities.
We hope that by joining we could be on the front end of policy work, as well as be able to connect and share information and best practices from other leaders. We would like to unite our client voices to the overall impact that C-TAC provides.