Overview of Partners in Care Innovations
As the dominant health needs of Americans continue to shift, we must change the way health care is delivered. Partners was created to address these issues:
- to help redesign systems of care and coverage
- to facilitate the identification and testing of new interventions,
- to improve and advance care and to strengthen individual ability to actively maintain and improve health and mitigate the impact of chronic conditions.
Partners’ mission is to serve as a catalyst to shape a new vision of care by partnering with organizations, families and community leaders in the work of changing health care systems, changing communities and changing lives.
In all our work Partners relies on collaboration, innovation, and impact to find new ways of bringing more compassionate, effective and efficient health and social services to care systems and, now, to move to a focus on individuals and families. Here are the innovative ways in which Partners exemplifies its mission:
Partners’ Research: The Institute for Change
Partners is the lead agency for many research, consulting and evaluation projects. Through its carefully formulated initiatives, identification of needed resources, project management, application of rigorous scientific design and evaluation, Partners produces nationally recognized new models of care. Recent examples include:
- Palliative Care: Working with Kaiser-Permanente Southern California, Partners has tested and evaluated a new model of end-of-life care that employs a multidisciplinary team approach. This model has demonstrated cost-effectiveness and high levels of patient satisfaction. Partners is now assisting Kaiser-Permanente in replicating this project in three other states.
- Medications Management Model: Frail older adults who receive care management or home health services are at high risk for medication-related problems. Over the past 10 years, Partners has developed and tested a successful medication-management model to prevent medication errors and improve medication management. The model has been replicated in three community-based senior care management programs in Los Angeles County. Based on strong findings from the program, Partners recently received additional funding to disseminate the model on a national level.
- Healthy Moves for Aging Well Physical Activity Program is an evidence-based intervention to bring increased physical activity through in-home exercise to frail, low-income older adults in care-management agencies. Partners developed and conducted a pilot project of the program with funding from The John A. Hartford Foundation and guidance from the National Council on the Aging. After six months of participation, 76.2% of the clients were retained in the program. The purpose of this initiative is to train care managers to teach evidence-based exercises to their homebound, frail elderly clients to improve their functional level of independence and quality of life.
Partners’ Collaboratives: Making Communities Stronger
Partners facilitates the development of community collaboratives to widen access to health care for vulnerable populations.
- Antelope Valley Partners for Health (AVPH) was developed through a collaboration led by Partners in Care Foundation with the Los Angeles County Public Health Department along with other community based health and social service providers. As a collaborative, AVPH improved coordination with the County Department of Health to promptly address health and social service needs in this fast-growing and underserved rural area. In February, 2008, after more than seven years of growth and success, AVPH was able to assume an independent leadership role in the Antelope Valley healthcare community. AVPH program highlights include:
- Save-A-Smile Dental Program
- Healthy Eating Active Living
- Carol White Physical Education Program
- Valley Care Community Consortium: The consortium brings together 180 public and private hospitals, public health and other agencies in the San Fernando Valley to conduct a large-scale needs assessment, address access barriers and related issues with a strong focus on low-income and multicultural populations. Partners is the contracting/fiduciary organization for the consortium. Additional projects include:
- Pacoima Diabetes Collaborative
- Pacoima Beautiful
- Project Improving Access to Care
- Triennial Community Needs Assessment
Partners in Care serves as the fudiciary of this consortium.
- Access to Care Collaborative: San Fernando Valley hospitals and community agencies work together to improve access to health care for the uninsured. The collaborative provides non-emergency care to low-income, uninsured adults via no-cost medical clinics staffed by volunteer physicians and healthcare professionals providing pro bono services.
Partners’ Direct Services: Serving At-Risk Populations
Diverse initiatives address ethnic health disparities like infant mortality rates and diabetes, access to care for the uninsured, timely detection of cancer in underserved women, and improvements in care for vulnerable populations, such as falls prevention, reducing medication errors and exercise programs for frail elders.
- Family Care Network: The program provides a safety net to individuals and families facing healthcare crises through small and large grants that cover costs not reimbursed by insurance or other sources. Grants provide necessary services, equipment and education that are most likely to prevent family breakdown, mitigate the risk for premature hospitalization, and improve quality of life. Examples include: respite care support, wheelchair ramps, hearing aids, dental treatment and outpatient healthcare. Since 2001, Family Care Network has directed more than $1.6 million in critical resources to diverse and vulnerable individuals and families.
- Multipurpose Senior Services Program: MSSP provides case management to seniors whose physical or cognitive disabilities put them at risk of unnecessary or premature placement in a nursing home. The program reaches over 1,000 seniors each year.
- Disease Prevention & Health Promotion Program: Funded by the City of Los Angeles Department of Aging, the program targets vulnerable seniors across multipurpose senior centers and congregate meal sites in Los Angeles. Through a collaborative of medical and health professionals and university faculty, the program provides health screenings, referrals, counseling and education to improve seniors’ health and quality of life. The program reaches nearly 7,000 seniors per year through direct service and outreach. Additional Projects include:
- Santa Clarita Adult Day Health Care Centers: Chronically ill or functionally impaired adults receive a full day of nursing care and therapeutic services as well as social and recreational activities and meals so they can remain at home and avoid premature admission to nursing homes or other institutions. The program assists patients’ families by providing support, information and resources. More than 900 people participate each year.
- Healthy Births Initiative and Black Infant Health: In the Antelope Valley African American infant mortality is three times that of the rest of the county of Los Angeles. The Health Births Initiative of the Antelope Valley works through local health and social service organizations as well working with the faith based community to reduce disproportionate African American infant mortality and low birth weights and to improve related health indicators among African Americans in Lancaster, Palmdale, Littlerock and Lake Los Angeles. Annually, the program will serve over 120 women.
- Care-A-Van: This mobile health clinic delivers basic medical care to the uninsured and impoverished working families in rural areas of the Antelope Valley and Eastern Kern County. The van serves residents who live below 200 percent of the federal poverty level and lack health coverage. It provides care to more than 3,200 children and adults per year. The traveling medical facility keeps healthy children in school, and allows adults to work to support their families. Additional projects include:
- AV Breast Cancer Resource Network
- Asthma Outreach and Education
Partners’ Education, Advocacy and Consultation: Advancing the Healthcare System
Partners takes a leadership role in research and evaluation, development and testing of new models for improving care and preventing disease. We provide technical assistance to organizations seeking to positively impact health care in Southern California communities.
Geriatric Social Work Education Consortium is the nation’s first major regional consortium to create a replicable, sustainable model for graduate geriatric social work education that integrates fieldwork and academic studies. Now independent, but originally funded by the John A. Hartford Foundation and the Archstone Foundation, the program is an alliance of the six graduate schools of social work in Southern California.