Community-Based Care Across Medi-Cal, Medicare, and Dual-Eligible Populations
Uniting healthcare and community-based services through coordinated, reimbursable care pathways.
Partners delivers a comprehensive continuum of community-based care programs and support services spanning Long-Term Services & Supports (LTSS), care coordination, transitional care, and in-home support. Through coordinated, reimbursable care pathways, we help individuals access the care, services, and support they need across Medi-Cal, Medicare, and dual-eligible programs.
CARE TRANSITIONS
98%+
Scheduled
Post-discharge PCP appointments
95%
Attended
Post-discharge
50%
Reduction inHospital Readmissions
Measurable improvement in care transitions
40%
Outreach &Engagement Rate
Exceeding IndustryBenchmarks
Nationally Recognized Leader in Community-based Care
As a nationally recognized leader in community-based care, Partners works alongside health plans, healthcare systems, providers, and public agencies to strengthen care transitions, improve continuity of care, and address the non-clinical factors that influence health outcomes and total cost of care.
Partners has maintained NCQA Accreditation for Case Management for Long-Term Services & Supports (LTSS) since 2015, demonstrating a longstanding commitment to quality, performance, and person-centered care.
Through a No Wrong Door approach, individuals can access coordinated support across programs and funding streams, ensuring services are connected, appropriate, and sustained over time.
Community-Based Care Programs
Including Long-Term Services & Supports (LTSS), care coordination, and waiver-based programs that help individuals remain healthy, independent, and safely supported in the community.
Programs
- Enhanced Care Management (ECM) & Community Supports
- Community-Based Adult Services (CBAS)
- Home and Community-Based Alternatives (HCBA) Waiver
- Multipurpose Senior Services Program (MSSP)
Transitional & InHome Support Services
Our care managers meet individuals where they are, in hospitals, homes, and communities, to build trust, assess needs, and connect individuals to appropriate services and support.
Programs
- Care Transitions
- Private Duty
Medicare Advantage & D-SNP Community-Based Support Services
Community-Based Services and operational infrastructure designed to support California Integrated Care Management (CICM), CMS Model of Care requirements, member engagement, care coordination, and continuity of care across Medicare and dual-eligible populations.
Programs
- California Integrated Care Management (CICM) Support Services
- Member Engagement & Navigation
- Care Transitions
- Community Care Hub Infrastructure
Community-Based Care Programs
Including Long-Term Services & Supports (LTSS), care coordination, and waiver-based programs that help individuals remain healthy, independent, and safely supported in the community.
Enhanced Care Management (ECM) & Community Supports
Enhanced Care Management (ECM) & Community Supports
Coordinated Community-Based Care for Individuals with Complex Needs
Partners delivers Enhanced Care Management (ECM) and Community Supports services for Medi-Cal managed care plans, helping individuals with complex needs navigate healthcare and community-based services, address barriers to care, and access the support needed to improve health, stability, and independence.
Our care managers build trusted relationships through in-person and community-based engagement, meeting individuals where they are to understand their goals, identify unmet needs, and help connect them to the right care, services, and support at the right time and in the right place.
Our Approach
Partners co-designs workflows with health plans and healthcare organizations to integrate community-based services into existing care models, creating a seamless experience for individuals while supporting program goals, operational requirements, and measurable outcomes.
Identification & Referral
Together with our partners, we establish referral pathways and engagement strategies that support timely identification of eligible individuals and connection to the full range of ECM, Community Supports, and community-based resources available to meet their needs.
Community-Based Engagement
Our care managers meet individuals where they are, in hospitals, homes, and communities, to build trust, assess needs, and connect individuals to appropriate services and support.
Care Coordination & Navigation
We help individuals navigate healthcare and community-based services while coordinating support across providers, caregivers, and community partners.
Ongoing Support & Stabilization
Through continued engagement and connection to Community Supports and other resources, we help individuals improve stability, strengthen independence, and remain safely supported in their homes and communities.
Who We Serve
Partners specializes in supporting individuals with complex needs, including those experiencing:
- Frequent emergency department or hospital utilization
- Homelessness or housing instability
- Risk of institutionalization
- Transitions from hospitals, skilled nursing facilities, or other care settings back to the community
A Trusted Partner in Community-Based Care
- Community-Based Engagement
- Complex Population Expertise
- Statewide Delivery Infrastructure
- No Wrong Door Access
- Proven Outcomes
- Quality & Operational Excellence
Community-Based Adult Services (CBAS)
Community-Based Adult Services (CBAS)
Supporting Older Adults and Individuals with Complex Health Needs in the Community
Community-Based Adult Services (CBAS) is a Medi-Cal benefit that provides health, therapeutic, and social services in a community-based setting for eligible older adults and individuals with disabilities. CBAS plays a critical role in helping older adults and individuals with complex health needs remain safely in the community while supporting care plan goals and reducing avoidable hospital and institutional utilization.
Supporting Access to CBAS
Partners in Care Foundation works with health plans, providers, and CBAS centers to facilitate timely, compliant access to CBAS services. We conduct eligibility evaluations and coordinate next steps, helping ensure individuals are appropriately assessed, connected to CBAS services, and supported throughout the process.
What Sets Partners Apart
Nurse-Led Evaluations
All evaluations are conducted by trained, multi-lingual registered nurses, ensuring accurate assessments and strong engagement with diverse member populations.
Proven Compliance
100% audit compliance across all managed care plan reviews since 2013.
Statewide Reach
Established relationships with 200+ CBAS centers, with the ability to complete evaluations in homes, CBAS centers, hospitals, and Skilled Nursing Facilities (SNFs).
Operational Infrastructure
Proprietary systems track each evaluation from referral through determination, supporting timeliness, quality oversight, and transparent reporting.
Flexible Partnership Model
Customizable evaluation and reporting services designed to meet health plan and provider needs.
Referrals & Eligibility
Referrals may be initiated by health plans, providers, CBAS centers, individuals, or caregivers.
Home and Community-Based Alternatives (HCBA) Waiver
Home and Community-Based Alternatives (HCBA) Waiver
Supporting Individuals with Complex Medical Needs at Home
Partners delivers the Home and Community-Based Alternatives (HCBA) Waiver, helping individuals with complex medical needs receive care and support in their homes and communities rather than institutional settings whenever possible.
For nearly three decades, Partners has helped individuals with complex needs navigate healthcare systems, access essential services, and receive the support needed to remain safely at home and in their communities.
Through comprehensive care management, service coordination, and connection to home- and community-based services, Partners helps individuals maintain independence, improve quality of life, and avoid unnecessary institutional care while remaining safely supported in the setting they call home.
Our Approach
Partners works alongside individuals, caregivers, healthcare providers, and community partners to coordinate services that support safe community living and reduce the need for institutional care.
Comprehensive Assessment & Care Planning
Our interdisciplinary care management teams, including nurses and social workers, assess medical, functional, environmental, and social needs to develop individualized care plans that support health, safety, and independence.
Service Coordination & Navigation
We coordinate healthcare, waiver services, community resources, and caregiver supports to help individuals access the services they need.
Home & Community-Based Support
We help connect individuals to services that support safe living at home, including personal care assistance, caregiver support, medical equipment and supplies, home modifications, transportation, and other home- and community-based services authorized through the HCBA Waiver.
Ongoing Monitoring & Care Management
Through ongoing assessment and care coordination, we help ensure services remain aligned with changing needs over time.
Who We Serve
Partners supports individuals who:
- Have complex care needs
- Require a nursing facility level of care
- Prefer to remain in their homes and communities whenever safely possible
- Meet HCBA Waiver eligibility requirements
Refer Someone to HCBA
Referrals may be made by individuals, family members, healthcare providers, hospitals, health plans, and community organizations.
Multipurpose Senior Services Program (MSSP)
Multipurpose Senior Services Program (MSSP)
Helping Older Adults Avoid Institutional Care
Partners delivers the Multipurpose Senior Services Program (MSSP), a Medi-Cal Home and Community-Based Services waiver program designed to help older adults (age 60+) remain safely in their homes and communities rather than entering institutional care.
As California’s leading MSSP provider, Partners works alongside older adults, caregivers, healthcare providers, and community partners to coordinate services, address barriers to independence, and support long-term health, safety, and well-being.
Refer Someone to MSSP
Refer Someone to MSSP
Referrals may be made by individuals, family members, healthcare providers, hospitals, health plans, and community organizations.
To be eligible for MSSP, individuals generally must:
- Be 60 years of age or older
- Have active full scope Medi-Cal coverage
- Require a nursing facility level of care (NFLOC) criteria
- Reside within an MSSP service area
- Be able to live safely in the community with appropriate supports
- IHSS overlap: MSSP can be received alongside IHSS and other services if not duplicative
Waiver capacity: MSSP is not an entitlement, waitlists may exist
Partners MSSP Service Area
Partners currently serves eligible individuals in designated service areas across Los Angeles County, Antelope Valley, Santa Clarita Valley, San Fernando Valley, plus Kern, and Santa Barbara Counties.
View full list of Zip Codes Covered by Partners’ MSSP. If you do not live in a covered area, visit the California Department of Aging site for the full list of MSSP Providers in California
Transitional & In-Home Support Services
Care Transitions, Private Duty.
Care Transitions
Supporting Recovery Beyond Discharge
Partners helps healthcare organizations reduce avoidable readmissions, strengthen continuity of care, and improve recovery following hospitalization through community-based transitional care support.
The days immediately following discharge are among the highest-risk periods in a person’s recovery. Timely follow-up, connection to services, and support navigating the transition from hospital to home can significantly improve outcomes while reducing avoidable emergency department visits and hospital readmissions.
Our teams engage individuals during the critical post-discharge period, helping them navigate the transition from hospital to home, connect with providers, access needed services, and address barriers that can impact recovery and long-term health outcomes.
Our Approach
Partners co-designs workflows with hospitals, health systems, provider groups, and health plans to integrate care transitions support into existing discharge and care coordination processes.
Early Post-Discharge Outreach
Individuals receive timely outreach following discharge to assess needs, identify barriers, reinforce discharge instructions, and support successful recovery.
Follow-Up Care Coordination
Our teams help coordinate primary care and specialty follow-up appointments, confirm attendance, and address challenges that may prevent individuals from accessing care.
Community-Based Support
We connect individuals to community-based services and resources that support recovery, stability, and ongoing health needs following hospitalization.
Ongoing Engagement
Through continued follow-up during the transition period, we help individuals remain connected to care while reducing the risk of avoidable emergency department visits and hospital readmissions.
Who We Serve
Partners works with healthcare organizations to support individual who are transitioning from one care setting to another and need support to ensure a safe and coordinated discharge.
- Patients discharged from hospitals, emergency departments, or skilled nursing facilities
- Patients identified as high risk for readmission or utilization
- Patients requiring follow-up appointment coordination, medication support, or care plan reinforcement
A Trusted Partner in Community-Based Care
- Industry-Leading Readmissions Outcomes
- Post-Discharge Engagement Expertise
- PCP Scheduling & Follow-Through
- Integrated Workflow Design
- Quality & Operational Excellence
Built for Interoperability and Care Coordination
As a participant in California’s Data Exchange Framework (DxF), Partners supports more connected care through secure information sharing and coordinated workflows across healthcare and community-based settings.
Private Duty Services
Helping Eligible Individuals Remain Safe and Independent at Home
Private Duty Services provide non-medical, in-home support for eligible individuals who need assistance with daily activities to remain safely at home and avoid unnecessary institutional care.
Available through CalAIM Community Supports, these services help individuals maintain independence, support aging in place, and provide important relief for caregivers.
Partners coordinates a statewide network of licensed Home Care Organizations, helping health plans deliver high-quality, person-centered services through a scalable model that combines local service delivery with centralized quality oversight, network management, and operational support.
Available Services
Depending on individual needs and health plan authorization, services may include:
Caregiver Respite Services
Temporary support that helps caregivers rest, manage personal responsibilities, and maintain their own well-being while ensuring continuity of care for their loved one. Respite Services are designed to be flexible and responsive to individual needs, whether for a few hours, a full day, or on a recurring basis.
Personal Care Services
Assistance with Activities of Daily Living (ADLs), including support delivered with a focus on dignity, safety, comfort, and independence.
Homemaker Services
Support with essential household activities that help individuals maintain a safe, stable, and functional home environment.
Why Organizations Partner with Partners
Partners serves as a statewide administrative and service delivery infrastructure for Private Duty Services, helping organizations expand access to high-quality, community-based support through a trusted network of licensed providers while reducing the operational burden of network management, quality oversight, compliance, reporting, and administration.
To be eligible for MSSP, individuals generally must:
Statewide Network Management
Partners coordinates and oversees a statewide network of licensed Home Care Organizations, providing broad geographic coverage and access to culturally and linguistically appropriate services across California.
Quality Oversight and Compliance
Partners provides ongoing oversight of network providers, including licensing verification, quality monitoring, performance management, and compliance review. Partners maintains NCQA Accreditation for Case Management for Long-Term Services and Supports (LTSS), reflecting a longstanding commitment to quality and operational excellence.
Licensed Provider Network
All network providers are licensed Home Care Organizations (HCOs) through the California Department of Social Services Home Care Services Bureau. Caregivers providing services are registered Home Care Aides (HCAs) who meet applicable state training, registration, and background screening requirements.
Streamlined Referral and Administration
Health plans benefit from a single point of entry for referrals, centralized coordination, streamlined reporting, and simplified billing processes that support efficient program administration.
Statewide Community-Based Delivery Infrastructure
With extensive experience developing and managing community-based service networks, Partners helps health plans expand access to in-home support services while maintaining quality, consistency, and member-centered care.
Partner with a Proven Statewide Delivery Model
Medicare Advantage & D-SNP Community-Based Support Services
Community-Based Infrastructure Supporting CICM, CMS Model of Care Alignment, and D-SNP Performance.
Medicare Advantage & D-SNP Community-Based Support Services
Partners supports Medicare Advantage organizations, D-SNP plans, ACOs, and healthcare systems through coordinated community-based services designed to strengthen engagement, improve continuity of care, support CMS Model of Care alignment, and address barriers that contribute to avoidable utilization.
As Medicare Advantage and D-SNP organizations face increasing expectations around member engagement, care coordination, and integrated care delivery, community-based support plays an essential role in improving outcomes, strengthening member experience, and addressing barriers that impact health beyond traditional clinical settings.
Extend Your Reach Through Partners Community Care Hub
Rather than managing multiple community-based contracts, vendor relationships, and service providers, healthcare organizations can access regional community-based services through a single trusted partner.
Partners operates as a structured, non-clinical extension of existing care systems, expanding community-based capacity while supporting quality performance, member experience, and integrated care outcomes Learn more about the Partners Community Care Hub.
Community-Based Solutions & Support Services
California Integrated Care Management (CICM) Support Services
Non-clinical CICM support functions aligned with DHCS guidance and CMS Model of Care requirements.
Care Transitions
Evidence-based transitional support designed to reduce avoidable readmissions and strengthen continuity across care settings.
Enhanced Care Management Support (Non-Clinical)
Non-clinical ECM support functions including assessment, interdisciplinary coordination, HRSN identification, stabilization support, and connection to community-based services and resources.
Engagement & Navigation
Culturally and linguistically meaningful outreach, including HRA completion, upstream risk identification, and connection to ECM and CICM pathways.