Partner With Us | Partners In Care Foundation

Partner With Us

Building a Bridge to Better Outcomes Between Medical Care and Social Determinants of Health

The CDC defines Social Determinants of Health as: “Factors that contribute to a person’s current state of health. These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature.”

Generally, there are five recognized determinants of health:

  • Biology and genetics.
  • Individual behavior.
  • Social environment.
  • Physical environment.
  • Health services.

There is a growing consensus among policy makers, lawmakers, and health care community leaders that adequately addressing patients’ non-medical needs is a critical element of advancing population health, improving the quality of medical care, and lowering the costs of care. Estimates suggest that 40–90 percent of health outcomes are attributable to social, behavioral, and economic factors.
Health Affairs November 2016

We believe in partnership, innovation and impact. That means bringing together healthcare, families and community-based services to offset the impact of determinants. The result is a full-range of evidence-based SDOH-focused programs and services complementing the clinical model of care.

Our Programs and Services


Do you have patients who take multiple medications? Avoid problems with a HomeMeds screening. Medications plan an important role in helping to control many illnesses, but they can also have serious side effects. Each years, nearly 100,000 older adults end up being hospitalized because of medication-related problems including falls, dizziness, heart issues, confusion and more.


Includes our HomeMeds services PLUS we conduct an in-home evaluation and assessment with a 30-day follow up to implement the care and service plan. In addition, we also screen for a variety of issues including, but not limited to, depression, cognitive impairment, daily living and functional capacity, home safety, abuse, nutrition and food, fall risks, and much more.

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Care Transition Choices

Avoid re-hospitalization of high-risk patients and cut costs with Care Transition Choices. We work with high-risk patients to build health self-management skills, review medication use, and identify the red flags of a worsening condition. When possible, a care transition coach first visits the patient in hospital to explain the benefits of the care transition, gain patient agreement to participate and to coordinate one of two, 30-day evidence-based interventions

Long Term Services and Supports

Create pathways to independence for your patients through ourLong Term Services and Supports. We help seniors age in place, by delaying or avoiding entirely, inappropriate and costly nursing home placement through the provision of long-term services and supports necessary for independent living. The cost of Long Term Services and Supports to Medi-Cal is $359 per person a month versus an average $3,200 a month for a nursing home.

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Evidence-based Health Self-Management and Fall Prevention Workshops

Help your patients learn how to manage their health, not let their health manage them. We understand adults suffering from a chronic condition, such as chronic pain, diabetes, or arthritis know that it can often feel like illness is taking over their life. We help people make the most ordinary daily living seem impossible. Our programs help people feel better through simple things that improve their quality of life and take control of their health - rather than letting the chronic condition control them. Our workshops are designed to help adults develop skills and confidence needed to manage chronic conditions and maintain independence.

And much more. Contact us today.

We believe in the partnership, innovation and impact which comes from bringing together healthcare providers, families, and community-based services. The result is a full-range of evidence-based Social Determinants of Health programs and services that complement a clinical model of care. We offer many more services including Chronic Care Management, S0cial Determinants of Health Planning and Consulting, a state-of-the-art Contact Center, and more. We are Partners in Care Foundation. WE have 20 years of experience delivering programs and services protecting and supporting adults with complex health and social service’s needs, frail older adults, people with disabilities, caregivers and families.

Contact Us Today
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