We Work With Hospitals and Health Systems

You Can Control Readmissions.

If your Hospital or Health System wants to control avoidable admissions and utilization, talk to Partners about our experience in decreasing these events.

Partners in Care resolves your patients’ social and behavioral determinants of health (SBDOH), which include many of the issues leading to avoidable ED visits and facility readmissions.

Utilizing a bold new partnership among health systems, hospitals, medical groups/IPAs and Health plans, our network can help you:

  1. Reduce hospital readmissions
  2. Achieve Nursing Home diversion
  3. Improve Quality Measures (HEDIS, Medicare Star, MACRA)
  4. Improve clinical outcomes
  5. Enhance the patient experience, achieving Net Promoter Scores of 80-85
  6. Keep people in their homes and communities, reducing costly institutional care

Partner’s doesn’t just improve a patient’s health. We help your bottom line through fewer and less acute readmissions, fewer avoidable ED visits, fewer penalties, and improved quality scores – all of which lead to a reduced cost of care.

Our approach uses an alternate workforce consisting of social workers, health coaches and community health workers. This team supports the work of medical care givers, resulting in whole person care for your patient.

As an extension of your team, we contribute to an improved experience for your patient and staff.
In a recent California CMS Demonstration Project, Partners helped participating hospitals achieve between 28-41% reduction in Readmission Rates for Pre-Intervention Baseline, All Cause, All Condition Medicare FFS Patients Compared to Post-Intervention CCTP Participants across 11 hospitals.

New study shows Partners’ programs cut costs and reduce readmission rates. California QIO report for CMS demonstrates success of Partners’ Care Transition Programs. Learn more here.

Our Programs and Services


Do you have patients who take multiple medications? Avoid problems with a HomeMeds screening.

  • Inventory all meds being taken
  • Assess for potential adverse effects including BP, pulse, falls, dizziness, confusion
  • Document adherence issues and understanding
  • Algorithm identifies targeted potential medication related problems (MRPs)
  • Pharmacist reviews potential MRPs and makes recommendations for resolution, contacts provider and/or patient (telepharmacy available in patient’s home)
  • Medication list provided to patient


Everything included with HomeMeds described above PLUS:

  • In-home evaluation and assessment with a 30-day follow-up to implement the care/service plan (arrange for & coordinate services). Additional follow-up at 60 & 90 days
  • Evaluate functional capacity (Activities of Daily Living)
  • Screen for depression and cognitive impairment
  • Assess home safety, cleanliness, & maintenance, and observe for evidence of abuse, odors, inadequate food, caregiver issues, flag potential fall risks from medications, trip hazards or poor lighting
  • Provide and encourage use of Advance Directives
  • Physician follow-up appointment reminders, coordinate transportation assistance to appointment
  • Coordination with clinical team

Care Transition Choices

Avoid re-hospitalization of high-risk patients and cut costs with Care Transition Choices.

  • Referral format: Daily Excel (example attached) provided via SFTP
  • Services begin upon discharge home (from acute or PAC)
  • Care transition home visit 24-72 hours after discharge from hospital or post-acute SNF using evidence-based Coleman Care Transitions Intervention (Coaching Model) & Bridge (telephonic Social Work model) based on patient availability; includes follow-up calls
  • Patient activation in their health through motivational interviewing, engaging family members and caregivers, shared-decision making
  • Coaching to work with care team to understand “red flags” for condition, avoid 911, manage self-care, use personal health record
  • Use any condition-specific handouts provided by physician group
  • For those who refuse home visit or live outside the service area, coaches do a telephonic needs assessment, create a care plan, and refer patient to community-based services as needed.
  • In-home medication reconciliation and risk-screening by coach with pharmacist review (HomeMeds)
  • Ensure patient has timely follow-up physician visit, ensure that transportation is available and, if not, provide referrals to transportation resources.
  • Services available for additional charge
  • Hospital room visit provided when average referrals from a single hospital exceed 25/week
  • Reporting and Metrics: Provide medication list to PCP; Monthly dashboard (example provided)

Chronic Care Management

Help your patients with Chronic Care Management.

  • Follow and engage Medicare FFS beneficiaries with 2+ chronic conditions for up to one year
  • In partnership with the practice, develop a whole-person, person-centered plan integrating medical & social care, and coordinate implementation
  • Promote patient activation in their health, including health self-management through motivational interviewing, engaging family members and caregivers, shared-decision making with care team
  • Provide coaching on advance care planning
  • Improve compliance with preventative visits and screenings; help implement annual wellness campaign; facilitate telehealth visits in the home environment
  • Support and capture quality measures, such as specific MACRA (MIP and APM) measures

Evidence-Based Chronic Disease Self-Management Programs

Help your patients learn how to manage their health, not let their health manage them.

  • Workshops facilitated by trained peer leaders in accordance with fidelity standards
  • Online and in-person sessions in local community for patients with 1+ chronic conditions
  • Participants learn to set goals for lifestyle change, communicate needs, manage depression/anxiety, medications, and how to effectively secure family support, etc.
  • A toolkit, containing a workbook to aid development of skills to self-manage chronic conditions, at relaxation and exercise CD
  • Licensed by the program developer, Stanford University

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 (SDOH) programs and services that complement a clinical model of care. We offer many more services including Chronic Care Management, SDOH planning and consulting, a state-of-the-art Contact Center, and more.
We are Partners in Care Foundation. We have been delivering programs, services, and protecting and supporting adults with complex health and social service’s needs, frail older adults, people with disabilities, caregivers and families for more than 20 years.

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