Tools for improving social care outcomes
Our Care Coordination Toolbox is a set of indispensable tools that drive successful coordination and implementation of care services in the homes of vulnerable, at-risk individuals.
Three of these tools help healthcare successfully transition patients back to their homes: Care Transitions Interventions, the Bridge Program, and HomeMeds Plus.
Partners has additional tools that help healthcare organizations address social determinants of health (SDOH), and at the same time, improve social care coordination with patients and their families. These include the Engagement Center, Partners at Home, HomeMeds, and a suite of chronic disease self-management and fall prevention programs available through our Community Wellness Department.
Each of these tools is invaluable for keeping individuals in their homes and communities, thus avoiding expensive and isolating institutionalization.
For the past 24 years Partners has worked to align social care and health care outside medical settings to improve the lives of people with complex health needs.
Our early experience visiting homes and seeing the needs presented – often invisible to the organized medical community – demonstrated to us that what happens in the home after medical treatment can enhance or diminish the impact of health care treatments. This in turn led to the innovations that make up this toolbox.