Partners at Home Network

The simplicity of one partner with the resources of many.”

June Simmons, CEO, Partners in Care

The Affordable Care Act created exciting new opportunities to achieve the ‘Triple Aim’ of improving care, improving health, and lowering costs, by creating a comprehensive, coordinated, patient-centered system of care. And now, the realization that social determinants of health can have greater impact on health than medical care, is leading to innovative partnerships between health care systems and social service agencies. These partnerships help meet the needs of high-risk/high-cost populations and achieve better health at a lower cost.

Partners at Home (PAH) is a new, specialty network of Community-Based Organizations (CBOs) leading the nation in prototyping models to provide patient-centered social services in the home and community.

Led by Partners in Care Foundation, a CBO accredited for Complex Case Management by the National Committee for Quality Assurance (NCQA), the PAH Network addresses vital drivers of health outcomes, including issues responsible for preventable emergency department use, hospitalizations, and nursing home admissions.

The work of the Partners at Home Network is made possible with the generous support of The Archstone Foundation, The John A. Hartford Foundation and The Ralph M. Parsons Foundation. The network is also grateful to The SCAN Foundation for its support via the business acumen learning collaborative, Linkage Lab.

Why Collaborate with the Partners at Home Network?

The Partners at Home Network streamlines access to multiple community-based care “extenders,” providing hospitals, physician groups and health plans with a simple, efficient, “one call does it all” coordinated community care system, staffed with a well-trained, culturally and linguistically competent workforce, experienced in helping patients whose health is fragile, and their care complex and costly.

How Can We Help You?

If you think partnering with Partners at Home Network might be right for your organization, please contact: Ester Sefilyan, VP, Network Services at 818 837 3775 x 106 /

What Services does Partners at Home Network Provide?

The Partners at Home Network addresses the social determinants of health, including issues related to preventable ED use, hospitalizations, and nursing home admissions. We do this in two ways:

1. Short-Term Service Coordination & Long-Term Services and Supports – the provision of evidence-based services including: home medication reconciliation (HomeMeds), Care Transitions, behavioral health interventions, and wraparound support services encompassing in-home assessments, medication management, safety evaluations, home-delivered meals, medical transportation and more.

In summary:

  • A single point of access to a large spectrum of services, scalable for regional and state coverage
  • Coordination of resources (medication management, home services, meal delivery, etc.) provided at a competitive price
  • Continuity of services provided by culturally diverse providers with local expertise to engage patients in their own outcomes
  • Quality-accredited provider of a full-continuum of patient centered services

2. Health Self-Management Education – In a groundbreaking departure from traditional approaches to chronic disease management, Partners created a contact center to pilot a unique outreach program, specifically designed to boost engagement in health self-management education.

The contact details of thousands of pre-screened health plan members are mapped to identify aggregations of sufficient numbers to form a workshop. Members within convenient driving distance of a workshop are then called, and those who indicate potential interest are connected to agents trained to assist the member in identifying which modality of self-management workshop best fits their lifestyle.

Participants are offered one of three programs developed by Stanford University School of Medicine:

  • Six, 2.5 hour in-person workshops
  • An online program of health self-management activities
  • A toolkit, containing a workbook to aid the development of skills to self-manage chronic conditions, and a relaxation and exercise CD

What Results Has the Network Achieved?

The Partners at Home Network has achieved significant results.

1. Short-Term Service Coordination & Long-Term Services and Supports

  • Our Care Transitions coaches providing social service coordination in Glendale, cut 30-day readmissions to the three hospitals served in the Glendale collaborative from 21.6% in first quarter the collaborative started CCTP intervention (May-July 2013), to 12.1% in the most recent quarter for which data exists (Aug-Oct 2014.)
  • Providing Long-Term Services and Supports for the dually eligible for Medicare and MediCal population kept nursing-home eligible seniors at home for an average of five years at a cost of $357/month versus $3,000+/month skilled nursing facility cost.
  • A study conducted by a leading physician group on our HomeMeds medication management interventions revealed that adults who received a home care visit, had their medications reviewed by a consulting pharmacist and received a psychological/functional needs assessment and home safety evaluation had a 13% lower rate of emergency department use and 22% fewer readmissions within 30 days when compared to those who received no intervention.
  • Pharmacists who conducted a medication evaluation as part of the HomeMeds program recommended medication changes in 63% of the cases reviewed.

2. Health Self-Management Education

Early results of the contact center outreach pilot are extremely promising. The pilot has seen an initial outreach to approximately 8,000 individuals with chronic conditions in Los Angeles County. Approximately 10% of those contacted expressed interest in participating in the program and 36% of individuals who expressed interest enrolled in one of the three modalities mentioned above. The illustrations below show program sign up by modality and median age.

Where Do We Provide Services?

The Partners at Home Network is active in the following counties across California, with further expansion in progress across four more counties:

  • Alameda
  • Butte
  • Contra Costa
  • El Dorado
  • Fresno
  • Humboldt
  • Imperial
  • Kings
  • Kern
  • Los Angeles
  • Madera
  • Marin
  • Mendocino
  • Merced
  • Monterey
  • Napa
  • Nevada
  • Orange
  • Placer
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego
  • San Francisco
  • San Mateo
  • San Joaquin
  • San Luis Obispo
  • Santa Barbara
  • Santa Clara
  • Santa Cruz
  • Shasta
  • Solano
  • Sonoma
  • Stanislaus
  • Tulare
  • Ventura
  • Yolo

Who Are Our Member Organizations?

In addition to Partners in Care Foundation, the Partners at Home Network Case Management Group is made up of the following members:

The California Health Collaborative is a nonprofit organization committed to enhancing the quality of life and health of the people of California, particularly the underserved and underrepresented. Founded in 1982 and headquartered in Fresno, California, the Collaborative has offices in Chico, Merced, Oakland, Sacramento, and San Bernardino serving residents in 54 out of the 58 California counties. Guided by its mission of “changing lives by improving health and wellness,” the Collaborative implements an array of health promotion and disease prevention programs, public health surveillance systems, and a variety of capacity-building and networking activities.

The Camarillo Health Care District is an independent special district and public agency dedicated to providing a wide range of community health, wellness and safety services. Recognized state-wide as an innovative and award-winning leader in person-centered care, the organization was formed in 1969 to provide community-based healthcare services, under the statues of the State of California Health & Safety Code. Over the decades, California State Legislators and visionary Board Members have responded to the needs of the community and kept the District on the leading-edge of community health and wellness.

Founded in 1967, SeniorServ (Community SeniorServ Inc.) is a respected leader in the national aging network and one of the nation’s largest nonprofit senior nutrition and supportive service providers, serving nearly a million meals annually to over 10,000 at-risk older adults. The organization delivers nutrition and care coordination programs and services that reduce hunger and improve wellness for seniors so that they may live independently in the homes and communities they love.

Community Care is a nonprofit agency that arranges affordable, competent help to enable people with disabilities or illnesses continue to live independently at home. The organization offers a wide range of programs across Lake and Mendocino counties. Its mission is to support frail, ill and disabled people to live at home at the highest possible level of independence, health and dignity.

Catholic Charities of the Diocese of Stockton provides social services to people in San Joaquin, Stanislaus, Calaveras, Tuolumne, Alpine, and Mono counties, and throughout the years, it has served as a sign of hope in local communities for people of all ages, religions, and races. Catholic Charities administers direct social services and advocacy through a variety of programs for the elderly, such as the Multipurpose Senior Services Program, Homemaker Services, Elder Abuse Prevention, and Transportation for seniors over 60 years or older, Long-Term Care Ombudsman Program, and Respite Care.

Family Service Agency (FSA) has long been regarded as one of Santa Barbara County’s most reliable and effective nonprofit human service organizations. FSA’s mission is to strengthen and advocate for families and individuals of all ages and diversities, helping to create and preserve a healthy community.

Family Service Association has been a leader among non-profits serving families in need since 1953. Over the years, FSA has responded to the changing dynamics of families, by expanding the scope of services to include comprehensive care for families in need. The organization’s mission is “Building community one family at a time, through compassion, advocacy and comprehensive model services, fostering self-sufficiency and sustainable impacts.”

Health Projects Center (HPC), offers health-related and social programs to health professionals, older adults and family caregivers. Health Projects Center exists to address the health and human needs of individuals, families and communities of California’s Central Coast by developing and implementing high quality programs and strategies. The organization serves the Monterey Bay region of California, and hosts the Del Mar Caregiver Resource Center, Multipurpose Senior Services Program, California Community Transitions Program and the Central Coast Area Health Education Center.

Since 1995 Humboldt IPA has partnered in delivering quality health care in Humboldt County. The Humboldt IPA provides leadership in working with health plans and health care providers to ensure that medical care is provided in a manner that enhances the public health and promotes access to quality care. Fostering local accountability while providing appropriate, proficient, cost effective medical care benefits the people of the community.

The vision of The Health Trust is a healthier Silicon Valley for everyone. Their work includes direct services, grant making and policy advocacy. It is organized under three initiatives: Healthy Eating, Healthy Aging and Healthy Living. Our work also includes Destination Home, a public-private partnership galvanizing our community to end homelessness in Santa Clara County.

LIFE ElderCare’s mission is to empower seniors to live with independence and interdependence by nourishing mind, body and spirit. The organization offers a range of services across Alameda County, CA helping to live and thrive independently at home by alleviating hunger, lack of transportation, loneliness, and fall risks.

Meals on Wheels and Senior Outreach Services began assisting seniors in Contra Costa County more than 47 years ago, providing services to help keep older adults well nourished. Today, with six programs operating at the heart of their Care Management model, they provide comprehensive health and wellness support enabling seniors to age in place independently, with dignity for as long as possible.

County of San Diego Aging and Independence Services provides services to older adults, people with disabilities and their family members, to help keep clients safely in their homes, promote healthy and vital living, and publicize positive contributions made by older adults and persons with disabilities.

Special Service for Groups (SSG) is a non-profit organization dedicated to provide community-based solutions to the social and economic issues facing those in greatest need. SSG has evolved into a model organization designed to provide services for diverse groups with maximum efficiency and impact. This is achieved by developing and managing programs which serve their many communities by encouraging involvement and self-sufficiency. SSG believes that the needs of groups and individuals cross traditional ethnic, racial and other cultural boundaries. SSG serves as a bridge between people with common needs to identify ways to pool resources for the greater good of all.

The Ventura County Area Agency on Aging, an agency of the County of Ventura, is the principal agency in Ventura County charged with the responsibility to promote the development and implementation of a comprehensive coordinated system of care that enables older individuals and their caregivers to live in a community-based setting and to advocate for the needs of those 60 years of age and older in the county, providing leadership and promoting citizen involvement in the planning process as well as in the delivery of services.

In addition to Partners in Care Foundation, the Partners at Home Network Self-Management Group is made up of The Camarillo Health Care District, San Diego AIS, Community Senior Serv and the following additional members:

The Area Agency on Aging Serving Napa & Solano provides leadership in addressing the issues that impact quality of life of older adults. The organization provides services that support seniors in their own homes and communities for as long as possible including congregate and home-delivered meals, support for family caregivers, the Multipurpose Senior Services Program, adult day care, and health promotion programs.

Creative Housing and Services has been providing affordable housing management services for 27 years. The organization specializes in the management of affordable homes for seniors in Southern California.

In July 2017, Shasta Senior Nutrition Program merged into Golden Umbrella to become Dignity Health Connected Living, a private non-profit agency, a subsidiary of Mercy Medical Center Redding, and a Dignity Health member. Animated by a spirit of compassion, caring, and collaboration, we provide: nutritious meals; adult day-care programs; case management; social services; health-related services; in-home support services; financial management and assistance; transportation; and community resource information. Connected Living also offers many community impact volunteer opportunities, some federally-affiliated, to promote and enhance the physical, social and spiritual health of seniors and under-served families in the greater Northern CA counties. These federally-funded and donation-supported programs serve multiple California counties including Shasta, Siskiyou, Trinity and Tehama.

With more than 300 physicians and 4,000 employees – nearly 1,000 of which are registered nurses– Kaweah Delta Health Care District provides the people living and working in California’s bustling Central Valley with access to high-quality health care just minutes from home. Located in Tulare County, the heart of the state’s rural Central Valley, Kaweah Delta is a 581-bed, eight-campus healthcare district established in 1961 and governed by a five-member board of directors.

Since 1961, Keiro has been a trusted senior resource in the Japanese American community. Keiro partners with leading institutions to provide evidence-based wellness programs and resources so that residents and those living in the community may experience a healthy and fulfilling life. For over 50 years, a committed community, a competent and caring staff, hundreds of dedicated volunteers, and thousands of financial supporters have enabled Keiro to deliver compassionate care and resources in a comfortable atmosphere, wherever older adults may live.

The Riverside County Office on Aging provides a range of programs and services for older adults and those with disabilities, including the Aging Disability Resource Connection Program, care coordination services for seniors and persons with disabilities wanting to live independently in the community, and Chronic Disease Self-Management Education for older adults experiencing chronic health conditions such as hypertension, arthritis, diabetes, heart disease and/or stroke.

Saint Agnes Medical Center opened in 1929 in downtown Fresno and has since evolved into a 436-bed, state-of-the-art Medical Center campus bringing together the most advanced equipment and facilities, from emergency, diagnostic and rehabilitative services to cardiac, cancer, neurological and orthopedic care, and the expertise of top-ranked physicians and staff.

Valley Interfaith Council’s mission is to create positive change within communities in the Greater San Fernando Valley through services including: community adult centers, nutrition meal services, emergency support services, social concerns & interfaith activities, transportation, health & wellness activities and social & recreational events.

The Watts Labor Community Action Committee (WLCAC) is a non-profit, community-based, human social services organization dedicated to improving the quality of life for South Central Los Angeles residents.

The Wilmington Jaycees Foundation, Inc., is a non-profit organization located in Wilmington, CA, organized to promote community pride and support for our senior citizens and youth in the South Bay area of the City of Los Angeles.

JM Homecare, dba Visiting Angels, is a private duty, licensed Home Care Organization (HCO) that has served the greater Bay Area and beyond for the past 20 years. They assist their clients with all Activities of Daily Living, including: Hygiene and Personal Care, Meal Preparations, Medication Reminders, Transportation, Shopping, Ambulation Assistance, Light Housekeeping, Safety, Companionship and Moral Support. They provide hourly and around the clock care 24/7/365 and can assist with short term care, long term care, respite care, dementia care and end of life care. Their mission is to assist their client’s in the safety and comfort of their own home, to improve patient outcomes and to help reduce hospital admissions. They have a very diverse caregiving staff and can also address several Social Determinants of Health. Their caregiving staff can act as an extra set of eyes and ears and can assist with communication and collaboration with family members and medical professionals.