Innovations | Partners In Care Foundation

Innovations

“This is our moment in healthcare history – we were born for this work.”

June Simmons, CEO, Partners in Care Foundation

Partners in Care Foundation has been in the business of bringing healthcare, families, and community-based services together since its inception in 1997. Our mission today, as it was then, is to design and implement new models of evidence-based care that address the key social determinants of health.

Partners has worked tirelessly to champion the integration of community-based and social services into health care delivery, building a legacy of transformational leadership that has established the organization as a national leader in health care reform.

That leadership role was in evidence last year, when June Simmons, Partners CEO, led members of Partners Leadership Team, the John A. Hartford Foundation and multiple federal, state and local aging services agencies in a brainstorming session with Kathy Greenlee, Assistant Secretary for Aging and Administrator of the Administration for Community Living, at Partners CA headquarters.

The vision articulated in that meeting – for an effective integration of medical and social care that affords older adults, and adults with disabilities, the ability to live and age with dignity and independence – is one that Partners has implemented through numerous bold health care innovations.

Partners has also been at the forefront of promoting the development and adoption of national standards for home and community-based services, becoming only the second community-based organization in the nation to receive a National Committee for Quality Assurance (NCQA) Accreditation for Complex Case Management.

Read a summary of Partners’ pioneering programs below, and then check out each page for more information and contact details. We hope you’ll work with us and be part of making health care history.

Kathy Greenlee speaks with Partners CEO June Simmons

Partners at Home Network

Partners at Home is the culmination of years of effort to build a network of community-based organizations with the expertise, local knowledge and cultural sensitivity to deliver services that enable people with disabilities and older adults to live in the community, streamlining access to these services for health plans and physician groups.

In summary, Partners at Home provides:

  • 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

For more information about this program, click here.

HomeMeds

Data shows that 40-50% of elders using home or community-based care are using medications inappropriately, leading to a range of preventable issues including falls, 911 calls, ER visits and hospitalization. HomeMeds℠ utilizes a computerized risk assessment and alert process. A pharmacist reviews medications to identify problems and follows through with the patient, their family and the prescriber. Now being implemented across 45 sites in 18 states, the US Administration for Community Living has awarded HomeMeds℠ with its Highest Evidence Level rating, and chose it for its rigorously screened Aging and Disability Evidence-Based Programs and Practices (ADEPP).

For more information about this program, click here.

HomeMeds℠ Plus

This program goes one step further than HomeMeds℠, adding psychosocial, functional needs and safety assessments to the evaluation. Performed by highly skilled health coaches competent in cultural and linguistic diversity, adept at patient engagement and knowledgeable about community resources, these evaluations are carried out in the home to create an individualized service plan. HomeMeds℠ Plus offers a menu of patient support options, with tiered pricing so that health plans and physicians have ultimate flexibility in tailoring a bundle of services that best meet their client needs. These include complex and thirty-day case management, medication safety reconciliation, home safety evaluation, home modifications for fall prevention, nutrition, and evidence-based health self-management programs available in community settings and online.

For more information about this program, click here.

The Aging & Disability Business Institute

The Aging and Disability Business Institute (Business Institute) is led by The National Association of Area Agencies on Aging (n4a) in partnership with Partners in Care Foundation, Elder Services of Merrimack Valley, Independent Living Research Utilization, the Evidence-Based Leadership Council and the American Society on Aging. It serves as the national focal point to build the business acumen of CBOs.

Other Programs and Services

Community-Based Adult Services Assessments (CBAS)

Partners is the largest provider of eligibility evaluations in California, serving four major managed care plans and more than 200 CBAS centers throughout the state. Our team of multi-lingual and culturally competent registered nurses is highly-experienced in undertaking “face-to-face” screening evaluations via the CBAS Eligibility Determination Tool (CEDT), either at a CBAS center or at member’s home. Partners has achieved 100% compliance in state managed care plan audits since July 2013.

For more information about this program, click here.

Community-Based Care Transitions

Partnering with hospitals and medical providers, this program helps individuals develop self-care skills, tracks medications, identifies the red flags pointing to worsening conditions, and connects patients and their caregivers with community resources. Partners longstanding work in the provision of evidence-based, in-home support services and strong relationships with regional hospitals and physician networks resulted in the Centers for Medicare and Medicaid awarding Partners one of only 72 CCTP grants nationally. Additionally, Partners’ CCTP provision in Kern County has resulted in CMS designating it a ‘best practice’ site.

For more information about this program, click here.

Participants of a Tomando Control de su Salud workshop celebrate the successful completion of the program

Chronic Disease Self-Management

This 2½ hour workshop, which runs once a week for six weeks, addresses the physical, mental, emotional, and social challenges of patients with one or more chronic health conditions such as high blood pressure, arthritis, diabetes, and heart disease. Proven to reduce outpatient visits and hospitalizations, the program boosts health, nutrition, cognitive symptom management, physical activity, and overall patient well-being, in an interactive group setting. The workshop is also available in Spanish as Tomando Control de su Salud.

Chronic Pain Self-Management

This six-week workshop was developed for people who have a primary or secondary diagnosis of chronic pain to assist them with developing new coping skills. In research results from this highly participative, evidence-based workshop, patients report that they have more energy, experience less pain and depend less on others. They also enjoy improved mental health, more satisfaction with their lives, and more involvement in everyday activities compared to people who have not taken the workshop.

Diabetes Self-Management

This workshop helps people diagnosed with type 2 diabetes to better understand and deal with their condition in a sociable and supportive group environment. Delivered in community venues by trained peer leaders, participants learn to manage their medications, work with doctors, and make weekly exercise and healthy-eating plans.

Evidence-Based Leadership Council

EBLC is a collaboration among twelve national partner organizations, offering 19 highly recognized evidence-based, health promotion programs delivered via a network of more than 2,000 community-based organizations. Programs include: Healthy IDEAS – designed to detect and reduce the severity of depressive symptoms in older adults with chronic conditions; Fit and Strong! – an eight-week physical activity and behavior change program for older adults with mobility and balance challenges; and A Matter of Balance – a program designed to reduce the fear of falling and increase activity levels among older adults.

Founding members of the Evidence-Based Leadership Council

Geriatric Social Work Education Consortium (GSWEC)

As one of ten Centers of Excellence, Partners in Care is a founding partner in the collaboration of universities and agencies facilitating the GSWEC program – the nation’s first integrated network to improve social work education and field training among those working in older adult services and care.

For more information about this program, click here.

In-home Palliative Care

Developed with Kaiser, and a standard of care in many areas of their system, the In-Home Palliative Care model is based on the premise that patients are empowered when they understand their treatment and actively participate in care decisions. This interdisciplinary program provides home visits by physicians, nurses, social workers, and other healthcare professionals to patients with an estimated life expectancy of one year. The program has resulted in significant increases in quality of life indicators, and a 30% reduction in costs associated with the last year of life. Partners offers consultancy services to assist health care providers in the planning of palliative care programs. For more information please contact Sandy Atkins at satkins@picf.org / 818 837 3775 x 111

Multipurpose Senior Services (MSSP)

This program empowers the elderly to live independently in the community for as long as possible, thus delaying or avoiding entirely the need for nursing home placement. In research conducted by the AARP, nearly 90% of seniors expressed a desire to stay in their own homes as they age, commonly referred to as “aging in place.” Even if they began to need day-to-day assistance or ongoing health care during retirement, most (82%) agreed that “life is better at home.” MSSP also provides tremendous cost savings to Medi-Cal, which pays around $359 a month for MSSP, versus an average of $3,200 for a nursing home.

Trained coaches visit the person at home to conduct a health and psychosocial assessment, enabling them to determine the best range of services for each individual’s needs. Services may include home delivered meals, transportation, chore and personal assistance, emergency response system, home safety modifications, medical equipment, protective supervision, counseling and caregiver respite.

For more information about this program, click here.

Project ECHO LA Geriatric Knowledge Network

Using video conferencing, this program provides clinicians with easy-access learning in the rapidly-evolving field of geriatric medicine. Doctors can submit actual patient cases for real-time discussion and consultation with specialist mentors. The network is made possible with the generous support of the Kaiser Foundation Hospitals and is a collaboration between Partners in Care and Project ECHO LA.

For more information on this program, click here.

PARTNERSHIP.   INNOVATION.   IMPACT.
WP-Backgrounds by InoPlugs Web Design and Juwelier Schönmann