Supporting Healthy Independence at Home

Last Updated June 9, 2022

Welcome to the California-based Partners in Care Foundation (Partners) and our innovative, evidenced-based tools designed to support and promote healthy independence of individuals and families at risk of losing their ability to live independently and safely in their homes.

Our social 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 hospitals successfully transition patients 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.

Since 1997 Partners has worked to align social care and health care to improve the lives of people with complex health needs. Our experience visiting homes and seeing the needs presented – often invisible to the medical community – demonstrated to us that what happens in the home after medical treatment can enhance or diminish the impact of health care treatments. Which in turn led to the innovations that make up this Toolbox.

Partners has been called  visionary for developing innovative and powerful models of social care coordination. Beyond pioneering the Community Care Hub model with a network of community-based services throughout California, we introduced an internship program for graduate social workers focused on the needs of older adults (GSWEC), and an evidence-based medication inventory and assessment tool that identifies medication problems that could lead to injuries or complications (HomeMeds).

Partners honed its tools for social care coordination and care transitions through participation in the Community-based Care Transition Program (CCTP) demonstration launched in March 2010 which was funded by the United States Health and Human Services (HHS) in conjunction with the Affordable Care Program (ACA). 

The CCTP demonstrated how care transition programs can lead to lower hospital readmissions and Emergency Room use when hospitals partner with community-based organizations (CBOs) to address a patient’s SDOH deficits as part of their medical discharge.

The demonstration tested evidenced-based models for improving care transitions from hospitals to other settings to reduce 30-day readmissions for high-risk Medicare beneficiaries.  Hospitals were required to partner with a non-profit community-based organization as the lead agency in order to receive finding for participating in the demonstration project. In just a few years since 2010, “care transitions” are emerging as an official component of population health by expanding to address SDOH drivers in the rapidly evolving healthcare environment moving towards value-based reimbursement of care. 

Partners used three tools from its Toolbox for this HHS-funded demonstration: Care Transitions Intervention (CTI,, the Bridge Model of Transitional Care (Bridge,,, and HomeMeds ( These tools are used by specially trained non-clinical coaches who interact with discharged patients and families. These coaches can intervene immediately in patient problems post-discharge, such as misunderstanding discharge orders, or addressing lack of transportation to provider appointments.  This promotes both cost-savings and access to health care facilities.

Care Transitions Interventions is a short-term home visit tool complementing healthcare system care teams by empowering the patient to develop self-care skills and helps them assume a more active role in their health using a whole-person approach.

The Bridge Model of Transitional Care is a telephonic, person-centered, social work-based interdisciplinary transitional care tool that helps adults with complex health and social needs safely transition from the hospital back to their homes and communities.

HomeMeds consists of a computer program combined with a home visit by specially trained coaches that ensures patient medication-related safety by inventorying all medications taken by the person at home. This inventory includes recently prescribed medicines, older medicines the patient still may be taking and other factors that impact medication safety and efficacy, including over-the-counter products and supplements, and even certain foods that may interact with medications. 

HomeMeds also includes a patient interview to identify signs of adverse medication effects, including impact on blood-pressure/pulse, dizziness, falls, and confusion. Adherence issues and understanding of the medication regimen are documented. 

An algorithm in HomeMeds is applied to assess for problem medication-related issues using algorithms designed by Beers for frail and elderly patients.   The program then guides the in-home survey and flags potential problems which a pharmacist reviews in order to make recommendations by contacting the prescribing provider or patient to resolve.  Pharmacists’ concerns and recommendations from the medication report are provided to the patient’s primary care physician.

Using these three tools, Partners provided the CCTP’s evaluators a unique opportunity to test their value in promoting successful care transitions.  These evidenced-based tools had a history of lowering unnecessary hospital readmissions and ER use while advancing patients’ health and independence at home.  These three tools allow Partners to integrate SDOH data in planning for care transitions and coordination of care programs for clients.   These tools hold the promise of much broader application to serve individuals of all ages who have complex health needs.

An evaluation of the performance of Partners’ tools to promote optimal care transitions from hospital to home for the CCTP demonstration was carried out by Econometrica Inc, looking at discharged patients who had received these three interventions, and a control group that had not.  The study found that Partners’ interventions for discharged patients from the 11 hospitals participating in the demonstration had significantly lower Medicare spending compared to controls for three-month, six-month, and nine-month follow-up post-discharge.  In addition, these patients also had significantly lower mortality rates than the matched companion group with no interventions post-discharge. 

These three tools are available singly or in coordinated fashion for medical and other providers to use through partnership with Partners.  They have been tested over time to assess how they support improved care transitions, care coordination and healthy independence.

Partners’ social care coordination and care transitions tools promote success and development of healthy independence for at-risk vulnerable individuals and their families.   SDOH challenges and unexpected medication problems can sabotage the best care transition and care management plans, resulting in the loss of independence. 

Achieving healthy independence for patients/clients is our primary goal.  But each successful patient and family indirectly supports the mandates for quality hospital care as well as insuring that scarce resources for supporting healthy independence in the home are not wasted by failure of a discharged patient to thrive.

If you are interested in learning more about PartnersCare Coordination Toolbox, get in touch. We’d be pleased to discuss how they improve patient care and lives.

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