Success Stories

ECM at Work: When a Simple Pain Isn’t Simple at All

Grace was having a difficult year. Things in her life had been improving, but then, at twenty-eight-years-old, she began periodically experiencing intense stomach pains, nausea, and vomiting. The events were turning her world upside down and were so frequent she had begun to take the pain for granted.

Grace’s health plan had initially referred her to the Partners’ Enhanced Care Management (ECM) program. Her health challenges at the time included diabetes and hypertension. Her first conversations with a Partners’ Care Coordinator helped her focus on chronic disease self-management as a means of dealing with those conditions.

Being part of the state’s ECM program is highly beneficial. It provided Grace with a free glucose monitor to keep track of her blood sugar level and made available educational resources on diet and nutrition for diabetes. “Those resources really helped me stay healthy,” she explained. “They also prevented any complications from the disease.”

Grace’s Care Coordinator also discussed with her the importance of annual eye exams for adults with diabetes and arranged a referral for her to see an optometrist. That visit checked for signs of retinopathy and diabetic macular edema, which is common for people with diabetes.

Things changed and started going downhill during June of 2022, when Grace began experiencing stomach pains that regularly landed her in the emergency room. A round of diagnostic imaging at the local hospital showed that a gallstone was present, and it was causing Grace’s gallbladder to expand in size. It was that expansion causing Grace’s bouts of pain, nausea, and vomiting.

What she had all along thought was “just stomach pain” turned out to be gallbladder inflammation and close to rupture.

Grace had been unsure about having the imaging done, being unsure about the cost. Her Partners Care Coordinator talked it through with her, and strongly encouraged her to have it done so she could find out what was behind the pain. According to Grace “Without that extra push,” she said, “I might not have taken the next step and ended up in a very different circumstance. The Partners team really looked after me.”

When her doctor saw what was visible in the diagnostic images, he immediately determined that Grace needed to go into surgery as soon as possible because she was close to a ruptured gallbladder.

Grace was nervous and fearful about the surgery, but she knew it was the best decision for her health. The surgery was a success, and Grace has been recovering well. Only once in the past three months has she returned to the hospital, and that was to retrieve new medication. This has significantly reduced Grace’s medical costs while improving her health.

According to Grace, “I was fortunate to have the Partners in Care Foundation helping me through these issues, and a Care Coordinator helped me advocate so strongly on my behalf. My doctor told us that if the complication had been overlooked any longer, it would have been life threatening.”

These days Grace is feeling healthier than ever with an effective nutrition plan for her diabetes, and no more stomach pain or nausea since the successful gallbladder removal surgery.

Nicholas Gonzales tapped on the window of a small, parked car. He’d already spoken by phone with the car’s driver, Kurt Johnson. 

Johnson peered out. He was an older man hunched over the steering wheel. Stacked in the backseat was just about everything he possessed. 

Gonzales, a Partners in Care Foundation Care Coordinator, explained he had been sent to help Johnson find a home. Mr. Johnson cautiously opened the door. 

“I was sleeping in my car,” says Johnson. At night he parked in a safe lot run by a nonprofit. Sometimes he stayed with relatives, but they could seldom take him in. During the day he just drove around. His car often broke down. 

He told Gonzales he was in pain and had trouble breathing. His feet were going numb, and he couldn’t see very well. “The street is no place for an old man,” he said. 

Johnson made big efforts to help himself, but they didn’t work out. He states bitterly, “Nobody helped.” He was told there was a six-year wait for housing. He couldn’t get to his medical appointments when his car needed repairs. He remembers that “everything was bringing me down.” 

Finally, he’d found a lifeline. Partners specializes in social care that supports medical care. Staffed by professionals whose mandate is to go the extra mile, it helps people like Johnson live safely in a home of their own – not to be forced into an institution, and above all, the street. 

Gonzales swung into action. He sent out a blizzard of applications for housing. Meanwhile, he worked to keep Johnson safe where he was and on track with his medical appointments and seven medications. He helped him buy food, clothing, and sanitary supplies which Johnson stashed in the trunk of his car. Gonzales stayed connected, making sure Johnson was OK, bolstering his spirits during a very dark time. 

“I’m Going to Enjoy the Rest of My Life” Partners’ ECM program at work in the community. Slowly, slowly, Johnson began to rally. He suffers from serious medical conditions such as congestive heart failure, Diabetes, and asthma. Keeping on top of his healthcare isn’t a luxury. It’s a matter of survival. 

Then his car broke down, and Gonzales showed him how to use free clinic transport. Scheduling medical appointments seemed an impossible task, keeping track of them even harder. Johnson gradually learned to do both. As Gonzales says, “Mr. Johnson doesn’t let pride get in the way when he needs to ask for help, and he is always cordial and has integrity about what’s going on with him.” After a few visits to his doctor, Johnson started feeling better. 

Partners found him a home a few months later, a record time in the face of a statewide shortage of housing for the homeless. It is a furnished small apartment in his old neighborhood with everything he needs to feel comfortable and secure. 

Good things continue to happen. Instead of struggling to get by Johnson has a regular life and can focus on his health. His daughter and grandchild visit several times a week. Gonzales checks in with supplies and encouragement.

 Best of all, Johnson sees his life back on path. Asked what he plans to do in the future, he laughs, “I’m going to enjoy the rest of my life!”

HCBA at Work: Meet Ellie

Meet Ellie and her family. Ellie experienced a traumatic birth injury that deprived her of oxygen for a concerning amount of time. She was transferred immediately to Children’s Hospital Los Angeles (CHLA) where she was diagnosed with a brain injury and other medical conditions. Ellie spent 59 days hospitalized and was discharged with feeding difficulties.

Ellie, now two-years-old, has made significant progress. She lives with her family and receives full-time care from her mother, who left her full-time job to become a full-time caregiver. Ellie requires occupational therapy and speech therapy. Therapy tools are slowly introduced to help her strengthen her suspected weakened mouth muscle and reduce her dependency on her G-tube. Although Ellie’s ability to eat has drastically improved, Ellie is still intimidated by some tools used by her therapists. She has a long road ahead of her, however with therapeutic interventions she continues to improve.

These excellent care and resources available to Ellie and her family through our Home and Community-Based Alternatives Waiver program. But there are many essentials recommended by her therapists that are not covered by insurance. In an effort to fill in some of the gaps, Partners used our Urgent Needs Fund to purchase mouth and tongue tools to aid with Ellie’s oral development and a Montessori toy for toddler sensory development.

Ellie’s family extends their thanks to Partners for meeting Ellie’s primary needs, especially from home, given the COVID-19 pandemic. They report that having the ability to continue to improve Ellie’s mouth muscle exercises with the therapy tools and fun straws has been beyond helpful. Ellie’s mother writes, “Thank you for allowing my sweet girl to continue to work to reach her full potential.”

ALW at Work: A Place to Call Home

After struggling with homelessness for over a decade, experiencing high levels of anxiety, and relying primarily on a wheelchair to move around, 70-year-old Linda Meyer found assistance through Partners in Care Foundation’s Assisted Living Waiver (ALW) Program.

The ALW program is a Home and Community-Based Services (HCBS) waiver making affordable housing, with personal and health-related services, available to eligible seniors and persons with disabilities throughout California. The goal is to offer these individuals, who reside in the community but are at risk of being institutionalized, the option of utilizing ALW services to develop a program that will safely meet their care needs while continuing to live in a community home-like setting.

Linda was living in a skilled nursing facility in Riverside when she was referred to the ALW Program in 2020 by the Blue Shield of California Promise Health Plan. She was grateful to obtain residency at an Assisted Living Facility and found comfort in a one-bedroom space. Previously, as a person without housing, she had nothing more than a storage facility to hold her personal belongings. Through the ALW program, Partners hired a maintenance team to assist Linda with emptying her storage facility and moved her belongings to the Assisted Living Facility. Without this monthly storage facility fee, Linda has more room in her fixed-income budget for other necessities and can now save money for her future needs.

Other care coordination services provided by Partners’ Assisted Living Waiver Program included conducting assessments, on-going case management, and monthly visits to ensure Linda received the services and care she needs. Partners arranged for Linda to receive assistance with instrumental activities of daily living such as toileting, home-delivered meals, and skilled nursing services as needed. Additionally, Partners’ care coordinators made sure that Linda had N95 masks and sanitation supplies to stay safe during the ongoing COVID-19 pandemic.

Linda has not had a place to call home in the past 10 years. Now through the ALW Program, she has found security living in her community, knowing she has a home and the help she needs to live happily and safely on her own.

HHP at Work: The Value of Care Coordinators

Living on her own has been tough. Struggling with high blood pressure, depression, and injuries suffered when she fell from a stroke are more than a 64-year-old should bear. But Destiny has lived with all that and the additional challenges of chronic neck and back pain as well. Things began to change for her, however, when she was connected to Mariah Vega, a Partners HHP Care Coordinator.

Destiny enrolled in the Health Homes Program (HHP) in 2020. This program offers a specific set of care coordination services at no cost to individuals with chronic health conditions and/or a serious mental illness. HHP Care Coordinators conduct intake assessments and identify what community and medical resources a member needs to be connected to, whether it would be housing, mental health, employment assistance, durable medical equipment, care coordination with medical team, etc. They also provide the member with ongoing support on a weekly basis to help track their progress and provide them with resources regarding their chronic health conditions. This high touch, participant specific care is all coordinated with the participants assigned health plan medical care team.

Destiny is grateful to have someone like Mariah to count on for assistance when needed. She does have a son living close by, but he struggles with his own health challenges, so it’s essential that she has someone she can also turn to for help when she cannot do something on her own.

Mariah was able to provide her assistance with getting her current medication refills through a Primary Care Physician (PCP) instead of going to the Emergency Room (ER) for them. This made it easier to request medications over the phone, and then have them sent directly to her pharmacy to avoid long ER wait times and potential exposure to other illnesses in the hospital. This also helped ensure medication adherence to avoid any medication related hospitalization.

Mariah also informed Destiny of great programs like the Dignity Fall Prevention Program that provided her with tools and services to live more safely at home, the Walmart Food Voucher Project that provided her with a gift card to purchase any necessities she may have, the Partners Mental Health Support Pilot that arranged Destiny with a therapist to speak with to help manage her depression, and lots more!

Destiny was also very thankful for the assistance she received in scheduling a COVID-19 vaccine appointment while having to navigate a complicated system where appointments were being filled up quickly. Her Care Coordinator was able to locate a Rite-Aid less than a mile away from Destiny’s home and arranged her with transportation to the site.

Destiny also met the requirements to participate in the Partners Google Speakers Distribution Program that gifted Google Home Speakers to help enhance digital access among older and disabled adults. Partners hope that this new device can be used to make handsfree phone call in the case of an emergency and get connected to valuable resources in her area. 

It’s important to Partners that participants have the necessary tools and services to live safely at home and avoid unnecessary higher cost care. Destiny is a great example of an individual that had a lot of health challenges but thrived after receiving assistance from the Health Homes Program. She now lives comfortably knowing she can focus on her health with the support of Mariah and community organizations.

MSSP at Work: Making the Complex Work

Mary is an example of the type of person with complex needs that Partners specializes in helping. She lives by herself in a mobile home in Santa Maria, CA. Without transportation, she spends a great deal of time by herself. In the early stages of Alzheimer’s, Mary also suffers from chronic leg pain, back pain, balance issues, and incontinence.

Fortunately, Mary’s son, David, began worrying about his mother spending so much time alone. He could see her mental status and poor eating habits were contributing to her deteriorating medical health. Her erratic diet meant she wasn’t getting the balance of nutrients necessary.

That was the situation Partners found following Mary’s MSSP enrollment in March 2018. Enrollment meant access to 35 IHSS hours a month, as well as access to medical and personal supplies that could address her failing health conditions.

The first thing Partner’s did was to assess Mary’s medicines, living conditions, access to food, and determine where deficiencies existed and identify ways to fill those gaps. To deal with her isolation and health, Partners early on purchased an Emergency Response Service. This was a great relief to Mary and her son, as they now know that she will get help if she should fall or hurt herself when alone.

There were simple things that Partners identified, though in the scheme of Mary’s life, they were highly significant. Mary didn’t have a bath chair in her shower, and she worried each time she washed due to her poor balance. Just as important, there was no bathmat next to the tub to keep her from slipping when getting out of the shower. So, Mary’s Case Manager arranged for the purchase of both a chair and a shower mat.

Incontinence is stressful and problematic. Mary was referred to Shield’s Healthcare, which arranged for “Pull-ups,” which she says, “have made her life a lot easier.” Mary’s caregiver, Christy, stated that the multipurpose washcloths, creams, and waterproof mattress protector that Partners arranged for Mary to receive, have also made Mary’s life easier and better.

The early Alzheimer’s causes Mary to forget to eat at times, which has wreaked havoc with her diet, and led to a deterioration in her health because she wasn’t receiving necessary nutrients. With MSSP benefits, Partners has been purchasing Ensure to help Mary regain the nutrition she needed, and her health has improved because of it. David, Mary’s son, has said that because his mom is so forgetful, he “doesn’t want her cooking,” and he is “glad to know the Ensures are there when she is alone or when food hasn’t been prepared ahead of time by her caregiver.”

Despite the complexity of her circumstances, because of Partners and the MSSP program, Mary has been able to safely live independently in her home. This is the goal of the MSSP program, and Mary is one of many examples demonstrating its success.

HCBA at Work: Getting A Young Woman Back Home

Partners has a long history of working with older adults, but more and more we are helping people of all ages. For example, we have recently been working with the parents of a 23-year-old woman who is about to be discharged from a skilled nursing facility (SNF) back to their home.

Angie” had a stroke in June of 2018 and was admitted to the SNF. Following the stroke, she became dependent on a Gastrostomy Tube for feedings, has a Tracheostomy and uses Oxygen due to respiratory issues. Non-ambulatory, she is dependent on others for all transfers and needs help moving in her bed. She is unable to perform any activities of daily livings or independent activities of daily living. As a result, she requires round the clock monitoring, seven days a week for health intervention.

The first step in Angie’s move was taken by the SNF director who applied on Angie’s behalf for a waiver from California’s Home and Community Based Alternatives (HCBA) Waiver program, and the California Community Transitions program. When Partners learned these applications had been approved, a team began working on the steps for Angie to leave the SNF and return home.

Once they learned of the application approvals, the Partners team visited with Angie in the SNF, and then performed an evaluation of her parent’s home. They determined the move back would require widening a bedroom door making it wheelchair accessible, and the construction of a wheelchair ramp so Angie could get in and out of the house.

Not only did the team identify what needed to be done to the home, they identified additional services that Angie qualified for, and the companies that could help with the home modifications.

Quickly a referral was made for her to In Home Support Services for personal care, such as feeding and bathing. The Center for Healthcare Rights was contacted for help with Medi-Cal benefits. A call went to Abilities Expo for up-to-date information on some disability programs and durable medical equipment. Pacific Coast Contractors were hired to put in the ramp and widen the bedroom door. A referral was made to Bet Tzedek Legal Services, which specializes in issues related to disability.

Making much of this possible was CCT, which provided a fund of $7,500 to purchase the durable medical equipment that would enable Angie to transition from the SNF to her parent’s home. LA Care helped locate a community PCP and Gerry Kane, Esq. helped her parents make plans for Angie’s future needs.

The Partners Team also identified that showering was going to be an issue best addressed by securing a portable shower. As these aren’t covered through any existing California program, they put a request to Partner’s Special Needs Fund, which agreed to purchase the item.

As progress was made, Angie’s mom told the team “How exciting to see things coming together. Thank you for all your help with funding the ramp and the shower! We are really thankful there is a program to help folks like us in need, and we are thankful from the bottom of our hearts for the waiver program! The teamwork demonstrated by Partners in Care was great. Our family will be forever grateful for all your coordinated efforts to get Angie home again.”

Care Transition Choices: When More Than Just Mom Needs a Helping Hand

Luciana is an 84-year-old woman living independently in La Crescenta who was recently admitted to St. Joseph Hospital suffering from chemotherapy induced neutropenia. Unfortunately for her, this was just the latest in a series of medical conditions afflicting her senior years. The list is lengthy, making every day a complex series of treatments addressing a UTI, ongoing sleep apnea, rheumatoid arthritis, ovary and breast cancer, hypertension, hyperlipidemia, hydronephrosis, hemorrhoids, severe hearing loss, ear disorder, diabetes type 2, degenerative arthritis of spine, chronic constipation, cataracts, back pain, and alopecia. Any one of these conditions alone would be a trial under the best of circumstances.

Luciana is blessed with three adult children – two boys and a daughter – though both sons live out of state. This means care responsibilities fall often to the daughter, augmented by some caregiver support. During Partners’ Care

Transitions Choices home assessment visit following Luciana’s discharge from the hospital, her daughter reported feeling burnt-out and overwhelmed from the duties in caring for her mom. Delia, Partners’ Coach performing the home visit, identified the two most important issues facing the family were to prevent Luciana from being unnecessarily readmitted to the hospital and to assist her daughter in dealing with the demands of Luciana’s care. Delia also noted that mom was a strong candidate for long-term case management through Multipurpose Senior Services Program.

Fortunately, Luciana already had IHSS benefits, and as part of Delia’s assessment, she recognized that Luciana could benefit from additional support hours. Delia worked with Luciana’s daughter to contact an IHSS social worker to request a re-evaluation of Luciana’s circumstances with the goal of increasing her mom’s IHSS hours. After the request was made, an IHSS social worker performed a home visit and recommended that Luciana’s hours be increased. Not only will this get Luciana additional regular help but will help diminish the circumstances causing her daughter to feel burnt-out and overwhelmed.

Luciana’s daughter also told Delia that prior to her mother being hospitalized, her hearing had been “normal.” That changed during the hospital stay when she lost the ability to hear. Luciana and her primary care provider are still trying to determine what happened to affect her hearing. In the meantime, she communicates by “writing everything down on a piece of paper or using simple sign language”. This further supported Delia’s assessment that Luciana would benefit from long-term case management, and a referral to Partners’ MSSP program, and is scheduled for an evaluation at the end of October 2019. Lastly, since both Luciana’s daughter and caregiver provide medical transportation, Delia worked with the daughter to complete a Department of Motor Vehicles handicap placard application, which was approved by Luciana’s doctor. Since Luciana is able to walk, but challenged by distance, the handicap placard will allow them specialty parking to easily access appointments and outings.

These actions by Partners’ coach have helped see Luciana pass the critical point following her hospital discharge when she might have needed readmission. It has also resulted in a lessening of pressure on Luciana’s daughter, which also helps her provide her mom with better care. And, both mother and daughter deeply appreciate the help, support, and advice provided by Delia. A testimony to the success of Partners’ Care Transitions Choices program.