These organizations power our innovations.

The funders listed below are key contributors in Partners’ work of aligning social care and healthcare.Without their generosity, belief in our abilities, and investment in a shared vision, neither Partners’ success nor its innovative care coordination models would be possible.

Together we have made a difference in the way healthcare and social care interact for the benefit of people – especially the vulnerable, the poor, the elderly, and the disabled.

On behalf of those in our care, and the staff providing that care, we say “thank you.”

W. M. Keck Foundation

Chronic Care Management

In 2018, Partners recognized an opportunity to provide care management services to individuals with multiple chronic health conditions under CMS billing codes. Under a grant from the W.M. Keck Foundation, Partners developed a pilot program to test implementation of both Transitional Care Management (TCM) and Chronic Care Management (CCM) services. As these services require a partnership with a CMS billing provider, Partners utilized new and existing relationships with several different partners, including hospitals, hospitalist practices, and physician groups. When the COVID-19 pandemic began, the program shifted to telehealth, delivering devices to participants who were otherwise unable to visit with a primary care provider. The TCM service has since developed into a hospital-focused transitional care program at seven hospitals, now called Bridge. Participants who were enrolled in the CCM service report high satisfaction with the care management Partners provides, which includes regular monthly calls, daily EMR monitoring for potential health issues, and assistance with health activities such as prescription refills and physician visits.

Administration on Community Living (ACL)

Chronic Disease Self-Management
$1.4 million

The CDSME grant goal is to reach 5,628 older adults and adults with disabilities in 9 counties:

Los Angeles, Tulare, Ventura, Fresno, San Diego, Kern, Orange, San Francisco, and Humboldt. This will be accomplished by strengthening and expanding the Partners at Home (PAH) network leadership while significantly increasing participation in CDSME and other self-management support programs, as well as social determinants of health (SDOH) initiatives. The primary programs included in this grant are Chronic Disease Self-Management Program, Tomando Control de su Salud, Diabetes Self-Management Program and Chronic Pain Self-Management Program. Two additional evidence-based programs are included as support programming: the Arthritis Foundation Exercise Program and HomeMeds.

Administration on Community Living (ACL)

Falls Prevention
$1.2 million

The Falls Prevention grant goal is to reach 7,808 older adults and adults with disabilities in ten counties: Alameda, Humboldt, Los Angeles, San Diego, San Francisco, San Joaquin, Santa Clara, Tulare, Orange, and Ventura. The Partners at Home Network (PAH) will integrate SDOH initiatives with falls prevention programming to address transportation, food security and social connectedness challenges. It will include seven approved Evidence Based Health Programs (EBHP) addressing fall risks/strength building: A Matter of Balance, Tai Chi for Arthritis, Tai Ji Quan: Moving for Better Balance, Bingocize, Enhance Fitness, SAIL and CAPABLE. All ten counties will receive funding and support to establish a partnership with their local Emergency Medical Service (EMS) Departments to create a referral process to EBHPs.

Administration on Community Living (ACL)

No Wrong Door / Network Lead Entity

Partners received this highly competitive two-year award to develop, test, and implement a software solution to strengthen the impact of our work as a network lead entity (NLE), The NLE provides administrative, contracting, training, and quality assurance for partner community-based organizations (CBO) delivering direct services. Partners pioneered the first statewide home and community-based services network of community-based organizations. Through our network leadership, we partner with hospitals, physicians, health plans, and large public systems that contract with us for their members, hospitals, or patients. These contracts support Partners and our CBO network to address the Social Determinants of Health (SDOH) leading to patient readmission reduction, health self-management, fall reduction, care transitions, or caregiver support. This ACL grant will fund our development of an integrated information technology system to continue and strengthen our care management and ensure delivery of the highest quality evidence based SDOH services for California adults.

Ann Peppers Foundation

Health Management Workshops in Pasadena

One-third of Pasadena’s population is 50 years of age or older. The Greater Pasadena area has a high rate of death due to diabetes and an age-adjusted hospitalization rate due to uncontrolled diabetes that is higher than that of LA County. The area also has a high age-adjusted hospitalization rate due to hypertension. This gift made workshops available to improve the health, function, and quality of life of older adults, as well as enhance the building of community, and thus reduce social isolation for participants.

Archstone Foundation

Innovative Workforce Development Initiatives

The Archstone Foundation is supporting our innovative workforce development initiative aimed at providing an excellent and accessible training program for individuals interested in becoming a geriatric Community Health Worker (CHW). In partnership with Los Angeles Valley College, Rush University Medical Center, and the City of Los Angeles Area Agency on Aging, we will develop a training curriculum focused on preparing CHW’s to bridge social care and health care for low-income older adults in Greater Los Angeles. The program, offered through our outstanding community college system, will be available at no cost to the student and meets a growing demand for skilled health workers to support California’s growing aging population.

CA Wellness Foundation

Health Homes Program Support

The California Wellness Foundationprovided project support for the Health Homes Program (HHP) to rapidly enroll another 400 eligible diverse low-income and medically fragile participants in Los Angeles County and connect them to social and health care services.

CommonSpirit Health

Partnership to Align Social Care

Partners in Care Foundation has received this generous award on behalf of the Partnership to Align Health Care – A National Learning & Action Network (Partnership). CommonSpirit Health has designated this funding for the purpose of supporting the Partnership, particularly to cover unmet core expenses, staffing, and initiating the initiative’s project communication plan.

Confidence Foundation

Support of Multipurpose Senior Services Program

The Confidence Foundationsupported our Multipurpose Senior Services Program (MSSP) by establishing a fund to provide services to those on the waiting list before full enrollment is completed. This generous gift also allowed us to fund a new, vital, and important Special Needs Fund to provide crucial services and resources during this waitlist period

Kaiser Baldwin Park

Enroll residents of San Gabriel Valley in ECM

This award supports Partners’ commitment to improving health outcomes in the San Gabriel Valley by enrolling eligible individuals in the Enhanced Care Management (ECM) Program, which builds upon and will replace our Health Homes Program (HHP) in January 2022. The target population is low-income adults that tend to be frequent emergency room users with chronic medical conditions and who are enrolled in a Medi-Cal managed care health plan in Baldwin Park and El Monte. Our experienced Engagement Center staff will contact up to 500 individuals in the target geographic areas on the ECM referral list, with highest security first, to remind them of the program, assess their eligibility, and obtain their consent for enrollment. Partners’ Care Coordinator will work with interested and eligible individuals to enroll at least 50 in the ECM program, conduct the assessment of their individual needs, develop an individualized care plan, and begin making referrals for services. Our ongoing care management services are designed to improve their ability to self-manage their health, minimize emergency room and hospital use, avert homelessness, and improve their overall well-being.

Mericos Foundation

Support of Multipurpose Senior Services Program

The Mericos Foundationhelped us support aging, frail, isolated and vulnerable people in the Santa Barbara region through our Multipurpose Senior Services Program (MSSP). Their generous gift enabled us to provide services designed to keep these individuals safe, healthy, and independent in their own homes.


Benefits Enrollment Center

The National Council on Aging has awarded Partners a two-year grant to continue our operation of our Benefits Enrollment Center. We will serve approximately 1,400 Medicare/Medi-Cal dually eligible beneficiaries in Los Angeles, Kern, and Santa Barbara counties. Many program beneficiaries are individuals who are already enrolled in, or on the wait list for, one of Partners’ long-term services and supports programs. Our staff, representing the cultural and linguistic profiles of those we serve, screen for eligibility for five core government-funded benefits, including LIHEAP and SNAP. If eligible, Partners staff will assist these clients with their applications and overcome any barriers to their receipt of these benefits. As operators of this Benefits Enrollment Center since 2017, we can attest to the importance of this screening and application assistance service to ensure that our clients can maximize the benefits of government services for which they are eligible.

Edward A. and Al O. Shay Family Foundation

Home and Community Based Waiver Programs

This was a three-year grant supporting Partners’ HCBA Waiver Program and our emergency safety net fund relief allowing for a rapid response during the Covid-19 crisis.


Support of Geriatric Social Work Education Consortium (GSWEC)

The UniHealth Foundation’s recent award has provided a substantial boost to one of Partners’ signature innovations, the Geriatric Social Work Education Consortium (GSWEC). Partners is the founder and convener of GSWEC, a collaborative of eight Southern California Schools of Social Work and twelve Centers of Excellence. The Centers of Excellence are top community organizations, including Partners, where field placements occur. This workforce development initiative combines instruction and practice interventions to prepare master’s degree level social work students in the Southern California area for careers serving diverse, socially complex populations of older adults and their families. UniHealth Foundation funding will support outreach and create additional field placement opportunities, a new website, and fortify the alumni network, all with a goal of attracting more students of social work to become leaders in the field of aging.