PARTNERS IN CARE FOUNDATION INC

Results: Partners collaborates with physician networks, health plans, community-based organizations, and federal and state agencies to deliver programs and services that protect and support adults with complex health and social services needs, frail elders, people with disabilities, caregivers and families. Our programs have been demonstrated to significantly reduce costly hospital readmissions, ED visits, and nursing home placements, resulting in improved health outcomes at lower cost through better coordinated care. We believe that health happens at home. Through unique, evidence-based interventions like our HomeMeds℠ program, a national, in-home medication review and safety program, we shift the emphasis of healthcare from catastrophic care to preventative care, reducing costs and enabling adults of all ages, especially seniors, to live with the dignity and independence they deserve. Partners many advances have been adopted by numerous healthcare providers and community-based organizations, becoming nationally recognized as models-of-care. HomeMeds℠ received a Strong Evidence Rating on the US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange. Partners is among a select group of community-based organizations (CBOs) working under a grant from the Centers for Medicare and Medicaid Services (CMS) to implement care transitions programs. The quality of Partners’ complex case management program has recently been recognized with a two-year accreditation by the prestigious National Committee for Quality Assurance (NCQA).

Target demographics: Partners collaborates with physician networks, health plans, community-based organizations, and federal and state agencies to deliver programs and services that protect and support adults with complex health and social services needs, frail elders, people with disabilities, caregivers and families.

Direct beneficiaries per year: Annually, we have been able to directly assist over 21,000 people through our partnerships.

Geographic areas served: Los Angeles, Kern and Santa Barbara counties

Programs: Multipurpose Senior Services Program (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. 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 55 sites in 16 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). 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. 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. Chronic Disease Self-Management A 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.