Driving alignment between social care & health care

aka Partners in Care   |   San Fernando, CA   |


Partners addresses the social determinants of health by aligning social care and healthcare.

Ruling year info


President and CEO

Ms. June Simmons MSW

Main address

732 Mott Street Suite #150

San Fernando, CA 91340 USA

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NTEE code info

Senior Centers/Services (P81)

Health Support Services (E60)

Community Health Systems (E21)

IRS filing requirement

This organization is required to file an IRS Form 990 or 990-EZ.

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Programs and results

What we aim to solve

SOURCE: Self-reported by organization

The health disparities in low income communities need resources to help them meet their health and social service needs, and improving the health and independence of frail elders, people with disabilities, caregivers and families. They need programs to reduce costly hospital re-admissions, Emergency Room visits, and nursing home placements, and improve health outcomes at lower costs through better coordinated care. These same issues affect all individuals facing health challenges and we work to modify the health system to include solutions for them as well.

Our programs

SOURCE: Self-reported by organization

What are the organization's current programs, how do they measure success, and who do the programs serve?

HomeMeds program

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).

Population(s) Served
Ethnic and racial groups

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.
Partners in Care Foundation operates 4 MSSP sites in California serving north and south Los Angeles County, Kern County and Santa Barbara County.

Population(s) Served

Health Self-Management Workshops:
Our workshops are broken down into three types: Physical Activity & Fall Preventions Programs, including A Matter of Balance and the Arthritis Foundation Exercise Program, Health Self-Management Programs, including Chronic Disease Self-Management Program and Diabetes Self-Management Program, and Caregiver Support & Memory Programs.
These 2½ hour workshops, which run once a week for six weeks, address 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.
The Chronic Pain Self-Management 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.
The Diabetes Self-Management 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.
Physical activity/Fall Prevention programs include:
A Matter of Balance, Arthritis Foundation Exercise Program and Arthritis Foundation Walk with Ease Program.
A Matter of Balance is a program for people who have fallen in the past, have a risk of falling and who may be reducing their activities due to a fear of falling. Participants learn to change their environment to reduce fall risk factors, to view falls and the fear of falling as controllable, set realistic goals to increase activity and exercise to increase strength and balance.
The Arthritis Foundation Exercise Program offers low-impact exercises and gentle activities to help increase joint flexibility and range of motion, and to help maintain muscle strength. Developed specifically for people with arthritis, the program is also beneficial to those without arthritis. Different classes are available to fit each individuals’ fitness level with exercises done while sitting, standing or on the floor.
The Arthritis Foundation Walk with Ease program was developed to help individuals create and implement a walking plan to meet their particular needs. This program encourages participants allowing them to stay motivated, manage their pain and learn to exercise safely to keep muscles strong and joints stable. The program helps boost participant energy, reduce stress and control weight.
The UCLA Memory Training is an innovative educational program for people with age-related memory concerns. In small groups, participants engage in memory quizzes and skill-building exercises through a combination of presentations with group discussions. This program focuses on teaching new skills in a low stress, fun environment.

Population(s) Served

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.

Population(s) Served

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.

Population(s) Served

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.

Population(s) Served

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.

Population(s) Served
Ethnic and racial groups

The Home and Community-Based Alternatives (HCBA) Waiver provides long-term, community-based services and supports to Medi-Cal-eligible beneficiaries in the community setting of their choice. These services include private duty, case management, and personal care services necessary to maintain the health and safety of an individual with nursing-level of care needs in the community and avoid institutionalization. We currently serve over 150 children, birth to age 21, living in a broad region that extends from Los Angeles to Antelope Valley and Long Beach. The medical conditions and disabilities of these participants range from genetic disorders, immune deficiency disorders, rare diseases, or result from sports injuries or motor vehicle accidents. Most require medical beds and special equipment as well as wheel chairs and assistance with variety of daily living activities. Our multi-disciplinary care team of nurses and social workers provide care coordination services and supports.

Population(s) Served

Where we work


Finalist 2006

Civic Ventures Purpose Prize

CEO of the Year 2009

Los Angeles Business Journal

Molly Mettler Award 2008

National Council on Aging

Finalist 2011

The Adaptive Business Leaders Organization - Innovations in Healthcare ABBY Awards

Unsung Heroes Award 2009

California Community Foundation and The Eisner Foundation

Our results

SOURCE: Self-reported by organization

How does this organization measure their results? It's a hard question but an important one.

Number of individuals with chronic health conditions participating in weekly workshops to set realistic personal health goals

This metric is no longer tracked.
Totals By Year
Population(s) Served

People with diseases and illnesses

Related Program

Chronic Disease Self-Management Education (CDSME)

Type of Metric

Output - describing our activities and reach

Direction of Success


Context Notes

Adults with diabetes, heart disease, arthritis or chronic pain participated in six-week 2.5 hour weekly sessions and learned to set health goals, manage their emotions, behaviors and healthcare.

Number of children having a medical home

This metric is no longer tracked.
Totals By Year
Type of Metric

Output - describing our activities and reach

Direction of Success


Context Notes

As of 5/22 we have 156 children enrolled in our Medi-Cal waiver Home and Community Based Alternatives Program. As a result, these children are enable to remain at home and avoid institutionalization.

Number of clients living independently

This metric is no longer tracked.
Totals By Year
Population(s) Served

People with disabilities, Ethnic and racial groups, People with diseases and illnesses

Type of Metric

Outcome - describing the effects on people or issues

Direction of Success


Context Notes

Each year we assist nearly 25,000 individuals to live with safety and dignity in the community home of their choice, minimizing hospitalizations and avoiding institutional settings.

Our Sustainable Development Goals

SOURCE: Self-reported by organization

Learn more about Sustainable Development Goals.

Learn about the organization's key goals, strategies, capabilities, and progress.

Charting impact

Four powerful questions that require reflection about what really matters - results.

• Create and/or adapting community-based social services and wellness programs that address new target populations while leveraging emerging trends in social service and healthcare delivery to meet the needs of consumers and payers.
• Spread/scale effective service coordination, care transition, and evidence-based health and self-management models, programs and practices.
• Expand and enhance the effectiveness of the statewide Partners at Home Network for delivery of health self-management, wellness, care transitions, home and community-based care coordination – and make it self-sustaining.
• Be a national change agent for integrating healthcare with home and community-based services by promoting best practices and the value proposition to healthcare providers, payers, organizations and government agencies.
• Build a strong, nimble infrastructure and culture, with sustainable financial resources to support the organizational mission and impact on the communities we serve.

1. Lead adoption of healthy behaviors in all adults, especially elders and people with chronic conditions: Disseminate evidence-based programs that improve physical and emotional health and quality of life for individuals by empowering them to change their health-related behaviors.
2. Drive system change: Drive care redesign changes in payor and provider methods of practice that improve patient health, functioning, and quality of life especially through linkages with community partners.
3. Change the design and delivery of home care and community services to support better health, greater independence and community living for chronically ill, aging and disabled populations: Identify, test and validate innovations that enhance access to and integrate home and community services. An important aspect of systems change work will be to work in communities, with a variety of partners, to address ethnic, economic, and gender-related health disparities.

Partners’ mission aligns with growing public sentiment to support needed change in addressing broad health issues such as critical need for prevention, enhanced self-care and methods of provider practice change. We maintain an outstanding record of success in creating and disseminating research-based, practical solutions that address the challenges of the aging demographic is receiving national recognition. This track record, along with a talented, capable professional staff and a highly respected Board of Directors provide us with a strong platform to move forward.

1. Partners works with other agencies and organizations to disseminate throughout the state and nationally, the Chronic Disease Self-Management Education evidence-based programs originally developed at Stanford University and managed by the Self-Management Resource Center.
2. Partners is the national office for the Evidence-Based Leadership Council to disseminate evidence-based chronic disease self-management programs.
3. Partners’ complex care management program has been recognized with a three-year Accreditation for Case Management by the National Committee for Quality Assurance (NCQA).
4. Partners takes a proactive approach to drive innovative and effective change in the care of older and disabled adults. Specifically, we have built new integrated social services network, community care transition programs to reduce hospital readmissions, an innovative HomeMeds Program and integrated medical and social services in a coordinated approach.

How we listen

SOURCE: Self-reported by organization

Seeking feedback from people served makes programs more responsive and effective. Here’s how this organization is listening.

done We shared information about our current feedback practices.
  • How is your organization using feedback from the people you serve?

  • Which of the following feedback practices does your organization routinely carry out?

  • What challenges does the organization face when collecting feedback?



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The people, governance practices, and partners that make the organization tick.


Connect with nonprofit leaders


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Connect with nonprofit leaders


Build relationships with key people who manage and lead nonprofit organizations with GuideStar Pro. Try a low commitment monthly plan today.

  • Analyze a variety of pre-calculated financial metrics
  • Access beautifully interactive analysis and comparison tools
  • Compare nonprofit financials to similar organizations

Want to see how you can enhance your nonprofit research and unlock more insights? Learn More about GuideStar Pro.


Board of directors
as of 04/16/2024
SOURCE: Self-reported by organization
Board chair

Jennifer Kozakowski


Term: 2023 -

Cathi Cunningham

Deloitte & Touche LLP

June Simmons

Partners in Care Foundation

Gordon M. Johnson


Seth Ellis

MemorialCare Health System

Robert W. Lundy

Hooper Lundy & Bookman

Stephen T. O'Dell

Prospect Medical Holdings

Mari Zag

AArete, LLC

Edward Kim

James B. Edwards

StartUp Health

Katherine A. Kirchhoff

Cain Brothers & Company, LLC

Jennifer L. Kozakowski

Providence Health

Manoj K. Mathew, MD

Agilon Health

Alexander Strachan

National Inpatient Care Management

Pete Brown

Cith of Los Angeles, Office of Councilmember Kevin de Leon

Terri Cammarano


Paul Craig

Keck Medicine of USC

Marta Fernandez

Jeffer Mangels Butler & Mitchell

Amanda Flaum

Kaiser Permanente

Jennifer Heenan

Spencer Stuart

Alfred Poirier

Beverly Hills Fire Department

Jack Schlosser

Gerald Sullivan

G.J. Sullivan Co., Reinsurance

Adriana Mendoza

AARP California

Donald Crane

Healthcare Advocacy

Poonam Gorakshakar, MD

Blue Shield of California

Rekha Murthy, MD

Healthcare Advocacy

Shawn Sheffield

Keck Medicine of USC

Board leadership practices

SOURCE: Self-reported by organization

GuideStar worked with BoardSource, the national leader in nonprofit board leadership and governance, to create this section.

  • Board orientation and education
    Does the board conduct a formal orientation for new board members and require all board members to sign a written agreement regarding their roles, responsibilities, and expectations? Yes
  • CEO oversight
    Has the board conducted a formal, written assessment of the chief executive within the past year ? Yes
  • Ethics and transparency
    Have the board and senior staff reviewed the conflict-of-interest policy and completed and signed disclosure statements in the past year? Yes
  • Board composition
    Does the board ensure an inclusive board member recruitment process that results in diversity of thought and leadership? Yes
  • Board performance
    Has the board conducted a formal, written self-assessment of its performance within the past three years? Yes

Organizational demographics

SOURCE: Self-reported; last updated 4/16/2024

Who works and leads organizations that serve our diverse communities? Candid partnered with CHANGE Philanthropy on this demographic section.


The organization's leader identifies as:

Race & ethnicity
Gender identity
Female, Not transgender
Sexual orientation
Gay, Lesbian, Bisexual, or other sexual orientations in the LGBTQIA+ community
Disability status
Person without a disability

Race & ethnicity

Gender identity

Transgender Identity

Sexual orientation


Equity strategies

Last updated: 12/18/2020

GuideStar partnered with Equity in the Center - an organization that works to shift mindsets, practices, and systems to increase racial equity - to create this section. Learn more

Policies and processes
  • We seek individuals from various race backgrounds for board and executive director/CEO positions within our organization.
  • We help senior leadership understand how to be inclusive leaders with learning approaches that emphasize reflection, iteration, and adaptability.
  • We engage everyone, from the board to staff levels of the organization, in race equity work and ensure that individuals understand their roles in creating culture such that one’s race identity has no influence on how they fare within the organization.