PARTNERS IN CARE FOUNDATION INC

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.

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.

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.

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.

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.

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.

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.