Partners Care Coordination Toolbox - Tools for improving social care outcomes.
Welcome to the California-based Partners in Care Foundation (Partners) and our innovative, evidenced-based tools designed to support and promote healthy independence of individuals and families at risk of losing their ability to live independently and safely in their homes.
Our social care coordination toolbox is a set of indispensable tools that drive successful coordination and implementation of care services in the homes of vulnerable, at-risk individuals. Three of these tools help hospitals successfully transition patients to their homes: Care Transitions Interventions, the Bridge Program, and HomeMeds Plus.
Partners has additional tools that help healthcare organizations address social determinants of health (SDOH), and at the same time, improve social care coordination with patients and their families. These include the Engagement Center, Partners at Home, HomeMeds, and a suite of chronic disease self-management and fall prevention programs available through our Community Wellness Department.
Since 1997 Partners has worked to align social care and health care to improve the lives of people with complex health needs. Our experience visiting homes and seeing the needs presented - often invisible to the medical community – demonstrated to us that what happens in the home after medical treatment can enhance or diminish the impact of health care treatments. Which in turn led to the innovations that make up this Toolbox.
Partners has been called visionary for developing innovative and powerful models of social care coordination. To learn more about our Toolbox and services, please contact us: Partners@picf.org or 818-837-3775.
Partners' Toolbox Resources
Partners' social care coordination and care transitions tools promote success and development of healthy independence for at-risk vulnerable individuals and their families. SDOH challenges and unexpected medication problems can sabotage the best care transition and care management plans, resulting in the loss of independence.
Achieving healthy independence for patients/clients is our primary goal. If you are interested in learning more about Partners’ Care Coordination Toolbox, get in touch. We’d be pleased to discuss how they improve patient care and lives. Contact us at: Partners@picf.org or 818-837-3775
-
Linking Technology to Address the Social and Medical Determinants of Health for Safe Medicines UseHomeMeds, a social health program in which trained social services staff make home visits to vulnerable clients, was combined with MedSafety Scan, a medical health, clinical decision support tool. Data captured in the home visits were entered into the HomeMeds and MedSafety Scan programs to detect those patients at the greatest risk of adverse health outcomes because of medications.You must log in to access content.
-
The Leveraging Exercise to Age in Place (LEAP) Study: Engaging Older Adults in Community-Based Exercise Classes to Impact Loneliness and Social IsolationA collaborative study involving Partners' Community Wellness programs.You must log in to access content.
-
A Collaboration Among Primary Care–Based Clinical Pharmacists and Community-Based Health CoachesMedication discrepancies and adverse drug events are common following hospital discharge. This study evaluates whether a collaboration between community-based health coaches and primary care–based pharmacists was associated with a reduction in inpatient utilization following hospitalization. A home visit conducted by a health coach combined with a medication review by a primary care–based pharmacist may prevent subsequent inpatient utilization. A collaborative study involving UCLA Health and Partners' HoeMeds.You must log in to access content.
-
Complexities of care: Common components of models of care in geriatricsThe American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults. HomeMeds is one of the services discussed.You must log in to access content.
-
Partners' Proven ResultsDon’t just take our word that Partners’ interventions work. These studies demonstrate the effectiveness of our approach. We can provide additional detail on any or all of these on request.You must log in to access content.
-
Partners' Engagement Center - Engagement is Key to Success.A phone call remains one of the most effective means of reaching and communicating with your customers, patients, or members. Engagement Center staff are expert at: • Targeted Outreach strategies • Engagement through motivational interviewing and call scripting • Enrollment and Scheduling processes Partners’ skilled staff achieve a high rate of success in reaching individuals, followed by success in convincing them of the importance of your services and appointments.You must log in to access content.
-
Partners' Care Transition Models - Three Evidence-Based Interventions.Our work serves as a bridge between medical care and what a person accomplishes in their own home. We manage the gaps in non-medical care that affect a person’s recovery and overall health. We represent a California network of community-based organizations (CBOs) and a national collection of similar networks providing evidence-based interventions. The result is happier, healthier people cared for at lower expense in their own homes and communities.You must log in to access content.
-
HomeMeds Plus - Reduce ED and Readmission Costs for High-Risk Patients with Partners' "Eyes and Ears in the Home" VisitWhy Use HomeMeds℠ Plus? Create an individualized service plan in concert with case managers, and review and revise periodically – all to keep patients out of the hospital, maximize your HEDIS quality measures and protect Medicare Advantage Star quality ratings. • WHO? Health plans and medical providers caring for high-risk patients recently discharged or with multiple chronic conditions. • WHAT? Medication, psychosocial, functional needs, and safety assessments performed by highly skilled health coaches competent in cultural and linguistic diversity, adept at patient engagement and knowledgeable of community resources. • WHERE? In the home, at ground zero of optimal health outcomes.You must log in to access content.
-
HomeMeds - Take The Right Meds...The Right Way!HomeMeds℠ is an evidence-based intervention addressing five important problem areas affecting individuals: • Unnecessary therapeutic duplication. • Falls and confusion related to possible inappropriate psychotropic medications. • Cardiovascular problems such as continued high/low blood pressure or low pulse. • Inappropriate use of non-steroidal anti-inflammatory drugs (NSAIDs) in people with high risk of peptic ulcer/gastrointestinal bleeding. • Review effectiveness of opioid prescriptions and alternate options.You must log in to access content.
QR code for the Scavenger Hunt!
Be sure to look through the rest of the exhibit for more information about the Partners in Care Foundation!
