GENERATIONS – Journal of the American Society on Aging

Partners in Care Foundation : A Change Agent in Community-Based Care By June Simmons and Sandy Atkins Impacts and outcomes of integrating social services with healthcare.

T wenty years ago, Partners in Care Foundation (Partners) was founded as a nonprofit com- munity-based organization (CBO) with the tag- line: “Changing the shape of healthcare.” Its mission still reflects this goal: “Partners shapes the evolving health system by developing and spreading high value models of community-based care and self-management for diverse populations with chronic conditions. This focus differentiates Partners frommany others in the field—the pri- mary purpose of Partners is not to be a provider, but rather to be a change agent.” This unique mission and purpose may help explain why Partners has been at the forefront of the effort to build contracted relationships between community-based organizations and healthcare entities. This effort has not been easy, by any means, but the Partners board and its organizational structure were designed spe- cifically to facilitate the integration of social services with healthcare. For example, the board has supported innovation and risk-tak- ing because those elements are baked into Partners’ purpose.

Also, leaders in top management at Partners were chosen for their backgrounds spanning healthcare and social services—hospital social work, nursing and retirement home administra- tion, and adult day health center management. Another element that contributed to its readi- ness for healthcare contracting is Partners’ gen- esis in a healthcare provider organization—the Visiting Nurse Association of Los Angeles. Partners’ Achievements So what have this unique purpose, structure, and history enabled Partners to accomplish in the realms of service coordination and self-manage- ment support for people with multiple chronic conditions? Partners now has contracts with the follow- ing organizations: two health systems (Provi- dence Health and Services and UCLA Health), which involve eight hospitals; one commercial health plan (Blue Shield of California; all lines of business); two Medicare Advantage plans (UCLA Health, Blue Shield); six Medicaid plans (L.A. Care, Care1st, Molina, Health Net, Anthem,

abstract Partners in Care Foundation has built a close and successful collaboration with UCLA Health across a span of more than seven years. Results have been powerful, benefiting thousands of older adults. The contract has stood the test of time and has expanded over the years. Of crucial importance is the use of the HomeMeds intervention under the leadership of UCLA’s MYMEDS pharmacists, who collaborate with the health system’s medical providers. | key words : ihealth systems, medications, care transitions, readmissions

32 | Spring 2019

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