Southern California Program

Partners in Care Foundation

Health Care
San Fernando, CA
June 2018

Partners in Care (Partners) will pilot new, collaborative chronic care management models to demonstrate the feasibility of sharing revenue between health care and social service providers in ways that benefit patients, healthcare providers and payers, and community-based organizations (CBOs).  The funding mechanism for new partnerships between CBOs and physicians is a set of recently revised Medicare physician billing codes, especially Transitional Care Management (TCM) and Chronic Care Management (CCM).  A two-year grant from the W. M. Keck Foundation will enable Partners to work through the numerous challenges involved—such as sharing reimbursement and changing workflows—and create a toolkit for physicians and CBOs across the country.  Partners has one health system contract to pilot use of Medicare reimbursement for TCM.  This project will extend this innovation to other new Medicare benefits for CCM and Dementia Care, and build on existing partnerships with healthcare entities to provide much-needed inter-sector care coordination to a high-risk group of Medicare and Medi-Cal beneficiaries.  Physicians will be better informed about their patients’ needs and can provide care in the context of what happens at home.  Patients will be screened for eligibility for additional benefits and will be provided with new supports to improve their own health through better nutrition, medication management, caregiver support, transportation, and other services provided by CBOs.

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