Grant Partners:

• Blue Shield of California

• California Department of Aging

• Health Projects Center

• Life ElderCare

• Los Angeles County Workforce Development 

Aging and Community Services

• Los Angeles Department of Aging

• Meals on Wheels Orange County

• Partners in Care Network Partners

• Providence Health System

Grant Objectives:

1. Develop an IT data solution to produce financial, 

clinical, and quality performance reports and 

analytics.

2. Integrate Partners in Care’s evidence-based tools 

into the new IT solution.

3. Integrate all Partners in Care’s services to 

streamline oversight and increase productivity 

and effectiveness.

Anticipated grant outcomes include:

1. No double-entry required of NLE, health plan, or 

network staff.

2. Performance standards and parameters for each 

contract can be set and will generate alerts to NLE 

staff to increase compliance and quality.

3. Health plans and providers will accept 

bidirectional data exchange with software.

4. HomeMeds and Vital@Home360 will be fully 

integrated with IT solution.

5. NLE will support a dashboard of quality and 

performance measures and support QI and NCQA

standards.

Scaling Network Lead Entities Grantee Profile

Network Name: Partners in Care

Grant Contact:

Ester Sefilyan, Partners in Care, esefilyan@picf.org

Grant Goal:

To strengthen the role of Partners in Care (Partners) as the network lead entity (NLE) by developing an integrated information 

technology (IT) solution to support all NLE functions and deliver the highest quality evidence-based social determinants of health 

services for California adults. Partners will implement a software solution that support NLE functions.

Target Population:

Older adults and people with 

disabilities

Grant Summary:

Partners serves as the NLE for the California community integrated 

health network (CIHN), creating a single point of contact and setting 

common expectations for contracting and service delivery between 

payers and community-based organization networks. There are 22 

agencies in the statewide CIHN, including Partners, and Partners 

contracts with each of the CIHN’s community-based organizations to 

deliver the services required.

The State of California leverages Aging and Disability Resource 

Connections (ADRCs) that are intended to act as a NWD system on a 

regional level. There are 17 county-based ADRCs acting as 

designated sites, or still emerging ADRCs. Partners, in coordination 

with county and state aging systems, is working to help establish the 

first ADRC in Los Angeles County. In the absence of a statewide NWD 

system or county ADRC, Partners implements the NWD strategy in all 

of their services. Partners works with hospitals, physicians, health 

plans, and large public systems that contract with them for services 

for members, hospitals, and/or patients.

Partners in Care holds 35 contracts with major California health 

payers, and uses these relationships to align healthcare with social 

services by addressing and mitigating social determinants of health.

Partners manages these extended services as the NLE for the 

statewide CIHN. By doing so, they create a single point of contact 

and set common expectations for contracting and service delivery 

between payers and CBO networks. The statewide CIHN is a model 

collaborative of credentialed CBOs. 

Partners in Care’s greatest strengths as an NLE lie in the domains of 

Leadership, Finance, and Business Development. 

Planned activities for NLE enhancement will focus on:

☐ Leadership

☐ Finance

☐ Business Development

☒ Network Development and Support

☒ Network Administration

Partners in Care recognizes that Network Development and Support and 

Network Administration are identified areas for improvement. They will use 

this grant to develop a more robust IT system and use that to manage 

contracts, meet compliance standards, and address billing and payments.

Award:

$287,851