Care Partners Sites (Phase 1)

The following sites were selected to participate in the Care Partners project on June 9, 2015.

El Sol Neighborhood Educational Center / SAC Health System

The Primary Care Clinic
Founded in 1991, El Sol serves the educational needs of San Bernardino and Riverside community members. Utilizing the Community Health Worker model, El Sol provides an array of culturally and linguistically competent community-based services, focused on promoting and maintaining the well-being of vulnerable communities.

The CBO
SAC Health System is a Federally Qualified Health Center Look-Alike, Teaching Health Center Graduate Medical Education programs providing primary care, behavioral health, dental, well woman, pediatric, family medicine and community resources to the residents of the Inland Empire

The Innovation
Providing a strong link between SAC Health System, the community-based health center, and the patient, El Sol, through their Community Health Worker program, the San Bernardino: Depression in Late Life Collaborative, will provide an innovative approach in improving health outcomes for individuals at-risk for or suffering from depression in the Inland Empire region.

From left: Oscar Bustillos (Project Lead), Amelia Zepeda (Project Lead), Tom Bazemore (Project Liaison), Irma Abaunza (Community Health Worker), Monica Fuentes (Community Health Worker), Adriana Gomez (Care Manager)

Family Health Centers of San Diego, Downtown Family Health Center at Connections / Serving Seniors

The Primary Care Clinic
Downtown Family Health Center at Connections (DTFHC) resides in the heart of downtown San Diego – home to many of San Diego’s lowest-income seniors  – and is co-located within a multi-service residential community designed to help homeless individuals move into permanent housing.

The CBO
Serving Seniors is an independent non-profit focused on improving the health and wellbeing of San Diego’s low-income seniors through the provision of essential services such as food, healthcare, housing, and social services.

The Innovation
Our partnership with Serving Seniors will allow FHCSD to create a medical neighborhood to enhance primary and mental healthcare for downtown seniors with depression. 

From left: Steven Ritter (PCP Champion), Myra Buby (Project Lead), Margarita Velosa (Care Manager), Dennis Dearie (Care Manager), Parwin Tahir (Care Manager), Nora Cole (Administration)

Institute on Aging / UCSF Housecalls and Center for Geriatric Care Program

The Primary Care Clinic
UCSF Housecalls and Center for Geriatric Care serve San Francisco’s homebound elders who are in need of home-based primary care, and who face difficulty in regularly receiving clinic-based services. 

The CBO
The Institute on Aging (IOA) has a long history of creating innovative mental health services for seniors and adults with disabilities, including the integration of behavioral health screening in existing IOA care management programs, a 24-hour suicide prevention and intervention hotline called the Friendship Line, home-based psychotherapy, and a psychology training program.

The Innovation
With UCSF’s primary care providers and IOA’s mental health clinicians having extensive experience in providing home-based services, this collaboration is an innovative model for serving isolated, homebound older adults struggling with depression. 

From left: Alyson Madigan (Care Manager), Clare Farrington (Care Manager), Carolyn Stead (Project Lead), Marisa Guardado (Project Liaison), Meredith Greene (PCP Champion, Project Lead)

LifeLong Medical Care / St. Mary's Center

The Primary Care Clinic
The LifeLong Over 60 Health Center is a leader in the delivery of integrated health and social services for the elderly.

The CBO
St. Mary’s Center is a community of hope, justice and healing, serving at-risk elders and preschoolers in the heart of Oakland.

The Innovation
FQHC and CBO will both identify older adults with depression, jointly offer a range of clinical and non-clinical services when depression is identified, and track outcomes so nobody falls through the cracks.

From left: Karla Salazar (Project Lead, Care Manager), Jesse Merjil (Care Manager), Eva Lumas (Care Manager), Alexis Bradley (Care Manager/Community Health Worker), Jennifer Elton (PCP Champion)

McClellan Outpatient Clinic / Family

The Primary Care Clinic
VA McClellan is an outpatient clinic in the Sacramento area that serves over 9000 veterans, the majority of whom are age 65 and above, that is developing integrated mental health and primary care services for veterans.

The Innovation
The key innovation of the VA McClellan site is to engage family members in older veterans’ depression care, including task-sharing related to psychoeducation, self-management (i.e. adherence, symptom monitoring), behavioral activation, and participation in primary care visits.

From left: Thuc-Nhi Nguyen (Project Manager, Evaluation), Angela Araneta (Care Manager), Brian Dahmen (Oversight), Ladson Hinton (Project Lead, Psychiatric Consultant), Jane Addagatla (PCP Champion)

Sonoma County Human Services / Petaluma Health Center

The Primary Care Clinic
Petaluma Health Center (PHC) is the principal safety net health care provider in southern Sonoma County. It serves approximately 23,000 patients a year (mostly low-income), with services ranging from primary care to mental health treatment and even dentistry for children.

The CBO
The Sonoma County Human Services Department, Adult & Aging Services Division (A&A) serves as the county safety net provider of senior services. The Division provides protective services, in-home care assessment, and case management services to older adults and people with disabilities throughout Sonoma County.

The Innovation
A&A will embed a social worker with responsibility for home visits and care coordination into the clinic treatment team at PHC. The assessment and care plan developed by this home visiting Care Coordinator will help inform the treatment team and ensure that the patient’s community needs are considered when developing a plan to treat his/her depression.

From left: Anne Percival (Care Manager Supervisor), Todd Finnemore (Project Lead and Program Coordinator), Diane Camurat (Care Manager), Vicki Rivera (Care Manager)

University of Southern California Dept. of Family Medicine / Eisner Pediatrics & Family Medicine and St. Barnabas Senior Services

The Primary Care Clinic
Located in Downtown Los Angeles, Eisner Pediatric and Family Medical Center is a Federally Qualified Health Center dedicated to providing comprehensive, high-quality healthcare for all ages. USC-Eisner Family Medicine Center at California Hospital, also an FQHC, is the primary residency clinic for the California Hospital/USC Family Medicine Residency Program, and a medical home within the Eisner system for patients of all ages.

The CBO
St. Barnabas Senior Services (SBSS) is a dynamic non-profit senior service agency dedicated to ensuring that older adults have the right to age with dignity by providing comprehensive and innovative programs that promote healthy aging, prolong independence, and enhance the well-being of more than 18,000 older adults each year.

The Innovation
Our innovation will be to coordinate between the two PCP sites and SBSS for training friends or family members to be Caregivers who will participate in evaluating, treating and advocating for their older adult with depression.

Top left: Camilo Zaks (Project Lead), Jose Luevano (Care Manager), Maria De Leon (Project Liaison)
Bottom left: Ana Rosas (Care Manager), Eveline Zamora (Care Manager), Cristina Sandoval (Care Manager), Sandra Avila (PCP Champion)