Partners 4 Health


Partners 4 Health

Partners 4 Health (P4H) is a partnership of four leading human service agencies in Wayne and Oakland counties: Common Ground, Neighborhood Service Organization, Oakland Family Services and Southwest Solutions. This partnership is dedicated to implementing a promising, integrated healthcare model for “complex patients.” Complex patients are patients with multiple or complex conditions, often combined with behavioral health problems and socio-economic challenges. The model integrates behavioral health and social support services with the medical care system and removes gaps and obstacles in the current healthcare delivery systems. Effecting this model improves patient care, outcomes and satisfaction. It also saves healthcare costs by reducing repeated emergency room visits and hospitalizations.


P4H is based on model of cooperative care that identifies high-risk patients, earns their trust, visits them in their homes, heads off medical complications before they occur, offers access to clinical services, and addresses social needs before they become medical problems. The model was pioneered by Dr. Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers.

The P4H model recognizes social determinants of health, such as housing, access to food, access to transportation, family or other support groups, all have a significant effect on the success of the medical treatments that members of our communities receive.

The P4H model works with the primary care physicians and the responsible insurer or health system to add trained nursing and social work resources into the care equation to better coordinate medical and behavioral care across different care settings. By meeting with physicians, patients, and reviewing both the medical care plans and developing social support plans to support the clinical care model, the P4H team assists our patients in better understanding and self-management of their disease process.

As part of the P4H coordination and assessment model, our teams manage care transitions from inpatient settings to home, perform medication reconciliations in patient homes, work with our patients to identify and arrange for social support needs and coach our patients in becoming a more activated patient.

Our goal is to have our patients better understand and be able to manage their own disease processes to improve their overall health.


P4H participants increase their Patient Activation Measure (PAM) scores by an average of four points

Each point increase is significant because it is scientifically shown to correlate with an increase in “patient activation,” an increase in proper medication use, and a decrease in ER visits and hospitalization.

Partners 4 Health and our sponsors are familiar with the hundreds of community resources to help our members improve their overall health and wellbeing
By helping our members better understand their health needs and assisting the primary care, other clinical providers and social support providers in supporting a patient-centered comprehensive care plan, we help the health systems and payers to improve clinical outcomes, member and physician satisfaction, and utilization performance.
P4H is contracted to interact with each patient regularly for 13 weeks. The average patient participates in the program for 110 days.
Currently, about 60% of the patients reside in Detroit.
P4H data indicates that the referred patients have been diagnosed with an average of four chronic illnesses.


For more information about Partners 4 Health, email Contessa Rudolph, program manager of P4H, or call 313-203-4083.


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