Hospice, Health Care Partnership Unveils Person-Centered Care Program for Rural Patients

California-based Legacy Health Endowment recently launched a program to improve care coordination and seniors’ awareness around their community-based health care options. 

Legacy’s Person-Centered Care program aims to help rural-dwelling seniors to age in place. The initiative is designed to provide support for rural patients who need care but are not yet Medicare-eligible or who do not qualify for California’s Medicaid program, Medi-Cal.

The Legacy program was born from a hospice, palliative care and home health partnership between CareLinx by Sharecare, Community Care Choices, TINRx and Community Health Centers of America.


Rural-based patients often have limited financial resources, which can prevent many from remaining in their homes as they age and receiving community-based care, according to Legacy executives. Women in particular are more likely to experience these difficulties, according to Legacy Health Endowment President and CEO Jeffrey Lewis.

“They shoulder the burden of rearranging their schedules, juggling doctors’ visits and prescriptions, squeezing in regular shopping trips and performing essential housekeeping chores … all while caring for a spouse or aging parent,” said Lews in an announcement. “Women who leave the labor force early because of care-giving responsibilities cost themselves an average $324,044 in lost salary, Social Security and pension contributions over their lifetimes. Those are dollars that they never make up. This economic toll underscores why poverty in old age has such a distinctly female face.”

Nearly 80% of more than 1,700 caregivers in two California counties indicated that their caregiving responsibilities affected their ability to afford household and living expenses, according to a survey from Legacy.


Nearly two-thirds (63.7%) reported that they used savings, borrowed money or increased credit card debt to pay for costs associated with caregiving. More than 60% of women participants indicated that they had to decrease their paid work time to care for loved ones.

In response to this growing need, the Legacy person-centered care program emerged to combat both caregiver burnout and help ensure that elderly, middle-class families have access to community-based, long-term health care services across the continuum, the organization indicated.

As rural seniors near the end of life, many feel that they are unable to receive home-based hospice care due to socioeconomic and geographic limitations, which have also been tied to a lack of caregiver support. Caregivers of the terminally ill are often left with heavy financial and logistical burdens. Without assistance or relief, these difficulties can impede access to hospice.

Research has shown that patients who are faced with end-of-life decisions may be less likely to choose hospice unless they have a network of friends or family who can serve as home caregivers.

The Person-Centered Care program was created to assist patients, caregivers and family members “in achieving their maximum level of independence while improving overall health outcomes,” the company indicated.

Legacy is rolling out a pilot of the program in Stanislaus and Merced counties in Central California. based in Turlock, California, the nonprofit health care grant-making foundation strives to improve health care for residents across 19 zip in both counties.

The partners involved in the Legacy program are all based in California.

CareLinx is a senior professional caregiver marketplace that connects families to services across the country. It became a division of Sharecare when the company acquired CareLinx in 2021. Sharecare is a digital health company that helps health care providers and payers manage their patient populations.

Community Care Choices is a community-based palliative care provider. The nonprofit program is part of Community Hospice, Inc.’s service line.

TIN Rx is an online pharmacy company that offers telehealth, medication therapy management, and specialty prescriptions programs. It operates from locations in both California and Texas.

Community Health Centers of America is a family medical group practice located in Mariposa, California.

Through the Person-Centered Care program, the providers will collaborate to provide different levels of community-based support for caregivers and patients. Respite care is provided for caregivers, along with skilled nursing services, and a minimum of 16 hours of monthly in-home care.

Other services include durable medical equipment; physician-provided telehealth, prescription medication support, social worker visits, mental health care for both patients and their caregivers, advanced care planning, and home modifications for fall prevention.

Initiatives focused on person-centered care are gaining momentum in the health care payment realm.

The Center for Medicare & Medicaid Innovation (CMMI) indicated in October last year that a “refreshed strategy” designed to foster greater health equity and improved health outcomes through “high-quality, affordable, person-centered care.” The approach centers around aligning more patients with value-based care; integrated care; health care equity and affordability, and the establishment of partnerships to achieve these aims.

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