Strategies

Revise health care processes and provider roles to integrate mental health and substance abuse treatment into primary care; continue to refer patients with severe conditions to specialty care

Use a case management model for frail elderly patients living independently, coordinating aspects of long-term care (LTC) such as status assessment, monitoring, advocacy, care planning, etc.

Build assets through child development accounts (CDAs) with contributions from a sponsoring organization, such as government agencies or nonprofits, and family, friends; also called children’s savings accounts (CSAs)

Implement multi-component efforts that include coordination of health services by multidisciplinary teams of health care professionals, patient self-management, and patient education

Support financial institutions providing services to underserved and disadvantaged communities

Apologize for discriminatory housing policies; increase subsidies, financing, and paths to homeownership for people of color; and invest in systematically disadvantaged neighborhoods

Support a collaborative approach by a multidisciplinary team of professionals working to meet the full range of long-term care (LTC) needs for frail elderly patients living in community settings

Return the rights to land, property, and resources to Native people as part of policies and initiatives that promote tribal sovereignty

Provide continuous, comprehensive, whole person primary care that uses a coordinated team of medical providers across the health care system

Engage practice coaches or facilitators to work with primary care clinic staff to redesign clinical practices, organize quality improvement efforts, improve communication, share best practices, etc.