Strategies

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

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

Provide culturally sensitive assistance and care coordination, and guide patients through available medical, insurance, and social support; also called systems navigators

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.

Provide interpretation services for patients with limited English proficiency (LEP) in outpatient and inpatient health care settings, following training and certification