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

Match disadvantaged or at-risk youth with volunteer mentors in school or community settings

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.

Provide preschool education and comprehensive support to families with low incomes, including small classes, student meals, and home visits with referrals for social service support as needed

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

Engage professional or lay health workers to provide education, referral and follow-up, case management, home visiting, etc. for those who experience barriers in accessing health care; also called promotoras(es) de salud or community health representatives

Combine academic, mental and physical health, and social service resources in schools for students and families via partnerships with community organizations; also called community learning centers

Provide child care, parent education, physical health and mental health services, and other family supports to pregnant women and parents with low incomes and children aged 0 to 3

Position registered nurses within a parish or similar faith community, or in a health care system to serve as a liaison to congregations; also called parish nursing or congregational nursing

Increase support for non-profit health care organizations and deliver comprehensive care to uninsured, underinsured, and vulnerable patients regardless of ability to pay; often called community health centers (CHCs)