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.

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

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)

Support self-contained, homelike dwellings for 10-12 elderly adults who require nursing care; universal caregivers, usually CNAs, provide care and other supports while clinical teams visit for specialized care

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

Integrate legal services into health care settings to address legal issues that affect health (e.g., housing, food, utilities); services provided by private practice lawyers, law students, etc.