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

Provide at-risk expectant parents and families with young children with information, support, and training regarding child health, development, and care from prenatal stages through early childhood via trained home visitors

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

Teach parenting skills in a group setting using a standardized curriculum, often based on behavioral or cognitive-behavioral approaches and focused on parents of at-risk children

Provide home visiting services to families who are at risk for adverse childhood experiences, starting prenatally or right after birth and continuing for three to five years

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.