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

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

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

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