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

Support temporary programs that work to energize participants to lose weight via prizes, often combined with education, weight status and food intake tracking, regular check-ins, and group support

Build, strengthen, and maintain social networks that provide supportive relationships for behavior change through walking groups or other community-based interventions

Engage a variety of partners in a highly visible, multi-component effort to increase physical activity, often with efforts to address cardiovascular disease risk factors

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 family members’ support for physical activity, often via educational sessions on health, goal-setting, problem-solving, or family behavioral management

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)