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 funding for local community development activities such as affordable housing, anti-poverty programs, and infrastructure development

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

Purchase the land a home is on to lease to homeowners with low and middle incomes and require homeowners to sell the home back to the trust or to another resident with low income upon moving

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

Provide grants to states and localities to fund activities that build, buy, or rehabilitate affordable housing for rent or homeownership, or provide direct rental assistance to households with low incomes