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

Offer debt advice from trained providers to tenants with unpaid, overdue rent to help repay debt and increase financial literacy

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 eligible families with low and very low incomes with vouchers to help cover the costs of rental housing; also called Section 8

Provide rapid access to permanent housing and support (e.g., crisis intervention, needs assessment, case management), usually for chronically homeless individuals with persistent mental illness or substance abuse issues

Facilitate mediation between tenants and landlords to resolve conflict and prevent eviction

Apologize for discriminatory housing policies; increase subsidies, financing, and paths to homeownership for people of color; and invest in systematically disadvantaged neighborhoods

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 legal representation for tenants with low incomes in eviction proceedings or offer limited legal assistance to prepare tenants to represent themselves in court

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.

Engage practice coaches or facilitators to work with primary care clinic staff to redesign clinical practices, organize quality improvement efforts, improve communication, share best practices, etc.

Transition families and individuals experiencing homelessness into permanent housing quickly, often with supports such as short-term financial assistance, case management, landlord negotiations, etc.

Provide permanent, basic rental housing with social services available on-site or by referral, usually for families with low incomes, older adults, veterans, or people with disabilities