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 culturally appropriate non-medical care and support throughout pregnancy, birth, and postpartum to birthing people at higher risk of poor outcomes and underserved by the medical community

Increase health care providers’ skills and knowledge to understand and respond to cultural differences, value diversity, etc. via factual information, skills training, and other efforts

Tailor health care to patients’ norms, beliefs, and values, as well as their language and literacy skills

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

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.