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 educational and behavioral interventions that support patients’ ability to actively manage their condition(s) in everyday life

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

Combine academic, mental and physical health, and social service resources in schools for students and families via partnerships with community organizations; also called community learning centers

Implement a coordinated effort to overhaul school operation, integrating curriculum, instruction, professional development, parent involvement, classroom and school management; also called school-wide or whole school reform

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

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)