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

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

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

Provide prenatal care in a group setting, integrating health assessment, education, and support

Increase patients’ health-related knowledge via efforts to simplify health education materials, improve patient-provider communication, and increase overall literacy

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