Strategies

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

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

Provide at-risk expectant parents and families with young children with information, support, and training regarding child health, development, and care from prenatal stages through early childhood via trained home visitors

Teach parenting skills in a group setting using a standardized curriculum, often based on behavioral or cognitive-behavioral approaches and focused on parents of at-risk children

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 a fixed, multi-component set of fall prevention interventions to older adults, usually in community settings, without an individualized risk assessment

Provide home visiting services to low income, first time mothers and their babies, starting during pregnancy and continuing through a child’s second birthday

Provide culturally sensitive assistance and care coordination, and guide patients through available medical, insurance, and social support; also called systems navigators