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

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)

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

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.

Provide health care services on school premises to attending elementary, middle, and high school students; physical and mental health services provided by teams of nurses, nurse practitioners, and physicians

Provide reminders, education, or self-management assistance for health conditions, especially chronic diseases, via text message