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

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

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

Provide teen mothers with services such as remedial education, vocational training, case management, health care, child care, and transportation assistance to support high school completion

Provide child care, parent education, physical health and mental health services, and other family supports to pregnant women and parents with low incomes and children aged 0 to 3

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