• Design an integrated system that is financially sustainable

• Prevent readmissions and reduce morbidity risk

• Evaluate health drivers, informatics, and data analytics to support decision making

• Establish a Transitions of Care program

• Integrate the caregiver into the patient-management plan throughout the transitions of care process

• ​​Cultivate a flexible and growth-oriented culture that is able to adapt to diversity and ongoing change

• Optimize organizational equity to reduce disparities and enhance care access points for all patients

• Integrate health literacy and cultural competence

• Measure outcome effectiveness to identify success and opportunities for excellence

• Customize programs for cutting edge leadership

• Implement strategies for integrated teams

• Emphasize effective communication strategies amongst professionals

• Enhance virtual and electronic interaction opportunities

• Optimize team decision making

• Ensure identification and retention of talent

• Introduce Motivational Interviewing models to assist in self-motivated growth

• Create a growth culture of individualized coaching

• Identify and prevent professional burnout

Communication and Motivational Interviewing—Optimizing Communication Between the Patient and Health-Care Professional:

• Implement an integrated program to optimize adherence

• Educate patients on self-management and effective communication strategies to reduce morbidity risk

• Address the impact of comorbidity on adherence

• Introduce active coping strategies that positively impact patient outcome

• Proactively assess and address depression and anxiety in chronic disease patients

• Consider the influence of pain and suffering to optimize palliative care

• Optimize communication between the patient and care coordination team

• Improve positive outcomes through metric assessments, intervention, and data analysis

Best practices and integrated strategies are used to identify and overcome barriers to adherence, self-management and optimal communication between the patient and multidisciplinary team:

• Customized education programs are designed to address identified areas of required growth

• Coaching is introduced to encourage self-motivated growth

• Initiatives are implemented to improve health and enhance quality of life.

• Introduce customized programs for the integrated healthcare team, the patient and caregiver

• Interactive psychoeducation groups are introduced for patients living with chronic illness to optimize adherence, decrease morbidity and enhance quality of life

• Interactive psychoeducation groups for caregivers are implemented to optimize their role in effective patient.

• to assist them to cope with caregiver burden, ongoing change, and high levels of stress

• Create a program to enhance patient advocacy

• Develop customized multidimensional education programs to enhance treatment outcomes

Collaboratively addressing continuity of care in Community Based Organizations:

• Support the CBO in a manner that integrates service alignment and continuity of care

• Provide supportive guidance and professional recommendations to collaboratively address challenges that impact community-based services

• Engage the CBO in patient-caregiver services to address gaps in navigating social and community-based services

• Design comprehensive needs assessments to identify high utilizers of medical and supportive health related services

• Enhance fiscal initiatives in support of unaddressed clinical and community-based care

• Identify population health impacts through capacity assessments to evaluate service needs

• Initiate value-based services and contracts to address the social determinants of care that impact the social/human service organization