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Table 2 Program design implications

From: The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations

Provider connection/care coordination Trauma support Mental health Coaching and paperwork assistance Peer-to-peer support
Enable additional avenues for care coordinator-patient connection (i.e. home visits, regular phone contact)
Appointment reminders should be the responsibility of the primary member of the care coordination team
Utilize non-nurse providers such as Community Health Workers to enable more continuous out of office contact
Offer direct treatment for trauma, or connect patients with external resources such as trauma and grief counseling
Provide trauma informed care training to all program staff, especially those operating as primary care coordinators
Appoint additional social workers as the primary care coordinator and first point of contact for appropriate patients
Incorporate psychiatric nurses into the care coordination team
Require mental health and addiction training for all staff to reduce patient stigma
Consider ways to identify patients with executive function deficits
Expand the community health worker role for patients identified as needing additional supports with paperwork and task completion
Emphasize the use of motivational interviewing techniques for patient coaching
Incorporate peer support arrangements, including through electronic communication and social networks