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98 ORGS · 642 ACTIVITIES ← all strategies ·
approach

Integrated Care Coordination

methodology: population_health_integration

By coordinating mental health, substance use, primary care, and social services across providers and community resources, the organization improves client stability and independence, because integrated support addresses the interconnected drivers of vulnerability and reduces systemic fragmentation. This strategy centers on breaking down silos between health, behavioral health, and social services by creating unified, client-centered systems of care. Unlike standalone clinical interventions or single-issue programs, it emphasizes cross-sector collaboration and holistic service delivery to address complex, overlapping needs—particularly for individuals experiencing homelessness, mental illness, or substance use disorders. What distinguishes it is its systemic focus: not just offering multiple services, but ensuring they are synchronized, accessible, and sustained over time.

98
orgs running it
642
activities of those orgs
12
activity groups touched
who runs it

Organizations running this strategy · 98

+ 68 more orgs
what it looks like in practice

Activities of orgs running this strategy

A sample of programmatic activities from the orgs above — what the strategy looks like on the ground.

  • Act as fiscal sponsor for substance abuse initiatives ALLIANCE FOR SAFE KIDS INC
    capacity building
    Provides fiscal sponsorship for the organization Drug Crisis in Our Backyard to support awareness, education, and family assistance related to prescription and illegal drug abuse.
  • Conduct community-wide youth prevention programs ALLIANCE FOR SAFE KIDS INC
    direct service
    Implements programs that equip youth with decision-making skills and engage families in protective involvement to prevent substance use and destructive behaviors.
  • Develop and distribute youth resource guides ALLIANCE FOR SAFE KIDS INC
    direct service
    Creates and distributes educational resource guides for youth on topics including mental health, substance misuse prevention, and digital safety, such as the Yorktown Together! guide series.
  • Distribute naloxone and provide overdose prevention training ALLIANCE FOR SAFE KIDS INC
    direct service
    Provides free training in naloxone use and distributes naloxone kits to the community to prevent opioid overdose deaths.
  • Offer wellness and mindfulness programs for families ALLIANCE FOR SAFE KIDS INC
    direct service
    Hosts a free weekly yoga class focused on somatic mindfulness, grounding, and breath regulation to support family members of individuals struggling with addiction.
  • Organize virtual wellness and resource fairs ALLIANCE FOR SAFE KIDS INC
    direct service
    Curates and hosts a virtual Save A Life Wellness Fair to connect the community with potentially lifesaving information and resources.
  • Produce educational materials on substance abuse and service ALLIANCE FOR SAFE KIDS INC
    research
    Authored and published the Drug Epidemic Awareness Memorial Resource Guide and the Playbook for Thoughtful Service to promote awareness and guide community action.
  • Provide family training and support for substance use prevention ALLIANCE FOR SAFE KIDS INC
    direct service
    Offers evidence-based training programs including CRAFT and Invitation to Change approaches, along with weekly family support groups and individual coaching to help families support loved ones struggling with substance use.
  • Support community coalitions for youth safety ALLIANCE FOR SAFE KIDS INC
    direct service
    Operates as a community coalition in Yorktown Heights, NY, fostering cross-sector collaboration among communities, nonprofits, and government entities to promote youth safety and prevent substance abuse.
  • Behavioral health services SCHENECTADY FAMILY HEALTH SERVICES
    direct service
    Provides on-site counseling and behavioral health care for depression, anxiety, ADHD, PTSD, substance use, and behavioral issues, integrated with primary care through coordinated provider teams.
  • Comprehensive dental care SCHENECTADY FAMILY HEALTH SERVICES
    direct service
    Operates a 30-chair dental facility offering comprehensive dental services including oral surgery, pediatric dentistry, and emergency appointments, serving patients across Schenectady and Amsterdam.
  • Primary and preventive medical care SCHENECTADY FAMILY HEALTH SERVICES
    direct service
    Provides primary medical care services for all family members in Schenectady and Amsterdam, including preventive and ongoing health management, delivered through in-person and telemedicine platforms.
  • School-based health and dental services SCHENECTADY FAMILY HEALTH SERVICES
    direct service
    Delivers school-based health services at Schenectady High and Mont Pleasant Middle Schools and provides dental outreach care at 17 school sites across the region.
  • Telemedicine services SCHENECTADY FAMILY HEALTH SERVICES
    direct service
    Offers telemedicine visits for established patients, enabling secure video and audio connections with providers from home.
  • Vision care services SCHENECTADY FAMILY HEALTH SERVICES
    direct service
    Provides vision care services as part of comprehensive health offerings in Schenectady and Amsterdam.
  • 24/7 medical access COMMUNITY HEALTH CENTER OF RICHMOND INC
    direct service
    Offers 24/7 phone access to medical providers for patients, ensuring continuous care and support outside of regular clinic hours.
  • Behavioral health counseling COMMUNITY HEALTH CENTER OF RICHMOND INC
    direct service
    Provides professional counseling services for mental and emotional health issues, including stress, anxiety, and depression, for individuals and families. Services include mental health assessments, care coordination, referrals, and discharge planning.
  • Community health education and outreach COMMUNITY HEALTH CENTER OF RICHMOND INC
    direct service
    Provides educational classes and workshops on childbirth, breastfeeding, safe sleep, and child development. Organizes and hosts annual health fairs and community events such as Nutrition Month, Easter Health Fair, and Spring Reading Celebration, including free mammogram screenings and school supply giveaways.