Starts with Motivational interviewing. Do you ask the right questions to even understand the patients needs? Housing needs? Food needs? Personal care needs? Sanitation needs. Many of these are difficult to address in a short stay. Example: COPD Patient lives in a high temperature area and had no A/C or running water.

To maximize community resources for patients with complex needs, research and compile a list of relevant local services, ensuring they match specific patient requirements. Build strong partnerships with service providers for referrals and collaborative care plans. Educate patients about available support options and guide them on how to access these services, empowering them to take charge of their care.

Identify Available Resources Research local services such as healthcare providers, non-profits, mental health agencies, social services, housing support, and transportation services. Foster partnerships with community organizations and stakeholders. A team-based approach ensures holistic care and addresses diverse needs like medical, psychological, and social support. Empower patients and their families with knowledge about available resources. Provide tailored guidance, pamphlets, or contact information, Use case managers or patient navigators to ensure services are utilized effectively, reducing gaps in care. Leverage TechnologyUse digital tools, such as apps or online platforms, to connect patients with services.

Maximizing community resources for patients with complex needs requires a strategic approach to identify, coordinate, and leverage available services. Conduct a thorough assessment to identify patient challenges and map local resources, including non-profits, government services, and support programs. Build collaborations with community partners, provide warm handoffs for patient connections, and use technology to streamline referrals and track progress. Monitor resource effectiveness, adjust care plans as needed, and ensure cultural competence to align services with patient values and needs.

First and foremost allowing the person to feel safe and gaining trust. Allowing people to know that their needs comes first before anything i am representing. Second when people speak, i listen per sentence to volume shifts, tone, if possible; body language and movement. This can display what is more important so i can prioritize what to say and do. Unless the person just wants to be heard. That is perfect time to build report and helps to build trust. That brings me to the 3rd thing. Prioritization brings efficiency. Not everyone wants long conversations. When listening intently. This tells me when to take as much time as possible. Or make the conversation efficient and effective

The best answer to all of this is to become a professional listener. It’s not how they got there. It’s where they’re heading. We can help people on a daily basis.if we just know what they want then we construct a structure around them to help them complete the incremental goals that they need to accomplish in order to be where they wanna be. It takes time and effort to understand yourself better read John Bradshaw‘s books work on your inner self. That’s where everything lies. Don’t allow the past to keep destroying your future step away. I have found solutions for over 100 people that are now successfully over their addictions over their therapeutic milestones and working with somebody to help them find themselves.

One thing I've found important among others when managing patients and to maximize community resources for support is to build a good report with the community. It all begins with clear communication and be accountable and transparent to the community. Being accountable and communicating the correct information on the necessary needs and challenges of patients to the community can attract a lot of support. Authencity, honesty, transparency and accountability are key factors in mobilizing resources.

1- Comprehensive assessment to identify the patient’s needs 2- Collaborate with a multidisciplinary team from mental health professionals and social workers. 3- Create a patient care plan by developing a comprehensive plan that utilizes the services available in the community. 4- By Educating the patient and their family about the resources available to them and how to use them. Also, training for family members to ensure they can provide the necessary support at home. 5- Advocate for policies that improve access to care, reduce barriers to services, and ensure that complex patients receive continuous, coordinated support across systems by ensuring communication between service providers, and focusing on the patient’s needs.

Partner with community organizations, non-profits, and health services that provide support for various needs, such as mental health, housing, and food security. Conduct a thorough assessment of available community resources. Create a directory that includes services such as mental health clinics, support groups, and social services to facilitate easy access. Form interdisciplinary teams that include social workers, mental health professionals, and healthcare providers to address the diverse needs of patients holistically. Involve patients and their families in community resource planning and development to ensure services are user-friendly and relevant.