Coordinated health and human services delivery system and process

14) A coordinated service delivery program for coordinated health and human services management comprising:

• an intake assessment and recruitment module for population stratification and recruitment for clients having chronic disease or disability;
• a primary intervention module for developing an individual development plan and for enacting action-learning through peer support team intervention;
• a secondary intervention module for providing coordination of services;
• and
• an information archive to coordinate services for monitoring and tracking client progress;
• wherein the coordinated service delivery system is a population-based, client-centric strategy that combines self-management skills with said services to facilitate functional and psychosocial needs of the client for focusing on community integration and re-employment.

33) A method for coordinated health and human services delivery comprising:

• assessing and recruiting clients and developing a team of professionals and third party providers;
• developing an individual development plan for said clients;
• supporting service groups and managing services for clients through action-learning and Peer Support Team Intervention;
• and
• sharing and archiving information for consolidating data from said services and for monitoring and tracking client progress.

53) A method of providing coordinated healthcare to promote community integration and employment for persons with disabilities comprising:

• providing active recruitment of eligible participants;
• providing a support service coordination system that is consumer-driven using a peer supported Action Learning approach to coordinate, advocate and manage services;
• and
• providing a comprehensive and coordinated network of support services through an integrated service network.

56) An information technology (IT) platform for providing coordinated health care and human services management comprising:

• a healthcare management service;
• a self-management service;
• a community and vocational service;
• an outcomes research service;
• and
• an IT platform combining access to said services for coordinating and managing said services within said information technology (IT) platform, wherein the information technology (IT) platform is a population-based, client-centric entity that facilitates a focusing of a client's functional and psychosocial needs on community integration and re-employment through the coordination and interaction of said services.