Article Figures & Data
Figures
- Figure 1.
Map of Bexar County, which contains the city of San Antonio, identifying the 6 priority ZIP codes and the location of our family health center. Each ZIP code is identified on the map by its final 2 digits; the full 5-digit ZIP codes appear at bottom right.
- Figure 2.
Project outcomes in 2011 to 2012, displaying run charts for rates of hospital admissions (top left), emergency department visits (bottom left), and urgent care visits (top right) for each month from January 2011 through November 2012. The panel on the bottom right displays the monthly panel size during various intervals.
Tables
- Table 1. Table of Classifications in Activities and Participation Component and Environmental Component of International Classification of Functioning, Disability, and Health
Activities and Participation Environmental Factors Learning and applying knowledge Products and technology General tasks and demands Natural environment and human-made changes Communication Support and relationships Mobility Attitudes Self-care Services, systems, and policies Domestic life Interpersonal interactions and relationships Major life areas Community, social, and civic life Instructions: Using your Presencia Viva ICF cards, reflect on what you know about the patient. Review the ICF domains in the form and write a sentence that captures what happened in the Nosotros story under the appropriate subdomain. Check a qualifier (impairment, functional or flourishing) that best describes the patient's current state. Be ready to share the story behind your coding. Code only what is touched by the story. Use your little ICF book to find more specific codes if needed. Domain Subdomains Impairment (1–4) Functional Flourishing d1 Learning and practicing what was learned d11. Paying attention with the senses d13. Basic learning d16. Putting to practice what was learned d2 General tasks and demands d22. Carrying out tasks d23. Making plans and completing them d24.Handling stress d4 Mobility d41. Changing body position d42. Transferring oneself d43. Lifting and carrying objects d44. Fine hand use d45. Walking d46. Moving around in different locations d465. Moving around using equipment d47. Using transportation d475. Driving d5 Self-care d51. Washing one self d52. Caring for body parts d53. Toileting d54. Dressing d55. Eating d56. Drinking d5700. Ensuring one's physical comfort (link to zoom-in) d5701. Managing diet and fitness d5702. Maintaining one's health (link to clinical care) d6 Domestic life d61. Acquiring a place to live d62. Acquiring products and services for daily living d63. Preparing meals d64. Doing housework d65. Caring for household objects d56. Assisting others d8 Major life areas d81.Informal education d82. School education (up to high school) d83. Higher education d84.Work preparation, apprenticeship d845 Getting, keeping and terminating a job d850. Paid employment part or full time d855. Work without pay d860. Basic economic transactions d865. Complex economic transactions d8700. Personal economic self-sufficiency d8701. Public economic entitlements d9 Community, social and civic life d9100. Informal associations d9101. Formal associations (unions, professional, etc.) d9102. Ceremonies d9200. Play d9201. Sports d9202. Arts and culture d9203. Crafts d9204. Hobbies d9205. Socializing d9300. Organized religion d9301. Spirituality d940. Human rights d950. Political life and citizenship ICF, International Classification of Functioning, Disability, and Health.
Government Faith-Based Nonprofit For-profit Bexar County Agency on Aging Blessed Sacrament Catholic Church Alamo Area Resources Apartment Wiz Bexar County City Public Services Catholic Counseling and Consultation Center Avanza Community Center AQTS-Home Health City of San Antonio Department of Community Initiatives Catholic Charities Crisis Intervention Center Heart for the Neighborhood Medical Solutions, Inc. Edgewood School District Holy Spirit Catholic Church Helping Hands Lifeline San Antonio Housing Authority Salvation Army Texas Diabetes Institute Mexican Consulate San Antonio Methodist Ministries Transitional House University Health System Jewish Family Counseling Center Identification of high-morbidity, high-need patients; medical record review Patients invited to participate in multidisciplinary group visits, assembled by ZIP code Nurse care management Pharmacist review for high-morbidity patients; also trigger of 10 or more meds Care transition management for hospital and emergency department visits Targeted patient experience surveys to determine chief reasons for visits to emergency department and urgent care center Process improvements to patient flow through family health center Process improvements in patient telephone access Education and assistance with maintaining health plan enrollment Close integration of practice clinicians with advanced primary care project initiatives Group visits for patients with intense medical and social needs
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