PT  - JOURNAL ARTICLE
AU  - Robert L. Ferrer
AU  - Carolina Gonzalez Schlenker
AU  - Raquel Lozano Romero
AU  - Ramin Poursani
AU  - Oralia Bazaldua
AU  - DeWayne Davidson
AU  - Melissa Ann Gonzales
AU  - Janie DeHoyos
AU  - Martha Castilla
AU  - Betty A. Corona
AU  - James Tysinger
AU  - Bryan Alsip
AU  - Jonathan Trejo
AU  - Carlos Roberto Jaén
TI  - Advanced Primary Care in San Antonio: Linking Practice and Community Strategies to Improve Health
AID  - 10.3122/jabfm.2013.03.120238
DP  - 2013 May 01
TA  - The Journal of the American Board of Family
                Medicine
PG  - 288--298
VI  - 26
IP  - 3
4099  - http://www.jabfm.org/content/26/3/288.short
4100  - http://www.jabfm.org/content/26/3/288.full
SO  - J Am Board Fam Med2013 May 01; 26
AB  - Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.