RT Journal Article
SR Electronic
T1 Advanced Primary Care in San Antonio: Linking Practice and Community Strategies to Improve Health
JF The Journal of the American Board of Family
                Medicine
JO J Am Board Fam Med
FD American Board of Family Medicine
SP 288
OP 298
DO 10.3122/jabfm.2013.03.120238
VO 26
IS 3
A1 Ferrer, Robert L.
A1 Gonzalez Schlenker, Carolina
A1 Lozano Romero, Raquel
A1 Poursani, Ramin
A1 Bazaldua, Oralia
A1 Davidson, DeWayne
A1 Ann Gonzales, Melissa
A1 DeHoyos, Janie
A1 Castilla, Martha
A1 Corona, Betty A.
A1 Tysinger, James
A1 Alsip, Bryan
A1 Trejo, Jonathan
A1 Jaén, Carlos Roberto
YR 2013
UL http://www.jabfm.org/content/26/3/288.abstract
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.