Advanced primary care in San Antonio: linking practice and community strategies to improve health.

Authors, Primary Ferrer,R. L.;Gonzalez Schlenker,C.;Lozano Romero,R.;Poursani,R.;Bazaldua,O.;Davidson,D.;Ann Gonzales,M.;Dehoyos,J.;Castilla,M.;Corona,B. A.;Tysinger,J.;Alsip,B.;Trejo,J.;Jaen,C. R.
Title Primary Advanced primary care in San Antonio: linking practice and community strategies to improve health.
Periodical Full Journal of the American Board of Family Medicine: JABFM
Pub Year 2013
Volume 26
issue 3
Start Page 288-298
Abstract 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.
Publisher Not Available
Place of Publication United States
Author/Address Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
PubMed Link
Reference Type(s) Not Available
Topic Tag(s) Care Coordination;Primary Care Workforce Issues;Team Based Health Care
Special Population(s) Not Available
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Commentary/Opinion Piece No
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