title: Advanced primary care in San Antonio: linking practice and community strategies to improve health.
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.
authors: Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA. FerrerR@uthscsa.edu
authors: Robert L
authors: RL
authors: Ferrer
authors: Carolina
authors: C
authors: Gonzalez Schlenker
authors: Raquel
authors: R
authors: Lozano Romero
authors: Ramin
authors: R
authors: Poursani
authors: Oralia
authors: O
authors: Bazaldua
authors: DeWayne
authors: D
authors: Davidson
authors: Melissa
authors: M
authors: Ann Gonzales
authors: Janie
authors: J
authors: Dehoyos
authors: Martha
authors: M
authors: Castilla
authors: Betty A
authors: BA
authors: Corona
authors: James
authors: J
authors: Tysinger
authors: Bryan
authors: B
authors: Alsip
authors: Jonathan
authors: J
authors: Trejo
authors: Carlos Roberto
authors: CR
authors: Jaén
mesh_terms: D003153:Community Health Services / Q000458:organization & administration*; D003191:Comprehensive Health Care / Q000458:organization & administration; D003695:Delivery of Health Care / Q000458:organization & administration; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration; D005194:Family Practice / Q000193:education* / Q000458:organization & administration*; D006293:Health Promotion / Q000458:organization & administration; D006295:Health Resources / Q000458:organization & administration; D006297:Health Services Accessibility / Q000458:organization & administration; D006301:Health Services Needs and Demand / Q000458:organization & administration; D006305:Health Status Indicators; D006801:Humans; D007396:Internship and Residency; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration*; D011634:Public Health; D055818:Public-Private Sector Partnerships; D012947:Social Work / Q000458:organization & administration*; D013781:Texas; D017664:Uncompensated Care
keywords: Community Medicine; Delivery of Health Care; Primary Health Care