Linking Practice and Community Strategies in San Antonio
Advanced primary care in San Antonio: linking practice and community strategies to improve health
Ferrer RL, Gonzalez Schlenker C, Lozano Romero R, Poursani R, Bazaldua O, Davidson D, Ann Gonzales M, Dehoyos J, Castilla M, Corona BA, Tysinger J, Alsip B, Trejo J, Jaén CR
This article describes an emerging community of solution to improve health outcomes for a population of 6000 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.
Journal of the American Board of Family Medicine; May-Jun;26(3):288-98 [Full Article]