Advanced primary care in san antonio: Linking practice and community strategies to improve health

Robert L. Ferrer, Carolina Gonzalez Schlenker, Raquel Romero, Ramin Poursani, Oralia Bazaldua, Dewayne Davidson, Melissa Ann Gonzales, Janie DeHoyos, Martha Castilla, Betty A. Corona, James Tysinger, Bryan Alsip, Jonathan Trejo, Carlos Roberto Jaén

Research output: Contribution to journalArticlepeer-review

19 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)288-298
Number of pages11
JournalJournal of the American Board of Family Medicine
Issue number3
StatePublished - May 2013


  • Community Medicine
  • Delivery of Health Care
  • Primary Health Care

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Family Practice


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