Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
J Am Board Fam Med. 2013 May-Jun;26(3):288-98. doi: 10.3122/jabfm.2013.03.120238.
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.
改善贫困人口的健康状况往往超越了狭义的疾病治疗。如果不解决疾病的复杂社会根源，就不可能取得有意义的成功。我们描述了一个正在出现的社区解决方案，旨在改善德克萨斯州圣安东尼奥市 6000 名居民的健康结果，他们参加了县卫生保健计划。该解决方案社区由县卫生系统、家庭医学住院医师培训计划、大都市公共卫生部门以及当地非营利组织和企业组成。针对个人及其社区需求的基于社区的活动由一群促进者（社区卫生工作者）推动，他们的使命包括在个人和社区层面进行变革。促进者以患者的功能目标为中心，动员家庭和社区资源，并考虑采取社区层面的行动来解决健康决定因素。在临床方面，护理团队实施基于人群的风险评估和护士护理管理，重点关注护理过渡以及其他满足高发病率和高医疗保健利用率患者需求的措施。基于人群的结果指标包括减少住院、急诊和紧急护理就诊以及相关费用。促进者还评估患者在选定功能目标轨迹上的进展。
