This article in The New England Journal of Medicine on Brazil’s family-health strategy may have lessons for U.S. community health efforts, be they of  hospitals, physician groups, Federally Qualified Health Centers or free clinics.

 Interdisciplinary healthcare teams are an important part of the system with each team having a physician, a nurse, a nurse assistant and four to six “full-time community health agents.”
“Each agent is assigned to approximately 150 households in a geographically delineated micro-area within the catchment area — usually the same micro-area where the agent lives. Agents visit each household within their micro-area at least once per month, irrespective of need or demand, and collect individual- and household-level data”

“{T}heworld can learn some lessons from the Brazilian experience. First, community-based primary care can work if done properly. It requires a solid blueprint, pilot testing and evidence generation, a long-term vision, and sustained financial and political commitments. ….Finally, building a robust primary care system is more than a bureaucratic exercise; in Brazil, it has required long-term social movements and professional commitments.”