By Claire Hutkins Seda, Writer, Migrant Clinicians Network and Managing Editor, Streamline
Several years ago, Fernando*, a 55-year-old migratory agricultural worker, was diagnosed with diabetes at a community health center in Wisconsin. Fernando planned to head south in the coming weeks for better work opportunities. His primary care provider was very concerned that Fernando, whose hemoglobin A1c was 14, would not be able to access his needed medication nor get the support he needed for lifestyle changes to bring his diabetes under control, as he repeatedly moved for work, so she signed him up with Health Network.
Health Network is Migrant Clinicians Network’s bridge case management system. Any patient with an ongoing health concern moving to any location can be enrolled -- the only system of its kind in the world. After enrollment, a Health Network Associate follows up directly with the patient, helps the patient get into care at the next stop, transfers medical records, and more. For mobile patients, who have to navigate complex health systems in a new community after each move, Health Network can be lifesaving. It’s free of charge for the patient and for the clinics, and helps clinics reduce the number of patients who become lost to follow-up.
After he was enrolled in Health Network, Fernando moved to Texas. A Health Network Associate talked with him directly to hear where he was going, found him a health center, and transferred his medical records. When it was time to move again for work, a Health Network Associate once more made sure he was linked up with a new clinic. Fernando was highly mobile, and moved several times a year for work for the next decade -- and Health Network stayed with him during every move.
After about five years, Fernando lost his health insurance. After years of declines, his A1c climbed back up. Health Network continued to work with him to try to find him regular care, despite his insurance situation. After about two years, he once again received health insurance. Over time, with his continued clinic visits, Fernando’s A1c again came down to the controlled range.
Finally, Fernando settled in Texas. A Health Network Associate closed his case, as he was no longer mobile. Over the course of 10 years, Health Network Associates made 46 clinic contacts and 124 patient contacts, and transferred medical records nine times to six different clinics. At the time of case closure, Fernando had maintained an A1c of around seven to eight percent for over a year.
*Name and details have been altered to protect the patient's identity.
Watch one of our archived webinars on Health Network to learn more about how it works. Visit our archived webinar page: https://www.migrantclinician.org/archived-webinars.html
Learn more about enrollment and access enrollment paperwork in three languages: https://www.migrantclinician.org/services/network.html
Contact Theressa Lyons-Clampitt to schedule a training for your community health center: firstname.lastname@example.org or 512-579-4511
Read this article in the Spring 2020 issue of Streamline here!
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