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Health Network and Diabetes: A Case Study

Graph from HN Case study

 

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.

Resources

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: tlyons@migrantclinician.org or 512-579-4511

Health Network and PRAPARE
In 2016, just as PRAPARE was set to launch, Migrant Clinicians Network was beginning to develop its new database to better serve patients enrolled in Health Network, MCN’s bridge case management program. Over the course of the following year, MCN configured the new database to allow for the integration of PRAPARE data, in which one health center’s PRAPARE data can be transferred to the next health center, as a mobile patient moves.
“When we started thinking about that data and [Health Network] case management work, so much of case management isn’t just ‘are you taking your medication every day?’ It’s more about, ‘How can I help you access care and manage your health in general?’” explained Anna Gard, RN, who assisted MCN in the development of the new database. “One piece of this is: ‘Let me help you find a health center.’ But the larger pieces around effective case management are, ‘How are you going to get there? Is there public transportation? How are you going to pick up your medications if you live in a hostile community and you’re afraid of leaving the house?’ PRAPARE gives a structured format to capture [these] data, in a form that’s been tested and validated.”
As more health centers provide case management and chronic care management to address the social determinants of health, Gard noted, integration of the PRAPARE data with Health Network, a virtual case management, seemed to make sense. Now, the Health Network team is working to fit PRAPARE into their own workflow.
Saul Delgado, Health Network Data Specialist, who has been integral in building and launching Health Network’s new case management system, notes that asking such personal questions over the phone, when a patient doesn’t have transferrable PRAPARE data from a previous health center, can be challenging. “When we call, the patient doesn’t know you. They’re very scared to answer these kinds of personal questions, whereas when you go the clinic, you at least see the nurse or case worker face-to-face,” he explained. But he recognizes the utility of the data, and has developed the PRAPARE data screens within the database to be easily accessed from the main patient information screen. With drop-down menus, Health Network Associates can populate the information they hear from patients, like how many people live with them in their household, or if they’re worried about losing their home. The information, either attained from a previous health center or inputted by a Health Network Associate, will be transferred when the mobile patient gets to his or her next destination, just as the basic medical records do.
“Health centers are doing more to integrate social and behavioral determinants of health, and we’re recognizing that all of those things have to be integrated with care management. So we’re on the forefront,” Gard concluded.

MCN Streamline Spring 2020

  

Read this article in the Spring 2020 issue of Streamline here!

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Authors

Claire

Seda

Director of Communications

MCN