At the Ventanilla de Salud (VdS) in Austin, Texas, Health Network Associate Leslie Diaz, LMSW, provides health information and resources to those who come to the Mexican Consulate for legal or other documentation concerns. Diaz links visitors with local health resources, and coordinates local health events and trainings in topics like nutrition and exercise. When a visitor to the VdS is moving or planning to move and has an ongoing health condition, Diaz enrolls him or her in Health Network, MCN’s bridge case management system, to transfer records and help them get into care at their next destination. In August, Juan Delgado* came to Diaz interested in a recently implemented nutrition class series at the VdS. Delgado, a construction worker in his 30s, told Diaz that he was at the Consulate to renew his passport, when he overheard her presentation in the waiting area on VdS services and for the class. He explained that he hadn’t been feeling well in recent months, and was trying to eat more healthfully, but it hadn’t yet made an impact. He was interested in the nutrition class to see how he could improve his health. Diaz asked additional questions on his health concerns, and discovered that Delgado was occasionally missing work at the construction site because he was too lethargic to get out of bed on some mornings. Even on days when Delgado did go to work, he felt tired and worn out.
Diaz recommended that he visit a health center to rule out common health concerns that may be responsible for his lethargy, including diabetes. She enrolled him in Health Network to track him as he traveled back to his hometown in another part of Texas, where she would find him an appointment and also look for nutrition classes for him. She found that the closest health center permitted walk-in appointments, and she quickly followed up with Delgado to encourage him to make time to go to the health center. Meanwhile, Diaz contacted her colleagues focused on nutrition education to find a group that offered classes in Delgado’s town.
Delgado went to the health center, and his clinician determined he had a hemoglobin A1C of 10. Although Delgado was hesitant to start medicine — he preferred a natural, non-medicated approach — he was prescribed medication that he began taking shortly thereafter. When Diaz called to follow up with Delgado, he told her that he was feeling better, and had consequently cut his medication back. Diaz explained the importance of maintaining consistency with his medication and encouraged him to stay at the prescribed dosage; Delgado recalled his doctor saying the same thing. He said he had a lot more energy and that he was no longer missing work. He also said that although the medication costs were large for him, at roughly $80 per month, he felt he could afford it. During a recent follow-up call, Diaz learned that Delgado has brought his A1c down to within a safe range. Delgado’s case demonstrates how Health Network’s case management reinforces important messages to empower patients to self-manage diabetes.
* Names, locations, and details have been altered to protect the patient’s identity.
Read this article in the Spring 2018 issue of Streamline here!
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