Health NetworkA Care Coordination Program for

Mobile Patients A force for health justice for the mobile poor

2018 All Rights Reserved. Florida Association of Community Health Centers 2

Factors contributing to mobility and housing instabilityImpact of mobility on access, quality, and outcomes Importance of care coordination Migrant Clinician’s Health Network

2018 All Rights Reserved. Florida Association of Community Health Centers 3

25,145, NCFH/USDA 2012

Over 1 million acres lost to development Population grew from 16M to 21M residents (30%)Orange juice production down by 50%

Citrus greening diseaseHurricane Irma and other disastersCompetition from Brazil

Value of Ag as a share of state economy down 50%From 55, down to 3 major independent tomato growers

Then

Now

188,027 Household members105,395 Farmworkers

Unaccompanied 58%

Accompanied42%

UF Shimberg Center for Housing Studies, 2016

Migrant29,99916%

Seasonal140,177

75%

H2A17,842

9%

UF Shimberg Center for Housing Studies, 2016

More work in growth industriesLess migrationMore social isolationLess concentrated in migrant camps, more dispersed

HUD, 2017

Veterans2,789

9%

Family Members9,36329%

Chronically Homeless and

Disabled5,12016%

Other14,837

46%

School children staying with family, friends or in hotels (72, 957)Doubled in 10 years

Homeless on Streets and Emergency Shelters (32,109)

105,066 Total

Florida Department of Children and Families, 2017

More than the general population… Aged out of foster careLGBTPregnantBlackContact with criminal justice systemMental health and substance abuse issues“Hidden” homeless“Couch surfing”

Deinstitutionalization and lack of behavioral servicesLack of affordable housingEmployment gaps, unemployment and low wage jobsDivorceDomestic violenceEvictionForeclosureNatural disastersPhysical disabilityPoor family support

Criminalization of homelessnessMoving from urban core to suburbs

Institute for Children, Poverty and Homelessness, 2016

Median asking rent up 70% since 1995 (adjusted for inflation)Real median renter income up 16% over the same period

UF Shimberg Center for Housing Studies, 2016

Florida 40% Cost

Burden

Area Median Income (HUD AMI) $50,860 NA

60% of AMI (Low income)Equivalent % of Poverty (Family of 4)

$30,516124%

30%

30% of AMI (Extremely Low Income, ELI)Equivalent % of Poverty (Family of 4)

$15,25862%

71%

Minimum wage - $8.10Affordable rent for extremely low income - $421

1 Bedroom

2 Bedroom

Fair market rent $862 $1,075

Wage needed to afford $16.52 $20.68

Hours needed at minimum wage 82 102

National Center for Children in Poverty, 2014

Low Income General Population

Moved in past year 19% 12%

Renter Home Owner

Lived elsewhere one year prior 24% 5%

Gaps in servicesGaps in educationGaps in employment

Housing instabilityPoorer psychological well-beingLack of social support

General Poor Health Exposure to toxinsAsthma Low Weight Developmental DelaysInsurance gapsPostponing Needed Health Care Postponing Needed Medications Mental Distress Incidents of Depression

13% to 27% of emergency department visits in U.S. could be managed in physician offices AHRQ

More than 75% of Florida ED visits by Medicaid beneficiaries were identified as potentially preventable AHCA

Managing care for complex patientsLong hoursHigh stressHigh burnoutHigh turnover

Differing expectations between providersPoor teamworkInadequate timeLack of standard proceduresConflicting recommendationConfusing treatmentsUnclear instructionsLimited discharge planning and risk assessment

Joint Commission

80% of serious medical errors involve miscommunication during the transfer of patients

Information is MisunderstoodUnrecordedMisdirectednever receivednever retrievedIgnoredDelayedDuplicated

Joint Commission

Poor quality and outcomes Medication errorsUnnecessary or repetitive testsFailure to get needed testsUnnecessary ER visitsPreventable hospitalizations

OutreachScheduling visitsMonitoring adherence Bridging gapsEnsure follow upEducate patients about resourcesHelp address nonmedical barriers Increase patient self-managementTranslationEmotional support

Lower costsImproved reachBetter servicesImproved standardization of coordination Reduced stressReduced workload - 30% -50% Less clinician timeIncreased job satisfactionReduction in ED visits (23%-51%)Reduction in hospitalizations and UC visits (21%-50%)

CMS Health Care Innovation Award 3 Year Findings 2018Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review, 2016

“To be a force for health justice for the mobile poor”

Training & Technical

Assistance Services

Continuity of Care

Violence Prevention

Environmental and Occupational

Health

Cancer Prevention

Photo by Earl Dotter

MCN Office Locations

Portland, OR

Chico, CA

Austin, TX

Salisbury, MD

Clinton, NY

Photo by Earl Dotter

10,000 +constituents

Migrant Mobile poor Immigrants

Clinicians

•Health educators•Nurses•Primary care providers•Dentists•Social workers•CHWs•Outreach workers•Medical assistants

Federally funded Migrant

& Community

Health Centers

State and local health

departments

MCN’s primary constituents

Training

Resource Development

Advocacy and Policy

Technical Assistance

Information Dissemination

Program Development

Networking

Agriculture has traditionally

been one of the sectors that has most relied on migratory labor

Increasing number of H-2A workers More males traveling alone

More established in rural communities as seasonal workers

Less trans-border crossing

Engaged in other industries during the off season (construction, meat processing, dairy and others)

Increasing number of indigenous agricultural workers

Less available housing (more dispersion of population)

Changing Patterns

Source: Passel, 2006

• Constant mobility causing discontinuity of care

• Immigration status of patient and/or family members

• Racism that motivates policies or actions that frighten members of particular racial/ethnic groups.

• Confusion about U.S. health systems

Barriers to Care and Healthy Lifestyles

Photo © Earl Dotter

5/4/2018 37

Cultural adaptations

• Culturally sensitive education• Appropriate language and literacy levels• Address cultural health beliefs & values

Mobility adaptations

• Portable medical records & Bridge Case Management

• EHR transmission to other C/MHCs

Appropriate service

delivery models

• Case Management• Lay health promoters (Promotores/as)• Outreach & enabling services • Coordination with schools and

worksites• Mobile Units

22 Years of Innovation

“Mobile-Friendly” Care Management AND Referral Tracking and Follow-up

Health Network?

39

Health Network

TBNet

Diabetes

Prenatal

Cancer

HIV

General Health

2,951 total clinics in U.S. and over 114 countries

Over 11,461 total HN enrollments

General Health

ENT Diagnoses10%

Preventative17%

Cardiovascular/Blood Diagnoses

27%

Respiratory Diagnoses

6%

Skin Diagnoses9%

Other7%

Developmental1%

Mental Health/ Neurological

7%

GI Diagnoses6%

Renal/ Urinary5%

Musculoskeletal5%

Total Diagnoses

1Health Network Enrollment Criteria

Patient is:• Mobile / Migrant• Thinking of leaving area of care

2 Patient has:• Need for clinical follow-up • Working phone number or family

member with phone number• Signed MCN consent form• Clinical base or enrolling clinic

MCN’s Health Network does not discriminate on the basis of immigration status and will not share personal patient information without patient permission

• Confidentiality is critical to all MCN staff and all Health Network procedures conform to HIPPA standards

• All patients are asked to sign (or have a witness sign) a consent form before enrollment in Health Network

Participant Benefits:

• A clinic / doctor / nurse is waiting

• Updated records are forwarded to clinic / patient

• Toll free number in the U.S. and Mexico

• Better understanding and diagnosis of condition

• Completion results stored in patient file

• Patient confidentiality

© Earl Dotter

Forms Required for Enrollment

2 Ways to Enroll

52

Option 1We Interview:

1. Simply have us interview the patient, we explain the program, fill out the forms

2. We will then fax the forms to you to have the patient sign them*

3. Then fax us the signed forms along with the patient’s medical records

*Please be ready to have the patient sign the faxed consent form immediately after an interview.

Option 2

You Interview:

1. Fill out the information about the patient2. Have the patient sign the consent form and

provide all the contact information (must include phone numbers)

3. Fax the signed forms and medical records to Health Network staff

Challenges to Success

Staff turnover at clinics Patient Cooperation Identifying migrant

patients Incorrect patient

information Delay in enrollment

Educating patients• How HN works and how they will benefit from

participating (clinical support)• How to use HN• How HN keeps all patient information confidential• The benefits, responsibilities and expectations

© Ryan K White

Maintaining a Patient in CareThe Patient’s Role…

© Earl Dotter

Provide as many phone numbers as possible

###-###-#######-###-####

###-###-####

Inform HN of any phone or address changes and contact HN staff after arriving in a new area

Stay on treatment as long as indicated

Notify new clinics of enrollment in HN

Team-Based Approach

Contacts patients on a scheduled basis

Contacts clinics on a scheduled basis

Assists patients in locating clinics for services and resources. Transportation/Scheduling

Reports outcome back to enrolling clinic

Health Network Summary of Services

Patient is a truck driver and initiates treatment on 8/5/2009Health Department contacts TBNet because the patient starts missing appointments due to his job as a truck driver. Patient is frustrated with treatment optionsThe patient is enrolled, and is made aware of the services that will be providedHe is given a number and instructed to call as soon as he knows he will be travelingThe patient travels to 3 different states and 5 Health Departments were made aware of this case in order to ensure continuity of care22 Clinic contacts were made and 16 patient contacts were made to ensure patient finished treatment on 3/12/2010

“Fernando” is a 56 year old migrant farmworker diagnosed with diabetes at age 49. He traveled each year from South Texas to Minnesota or “wherever I can find work”

Enrolled in Health Network 8/02

10/02

1/03

10/03

11/05

12/06

6/07

10/074/09 Fernando was

closed out of Health Network in 2013 because he said that he was no longer migrating.

Over the ten years he was enrolled, Health Network made 46 clinic contacts, 124patient contacts, transferred medical records 9times to 6different clinics.

Diabetes Case Study #2

Health Network IMPACT• Bridge between patients and their providers• Fewer patients lost to follow up • Higher % of patients completing treatment for

Active and/or Latent TB• Treatment completion reports• Improved patient participation

Informational Videos about Health Network

Download Enrollment Packets in English, Kreyol, Portuguese and Spanish

Enrollment resources at your finger tips

www.migrantclinician.org

Tools for Maintaining a Patient in Care

Make sure patients have the HN toll free number:

800-825-8205 or

01-800-681-9508 if calling from Mexico

Business Associates Agreements

Required to be compliant with HIPAA

Contact Us• Health Network telephone:

800-825-8205 (U.S.)01-800-681-9508 (from Mexico)

• Health Network fax: 512-327-6140

• MCN website: http://www.migrantclinician.org/

• If you have additional questions about the program, you may also contact

Theressa Lyons-Clampitt: 512-579-4511 or tlyons@migrantclinician.org