Post on 22-Aug-2020
transcript
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