Have you ever been concerned about follow up of a patient with tuberculosis, HIV, Hepatitis C, a complicated pregnancy, or complicated diabetes who is moving out of your area, or out of the country?

A few years ago, a Mexican American patient at Community Health Clinic Olé in Napa was diagnosed with active tuberculosis and started on standard four-drug treatment while awaiting culture results. The patient planned to leave the area to go to Washington State to work. If he stopped his treatment, he was at risk of developing resistant tuberculosis. It was really important to plug him into health care as seamlessly as possible in spite of his move. At the time, the Health Center nurses and the public health department had to make lots of phone calls to get his medical records transferred to a clinic near to where he was moving and ensure continuity of treatment.

Now, though, this process can be much easier. A free international case management service has been established, funded by the U.S. government, which would have been invaluable for this patient. It may be helpful to you to ensure continuity of care for serious conditions, if you have a patient moving elsewhere, in the United States or abroad.

The program, Health Network, is run by a group called the Migrant Clinician’s Network (MCN). Originally focused on TB continuity (and called TB Net), it has been renamed Health Network to reflect the expanded conditions eligible for case management. It is designed to facilitate continuity of care for mobile patients, not only in the U.S., but also around the world. The program tracks patients who require follow-up treatment for any chronic condition. This ensures patients remain under care despite their mobility. Enrolling patients is easy, FREE, and all Community and Migrant Health Centers are encouraged to participate.

Remember, migrant workers include more than just farm workers! Any low wage workers who move to find new work are considered migrant laborers, and would likely qualify for this program.

The goal is to provide these mobile patients with continuity of care through global patient navigation and bridge case management. Enrollment into Health Network is simple and can be a great tool for establishing a patient-centered medical home. Please make note of the following enrollment requirements:

1)       MCN Consent Form (signed and dated)
2)       MCN Patient Information sheet, including the patient’s working phone number(s), intended address, and general information
3)       Medical records

To learn more, please visit the web page of the program at: http://www.migrantclinician.org/services/network/bridgecasemngmt

This service has been spreading widely in Texas and Florida, but is little used in California. Let’s work to change that!

Keep this program in mind if you encounter a patient who is moving, who you think needs case management to assist with connecting to medical care in their new community, whether in the United States or abroad.

Robert Moore, MD