Isabela, a 50-year-old female, was referred to Health Network, MCN’s virtual continuity of care program, from a physician in the Northeast. She had been diagnosed with cervical cancer after an abnormal pap smear. Isabela would be moving from the Northeastern state where she had been diagnosed to a Southern state to continue working on farms as a worker. This move would disrupt her care, which could quickly lead to a worsening of her condition that would be more difficult and more expensive to treat. Health Network was called in by the physician to find a clinic that she could afford at her next location, and transfer medical records to that new clinic, to make sure Isabela would not have to repeat diagnostic tests and could most efficiently continue her care.
A Health Network Associate was assigned to this patient and conducted a three-way referral, with Isabela, the enrolling physician, and the Health Network Associate on the phone. During that call, the patient was introduced to Health Network and how they would help to provide continuity of care services and ensure that her cancer treatment was not interrupted when she moved.
The patient requested to have her care transferred to a specific community health center in the region where she was moving, so the Health Network Associate worked to set up initial appointments to start Isabela as a new patient. The Associate requested medical records from the referring clinic and received 73 pages which they then provided to the clinic.
Isabela was put in contact with her new clinic and, also, informed of the OB/GYN services and financial aid programs, including a 35% discount for uninsured patients, that would be available to her.
After the initial appointment date, the Health Network Associate followed up with Isabela to ensure the transfer of her care had gone smoothly. The patient informed the Associate that she had spoken to a care coordinator at the clinic who would be helping her apply for Medicaid in her area, and if she did not qualify, the state’s Department of Health would be able to assist by working with her on a sliding pay scale.
The Health Network Associate regularly followed up with the patient to make sure her care continued, providing those updates to the enrolling clinic. The last update the Health Network Associate received from Isabela was that she was cancer-free, still visiting the clinic, and waiting for her Medicaid application to be approved.
Health Network closed Isabela’s case after following up and checking in with her more than 25 times and successfully connecting her to local resources.
Learn more about Health Network at our Health Network webpage: https://www.migrantclinician.org/our-work/health-network.html
MCN regularly hosts webinars for clinicians to learn how to enroll patients in Health Network. Watch our upcoming webinars page for the next one: https://www.migrantclinician.org/webinars/upcoming
