Care Management Offers Lifestyle Support to Address Social Determinants of Health

Vanderbilt Health Affiliated Network (VHAN) is committed to improving health care equity and focusing on whole-person health. To accomplish these goals for patients, it’s essential to examine and address the underlying causes of their health challenges.

VHAN understands the varied ways that social determinants—external economic and social conditions and individual behaviors that affect health—can and should be factored into diagnoses. It is now widely recognized that problems with housing, transportation, food security, health insurance and other economic factors have a big influence on health outcomes.

Identifying and responding to patients’ social needs is an integral part of the work of VHAN’s Care Navigators. In a recent phone conversation with a VHAN RN Care Navigator, a 38-year-old female patient living in East Tennessee reported multiple social and financial barriers to her continuity of care. A kidney transplant recipient, she had recently lost her father to COVID-19, and she was having difficulty managing her health condition, finding work and paying bills.

The patient explained to a RN Care Navigator how her father’s recent passing had left her without any other family support nearby. Her goal was to move closer to Nashville where both her extended family and transplant team are located. However, she was hindered by her current lack of employment and the fact that her son was resistant to the idea of pulling up roots and leaving his friends behind.

Bringing Social Determinants Into the Light

The RN Care Navigator talked the patient through some ways to improve her problem-solving skills and helped her formulate small, actionable steps that would move her closer to her longer-term goal of moving to Nashville. They explored savings plans as well as educational support options to help the patient get her GED and pursue higher-paying jobs.

The RN Care Navigator made a significant effort to provide helpful psychoeducation to the patient, integrating emotional and motivational advice and guiding her to better understand the relationship between her stress levels and her unmanaged diabetes. They also spent time talking through stress management techniques, including meditation, yoga and aromatherapy. The RN Care Navigator also gave the patient two local resources to help with rent payments.

The VHAN Care Navigator’s assistance went beyond addressing the patient’s medical conditions—her partnership helped the patient begin a journey toward overcoming social determinants that were negatively affecting her overall health.

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