VHAN social worker Amber Colbert often supports Medicare patients who have been hospitalized and then moved to a skilled nursing facility (SNF). Sometimes these patients face difficult end-of-life choices. A recent case illustrated the vital role a social worker plays in this process and how collaboration between the social worker and other team members can ease pain and give patients greater comfort and a sense of peace.

While VHAN Social Worker Mary Brooks has worked on dozens of memorable cases, a recent experience with one particular patient stuck with her. The patient was discharged from the hospital with an open wound and a significant recovery ahead. Unfortunately, when she arrived home, she found that her air conditioning was no longer working in the middle of a heat wave in West Tennessee. Read the full story to learn how Mary found a way to get the air conditioning fixed and built trust with her patient.

While caregivers make a significant difference in the lives of patients, the hard work and dedication of caregiving can take a serious toll. The many-pronged tensions of caregiving are illustrated by a young parent who recently gave birth to a female with Down syndrome. Read the full article to learn how VHAN’s Care Management team worked with the parent to ease her anxiety and connect her to childcare resources.

Adolescence, those formative years between childhood and adulthood, can be a confusing and sometimes challenging time as young people go through changes both emotional and physical. It’s also a time of discovery as they learn to form their individual identity. A big part of that journey is sexuality, finding where they fit in and how they identify on the spectrum. VHAN Social Workers support young patients through all stages of life, providing behavioral health referrals when needed along the way.

For patients recovering from a recent hospitalization, trying to better manage a chronic disease or navigating a complex medical condition, VHAN’s Care Management program offers personalized care that goes beyond simply addressing physical symptoms. VHAN’s team of care navigators consider their mental, emotional and psychosocial needs as well, improving the patient experience and producing more positive outcomes. Read the full article for a real-world example of how VHAN Care Navigators go above and beyond to help patients.

VHAN’s RN Care Navigators are trained to help patients find their way through a complex health care system. But beyond untangling health care’s confusing details, these professionals also exhibit compassion for every patient they encounter, listening and showing genuine concern that’s as powerful as any prescription. In the case of one patient, the care management team’s ability to listen closely had potentially life-saving results.

Coordinated care provides multiple touchpoints to ensure that no symptom goes untreated, and no patient falls through the cracks. At Vanderbilt Health Affiliated Network (VHAN), clinical pharmacists, social workers and nurse care navigators collaborate to deliver proactive, timely care to patients who need it most. 

For Population Health Clinical Pharmacist Lauren Cook, PharmD, BCPS, BCACP, VHAN’s cooperative approach means staying alert for complications that may arise unexpectedly with patients. Cook’s vigilance recently helped a 64-year-old blind patient avoid a potentially catastrophic health event.

VHAN’s Care Management team often works with patients in the Diabetes Outreach Program to assist them in overcoming health obstacles that can stand in the way of positive outcomes. This was the case with a recent patient who was unable to complete the program due to difficulty having his labs drawn. VHAN Patient Service Specialist Lisa Fatzinger stepped in to offer direct communication and additional support, eventually helping him to complete the program successfully.

Recently, a VHAN RN Care Navigator was able to connect an overlooked patient to much-needed follow-up care after a joint replacement. The 63-year-old female patient with comorbidities was admitted to a hospital for a planned knee replacement, expecting that she would be referred to a rehab facility at discharge. However, after spending a week in the hospital, she was sent home with no follow-up instructions. She understandably felt confused and disconnected from the system and worried about what would happen next—that’s where VHAN’s RN Care Navigator Cheryl Landis stepped in.