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 steps in to provide relief and assistance to overworked caregivers. Recently, this coordinated approach benefited an overwhelmed daughter caring for her 75-year-old mother with a history of vascular dementia and multiple strokes. The patient came to VUMC with increased blood sugars, along with weakness and confusion that had resulted in a fall at home. The VHAN Care Management team not only help patients cope with complex conditions, but they also provide compassionate service and a listening ear to caregivers, reminding them not to neglect their own health while in pursuit of their loved one’s healing.

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.

As the cost of prescription drugs continues to rise, patients’ refusal or inability to pay for costly medications contributes to an estimated 125,000 deaths every year. VHAN’s Care Navigators often take a closer look at patients’ medications and collaborate with the VHAN Pharmacy team to ensure patients are taking the most effective, affordable medications.

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. Read the full article to learn more about how VHAN’s Care Management team helped this patient during a difficult time.