From ‘Just a Stoop’ to a Lifeline: How Care Management Propelled One Patient’s Recovery 

When VHAN Care Management team member Cheryl Landis, RN, called a patient who had recently been discharged from the hospital after a stroke, the goal was simple: Make sure she had what she needed to recover safely at home. 

The patient had moved from the hospital to a small camping trailer parked on a friend’s property. She was living alone while trying to manage new right-sided weakness and regain her independence. 

What Cheryl uncovered in that first call, though, was something far more urgent. 

A Hidden Risk at Home 

Like many care coordination calls, the conversation started with the basics—checking in on the patient’s medications and follow-up appointments. But Cheryl has learned to listen for what isn’t explicitly said, too. 

“I do a safety assessment and ask about their support at home,” she explained. I ask questions like, ‘Who’s checking in on you? What does your day-to-day look like?’” 

During such a conversation, the patient casually mentioned how she got in and out of her home. Unable to use the camper steps safely, she was laying on her stomach to lower herself three feet out of the trailer door to the ground.  

“She had actually fallen out of the trailer at one point,” Cheryl said. “And with her weakness, she was basically having to crawl in and out.” 

Even taking her dog outside had become a dangerous task. 

“The situation could have been catastrophic,” Cheryl said. 

Cheryl immediately looped in Jackie Davis, a social worker on the VHAN Care Management team. Together, they handle complex cases where medical needs and real-life barriers collide. 

From the start, Jackie noticed a familiar refrain from the patient. 

“She was so sweet,” Jackie said. “But she kept saying, ‘I don’t need a ramp. I just need a stoop.’ She was trying to minimize the challenge as much as she could.” 

That’s something both Cheryl and Jackie see often: patients who downplay their needs, even when those needs are critical. 

“Many patients will say, ‘There’s probably somebody who needs it more,’” Cheryl said. “And we’re like, ‘No, you need this, and we can help.’” 

Navigating Barriers One Step at a Time 

Even after a safe solution was identified, making it a reality took a lot of effort. 

Jackie first began searching for local resources near the patient’s rural community. While some organizations could provide labor, none could cover the cost of materials. The patient simply didn’t have the means to pay for her own ramp. 

Eventually, Jackie helped her apply for a statewide home access program administered through the United Cerebral Palsy Foundation.  

Finally, after months of coordination, funding approval and construction planning, the solution arrived—not as a small stoop, but as a full, professionally built ramp. 

A Turning Point in Recovery 

When the ramp was completed, the impact was immediate. 

“It was dramatic,” Cheryl said. “She was so excited. She told me, ‘Now I feel safe.’” 

The ramp not only reduced the patient’s fall risk, but it also restored her ability to live independently, return to work part-time and re-engage with her community.  

“For someone recovering from a stroke, being able to get out of your house is huge,” Jackie added. “How do you go to physical therapy, or even stay motivated to heal, if you can’t get out of the house safely?” 

The change wasn’t just physical—it was emotional, too. 

Building better accessibility for patients “has a huge impact on isolation,” Jackie said. “Physical and mental health go hand in hand.” 

The Ripple Effect 

In a surprising turn, the story didn’t end with one patient. 

The local church that helped build the ramp had leftover materials and used them to assist another community member in need. 

For Cheryl, this case is a powerful example of what care management can do for people. What may begin as a routine post-discharge call can quickly evolve into something much more impactful and long-lasting. 

“This is not just a job for me,” she said. “Doing this work is the best thing ever.” 

“There’s really no limit to what our team can do when we find out a patient needs something,” Jackie added. “We’re there from start to finish.” 

From nursing and social work to pharmacy and beyond, the VHAN Care Management team works together to address not just medical needs. but the real-life challenges that shape recovery. 

As part of their membership, VHAN members can refer patients to VHAN’s Care Management team at any time. To refer a patient, fill out the form or call (615) 936-2828.