When a fragile relative returns home after a hospital stay, family members may be left to provide care they don’t have the experience to deliver, leading to physical and emotional distress. This was the case for a wife who didn’t understand how to manage her husband’s complex needs. VHAN RN Care Navigator Martha Merry stepped in with empathy and expertise. “She was in tears,” Merry says. “The first thing I told her was, ‘We’re going to help you. We are going to figure this out and I’m here for you.’” Read the full story to learn how the VHAN Care Navigation team assisted this family.

VHAN Clinical Pharmacist Lyndi Tarr knows how important it is to speak a patient’s language and relate to them as an individual. Recently, Tarr put this truth into practice when she veered off the usual path to help a patient who was struggling with medication adherence following a lengthy hospitalization.

Read the full story to learn how Lyndi tapped into a patient’s personal interests to help him understand his medications and improve his adherence.

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.