The VHAN Care Management Social Work team serves as the connection point between patients, families and providers. One of the primary goals of Social Work Care Navigators is to identify issues that might put patients at risk, such as difficulty getting medications, worsening symptoms or accessibility issues. These care navigators also work to mitigate Social Determinants of Health, including transportation concerns.

Transportation challenges are a common but surmountable barrier to health, as illustrated by a patient recently referred to the VHAN Care Management Social Work team after a hospital stay. The patient, who reported financial and behavioral health issues, had a follow-up with her cardiologist but couldn’t make the appointment. The patient told the VHAN social worker that her vehicle needed repair and she didn’t have the money to pay for public transit rides. The social worker was able to connect the patient to a contact person at a local community outreach agency who could assist with transit passes.

After getting a ride from her neighbor to the local agency to pick up the passes, the patient expressed appreciation for social worker’s assistance.

If you’re a VHAN member, click here to refer a patient to the VHAN Care Management program.