VHAN Social Work Team Supports Patients at Every Stage of Life

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.

“We never want to think about getting older, but we will all face the end of life, and we need somebody in our corner who has been there before,” Colbert says. “I can help a patient know what to expect and make informed decisions based on their goals.”

Checking in recently with a very sick patient in a SNF, Colbert realized that he was about to miss an important appointment. With limited mobility and no transportation, the patient couldn’t get to a crucial in-person visit with his primary care provider.

“I first made sure there was going to be transportation from the SNF to the appointment,” Colbert says. “As a safety net, I reached out to see if the primary care provider would be willing to meet with him virtually.”

His primary care provider, Moana Karlekar, MD, readily agreed to meet virtually or in-person. As Medical Director of the Palliative Care Program at Vanderbilt University Medical Center, Dr. Karlekar knows the importance of a supportive, collaborative team to meet patients where they are.

“Both palliative and hospice involve interdisciplinary care, with a team-based approach,” Dr. Karlekar says. “Vanderbilt’s palliative care services team includes doctors, a social worker, nurses, nurse practitioners, a case manager, chaplains and a music therapist.”

Colbert was able to arrange the patient’s transportation to his appointment, where it was determined that he should be moved immediately to hospice care. For both Colbert and Dr. Karlekar, these emotional conversations are easier when they consider the comfort they can provide to patients and their loved ones.

“It’s important that patients have support at the end of their life and that their family also has the support they need,” Colbert says. “Going into hospice means you’re withdrawing from medical care, so you lose connection with most of your care team. I appreciate the opportunity and privilege to be allowed into this very intimate part of someone’s life. In that sense, my job is very fulfilling.”

Dr. Karlekar concurs. “I can’t cure cancer, I can’t fix someone’s arteries or give them a transplant, but I can make them feel better and make life less bad,” she says. “I can also help them understand what’s going on and empower them to make active decisions that matter to them.”

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