When VHAN Social Worker Mary Brooks found out that one of her patients in West Tennessee had fallen and broken a foot while trying to get into her home, she immediately began thinking of ways to help. Brooks’ patient has several serious diagnoses, including a vascular disorder, diabetes, congestive heart failure and swelling in her lower extremities, that affect her mobility and sometimes land her in the hospital. Brooks was concerned that the patient might fall again while trying to navigate her front stairs on crutches.

“She mentioned that she wished she had a ramp to help her get in and out of the house more easily,” Brooks recalls. “I told her I would try to help, and I started calling around to churches in the Selmer and Savannah areas of West Tennessee.”

Eventually, Brooks connected with a men’s group at Selmer’s First Baptist Church. The group regularly takes on community service projects and agreed to build a ramp for the patient. In early December the men arrived at her house with building materials and an eagerness to get to work.

“I happened to call the patient the day the men got there, and she was delighted they were building the ramp,” Brooks says. “The ramp is a lifechanging thing, helping her avoid falls and potential hospital visits from falls.”

Brooks and her VHAN Social Worker colleagues serve as the connection point between patients and their providers, which may include primary care providers and home health services. The Social Work team identifies issues that might put a patient at risk, such as difficulty getting medications, worsening symptoms or—in this patient’s case—the risk of falling at home.

“We do report concerns to a patient’s primary care provider, but we also encourage the patient to fall back on their provider before going to the hospital or allowing their condition to worsen,” Brooks says. “We bridge the gap between the patient and their providers, with a goal of improving patient care.” 

If your practice is interested in learning how VHAN Care Management can partner with your team to support patient care needs, please connect with us at info@vhan.com.