VHAN Social Worker Provides Medication Coordination to Improve Patient Care

Social workers play an important role in closing care gaps that arise between caregivers, patients and health care providers. VHAN social workers in particular are skilled at detecting the seemingly small obstacles and complications that can make a big difference in a patient’s quality of life.

As manager of the VHAN Social Work team, social worker Cate Mart and her team members regularly check on patients after a hospital stay, whether they have transitioned home or to a rehabilitation center or skilled nursing facility. These social workers provide an added layer of support to ensure the patient can manage their care outside of the hospital. While it’s a regular part of Mart’s job, a recent call was not so routine.

“I explained to the patient that I was a social work care manager calling to check on him,” she says. “That short introduction gave him a foothold to open up and let me know that he was having a horrible experience. Sometimes it takes time to find out how we can help a patient, but this patient was ready to accept assistance.”

When he entered a rehabilitation facility following a hospital stay, the patient notified nurses that nobody had filled his prescription for Trazadone, an anti-depressant and sedative he needed for sleep. He had endured two consecutive sleepless nights when Mart called.  Fortunately, she was able to access the patient’s medical records immediately, where she found a psychiatrist’s note specifying the prescription for Trazadone. With the prescription in hand, Mart was able to arrange for the patient’s medications to be adjusted. 

“Though this was a medication adherence issue, it wasn’t the patient struggling to adhere,” Mart says. “In this case, the patient really wanted this medication, but the provider at the end of the chain did not get all the information needed for this patient to feel well and do well. It was one of those things that happens to a patient when they have experienced multiple handoffs.”

It’s also a good example of how Mart and her fellow social worker care managers are essential links to successful care coordination.  

“I work with patients whose voices are not often heard in the system—people who are chronically disabled, lack resources and don’t have a lot of social capital,” Mart says. “It’s gratifying to feel like I can amplify someone else’s voice and alleviate some of their suffering.”

To refer a patient to the VHAN Care Management program, VHAN members can fill out this form or call (615) 936-2828.

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