Care Navigators identify issues that might put patients at risk, such as difficulty getting medications or accessibility issues. Here’s a story of how a Social Work Care Navigator helped mitigate a transportation challenge for a patient.

Ensuring all patients receive the coordinated care they need in between visits and across care settings is a top priority for providers. That priority gets a helping hand when you partner with VHAN’s highly integrated Care Management team.

The VHAN diabetes team continues to make telehealth more personal, particularly in the area of remote patient monitoring (RPM).

The Jackson Clinic created a robust transitions of care system in 2015, to ensure providers are notified when patients go to the emergency department or are admitted to the hospital.

VHAN’s multidisciplinary team of pharmacy experts includes Ashley Sigg, a Transitional Care Management Pharmacist who offers medication reconciliation and support for 30 days after a patient’s hospital discharge.

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.

This fall and winter, make sure to prioritize post-discharge follow-up visits when appropriate and via telehealth when necessary. Check out the following timeline of key post-discharge activities to help you stay on track.

Watch a short video on how the VHAN Care Management Team supported a patient in managing her diabetes.