Collaborative Care Management Helps Patients Manage Complex Conditions

The VHAN Care Management team serves as an important connection point between patients, providers and caregivers. This service is particularly helpful when patients are managing multiple complex conditions and additional barriers to care, such as transportation issues, lack of insurance, financial difficulty and other social determinants of health (SDOH). 

Multiple SDOH barriers were a problem for a 67-year-old VHAN patient who was struggling to stay out of the emergency department. Sarah (name changed for anonymity) is obese and has hypertension, frequent urinary tract infections, COPD and severe aortic stenosis. In addition to physical challenges, she suffers from social and emotional factors that make managing her health more difficult.  

After a recent hospital stay, Sarah was discharged to a skilled nursing facility for recovery. Since Sarah had such a long history of being uninsured or underinsured, financial barriers that limited her transportation options, lack of social support, and a significant mental health history, VHAN’s social work team stepped in to coordinate Sarah’s care and improve her outcomes.  

Providing Team-Based Care Management 

A social worker care navigator joined forces with Sarah’s husband to develop a discharge plan and followed up with the patient at home to review her care plan, medication changes, dietary needs and transportation options. The social worker then referred Sarah to a nurse care navigator and VHAN pharmacist who closely managed her congestive heart failure.  

The nurse care navigator worked with a cardiologist to get Sarah a blood pressure cuff and scale to manage heart failure. The VHAN pharmacist reconciled her medications and provided education on inhaler use and vitamin D deficiency, and worked directly with the patient’s provider to refill prescriptions. 

Once the care management team helped Sarah get through her initial discharge, they provided counseling sessions, made a referral to Meals on Wheels, and supported Sarah through her follow-up care. The team also worked with Sarah’s providers to consolidate her appointments and ensure she was taking antibiotics correctly to treat a urinary tract infection.  

Thanks to the personalized support of the care navigators, Sarah has been able to better manage her heart conditions and improve her medication adherence, ultimately reducing her chances of adverse health events.