Coordinated care provides multiple touchpoints to ensure that no symptom goes untreated, and no patient falls through the cracks. At Vanderbilt Health Affiliated Network (VHAN), clinical pharmacists, social workers and nurse care navigators collaborate to deliver proactive, timely care to patients who need it most. 

For Population Health Clinical Pharmacist Lauren Cook, PharmD, BCPS, BCACP, VHAN’s cooperative approach means staying alert for complications that may arise unexpectedly with patients. Cook’s vigilance recently helped a 64-year-old blind patient avoid a potentially catastrophic health event.

VHAN’s Care Management team often works with patients in the Diabetes Outreach Program to assist them in overcoming health obstacles that can stand in the way of positive outcomes. This was the case with a recent patient who was unable to complete the program due to difficulty having his labs drawn. VHAN Patient Service Specialist Lisa Fatzinger stepped in to offer direct communication and additional support, eventually helping him to complete the program successfully.

Recently, a VHAN RN Care Navigator was able to connect an overlooked patient to much-needed follow-up care after a joint replacement. The 63-year-old female patient with comorbidities was admitted to a hospital for a planned knee replacement, expecting that she would be referred to a rehab facility at discharge. However, after spending a week in the hospital, she was sent home with no follow-up instructions. She understandably felt confused and disconnected from the system and worried about what would happen next—that’s where VHAN’s RN Care Navigator Cheryl Landis stepped in.

As the cost of prescription drugs continues to rise, patients’ refusal or inability to pay for costly medications contributes to an estimated 125,000 deaths every year. VHAN’s Care Navigators often take a closer look at patients’ medications and collaborate with the VHAN Pharmacy team to ensure patients are taking the most effective, affordable medications.

Earlier this year, VHAN staff presented on VHAN’s Community Health Worker (CHW) pilot during Aetna’s quarterly Provider Clinical Transformation Webinar Series. The pilot, launched in 2019, was designed to improve access to care and resources for obstetric patients at Gallatin Women’s OBGYN Center (GWC) in Gallatin, Tennessee, which has a large prenatal patient population with approximately 350 babies born annually. The CHW pilot was designed to help with resource referrals and interventions for patients who need assistance with access to health care, physical and behavioral health support, and social determinants such as homelessness, food insecurity and unemployment. During the Aetna presentation, VHAN shared some initial results of the pilot.

Identifying and responding to patients’ social needs is an integral part of the work of VHAN’s Care Navigators. In a recent phone conversation with a VHAN RN Care Navigator, a 38-year-old female patient living in East Tennessee reported multiple social and financial barriers to her continuity of care. A kidney transplant recipient, she had recently lost her father to COVID-19, and she was having difficulty managing her health condition, finding work and paying bills. Read the full article to learn more about how VHAN’s Care Management team helped this patient during a difficult time.

During a recent checkup call with a 75-year-old male patient with a history of stroke, a VHAN RN Care Navigator talked to the patient’s wife, who spoke of feeling stressed and overwhelmed. After working full-time and serving for some time as the primary income provider, she was exhibiting classic signs of caregiver burnout—exhaustion combined with feelings of hopelessness and isolation. Read the full article to learn more about how VHAN’s Care Management team helped this caregiver navigate a difficult situation.

For every 10 people who visit a doctor, it’s estimated that seven are seeking care for behavioral health-related reasons, such as depression, anxiety, diabetes management, weight loss or substance abuse. VHAN’s Care Management team facilitates collaborative care that is designed to bridge the gap between physical and mental health care, delivering the right kind of care where and when it is needed.

Recently, VHAN Social Workers were able to create a coordinated plan for psychiatric care, anger management and medication management while providing a patient with the support and encouragement he needed to take proactive steps to manage his physical and mental health.

VHAN’s Care Management team of registered nurses, Certified Diabetes Educators (CDE), social workers, pharmacists and Care Navigators work together every day to address the physical, mental, spiritual and social needs of patients. Recently, the team applied multidisciplinary efforts to help a patient heal from a hospital stay while simultaneously recovering from a personal tragedy—a fire that took her home and most of her belongings. Read the full article to learn more about how VHAN can help patients manage their health through the most difficult times.