VHAN Transitions of Care Program Offers Extra Support

Patient transitions are rarely well-coordinated, and follow up care is highly variable and inconsistent, leading to poor patient outcomes. Working directly with our member hospital systems and practices, VHAN aims to improve the transition process and improve continuity of care, thus reducing adverse events and readmissions. Here’s just one example of how VHAN’s transitions of care support helps patients:

Robert is 77 years old and was recently hospitalized due to shortness of breath and lower extremity edema. He has a history of high blood pressure and high cholesterol. After Robert was discharged from the hospital, a VHAN RN followed up and learned that Robert needed extra support. 

During an initial check-in call, Robert was unable to find his discharge paperwork. The nurse knew it was not likely that he was properly taking medications or following his care plan. The nurse explained to Robert how to administer his dosages and the reasons for taking each medication. She also coordinated with a home health provider and alerted them to the likely medication discrepancies. Robert’s primary care physician and cardiologist were both notified of his discharge and the concerns shared by his nurse. 

On a follow-up call, the VHAN RN spoke with Robert’s spouse, who reported that he was feeling better. Robert had been compliant with sodium restrictions, had lost some weight and was now taking all of his medications appropriately. His overall condition had improved, making it far less likely that he would need to be re-admitted to the hospital.