VHAN’s Care Management Team Helps Diabetes Patients With Long-Term Control

The Vanderbilt Health Affiliated Network (VHAN) diabetes team brings an innovative approach to diabetes prevention, detection and care. One way the team supports pre-diabetic and diabetic patients is with the VHAN Diabetes Outreach Program, which facilitates access to health care and social services. It also helps patients and their caregivers better understand and manage this chronic illness.

The 12-week program requires labs to be taken at regular intervals so patients learn to track their blood sugar readings and A1C levels. Patients also learn about medication adherence and lifestyle changes, helping them better manage diabetes for the long haul. 

The diabetes team works closely with VHAN’s Care Management team to ensure that VHAN’s technology and standards of care reach patients wherever they are. The Care Management team can also assist patients in overcoming health obstacles, such as limited access to care or food and housing insecurity, that can stand in the way of positive outcomes. For patients with diabetes and their families, personalized care and direct patient-provider communication make a significant difference in their ability to cope with the disease.

How VHAN Care Navigators Support Patients With Diabetes

Lisa Fatzinger, VHAN Patient Service Specialist and member of the Care Management team, provides vital communication to patients and coordinates their care among several providers. Fatzinger serves as a point person for the team, facilitating communication among pharmacists, social workers, nurses and other clinical experts—all while collecting and organizing critical patient data.

Fatzinger’s years of experience and contacts within the VHAN network serve her well in keeping patients on track with the Diabetes Outreach Program. The job requires patience and persistence, as well as the ability to establish trust with the patient.

“It can take a lot of messaging to motivate patients to get their labs done, especially during the pandemic,” Fatzinger says.

Fatzinger monitors each patient’s three most recent A1C labs, which are required for them to graduate from the program on time. Sometimes monitoring takes more effort than usual. In a recent case, the team was having difficulty reaching a male program participant who was due for his latest A1C labs. After repeated efforts, Fatzinger was able to contact the patient and quickly coordinate appropriate labs and follow-up care.

“We try not to inconvenience the patient, but the goal of the Diabetes Outreach Program is to get the patient to a place where they no longer need to be contacted by a Care Navigator,” Fatzinger says. “When they can keep their A1C level down to an appropriate level, we know they’re doing well.”

Thanks to the perseverance and collaborative spirit of Fatzinger and her team members, this patient successfully completed the program. Like his fellow countless graduates, he is now on a healthy track and able to independently monitor and manage his diabetes.

Watch this video to learn more and visit this page on VHAN Hub.

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