When Butch O’Neal’s 80-year-old mother was hospitalized for the second time in the months following her initial hospitalization for COVID-19 in early 2021, he and his three siblings felt unprepared to manage her steadily deteriorating health.
But then, just as his mother was discharged from Vanderbilt University Hospital in July, he received a phone call from Angela Glatt, RN, CCM, a care navigator on the Vanderbilt Health Affiliated Network (VHAN) Care Management Team. Glatt quickly began connecting the O’Neal family to additional resources and skilled providers to assist them in providing the best possible care for their loved one.
O’Neal’s mother had been struggling to breathe, and congestive heart failure, chronic obstructive pulmonary disease (COPD) and other health issues contributed to the decline that led to her most recent hospitalization. She was then diagnosed with a hiatal hernia, which led to the development of aspiration pneumonia. When she was stabilized, her son admits her pending hospital discharge brought both joy and anxiety.
“We honestly didn’t know exactly what was available, and the Care Management Team has been great,” said O’Neal. “I just said to my brother, ‘These guys have just been awesome.’ I don’t use that word unless I truly think it’s been God-inspired. That’s about as high a rating as I’ll give anybody. I’ve got nothing but good to say about this team and what they’ve done for my mother.”
Ashley Sigg, PharmD, BCACP, a pharmacist on the VHAN Care Management Team contacted the O’Neal family following her discharge to review their mother’s medications and helped with her application for the Vanderbilt University Medical Center Medication Assistance Program (MAP). VUMC patients qualifying for financial assistance are provided access to free medication if uninsured or the MAP will cover medication copayments for qualifying insured patients.
Cate Mart, LMSW, a VHAN Care Management Team social worker, shared additional support resources with the O’Neals, and a physical therapist visited her at home to provide more education and support. O’Neal said he was impressed by how everyone on the Care Management Team communicated with all her medical providers so everyone was on the same page.
VHAN is a clinically integrated network in Tennessee and surrounding states that now includes more than 6,400 clinicians, 70 hospitals, 13 health systems and hundreds of physician practices and clinics. From January through June 2021, the VHAN Care Management team assisted nearly 11,000 patients and their caregivers throughout Tennessee. Of that number, more than 9,800 engaged in program interventions, and more than 2,400 patients graduated from the care management program, according to Nikki York, MBA, MSN, RN, NE-BC, director of Population Health Care Management.
The VHAN care navigator can notify a patient’s primary care provider (PCP) of inpatient and emergency department admissions and discharges from any of the more than 100 hospitals in Tennessee. Within 24-48 hours of the discharge, the care navigator works with the PCP and clinic team to ensure the patient has a follow-up appointment when appropriate and the necessary support to return to their baseline health status.
“From a clinician perspective, the value of the VHAN Care Management team is knowing their patients have a trusted, reliable and consistent care navigator to provide an extra layer of support through care transitions, disease management, health care system navigation, medication management, psychosocial services and more,” said York. “We also educate patients on the appropriate use of the emergency department and can provide alternate care sites such as urgent care or walk-in clinics when appropriate.
“As the health care system continues to become more complex, patients often do not know who to contact when they need something. There are home health nurses, insurance company case managers, specialist clinicians and durable medical equipment vendors to name a few. A VHAN Care Navigator provides the patient with a direct contact number to a consistent nurse, social worker or pharmacist to help the patient navigate communication across providers and teams, set patient-centered goals, coordinate appointments, obtain medications, connect the patient to community resources, supply educational materials related to conditions and more.”
Patients best suited for referral to the VHAN Care Management team are those considered to be medically complex with several acute or chronic comorbidities, but patients who face additional challenges beyond their medical health and well-being can also benefit from the connection, York said.
“In diverse populations like ours we must also consider social determinants of health, which can affect the way in which a patient can care for themselves,” she explained. “Complex patients often need multidisciplinary support in addition to the care provided by their primary care and specialist clinicians.”
Complex patients often have complex medication regimens — meaning they take more than 10 medications, have multiple daily doses or a variety of dosage forms, have multiple prescribers or pharmacies, or take high-risk medications such as insulin or anticoagulants, said Erin Neal, PharmD, MMHC, director, Population Health Pharmacy Services.
“VHAN Care Management pharmacists and pharmacy technicians work with patients to review all their medications and ensure that each one is indicated, effective, safe, and that the patient can access and take the medication as prescribed,” Neal said. “The pharmacist then works with the patient and their care team to resolve any problems and simplify the regimen as much as possible.”
The number of network clinicians and patients the VHAN pharmacy team works with continues to increase, and medication access continues to be a common issue. There is also a tremendous and growing need to provide support for managing chronic conditions such as diabetes and hypertension, conditions commonly treated with medications. Because of these factors, there are plans to double the number of pharmacists and pharmacy technicians on the team this year, Neal said.
Carmen Tuchman, MD, a primary care physician with Vanderbilt Primary Care North One Hundred Oaks, said she consults with the VHAN Care Management team daily, most often communicating with the group through patients’ electronic health records (EHR). She likens the collaborative interaction to “the outpatient version of multidisciplinary rounds.” And because the involvement of the VHAN Care Management team can greatly increase the points of contact with patients, she calls their assistance invaluable.
“When you’re dealing with health problems like high blood pressure or diabetes, and you’re trying to get a better trend over time, if I have a patient coming to see me every three months, that means we might only be making four changes a year,” Tuchman said. “If you have someone calling a patient every couple of weeks, we could be making 15-20 changes, which can make a huge impact on their health within a year.”
While ER and hospital discharges can identify individuals for potential intervention by the VHAN team, a patient’s VHAN-affiliated care provider or a member of the hospital team who treated the patient can also request VHAN Care Management assistance for a patient via eStar.
Referrals can also be made through a digital referral form available on www.VHANHub.com, by calling 615-936-2828 or by emailing info@vhan.com.
