Michael Hackett was struggling to recover following surgery in 2022 to relieve debilitating pain from spinal stenosis, a condition where the spinal column narrows and compresses the spinal cord.
Post-surgical complications led to repeat emergency room visits and re-hospitalizations. The then 75-year-old Williamson County resident had also recently lost his beloved wife of 48 years, Beth. He admits he was “just about done.”
“I’d never been sick, and I’d never been in the hospital,” he said. “It was an enormous emotional event to lose my wife. It was the first time in my life I’d ever really been alone. And I had already been dealing with my back before she died. I had passed out two or three times from the pain.”
As his health setbacks began to snowball, Hackett received a phone call from Katie Crider, RN, a patient care coordinator with the Vanderbilt Health Affiliated Network (VHAN)’s Care Management Program. The pair began connecting by phone regularly for more than a year and a half as Hackett underwent two more back surgeries as well as procedures to address a urological issue and skin cancer.
“We talked more frequently after his hospitalizations and during his time of healing when he required more nursing care and direction,” Crider said. “I kept his providers in the loop with any symptoms or concerns he was having. I referred him to our social work team for grief counseling. I think most importantly to him, he knew I was there for him and would help support him through any of the hurdles that he faced.”
Crider said she enjoys connecting with patients like Hackett during calls.
“We’re not rushed like nurses often are in clinics,” she said. “We get to know them and listen to their concerns. There is extra time to educate them and resources to refer them to, if needed.”
Hackett calls Crider “the sweetest, most caring person” he’s ever met.
“I would always look forward to hearing from her,” he said. “She would ask about my pain level, about my medications, and about how I was doing. She was helping me with the recovery of my back, which was rough, but she was also helping me recover from the loss of my wife.”
VHAN is a clinically integrated network in Tennessee and surrounding states that now includes over 7,000 medical providers, 66 hospitals, 12 health systems and more than 360 physician practices. This includes all Vanderbilt Medical Group providers.
The VHAN Care Management Program provides additional support for patients recovering from a recent hospitalization, trying to better manage a chronic disease or navigating a new or complex medical diagnosis. Individuals can be referred to the Care Management team by VHAN medical providers.
The team includes 20 registered and advance practice nurses who function as care navigators after a patient referral is received. The team also includes two nurse managers, a patient access specialist, two diabetes educators, five social workers and 15 pharmacists and pharmacy techs.
The goal of the program is to reduce hospital readmissions, improve medication management and treat complex behavioral health conditions, all while keeping patients’ health goals first in mind.
The VHAN care navigator can notify a patient’s primary care provider (PCP) of inpatient and emergency department admissions and hospital discharges. 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 any needed support to return to their baseline health status.
“In addition to individuals who receive their care through Vanderbilt Health, we serve patients who are cared for by any of our VHAN providers throughout Tennessee,” said Robin Holbrook, FNP-C, MSN, MBA, director of Care Management. “And we serve all ages, from pediatric patients to the elderly. Our entire Care Management team, including nurses, social workers and the pharmacy group, made 76,086 outreachs to individuals in 2023.”
A specialized service of the Care Management program is the Diabetes Care Management Program designed to help patients better manage diabetes and meet health goals. This includes a 12-week “Living Well with Diabetes” program for individuals with a new diabetes diagnosis or who could benefit from additional education and supplemental tools.
Despite most people having only a cellphone that they often ignore when a number is unknown, the VHAN Care Management team has an impressive 50% success rate in getting patients to respond to their calls. Of those who are reached, 73% agree to engage in the Care Management program.
“Our model is patient-centered,” Holbrook said. “We meet the patient where they are. We have the advantage of a multidisciplinary team, with nursing, pharmacy and social work, so we can handle the entire spectrum of what a patient may need. We’ve hired nurses with all types of experience. We have oncology nurses, geriatric nurses, pediatric nurses. The team members can rely on each other for additional expertise.”
Holbrook credits much of the program’s success to the team members who compassionately guide their patients through what can be confusing and frightening moments.
“The thing that really sets us apart is our nurses,” Holbrook said. “And our social workers and pharmacists are amazing. They love to help people, and that comes across even in the first minute of a call. It makes every day a joy because they all love what they do. At 3 o’clock, near the end of the day, they’re volunteering for extra calls. I think they’re the absolute best in the industry.”
Hackett said he will always miss his wife, but he’s learned how to better deal with her loss. And he’s able to focus more on activities he loves, especially being with his family, including 18 grandchildren, and participating in church events.
Providers can refer patients to VHAN’s Care Management Program, including the Diabetes Management Program, through a digital, HIPAA-compliant referral form or by calling 615-936-2828.