Every patient gets a care manager.

VitalityCall is an AI care manager that calls every patient with a chronic condition, as often as their condition requires. It works from a care plan the patient's own physician signs off on, catches early warning signs, and escalates before problems become emergencies.

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Physician led HIPAA aligned data handling Built for value based care No diagnosis, no treatment

The problem

Most primary care still runs on one instruction: come see me when you feel sick. A patient with a chronic condition sees their doctor a couple of times a year. The other 360 days, they are on their own.

Care management works. Almost no one can afford enough of it.

One nurse can manage a couple hundred patients. Most organizations end up actively managing a small fraction of the people who need it, and often for only part of the year.

The numbers
Roughly half of adults with diabetes do not have their blood sugar controlled, and control has been declining rather than improving, a trend documented in the New England Journal of Medicine. Fewer than one in four have blood sugar, blood pressure, and cholesterol all managed at once. The patients most likely to land in the emergency room are often the ones no one had the capacity to check on.

What already solves it

The answer is not a new idea. It is a care manager.

Someone who knows the patient, builds a plan, checks in before things go wrong, and makes sure recommendations are actually followed. It works. It has always worked. There has just never been enough of it to go around.

We built that care manager as software. It calls. It listens. It works from the patient's own record. And the physician stays in charge of every plan.

Why it has stayed out of reach
A care manager finds the gaps in a patient's health, sets goals, and works the plan with them over time. Early detection, care planning, and escalation to the treating physician is the standard playbook in accountable care. The limit was never whether it works. The limit was headcount.

What coverage looks like

Everyone is covered. Not everyone the same way.

Four patients from one panel, over eight weeks. The sickest are called daily. The stable are called monthly. Everyone is called.

W1W2W3W4W5W6W7W8
check-in call concern escalated to physician followed up, loop closed

How we fill the gap

We make it possible to give one to everyone.

Every patient gets a care plan and a call schedule that matches what they actually need. Every call builds on the last. Nothing starts cold.

A care plan for everyone

Built from each patient's conditions, medications, and history, with clear goals. Short for a healthy patient, substantial for someone managing several conditions. It updates as things change.

The loop gets closed

When something is escalated, we follow up to confirm the appointment happened and the medication was picked up. Recommending is not the hard part. Following through is.

A cadence you control

Daily, weekly, or occasional. Set it yourself or let VitalityCall suggest it.

Self-management and healthy habits

Checking blood pressure at home, tracking blood sugar, daily weights where they matter, alongside diet and exercise.

Closer watch after discharge

Check-ins intensify during the 30 days after a hospital stay, when the risk of readmission is highest.

What it is not

The care manager does not diagnose and does not treat.

She recognizes early warning signs and routes them to the right person, the same way a great human care manager would. Every outcome is simple and actionable.

Call your doctor tomorrow See your doctor Go to urgent care Seek emergency care
What the decisions are grounded in
Each check-in runs on established clinical triage protocols, against the patient's own record as supplied by your organization, and is measured against the control standards their physicians already use, including those set by the American College of Cardiology, the American Heart Association, and the American Diabetes Association.

Why this is proven

Tried and true, made massively scalable.

There is nothing experimental about the approach. What is new is the reach. Care management is no longer limited to the top few percent of a panel.

What changed, and what did not
Practices have used care managers for early detection and readmission prevention for years. The playbook is well established and the evidence behind it is not in question. The only thing that has changed is that a person no longer has to make every call, so every patient can have one at the frequency their conditions call for.

Who it is for

Built for organizations responsible for a population's health.

For ACOs

Better chronic disease control moves your quality scores. Early escalation keeps patients out of the hospital, and that is shared savings. Your nurses focus on the patients who need a human, while every other patient still gets a call.

For concierge practices

The promise your patients are already paying for: someone is watching. Every patient gets a regular check-in, in their language, on their schedule. You are alerted early, and your patients feel the difference.

Accountable Care OrganizationsSee the fit Health plans and Medicare AdvantageSee the fit Managed Medicaid plansSee the fit Concierge and membership practicesSee the fit Primary care practices moving toward value based careSee the fit

Who we are

Built by people who have actually run this.

We have run accountable care organizations, managed populations at risk, practiced medicine, and read the literature. We are not technologists guessing at how care works.

More about the team
Our leadership includes practicing physicians and specialists in Medicare, population health, and compliance. The platform is designed around HIPAA aligned data handling.

Latest thinking

Notes from practice.

Our physicians on chronic care, early detection, and what actually keeps patients out of the hospital.

Richard Ferrans, MD, ScM

The pound a day nobody asked about

A patient with heart failure who gains a pound a day is not gaining weight. They are retaining fluid, and that fluid has a predictable destination.

Read the article
Richard Ferrans, MD, ScM

Why coverage, not capability, is the real problem

Care management has been proven for two decades. The constraint was never whether it works. It was how many people one nurse can carry.

Read the article

All insights

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Tell us a little about your organization and we will set up a short conversation and a live demo. Two fields are all we need.