How it works | VitalityCall

What it is for

Three jobs, in plain terms.

Everything below serves one of these. If something does not, it does not belong in the call.

We find the root cause

Not just who is out of control, but why. We draw on records from doctors, hospitals, and pharmacies, and the conversation with the patient fills in the blanks.

What the blanks usually are

Maybe they avoid doctors. Maybe they never picked up the prescription, or cannot afford it, or have no ride to the appointment, or are depressed. We work out which it is and tell the physician, who has about fifteen minutes in a visit and no way to assemble all of it alone.

We monitor and intervene early

Regular contact means we hear the change early, and escalate to the patient's own doctor before it becomes an emergency room visit.

After a hospital stay

The patient moves to the high priority tier for the following month, when the risk of readmission is highest.

We motivate and educate

Trust is built across repeated calls. We use motivational interviewing to encourage patients to monitor and manage their own conditions. The goal is empowerment, not instruction.

Every call happens in the patient's own language.

The flow

From your patient list to your dashboard.

Share your patients

The list you already have.

What we need

Demographics, conditions, and medications, in whatever format you already export. Most organizations send this on day one without building anything new. There is no separate system for your team to learn.

A care plan for every patient

Built before the first call, and it changes as they do.

How the plan is built

Each plan comes from the patient's own conditions, medications, and history, with clear goals to work toward. A healthy patient's plan may be a fall vaccination and an upcoming screening. Someone managing four chronic conditions gets a working plan the care manager returns to on every call. Plans update as things change, including anything the patient confirms or corrects on that first call.

Set the risk tier

High priority, medium, or low. The tier sets the call frequency.

How the tiers work

High priority is twice a week, medium is once a week, and low is once a month. Our physicians define what puts a patient in each tier, so the decision is a clinical one rather than a scheduling exercise. Three options rather than an open field keeps it fast to assign across a whole panel.

The first call

Simple, smooth, and conversational. It sounds like a phone call, because it is one.

What happens on that call

The care manager introduces itself, explains it is working with the patient's own doctor and that their information was shared in keeping with HIPAA, then confirms their conditions and medications, including anything over the counter. Routine check-ins begin only after the patient understands what this is.

Physician notes carry forward

Add a note at any time and the next call addresses it.

Why this matters

A physician or a care team member can add a note to a patient's record whenever something changes, and the next call picks it up and works it into the conversation. A medication change, a result to follow up on, a question to ask. The plan moves when the clinician moves it, without waiting for the next appointment.

Regular check-ins

Every call builds on the last. Nothing starts cold.

What gets covered

Conditions, medications, and symptoms, alongside encouragement toward self-management and healthy habits. Self-management is the specific work: checking blood pressure at home, tracking blood sugar, weighing daily where it matters. Those home readings are what the evidence now treats as the real number, not the single reading taken in the office. The care manager remembers what was said last time and follows up on it.

Escalate, then close the loop

Route the concern, then confirm it was acted on.

Why the second half matters

Concerns go to the patient's own physician, with a clear action: call your doctor tomorrow, see your doctor, go to urgent care, or seek emergency care. Then we follow up. Did the appointment happen. Was the medication picked up. A recommendation nobody acts on changes nothing, and most systems stop at the recommendation.

We are also testing a warm handoff. When the right action is to call the office now, the care manager says so and transfers the patient straight through to the practice's reception desk, so the patient never has to hang up, find the number, and start again. In test now.

See everything

One dashboard, and the full record of every call.

What your team sees

Escalations as they happen, whether each patient's conditions are trending better or worse, and complete call transcripts whenever someone wants the detail. Nothing is summarized away.

Where the attention goes

Everyone is covered. The watch is not evenly spread.

Coverage for all of them does not mean the same treatment for all of them. Our physicians place every patient in one of three risk tiers, and the tier sets the call frequency. Three options rather than an open field, so nobody has to design a schedule from scratch.

High priority

Conditions outside the range their physicians are treating toward, or a recent hospital stay. Roughly the top few percent of a panel, and the closest watch on it.

Twice a week

Medium

Patients who miss medication pickups, skip appointments, or do not complete what was recommended. Often the earliest signal that something is wrong.

Once a week

Low

Patients doing well, whose conditions are managed. Lighter contact, still a care plan, still covered.

Once a month

The 30 days after discharge

The riskiest month in a patient's year.

What prevents a readmission is well understood: get the patient in front of their doctor in the first week, make sure the medications were picked up and are being taken correctly, and watch closely enough to catch trouble early.

What changes during that window

Check-in frequency increases automatically for the 30 days following a discharge. The care manager works through the discharge instructions with the patient, confirms the follow up appointment is booked and then that it happened, and verifies medications were filled and understood. Anything concerning escalates to the treating physician the same way it would at any other time. The readmission figures come from CMS data on Medicare readmissions.

What your team sees

Who needs attention, and which way they are heading.

The question a care team actually asks is not what happened on a call. It is who is getting worse, who is getting better, and where should we look first.

Margaret R.
Diabetes, hypertension, heart failure, COPD

A1c BP Weight

James T.
Heart failure, discharged 14 days ago

BP Weight Follow up seen

Dolores A.
Diabetes, hypertension

A1c BP

Control status is measured against the standards your physicians already use, including those set by the American College of Cardiology, the American Heart Association, and the American Diabetes Association. Laboratory values come from the record. Home readings come from the patient, on the call.

The measure that matters most

Frequent escalations across a population are worth looking at on their own. If a team is handling exceptions constantly, something upstream is off, and that is visible before anyone opens an individual chart.

The same care. Far more of it.