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.

Catch it early, then escalate

Notice the change while it is still small, and get it in front of the physician who knows the patient, before it becomes an emergency.

Get to goal, and stay there

Move conditions from not in control to in control, and keep them there. Not for a quarter. For the rest of someone's life.

After a hospital stay, keep them safe

Safety first in the days after discharge, when patients are most vulnerable. Preventing the readmission follows from that.

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 cadence

You decide who gets called, and how often.

Who sets it

Daily, weekly, or occasional, matched to how much support each patient needs. Set it yourself or let VitalityCall suggest a starting point. You can adjust any patient at any time and leave notes the care manager will carry into the next call.

The first call

Introduce, confirm, and get the patient's agreement.

What happens on that call

The care manager introduces herself, explains she 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.

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.

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. The patients most likely to end up in the hospital get the closest attention.

Conditions not in control

Patients whose chronic conditions are outside the range their physicians are treating toward. The closest watch on the panel.

Daily to every few days

Gaps in follow through

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

Weekly

Steady

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

Every other week to monthly

The 30 days after discharge

The riskiest month in a patient's year.

A significant share of readmissions happen within 30 days of a hospital stay, and many of them are preventable. What prevents them 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.

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.