Care Beyond the Clinic, Fully Managed

We look after your patients between visits, and show you it's working.

We become part of your team, whether you are a practice, a health system, or a risk-bearing organization. Real care coordinators get to know your patients by name and run your RPM, CCM, PCM, and TCM programs day to day, so no one falls through the cracks between appointments. And you always know how it is going, from the first onboarding call to every quarterly review.

Live in about six weeks A team who knows your patients Always clear on the results
A care coordinator reviewing care with a patient at home
A care coordinator with a patient at home. Care that starts with a real relationship.
Care Beyond the Clinic, In Real Time

Minutes of care delivered, and counting.

Why We Exist

“We believe every individual deserves to be met where they are, with the support needed to live a healthier and more meaningful life.”

The Vitasora Core Belief

Conditions We Help Manage

Care for the chronic conditions your patients live with most.

Our RPM, CCM, PCM, and TCM programs support the full range of chronic and high-risk conditions, from the most common to the most complex.

COPD Hypertension Anemia Heart Failure Depression Type 2 Diabetes Asthma Chronic Kidney Disease Atrial Fibrillation Osteoporosis Hyperlipidemia Obesity Coronary Artery Disease Hypothyroidism Anxiety Sleep Apnea Arthritis Stroke GERD Cancer Prediabetes Chronic Bronchitis Peripheral Artery Disease Gout Rheumatoid Arthritis Diabetic Neuropathy Chronic Pain Parkinson's Disease Hypertensive Heart Disease Cirrhosis Fibromyalgia Metabolic Syndrome

And many more. If your patients live with it long term, we can help you manage it.

What Partnering Includes

Everything you need to run continuous care, in one partnership.

No new hires, no new software to buy. We bring the people, the technology, and the operating muscle, and we plug into the way your practice already works.

  • Eligible-patient identification, outreach, consent, and enrollment
  • Connected cellular and Bluetooth devices, shipped paired and ready
  • A dedicated care coordinator, backed by clinical supervision
  • Thrive behavioral coaching, built on Patient Activation and Motivational Interviewing
  • Live monitoring with threshold escalations routed to your team
  • Care plans and documentation in our certified EMR, connected to your EHR
  • Medicare-compliant time tracking, code selection, and clean claims
  • Monthly performance reporting and quarterly business reviews
  • HIPAA-aligned operations, with a BAA in place before day one
  • RPM, CCM, PCM, and TCM under one continuous care relationship
How Partnering Works

Fully managed, from your first patient to every quarterly review.

You keep clinical oversight. We carry the day to day, and we stay accountable to the goals we set together, measured and reviewed with you along the way.

  1. 01 Weeks 1–4

    Onboard

    We integrate with your EHR, surface eligible patients, and run outreach, consent, and enrollment in plain language.

  2. 02 By week 6

    Implement

    Cellular and Bluetooth devices ship paired and ready. A dedicated care coordinator is assigned and trained on your protocols.

  3. 03 Every day

    Deliver

    Live monitoring, Thrive coaching, threshold escalations to your team, and documented, clean claims to your billers.

  4. 04 Every quarter

    Review & Prove

    Outcome dashboards and quarterly reviews follow every program against the goals you set, so you always know it's working.

Accountable, Not Just Active

You will always know how your programs are performing.

Every partnership runs on clear service commitments and a steady reporting rhythm. No black box, no guessing. Just the numbers that matter, on a schedule you can count on.

  • Clear service commitments. Two-business-day outreach after discharge, same-day escalation on critical readings, and monthly clinical time met and documented.
  • Quarterly reviews together. Outcomes, enrollment, and revenue, looked at against your goals with the success lead who knows your account.
  • A team that stays. The same coordinators and clinical supervisor behind your panel, never a rotating call center.
See the full playbook
Monthly Outcomes Illustrative
312Patients enrolled
94%Monthly adherence
-38%Avoidable ER visits
$41kCare revenue / mo
A preview of the outcomes dashboard every partner receives. Your real metrics appear here once your programs are live.
The Value Proposition

Eight ways this program pays off.

Better care for your patients, real revenue for your practice, and less load on your team — at the same time.

  1. Your patients follow the plan

    Structured monthly contact catches non-adherence while it's still fixable.

  2. Your patients' status improves

    Continuous data catches clinical drift before it becomes an emergency.

  3. Your patient churn declines

    Regular contact keeps patients close. It's a retention mechanism, not just a clinical one.

  4. You're paid for care coordination

    For the work you already do informally, plus the work we do in partnership, finally billed correctly.

  5. Revenue that's real and predictable

    Recurring monthly reimbursement, with no added chair time.

  6. No additional FTEs

    The staffing is ours. Nothing to open, train, or cover.

  7. A lighter front desk

    Monitoring and care calls route to the care coordinator, not your scheduling staff.

  8. Your quality metrics improve

    Monthly contact closes care gaps, addresses HEDIS, and lifts Star Ratings.

Why Vitasora

Why we're different, in one view.

Not an outsourced call center. A complete continuous-care capability — the people, the science, the technology, and the accountability, together.

People

A dedicated care coordinator who knows your patients by name.

Patient Activation & MI

Coaching grounded in Patient Activation science and Motivational Interviewing.

Behavior change

Thrive helps patients actually do what the care plan asks.

V-care technology

Our V-care platform and certified EMR power real-time monitoring, documentation, and reporting.

Clinical delivery

A licensed clinical team stands behind every interaction and escalation.

Reimbursement, done right

Documented to Medicare standards and billed as clean, audit-ready claims.

Measurable outcomes

Tracked against your goals and reviewed with you every quarter.

Powered by V-care

The technology behind the care team.

V-care is our own platform and certified EMR. It gives your patients connected devices, gives our care team a live view between visits, and gives you clean documentation and reporting — so continuous care runs on real infrastructure, not a call list.

  • Connected devices, real-time data

    Cellular and Bluetooth monitors stream readings into V-care as they happen, no patient setup required.

  • A live view of every patient

    Your care coordinator works from one dashboard of trends, gaps, and who needs attention today.

  • ONC-certified EMR at the core

    Documentation, care plans, and time tracking live in our own EMR, certified under the ONC Health IT Certification Program.

  • Alerts and escalation

    Readings outside range surface immediately and route to the right person, with a clear path back to your clinicians.

  • Works with your EHR

    V-care integrates with your systems so notes and results land where your team already works.

  • Audit-ready reporting

    Every minute of care and every claim is captured and reportable, ready for review whenever you ask.

The V-care clinical dashboard displaying patient vitals and trends
V-care gives the care team a live view of each patient between visits.
Drummond Certified — ONC Health IT

Our EMR is certified under the ONC Health IT Certification Program, independently tested and certified by Drummond, an ONC-Authorized Certification Body.

Our Guarantees

Promises we put in writing.

We hold ourselves to the standard we ask you to expect. These are commitments, not marketing.

Live in about six weeks

Or we keep working, at no added cost, until your programs are up and running.

Audit-ready claims

Every qualifying minute tracked and documented, so every claim is clean and ready for audit.

A dedicated care coordinator

A real person who knows your patients by name, never a rotating call center.

No new staff or software

We bring the people and the certified EMR. No new hires, and nothing for you to buy.

Care for the 97%

Care that lives where life happens.

Most of life with a chronic condition is lived between appointments, in the small daily decisions that add up. Vitasora is built for that space, with real support behind every choice.

97%

of life with a chronic condition happens between visits, exactly where Vitasora goes.

6in 10

U.S. adults live with at least one chronic condition.

20+ yrs

of behavioral science and patient activation research behind every program.

Thrive · Brand in Action

Meet Thrive. The coaching capability that changes behavior.

Thrive is Vitasora's evidence based coaching program, built on Patient Activation science and Motivational Interviewing, and designed to help every patient lead their own health journey.

01

Patient Activation

Every patient is assessed with a health confidence score, a validated tool that identifies where each person is on their journey from passive to empowered.

Knowledge, skills, and confidence delivered at the patient's level, on the patient's timeline.

02

Motivational Interviewing

Vitasora coaches are trained in Motivational Interviewing, the evidence based practice that aligns with how human motivation actually works.

Coaches ask first. Patients change when it is their idea. Small steps, measurable progress, longer engagement.

03

Proven Outcomes

When patients are met where they are and coached with evidence based technique, the results are measurable and consistent across every program we run.

56% fewer hospital readmissions. 50%+ fewer hospital visits. Longer enrollment, more meaningful care.

What We Offer

A continuous safety net, built into your practice.

Vitasora is a complete extension of your team, combining real time physiological data with the science of patient activation, delivered by care coordinators trained to listen first.

Remote Patient Monitoring

Connected devices from Tenovi, SmartMeter, and Wheezo stream physiological data in real time, so your team sees every signal that matters between visits.

Learn more

Chronic Care Management

A care coordinator matched to each patient with two or more chronic conditions, a real relationship that guides sustainable decisions in the moments that matter.

Learn more

Principal Care Management

Focused, continuous support for patients managing a single high risk chronic condition. The same care coordinator relationship and live monitoring, scaled to where it is needed most.

Learn more

Transitional Care Management

The 30 days after a hospital discharge are when continuous care matters most. We bridge that window with daily check ins, medication reconciliation, and a fast track back to your office.

Learn more

All four programs are fully managed and HIPAA aligned. Vitasora handles enrollment, monitoring, and billing inside your existing EHR.

Who We Help

Built for the way your organization is built.

One care model, matched to how you deliver care. From a solo practice to a multi-hospital system, Vitasora scales to your size and slots into your existing EHR and workflow.

Hospitals & Health Systems

A long-term partner for population health. Lower readmissions, advance value-based care, and scale continuous monitoring across your whole panel without adding headcount.

Learn more

Multi-Specialty Practices

Differentiate and grow. Deliver proactive, data-driven care across diverse conditions while we handle enrollment, coordination, and billing inside your EHR.

Learn more

Small & Independent Practices

A simple start. Add a reimbursable care program and a real care coordinator to your team, up and running in about six weeks with no new hires or operational strain.

Learn more

Specialist Practices

Condition-focused continuity. Proactive PCM and RPM for chronic, high-risk patients, improving adherence and outcomes without increasing clinical workload.

Learn more
Care coordinator listening with a patient
Your care coordinator listens first, then builds the plan around you.
The Patient Experience You Deliver

Care that walks beside your patients, every day.

Under your practice's name, each of your patients gets a real care coordinator who knows them by name, along with their goals and priorities. It is the experience your patients feel, and the reason they stay with you.

“We will meet you where you are with empathy, expertise, and consistency, so that managing your health feels like something you can actually do, one day at a time.”

A Vitasora patient
Chronic Care Management

“You're the only one who helps me. I'm blessed to have someone I can count on.”

He always struggled to get his referrals authorized and completed; the referral department never took his calls. Now he knows to call his care coordinator, the one person who will see it through, for anything to do with his health.

“Someone I can count on”
Referrals authorized and completed
Learn about Chronic Care Management
A Vitasora patient
Chronic Care Management

“I called you because I knew I could always reach you.”

She couldn't remember when her appointment was and couldn't get through to the clinic, so she called her care coordinator. Together they confirmed her PCP visit, caught a forgotten radiology appointment, and fixed transportation she had booked for the wrong day, with time to spare.

2 appointments saved
PCP, radiology, and transport back on track
Learn about Chronic Care Management
Nancy, 77
Remote Patient Monitoring & Chronic Care Management

“My care coordinator has been a blessing.”

Nancy has been dealing with a lot of health issues recently and had not left her house in six weeks. She repeatedly shares how grateful she is for the service, and says her care management has been a huge asset to her and her care.

“A huge asset to my care”
In Nancy's own words
Learn about Remote Patient Monitoring
In a Risk Contract?

Continuous care that performs in value-based models.

Close care gaps, lower avoidable utilization, and improve quality scores, while generating fee-for-service revenue along the way.

Explore Value-Based Care
Proof & Accountability

Built to prove its value.

Care at real scale, delivered every month. From day one, your programs are measured against your own goals, not ours.

How effective the care is

98%

Of enrolled patients reached by our care team every month.

2.4×

Growth in patient engagement across an established program in 2026.

47min

Of dedicated care per patient, on average, every month.

From active Vitasora programs, 2026. De-identified; no patient-level data. Engagement growth reflects one established program measured across the year.

Real results, measured at a partner practice

8.5pts

Lower systolic blood pressure among patients who started high, over 11 weeks.

70%

Of those patients improved; 35% returned to the controlled range.

89%

Of monitoring patients stayed engaged through the period.

A partner primary care practice, July 1 to September 16, 2026. Observational; each patient measured against their own earlier readings. See the full results

Our Own Certified EMR, Connected to Yours

Everything runs on Vitasora's own EMR, certified under the ONC Health IT Certification Program, so there is nothing for you to buy or build. It connects with the systems your team already uses.

Epic Oracle Health athenahealth eClinicalWorks NextGen
ONC Health IT Certified HIPAA Aligned BAA Provided AES-256 Encryption U.S. AWS Hosting Security & compliance
See the Numbers

What could continuous care return for your panel?

See what continuous care could mean for your panel, in about a minute.

Open the ROI calculator
Request a Consult

See your practice's potential in 15 minutes.

Tell us a little about your organization and our team will follow up to walk through a sample eligibility view, the workflow, and projected revenue and outcomes by program.

  • No cost, no obligation
  • Response within two business days
  • HIPAA-aligned, EHR-friendly
Always-On Care

Let's bring care all the way home.

Whether you are a patient looking for a care keeper or a physician looking to extend your practice, we would like to hear from you.

Book a Demo