VitalBridges
VitalBridges: a VitalCare Program
Scott & White Health Plan (SWHP) has established VitalBridges, a new program designed to improve coordination of care for members after they have been discharged from the hospital. This program will aid in a successful and smooth transition to home. It will enhance the coordination of care across care settings and ensure a better member experience. This enhanced coordination of care program is focused on some of the health plan's most severely ill members.
VitalBridges is designed to identify a member's unique needs after being discharged from the hospital. Within two days of discharge, the member will be called so that information about any unmet needs can be gathered. Once these needs are identified, we can assist the member.
Members will be asked if they have scheduled a follow-up visit with their regular doctor. They will also be asked if they need help getting to their doctor appointment. They will be asked if they need in-home services such as visiting nurses or home health services. SWHP will intervene to help the member with any identified needs.
If members have questions about their medications, a SWHP pharmacist will call and assist them with their questions. The pharmacist will do a medication reconciliation. The pharmacist may make a medication recommendation or help the member prepare for that at their doctor visit.
If members have a question about their health or condition, they will be given the SWHP Nurse Advice Line number to call. An outbound call from the Nurse Advice Line can also be arranged if that is needed. Other member needs will be assessed and if found these will be referred back to SWHP to follow-up. VitalBridges is designed to identify member issues and refer them back to the health plan for follow-up.
Regular feedback on call volumes, issues identified, and other service and health related issues will be given to the health plan. This feedback will help us better assess what services newly discharged members most urgently need. This will be helpful in planning our health plan services and benefit design. If quality or safety issues are identified, they will be directly called in by VitalBridges to a Medical Director for follow-up.
VitalBridges is designed to improve member satisfaction. It will identify concerns, safety issues, and unmet member needs during the transition from hospital to home. We expect VitalBridges to provide SWHP with important information. This will help reduce unplanned re-admissions and increase member's experience and loyalty to SWHP.