Vitalis Health Head of Virtual, Iman Malek, unpacks the data showing how digitally enabled, clinician-led care can extend healthcare beyond the hospital while maintaining strong patient engagement and clinician oversight.
“Quality, integrated and person-centred care for all Australians” is a stated objective of the Australian Government’s Primary Health Care 10-Year Plan, 2022-2032.
By aligning technology-enabled remote patient monitoring with clinical telehealth support and, if necessary, in-person clinical escalation, the Vitalis Virtual Program has developed an effective, patient-centred way of supporting individuals living with chronic conditions while improving engagement and self-management.
Key components of the Program include:
- Active clinician oversight rather than passive monitoring
- Structured care pathways with clear escalation criteria
- Regular patient feedback loops
- User-friendly technology and automated reminders – app notification vs. text.
High levels of patient engagement are strongly associated with improved chronic disease management, earlier identification of deterioration and more efficient use of healthcare resources.
Over a 12-month period from June 2025 to June 2026, Vitalis Health evaluated patient engagement level within the Virtual Program. These are the findings.
About the Vitalis Virtual Program
TThe Vitalis Virtual Program combines weekly remote patient monitoring, symptom surveys, nurse-led telehealth consultations and evidence-based escalation pathways to support people living with chronic conditions in their own homes. The program aims to identify deterioration early, promote self-management and reduce reliance on hospital-based care while ensuring patients remain connected to a clinical team.
The Program is delivered across three sequential care phases, progressing from intensive onboarding and education through ongoing supported self-management.
Methods
Data was collected from active participants across the different phases of the Program. Measures included the timely completion of scheduled activities throughout each program phase:
- Weekly clinical observations
- Weekly symptom surveys
- Scheduled clinical follow-ups with Vitalis telehealth Registered Nurses
- Patient-reported experience measures (PREMs)
- Patient-reported outcome measures (PROMs).
Key findings
The evaluation demonstrated:
- Sustained patient engagement throughout the program
- High adherence to scheduled monitoring activities
- Excellent patient satisfaction
- Measurable improvements in patient-reported outcomes
- Early identification of clinical deterioration through structured monitoring
- Effective delivery of care outside traditional face-to-face settings.
Key insights
1. Patient engagement remained consistently high throughout the Program.
| Measures | Phase 1 | Phase 2 | Phase 3 |
| Clinical observations | 93% | 72% | 76% |
| Symptom survey | 84% | 69% | 76% |
| Scheduled clinical follow-ups | 100% | 100% | 100% |
| PREM | 96% | 86% | 100% |
| PROM | 96% | 86% | 100% |
| Average patient engagement | 94% | 83% | 90% |
Sustaining patient engagement is widely recognised as one of the greatest challenges in digital health. A 2024 systematic review of 292 studies found that 77% reported declining engagement over time. Against this backdrop, the Vitalis Virtual Program maintained average patient engagement above 80% across all phases of care, demonstrating the effectiveness of combining remote monitoring with proactive nurse-led clinical support.
2. PREM findings
- 96% reported positive communication experiences with the Vitalis clinical team.
- 61% rated communication as Excellent.
- 35% rated communication as Good.
- 86% reported a better understanding of their health condition because of participating in the program.
3. PROM findings
PROMs were assessed using the PROMIS+29 questionnaire at onboarding and repeated at the completion of each program phase. The results demonstrated measurable improvements (and no reductions) across all assessed PROMIS+29 domains, with particular improvement recorded in the Physical Function, Cognitive and Social Participation domains where almost 50% of all participants noted improvement. Taken together, these improvements reflected enhanced wellbeing, increased self-confidence, and an overall improvement in quality of life.
Patient feedback
In addition to data, we also collected patient feedback on everything from their experience of the Vitalis telehealth service staffed by registered nurses to the number of GP visits.
“Roopa [Vitalis telehealth RN] is a committed partner for me. She is always diligent and informed and caring in her weekly phone call.”
“My wife said the GP was very impressed when she spoke about the service to him. My visits to the GP have decreased since enrolling in service”
“I found it very easy with Roopa and appreciate her support.”
“The GP and specialist were happy to know that I’m enrolled into the service. I found the service very helpful myself.”
“The direct support, follow up and information from Vitalis was very valuable.”
“It made me feel secure. Was very helpful and I feel much better now from when I started the program.”
I have enjoyed the Vitalis Program and weekly calls very much thank you very much from the bottom of my heart, Katrina [Vitalis telehealth RN], truly.”
“I always look forward to our calls, Katrina, you are very empathetic.”
“I think the program is a good idea as you can monitor any deteriorations.”
Conclusion
This evaluation demonstrates that a clinically led virtual model of care can successfully combine remote monitoring, telehealth and structured escalation pathways to achieve sustained patient engagement and improved patient-reported outcomes. The consistently high engagement observed across all program phases suggests that integrating technology with proactive clinical support is an effective approach to helping people with chronic disease remain connected, confident and actively involved in managing their health.
As health systems continue to shift towards more integrated and person-centred models of care, the Vitalis Virtual Program demonstrates how digitally enabled, clinician-led care can extend healthcare beyond the hospital while maintaining strong patient engagement and clinical oversight.
Partnering with Vitalis to enable patient-centred healthcare
Vitalis Virtual Hospital enables hospitals and private health insurers to extend clinical oversight beyond traditional settings, supporting earlier intervention and coordinated care across the recovery journey.
By combining remote monitoring, clinical governance frameworks and integrated care pathways, Vitalis supports partners to deliver hospital-standard care in the home environment while improving patient experience and optimising resource utilisation.
Learn more about partnership opportunities: https://vitalis.health/virtual-and-remote-services/virtual-hospital-care/