Personalized service management: a proven approach

Vitalité Health Network – Friday, March 17, 2023 – The personalized service management model developed by Vitalité Health Network is producing promising results.

The program is designed to help high-volume users of hospital services, namely people who have visited the emergency room five or more times or have been hospitalized three or more times in the past 12 months. 

Our teams now proactively reach out to these patients to offer support. A nurse then provides intensive follow-up by developing a personalized intervention plan. A social worker may also be involved.

“The goal is to identify the unmet needs underlying patients’ consumption of services in order to help them better manage their health condition and improve their quality of life,” explains Stephanie Roy, Assistant Director of Primary Health Care.

“To meet a patient's needs, we organize interdisciplinary meetings and collaborate with several partners, such as the Extra-Mural Program, the Department of Social Development or community organizations. This may include, for example, facilitating access to a support group, mental health care or transportation.”

After being implemented in the Edmundston, Bathurst, Campbellton and Moncton regions, the program was recently expanded to the Acadian Peninsula and Kent County.

Depending on the region, a reduction in emergency room visits ranging from 45% to 65% has been noted among participants, as well as a decrease in hospitalizations ranging from 15% to 40%.

Manon Roussel, Primary Health Care Services Management Coordinator

Manon Roussel, Primary Health Care Services Management Coordinator

“This approach allows for in-depth assessment and ensures better management of complex health situations. Patients are appreciative, they feel supported and listened to,” says Manon Roussel, Primary Health Care Services Management Coordinator.

“Helping one patient at a time is very rewarding. You always feel like you’ve made a difference.”

Personalized service management complements other initiatives in which the Network is involved, such as the single entry point for complex health situations and the At Home Program for vulnerable seniors.