CipherHealth helps ACOs, CINs, risk-bearing providers, and payer-aligned health systems operationalize value-based care across the patient journey. Evidence-based outreach pathways, longitudinal engagement, integrated clinical escalation, and EHR-connected workflows help organizations close contract-relevant care gaps, improve transitions, reduce avoidable utilization, and extend care-team capacity. Programs are aligned to each organization's specific quality measures, attributed population, risk arrangement, and economic objectives — measured by completed actions and validated outcomes, not outreach volume alone.
Outcomes from value-based care programs
AWV completion
Advocate Health lifted annual wellness visits from 44% to 80%.
patients reached
Prisma Health inVio reached patients across VBC programs since 2023.
discharge reach rate
A large academic center reached 92% of discharged ACO patients.
Attribution is not engagement. A name on a risk list is not a closed gap, a completed screening, or a prevented readmission. Value lives in evidence-based pathways, longitudinal outreach, and clinically governed escalation — identifying symptoms, barriers, and deterioration, routing patients to the right care team, and integrating documentation into the workflows your teams already run. Cipher turns patient engagement into measurable action — and measurable action into clinical and financial outcomes.
The same infrastructure runs for MSSP ACOs, CINs, Medicare Advantage, capitated groups, and delegated population health programs — with workflows mapped to each contract's quality measures, attributed population, and economic objectives.
Whether you share savings, take capitation, or hold full risk, CipherHealth runs outreach, gap closure, and transition workflows aligned to how your contracts are scored.
Disease-specific pathways on the attributed cohort; care-gap closure and screening completion on contract- and program-specific measures (e.g., APP Plus quality measures).
AWV-enabled gap closure, medication adherence, chronic-condition management, and support for accurate documentation of clinically supported conditions.
Member engagement across the panel — gaps, screenings, transitions, adherence — to manage medical cost under contract-specific arrangements.
Multilingual outreach matched to the population, SDOH screening, and care-transition workflows.
Extend an existing care team as a workforce multiplier — scale reach without adding FTEs.
For risk-bearing and payer-aligned provider groups, each workflow can be aligned to the relevant quality, risk-adjustment, utilization, or revenue objective in the organization's contracts.
Contract- and program-specific gap closure (mammography, colorectal, glycemic status for MSSP APP Plus; diabetic eye and other measures for MA Stars/HEDIS), AWV completion that creates opportunities to close Stars/HEDIS gaps and support accurate clinical documentation, medication adherence, CAHPS, and SDOH outreach for barrier identification and intervention.
Care transitions and post-discharge follow-up, fewer avoidable readmissions, lower avoidable ED and utilization, and TCM capture and bundled-episode performance — high-impact utilization levers that can contribute to lower total cost of care.
Operationalize value-based care with evidence-based pathways, clinically governed escalation, and integrated workflows — across care transitions, gap closure, chronic condition management, and utilization reduction at panel scale.
The transition workflow most teams still run manually — automated and scaled.
Post-discharge follow-upGap closure and screening completion on contract-relevant measures, with SDOH outreach to identify and address barriers.
Close care gapsDisease-specific outreach for diabetes, hypertension, and rising-risk cohorts — with symptom identification and escalation when intervention is needed.
Medication adherenceHigh-impact utilization levers that can contribute to lower total cost of care — fewer avoidable admissions and ED visits.
Readmissions reduction“CipherHealth is our workforce extender. By using the system, we are able to scale the power of our care transitions team by bubbling up the patients most likely to experience a care barrier. This translates to better outcomes for our patients and a better experience for our team.”
Healthcare-grade security controls verified through rigorous third-party review.
Bidirectional integrations with Epic and 85+ production EHR integrations and health-system environments — complementary to the systems you already run.
Reach attributed members in their preferred language across phone, text, and automated workflows.
Our featured value-based care customers operate in Epic environments. CipherHealth connects to your EHR with evidence-based pathways, clinically governed escalation, and gap-closure workflows aligned to the contracts your organization is accountable for.
Explore EHR integrationsEHR Integrations · Bidirectional
HL7 v2 · FHIR R4
Live · 98% message delivery
Patient lists · orders · documentation
HITRUST, HIPAA, SOC 2 Type 2, and TX-RAMP Level 2 — the compliance posture risk-bearing organizations require before scaling outreach across attributed lives.
Security & complianceSecurity & Compliance · Certified
Audited annually
Built and audited for healthcare data.
Independently attested across the certifications health systems and procurement teams require.
HITRUST
CSF
SOC 2
Type II
HIPAA
Compliant
TX-RAMP
Level 2
Continuous monitoring
AES-256 · TLS 1.2+ · RBAC
FAQ
We'll show you what quiet, reliable execution looks like — on your data, not a demo account.
Resource library
Customer stories, sessions, and evidence that show how we help health systems succeed—selected for this page’s topic (match: ACO CIN value-based care MSSP shared savings Stars care gaps attributed…).
Learn how UCSF uses population health strategies to improve care transitions and address care gaps, leading to better outcomes and value-based care reimbursements.
See why healthcare systems like Intermountain Healthcare, UCSF Health, and Advocate Aurora Health rely on CipherHealth’s post-care communication solutions.
