The execution layer that turns attributed lives into value — closing care gaps, owning care transitions, and completing the screenings your contracts are scored on. Whether you share savings or carry full risk, quality and medical cost land on one P&L.
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 the execution — the follow-up call, the mammogram booked, the escalation when a symptom surfaces — done reliably, at panel scale, without burying your care team.
The same infrastructure runs for MSSP ACOs, CINs, Medicare Advantage, capitated groups, and delegated population health programs.
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 scored measures.
AWV capture, HCC recapture, medication adherence, and chronic-condition management.
Member engagement across the panel — gaps, screenings, transitions, adherence — to manage medical cost.
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, every completed screening, closed gap, and managed transition is Stars performance, risk-adjustment accuracy, and medical-cost savings at once.
Care gaps closed on scored measures, screenings completed (mammography, colorectal, diabetic eye & A1c), AWV & HCC recapture, medication adherence, CAHPS, SDOH & behavioral outreach.
Care transitions & post-discharge follow-up, fewer avoidable readmissions, lower avoidable ED & utilization, TCM capture & bundled-episode performance.
The execution layer for 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 the measures you're scored on, plus SDOH.
Close care gapsDisease-specific outreach for diabetes, hypertension, and rising-risk cohorts.
Medication adherenceThe core medical-cost metric — 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+ EHRs — complementary to the systems you already run.
Reach attributed members in their preferred language across phone, text, and automated workflows.
Every organization in our value-based care proof set runs on Epic. CipherHealth sits above it as the execution layer — running outreach, post-discharge follow-up, disease-specific pathways, and gap closure that your contracts pay 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.
