AI-Powered Value-Based Care Software for Healthcare

Empower your organization with intelligent AI Agents that proactively close care gaps, optimize risk capture, and elevate quality scores across value-based contracts.

Hi! I'm Mantra, your AI therapist. I'm here to support you through whatever you're facing. How are you feeling today?

I've been feeling overwhelmed with work lately and having trouble sleeping.

I understand how challenging that can be. Let's work together on some strategies to help you manage stress and improve your sleep. Would you like to start with some breathing exercises?

Sure, that sounds helpful.

Great. Let’s start with a simple deep breathing exercise. Breathe in slowly through your nose for 4 seconds... hold for 4 seconds... and exhale through your mouth for 6 seconds.

Okay, I did that. Feeling a bit calmer already.

That’s wonderful to hear. Would you like to try journaling next or talk more about what’s been stressful?

Let's do journaling.

Perfect. Here's a prompt: "What are three things that made me feel stressed this week, and how did I respond to them?"

Mantra is typing...

Why Value-Based Care Underperforms And How AI Fixes It

Value-based care strategies are strong. Execution gaps are where revenue leaks, quality scores drop, and patients disengage. Intelligent AI Agents close those gaps at scale.

Care Gaps Identified - But Not Close

Dashboards flag the open measures. Outreach is where it stalls.

AI Solution:

AI agents step in, directly engaging patients, scheduling screenings, and closing gaps before deadlines hit.

Patients Disengage After Visits

Care plans break down within weeks when follow-up isn’t structured.

AI Solution:

Automated coordination and post-discharge follow-ups keep patients on track and cut avoidable utilization.

Preventive Outreach Doesn’t Scale

Manual calling maxes out long before population health goals are met.

AI Solution:

Omnichannel AI engagement scales that outreach across your entire attributed population.

Document Gaps Impact Risk Scores

Missed HCC capture and incomplete diagnoses quietly cut reimbursement.

AI Solution:

AI chart reviews catch what’s missing: complete documentation, accurate HCC capture, stronger RAF performance, before claims go out.

Data Exists — But Action Is Delayed

Insights sit in dashboards while quality opportunities quietly expire.

AI Solution:

AI tracks open measures continuously and triggers workflows automatically driving real Star Rating and ACO/MA gains.

Contracts Signed, Performance Lags

Payer terms get signed, but performance rarely gets actively managed after.

AI Solution:

Analytics keep optimizing VBC program performance, contract outcomes, and physician-level impact continuously.

What Value-Based Care Enablement Means at Mantra Assist

AI-powered execution closes care gaps, strengthens risk capture, and lifts performance across your value-based contracts.

What We Don't Do

We don't replace clinicians or clinical decision-making.

We don't replace your EHR or population health platform.

We don't add more dashboards without driving real action.

We don't disrupt your existing clinical workflows.

We don't create extra administrative burden for your staff.

We don't require complex rip-and-replace implementations.

What We Do

We close more care gaps through proactive AI patient engagement.

We optimize clinical documentation for accurate HCC and RAF performance.

We automate care coordination and post-discharge workflows.

We improve Star Ratings and ACO/MA quality performance.

We activate care plans at population scale through intelligent outreach.

We optimize VBC contract and payer performance.

Automation that activates care, improves risk accuracy, and elevates quality performance — outside the clinic walls.

Built for Value-Based Care Execution

Every capability directly supports care gap closure, risk accuracy, quality performance, and contract optimization — turning VBC strategy into measurable results.

Care Gap Closure & Preventive Outreach

AI agents engage patients directly, closing open care gaps, scheduling screenings, and activating preventive care at scale.

Chronic Care Management & Followups

Ongoing AI check-ins support diabetes, hypertension, and other chronic conditions, improving adherence and long-term outcomes.

Post-Discharge & Care Transitions

Automated transitional care workflows cut avoidable utilization, prevent readmissions, and keep care continuous.

Medication Adherence & Refill Optimization

Proactive outreach improves medication compliance and keeps pharmacy follow-through on track, protecting your quality metrics.

Intelligent Patient Engagement (Voice AI)

Human-like AI voice agents reach patients outside clinic walls, driving action, scheduling, and gap closure.

Risk Detection & Clinical Escalation

Responses get monitored in real time, and high-risk patients are routed straight to care teams when intervention is needed.

Quality & Population Health Analytics

Open measures, engagement performance, Star Ratings, ACO/MA metrics, and quality outcomes are all tracked in real time.

Scheduling & Care Activation

Appointment scheduling, confirmations, and reminders run automatically, cutting no-shows and speeding up care plan execution.

How It Works

From identification to documentation—a complete operational flow for value-based care execution.

Identify

Care Gaps & Risk Opportunities

Data comes in from EHRs, population health platforms, and payer files. From there, open care gaps, undocumented diagnoses, and high-risk patients all get flagged.

Engage

AI-Powered Outreach at Scale

Voice and digital campaigns launch automatically, targeted by care gaps, risk stratification, chronic conditions, and your program priorities.

Capture

Risk & Clinical Documentation Insights

AI conversations collect patient-reported data, symptoms, and care confirmations. Chart reviews run alongside, catching incomplete diagnoses and missed HCC capture.

Escalate

Care Coordination When Risk Is Detected

High-risk responses route straight to care teams for timely intervention, transitional care management, or follow-up scheduling.

Follow Up

Continuous Care Activation

Re-engagement workflows keep running, supporting medication adherence, preventive screenings, chronic care management, and post-discharge transitions.

Report

Quality, Risk & Contract Performance

Care gap closure, Star Ratings, ACO/MA metrics, RAF impact, and payer contract performance are all visible on real-time dashboards.

Use Cases for Value-Based Care

Activate AI Agents across your highest-impact VBC initiatives — closing gaps, improving risk accuracy, and maximizing contract performance.

Population Health Management

Engage attributed populations using AI-driven outreach based on risk stratification, open quality measures, and payer priorities.

Higher gap closure rates Scalable population outreach Improved Star & ACO performance

Chronic Care Management (CCM)

Automated monthly engagement supports chronic condition monitoring, medication adherence, & documented care plan compliance.

Structured, billable touchpoints Improved long-term adherence Reduced avoidable utilization

Transitional Care Management

Post-discharge outreach within 48 hours with ongoing follow-ups to reduce readmissions and ensure care continuity.

Lower readmission rates Stronger care coordination Timely escalation when risk detected

Preventive & Wellness Programs

Automate reminders for wellness visits, screenings, immunizations, and age-appropriate preventive services tied to quality programs.

Increased preventive compliance Improved quality measure performance Higher patient engagement

High-Risk Patient Monitoring

Continuous AI-driven check-ins identify symptom changes and trigger escalation protocols for early intervention.

Early risk detection Coordinated clinical follow-up Reduced ED utilization

Remote Patient Monitoring (RPM)

Voice-based symptom capture and documentation review complement device-based RPM programs & improve HCC accuracy.

Enhanced RPM coverage Patient-reported clinical insights Accurate HCC & RAF capture

Ready to Operationalize Value-Based Care?

Close care gaps, reduce costs, and improve outcomes—without adding headcount. See how Mantra Assist can work for your organization.

Request a demo

Answer a couple of questions and we’ll connect you with the right team member.

What is value-based care software?

It’s software that helps practices proactively close care gaps, improve risk-score (HCC/RAF) accuracy, and track quality performance across value-based contracts like ACOs and Medicare Advantage.

How does AI improve HCC and RAF score accuracy?

AI-driven chart reviews ensure complete diagnosis documentation, helping capture accurate HCC codes and strengthen RAF performance before claim submission.

Can it identify care gaps automatically?

Yes, it ingests data from EHRs and payer files to flag open care gaps, undocumented diagnoses, and high-risk patients needing outreach.

Does it replace my EHR or population health platform?

No, MantraAssist explicitly does not replace your EHR or population health platform; it activates outreach and closes gaps using the data already in those systems.