AGENTIC AI · VALUE-BASED CARE
Description An Agentic AI platform that orchestrates care coordination, risk management, quality improvement, and member engagement to maximize Value-Based Care outcomes
Trusted · Transparent · Accountable
Three layers that turn risk into action into outcomes.
VBC AI is built on three integrated, independently scalable layers over a unified FHIR-compliant Longitudinal Patient Record. Together they form a closed loop that moves from prediction to action to measured outcome
continuously with human oversight wrapped around every consequential decision.
THE OPERATING MODEL
01
Predictive Analytics
WHAT WILL HAPPEN?
20+ disparate sources, manual CCD loads, no
standardized layouts, and unresolved member identity
stall gap visibility
Hospitalization & readmission models
SDOH risk scoring
Disease progression & cost models
Real-time HEDIS gap detection
02
Agentic AI
WHAT SHOULD WE DO?
Reasons about the best intervention for each member,
orchestrates multi-agent workflows, and adapts based
on observed outcomes.
10 purpose-built AI agents
Clinical decision support (MCG/InterQual)
Agent orchestration framework
Human-in-the-loop escalation engine
03
Workflow Automation
HOW DO WE GET IT DONE?
Executes the interventions the AI recommends across
EHR, CRM, scheduling, and communication systems
then tracks them to completion.
EHR integration (Epic, Cerner, Oracle)
CRM care-team task management
Outreach: SMS, voice, portal, IVR
Scheduling & referral automation
Ten agents. Each with a trigger
A memory and an escalation rule
VBC AI is a multi-agent system. Agents run in parallel through the orchestration framework and share state via the
Longitudinal Patient Record. No agent has autonomous authority over clinical decisions, denials, coding, or
care plan activation that boundary is enforced in the architecture.
THE AGENT INVENTORY
Population Risk Stratification Agent
Recomputes a composite 0–100 risk score on every patient event; tiers and ranks members.
Care Gap Detection Agent
Monitors every member against HEDIS specs in real time; emits evidence-cited gap records.
Care Pathway Planning Agent
Selects the optimal intervention pathway per member, reasoning over clinical & SDOH context.
Patient Outreach Agent
Delivers personalized, HIPAA-safe outreach across voice, SMS, portal, email, and IVR.
Care Manager Agent
Prepares prioritized queues, patient briefs, and draft documentation for human care managers.
Chronic Disease Management Agent
Tracks condition biomarkers and adherence for diabetes, HF, COPD, HTN, CKD.
Discharge Follow-Up Agent
Activates within 30 min of discharge; drives CMS-timed transition tasks to prevent readmission.
Medication Adherence Agent
Watches PBM refill gaps; computes MPR/PDC and flags non-adherence by drug class.
Risk Adjustment Agent
NLP-flags undocumented HCC conditions for physician attestation — never codes autonomously.
Utilization Mgmt & Prior Auth Agent
Auto-approves clear PA cases; routes denials to a physician. No autonomous denials.
Six workflows, one closed loop from signal to closure.
Each use case follows the same loop: an event triggers the right agents, they reason and act, and a human
authorizes anything consequential. The VBC impact below reflects the platform’s target outcomes.
CLINICAL USE CASES
Risk stratification
Recomputes composite risk on every event; high-risk members trigger pathway planning, 2-hour outreach, and a care-manager task.
HEDIS care-gap closure
Monitors members against HEDIS specs, prioritizes by Star-Rating impact, and drives closure with validated evidence.
Chronic disease management
Tracks biomarkers and adherence for diabetes, HF, COPD, and HTN; flags deterioration before an acute event.
Care transition management
Activates on discharge within 30 min; automates CMS-timed follow-up, med reconciliation, and outreach.
Risk adjustment optimization
NLP surfaces undocumented HCC conditions with cited evidence for physician attestation — never auto-codes.
Prior auth & utilization
Auto-approves clear PA cases, routes borderline to nurses, and requires physician sign-off on every denial.
FAQ
FDA SaMD risk tiers, EU AI Act Annex III, and clinical domain classification — out of the box on day one. Horizontal tools require weeks of custom configuration.
Auto-mapping to FDA, ONC, CMS, CHAI, NIST, and ISO maintained as regulations evolve. No manual update cycle, no compliance drift.
Calibrated to known clinical disparities: pulse oximetry bias, pain assessment inequity, maternal mortality gaps. No generic fairness proxies.
FDA post-market reports, Joint Commission evidence packages, and ISO 42001 audit-ready documentation generated automatically from governance activities.
Tracks PHI provenance through AI pipelines using healthcare interoperability standards — the only governance platform built natively on healthcare data infrastructure.