Scale Value-Based Care.
Extend evidence-based care beyond the clinic by engaging patients between visits, closing care gaps, and improving population health outcomes at scale.
Value-Based Care Requires Continuous Engagement. Most Systems Only Deliver Episodic Care.
Value-based contracts hold organizations accountable for outcomes that are determined between visits, not during them. Medication adherence, care plan compliance, screening completion, and behavioral change all happen in the patient's daily life.
Without infrastructure to engage patients longitudinally between encounters, value-based organizations are left measuring outcomes they had no systematic influence over. The patients who need the most support are often the least reached.
The gap between what needs to happen for value-based success and what traditional care delivery systems actually support is where performance is won or lost. Organizations succeeding in risk arrangements have built the engagement infrastructure to bridge that gap.
The Gap Between Fee-for-Service and Value-Based Performance Is Measured in Engagement.
Organizations succeeding in value-based contracts aren't doing it with better clinical protocols. They're doing it by building engagement infrastructure that reaches patients between visits.
Nine out of every ten healthcare dollars are spent managing and treating chronic conditions, making proactive population health management the primary lever for total cost of care reduction.
CDC, Health and Economic Costs of Chronic Conditions (2024)
More than one-third of the country is living with conditions requiring longitudinal engagement, care gap closure, and proactive monitoring to prevent escalation into high-cost acute episodes.
CDC, About Chronic Diseases (2024)
ACOs generated a record $2.4 billion in Medicare savings in 2024, demonstrating that value-based care works at scale when population health management is operationalized and proactive.
CMS, Medicare Shared Savings Program PY2024 Results
Multi-morbidity is now the rule, and patients with multiple chronic conditions are your highest-risk, highest-cost, most care-gap-prone population, requiring systematic engagement to manage effectively at scale.
CDC, Multiple Chronic Conditions Trends, 2013-2023 (2025)
Three out of four ACOs in the Medicare Shared Savings Program earned performance payments in 2024, the highest rate in program history, tied directly to quality metric performance and care gap closure.
CMS, MSSP PY2024 Fact Sheet
Talk to a Subflow expert about your quality performance goals and population health strategy.
Calculate Your ROIContinuous Care Delivery Between Every Visit.
Subflow identifies at-risk patients, deploys automated engagement programs, and gives population health teams the tools to close care gaps and improve outcomes, at the scale value-based contracts require.
From Panel Size to Patient Level: All in One View.
Managing a value-based population requires understanding it at every level. Subflow gives population health teams a real-time view of risk stratification, open care gaps, and quality measure performance across their entire attributed panel.
Instead of waiting for retrospective data, teams can see exactly which patients are driving quality performance gaps, which cohorts are most actionable, and where to deploy outreach programs to have the greatest impact before the measurement period closes.
- Risk stratification across your full patient population in real time
- Automated identification of actionable care gaps by measure and cohort
- Prioritized patient lists by risk tier for targeted care management
- Longitudinal engagement analytics to measure what's working at population scale
- Quality measure performance dashboards updated as gaps are closed
Reach Every Patient Between Visits. Without Hiring More Staff.
Subflow extends your care delivery capacity by automating the longitudinal engagement that value-based success requires, at a scale that manual processes can't achieve.
Automated Cohort Engagement
Deploy targeted engagement programs to specific patient cohorts: diabetics overdue for HbA1c, patients with uncontrolled hypertension, high-risk patients not seen in 90 days.
Longitudinal Care Plans
Enroll patients in evidence-based care programs that follow them between visits, delivering education, reminders, and check-ins continuously over time.
Care Gap Closure Automation
Automatically identify and reach out to patients with open care gaps, scheduling preventive visits, collecting screening results, and driving closure at scale.
Chronic Disease Management
Automate the continuous engagement required for effective chronic disease management, monitoring adherence, collecting biometrics, and escalating clinical concerns.
Health Equity Outreach
Ensure underserved and hard-to-reach populations receive the same quality of engagement as everyone else, with multi-language support and communication channel flexibility.
Ready to see it live?
See how Subflow helps value-based organizations close care gaps and improve quality performance at scale.
Better Quality. Lower Cost. More Scalable Care Delivery.
These are the performance improvements organizations experience when they deploy Subflow to support their value-based care programs.
Longitudinal care programs built on Subflow achieve sustained patient engagement. It is the foundation for closing care gaps and improving population health metrics.
Aggregate: Subflow longitudinal care deployments
Proactive post-procedure monitoring and early intervention reduces avoidable emergency utilization, directly improving total cost of care metrics.
Longitudinal care case study
Automating care gap outreach, documentation, and follow-up at scale reduces the administrative overhead of value-based care programs, improving program economics.
Aggregate: Subflow deployments
Built to Work With the Systems You Already Use
Subflow Health is designed to fit into your existing technology ecosystem, not replace it. Through our partnership with Provision Group, we bring decades of enterprise integration expertise to connect Subflow with your EHR, clinical systems, and broader technology stack.
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Built for Organizations Accountable for Population Outcomes.
Accountable Care Organizations (ACOs)
Improve shared savings performance by engaging beneficiaries between visits, closing care gaps, and reducing avoidable utilization across your attributed population.
Health Systems
Scale value-based care delivery across your population without proportional increases in care management staff, using automation to extend your clinical team's reach.
Risk-Bearing Provider Groups
Manage chronic disease and preventive care at scale in capitated and risk-sharing arrangements, with the engagement infrastructure to improve performance.
Health Plans & Payors
Deploy member engagement programs that improve quality ratings, close HEDIS gaps, and reduce medical cost ratios across your book of business.
CINs & IPAs
Give independent practices the population health engagement tools they need to succeed in value-based arrangements, without burdening individual providers.
FQHCs & Safety Net Providers
Address health equity by ensuring every patient receives consistent, structured engagement, closing persistent gaps for underserved populations.
Ready to Scale
Value-Based Care?
See how Subflow helps risk-bearing organizations engage patients between visits, close care gaps, and improve population health outcomes at scale.