Request a Demo
Ziva Health›Solutions›ACOs
For ACOs & value-based care organizations

Thousands of patients.
A few visits a year.
One continuous view.

Your care teams are responsible for thousands of lives, but most patient changes happen between visits. Ziva provides a continuous view of health between encounters, helping teams identify who needs attention today - before small changes become costly events.

HIPAA compliant · EHR & care platform integration · Scales to any attribution list · MSSP & ACO REACH aligned

Book a demo How Ziva helps →
Program Overview
📅 This morning
◎
52,318
Patients monitored
⚑
2
Immediate action
◈
8
Monitor closely
✓
52,308
Stable
Top conditions flagged
10
Flagged
CHF · 3 (30%)
Hypertension · 3 (30%)
COPD · 2 (20%)
Diabetes · 1 (10%)
Other · 1 (10%)
Rising-risk patients
View full queue →
MT
Mary T., 79* · CHF, T2D, HTN
Weight +4 lb in 5 days
High Risk
DR
Dorothy R., 73* · Hypertension
BP ↑ 2 weeks, stress ↑
High Risk
FD
Frank D., 68* · COPD
SpO2 trending down 6 days
Monitor
JK
James K., 61* · Type 2 diabetes
Glucose ↑ 9 days
Monitor
Isabella
"Mary's weight is up 4 lbs in 5 days with rising BP — a pattern consistent with early CHF decompensation. I've moved her to the top of today's care manager queue."
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary.
The gap

Your panel is huge.
Your visibility is a snapshot.

An ACO can manage 10,000, 50,000 or 250,000 patients - but each one is seen by a provider only a few times a year. Between visits, the population goes dark, and today's tools mostly tell you what already happened.

Effectively blind between visits
Care teams rely on EHR data, claims and care manager calls. Important changes - a missed refill, a weight climb, a mood shift - happen in the months nobody is watching.
Claims arrive too late
Claims data lags weeks to months behind the event. By the time a hospitalization shows up in a report, it has already cost the ACO money and the patient a bad outcome.
Care managers can't call everyone
A handful of care managers cannot proactively reach thousands of attributed lives. Without triage, outreach becomes reactive or effectively random.
Ziva's role

The layer that connects patients
and care teams between visits.

Ziva doesn't replace clinicians or care managers. It tells them who needs attention today - turning wearables, devices, labs, questionnaires and medication data into a single ranked signal your existing team acts on.

01
Signal, automatically
BP, weight, pulse ox, activity, sleep, nutrition, labs and questionnaires stream in daily from every enrolled patient - no app fluency required.
02
Isabella interprets
Each patient is read against their own baseline, not a population threshold, and correlated across data types - not single readings in isolation.
03
Prioritized, not raw
A ranked list replaces a data firehose - the population narrows to the handful of patients who actually need a call today.
04
Care team acts
Care managers, nurses, PCPs and specialists get the alert with underlying data attached - days or weeks before it would surface any other way.

Most ACO technology answers "what happened?" - claims, EHR data, billing reports. Ziva answers "what is happening right now?" - the shift from retrospective to real-time visibility that value-based care has been missing.

How the signal flows
WearablesBlood pressureWeightPulse oxNutritionSleepExerciseLabsQuestionnairesMedication
↓
Ziva · AI insights & provider tasks
↓
Care managersNursesPrimary careSpecialists
↓
Earlier intervention

Ziva doesn't replace clinicians. It tells them who needs attention today.

How Ziva helps

What Ziva does for
an ACO's care teams.

Ziva is not another population health dashboard for your analysts to query. It does the daily watching, the triage and the documentation, and hands your existing care managers a short list worth calling.

Monitoring
Daily signal at population scale
Every enrolled patient monitored every day, regardless of whether your list is 10,000 or 250,000 lives.
Triage
A ranked list, not a dashboard
Isabella filters normal variation across the whole population and surfaces a short, reasoned outreach list each morning.
Efficiency
Care manager time, targeted
A handful of care managers can cover a huge attribution list when outreach is aimed at who actually needs it today.
Quality
HEDIS & Stars-relevant support
Medication adherence, screening gaps and follow-ups surfaced continuously - not discovered in a year-end chart chase.
Risk
Rising-risk identification
Patients drifting toward an acute event are flagged from daily patterns, not from a claims-based risk score computed months later.
Documentation
Audit-ready outreach records
Every alert, contact and outcome is logged - supporting quality reporting and any RPM/CCM billing your affiliated practices run.
Impact

What ACOs are
actually buying.

Not AI. Not wearables. Not a nutrition app. ACOs buy fewer expensive events - and everything downstream of that.

Earlier
Rising-risk identification
Days of drifting vitals or adherence, surfaced before an ED visit - not a claim weeks later
Targeted
Care manager outreach
A ranked list replaces cold-calling or reactive outreach across a huge attribution list
Fewer
Avoidable ED visits & admissions
The core lever behind total cost of care and shared-savings performance
Illustrative
Total cost of care
Directional modeling available for your attributed population - ask your rep

Directional framing based on Ziva's platform capabilities; actual results depend on population size, risk mix and enrollment.

Proof

Continuous contact that
changed the outcome.

Conditions covered

The conditions driving your highest-cost cohorts.

Ziva runs condition-specific protocols and typically starts with an ACO's highest-risk cohorts before expanding across the panel.

Heart failureDiabetesCOPDHypertensionChronic kidney diseaseMental healthWeightAll conditions →
Value-based impact

Built to move the metrics
value-based contracts pay on.

Fewer avoidable admissions and ED visits are what total cost of care and shared-savings performance are built on. The same daily contact supports the quality measures tied to your MSSP, ACO REACH or Medicare Advantage contracts.

↓Avoidable ED visits and hospitalizations
↓Total cost of care across your attributed population
↑Medication adherence and care gap closure rates
↑HEDIS / Stars-relevant quality performance
↑Care manager capacity — same headcount, larger effective reach
RPM & CCM still apply

Value-based contracts don't replace fee-for-service billing at the practice level. Ziva's time logs and monitoring records support RPM (99453–99458) and CCM (99490, 99439, 99487, 99489) claims for your affiliated practices, so the same program funds itself through both channels at once.

See the RPM/CCM revenue model →
Get Started

See it against
your own attribution list.

Send us a de-identified population summary and we'll model risk stratification, care manager workload and expected impact for your ACO specifically.

✓Risk-cohort analysis across your attributed population
✓Care manager workload estimate at your current headcount
✓Staged rollout plan by cohort, condition or region
✓Integration plan for your EHR and care management platform
Request a 30-minute demo
We'll walk through enrolment, alert configuration, and the revenue model for your practice.
Book my demo →
No commitment. We'll follow up within 1–2 business days.
Security & compliance

Built for healthcare.
Trusted by clinical teams.

Ziva was designed from the ground up for clinical environments - not adapted from a consumer app. Every data flow, access control, and integration meets the standards your compliance team requires.

🔒
HIPAA compliant
BAA available. All PHI encrypted in transit and at rest.
✅
End-to-end encrypted
All PHI encrypted in transit and at rest. HL7 FHIR R4 compliant data exchange.
🏥
US data residency
All patient data stored and processed within the United States.
📋
Audit-ready logs
Consent records, access logs, and outreach documentation stored and exportable.
Questions

ACO FAQ