Maetra - Chronic Disease Management Platform
Identify Risk Earlier. Act Faster. Improve Outcomes.
Maetra is a precision chronic disease management platform built to operationalize risk‑to‑action workflows at population scale. It unifies patient attribution, dynamic risk stratification, and continuous condition‑specific trend monitoring with AI‑driven early warnings that prioritize outreach to the right members at the right time. Smart escalation triggers route clear next steps to care coordinators, while automated patient engagement nudges adherence across medications, labs, appointments, and daily self‑management tasks.
A compliance and reporting hub captures auditable activity aligned to quality programs, and an optional revenue impact tracker connects operational improvements to value‑based financial metrics. The result is a coordinated, data‑driven approach that helps payers, ACOs, and risk‑bearing providers intervene sooner, streamline care operations, and sustain measurable improvements in outcomes and program performance.
Built For
Patients
- Access a unified daily plan with medications, labs, appointments, and
personal health goals all in one place personalized for chronic conditions including hypertension, obesity, arthritis, chronic kidney disease (CKD), COPD, and diabetes. - Understand key condition indicators with plain‑language insights and clear trend visuals across vitals, biomarkers, and lifestyle data.
- Receive timely reminders and nudges that support adherence and healthy routines.
- Book visits or virtual consults and review past recommendations anytime.
Care Coordinator
- Work a prioritized queue driven by risk stratification, AI early warnings, and smart escalations.
- Automate outreach across medications, labs, and follow-ups to close gaps faster.
- Track tasks, compliance, and member progress in dashboards that reduce swivel-chair work.
- Generate audit-ready reports aligned to quality programs and operational metrics.
Provider
- See an integrated view of clinical data, lifestyle context, and key condition indicators for informed decision‑making.
- Apply guideline‑aware care plans with clear next steps and follow‑up thresholds.
- Collaborate with coordinators through shared worklists that accelerate risk‑to‑action time.
- Measure outcomes and program performance with reporting that maps to value‑based goals.
Features
Patient Attribution Engine
Consolidates EHR, lab, and claims inputs to build an accurate, current roster of attributed members with chronic conditions; keeping panels synchronized, reducing leakage, and enabling proactive population management across programs and cohorts
Dynamic Risk Stratification
Scores risk dynamically using clinical history, vitals, utilization, and lifestyle signals, generating prioritized cohorts for outreach so care teams focus effort where deterioration risk and impact are highest
AI‑Based Predictive Risk Detection
Consolidates EHR, lab, and claims inputs to build an accurate, current roster of attributed members with chronic conditions; keeping panels synchronized, reducing leakage, and enabling proactive population management across programs and cohorts
Condition Trend Monitoring
Smart Escalation Triggers
Transforms risk signals into routed, actionable tasks with next‑best actions, guideline‑aware thresholds, and service‑level targets ensuring the right coordinator intervenes quickly and consistently for the highest‑priority members.
Automated Patient Engagement
Automates member outreach across medications, labs, appointments, and care plan tasks using targeted reminders and nudges; boosting adherence, closing gaps faster, and freeing coordinator time for complex, high‑value interactions
Compliance and Reporting Hub
Aggregates engagement and clinical activity into audit‑ready dashboards aligned to quality programs, simplifying measure tracking, documentation, and reporting for HEDIS, CAHPS, and internal leadership, all without manual spreadsheet effort.
Benefits
Accelerated risk-to-intervention
Accelerated risk-to-intervention
Real‑time triggers and automated stratification surface high‑risk members sooner, pushing them to the top of the worklist with next‑best actions. Alerts and escalations prevent slippage, so teams intervene fast with personalized plans - reducing events and delays.
Automation‑driven care coordination efficiency
Automation‑driven care coordination efficiency
Automation takes over intake, triage, scheduling prompts, and documentation, cutting manual clicks and cycle time. Standard templates and playbooks keep work consistent, while a unified member view reduces rework - freeing coordinators for complex cases and engagement.
Star Ratings Uplift & Measurable Revenue Impact
Star Ratings Uplift & Measurable Revenue Impact
Reliable gap closure lifts HEDIS® performance and smooth coordination improves CAHPS® experiences. With standardized documentation and traceable workflows, audits become easier. Together, these gains support a Star‑rating lift and translate into retention and MA revenue.
Stronger Guideline Alignment & Care Plan Execution
Stronger Guideline Alignment & Care Plan Execution
Embedded guidelines turn into personalized, portal‑visible care plans that show goals, gaps, and next steps. Reminders, nudges, and progress dashboards keep members on track, improving adherence and giving teams ownership to close milestones on time.
AI Capabilities - At a Glance
Actionable AI that predicts, personalizes, and accelerates chronic conditioncare. Optimize outreach, clinical decisions, lifestyle guidance, and goal‑setting at scale.
- Best Time to Contact: Predicts the best time to contact each patient to increase connection and engagement rates.
- Next Best Action: Surfaces evidence‑based next‑best actions using history, biometrics, lifestyle data, and risk signals.
- Nutritional Analysis: Interprets meal photos and lifestyle inputs to estimate nutritional impact and suggest healthier choices aligned to the patient’s condition.
- AI Care Recommendation: Auto‑suggests personalized care goals and tasks based on recent clinical encounters and evolving patient data.
Intelligent Workforce Management in Enterprise Healthcare Operations
Information Hub
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How does Maetra improve outcomes in value-based chronic disease programs across payers and providers?
Maetra unifies patient attribution, dynamic risk stratification, and condition‑specific trend monitoring in one platform. AI early warnings, smart escalations, and automated engagement accelerate interventions, improve adherence, and reduce avoidable utilization across value‑based chronic disease programs.
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Which AI capabilities power Maetra’s proactive, personalized chronic condition management at population scale?
Maetra’s AI suite includes Best Time to Contact for predictive outreach, Next Best Action for decisions, nutritional analysis from meal photos, and suggested care goals - personalizing chronic condition management at population scale and reinforcing guideline adherence.
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How does Maetra integrate with EHRs, labs, claims, and devices securely for interoperable deployments?
Maetra integrates securely via FHIR, HL7, and enterprise APIs to unify EHR, lab, claims, and wearable data. HIPAA‑aligned deployments and role‑based access enable interoperable, scalable implementations supporting continuous monitoring, risk stratification, engagement, and reporting.
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What compliance and reporting features support HEDIS, CAHPS, and Star Ratings performance?
Maetra’s Compliance and Reporting Hub centralizes engagement and clinical activity into audit‑ready dashboards for HEDIS, CAHPS, and Star Ratings performance. Teams track gap closure, adherence, and compliance - aligning value‑based reporting with payer and regulatory requirements.
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How are outcomes measured and validated for value-based contracts and Medicare Advantage?
Maetra measures impact through time‑to‑intervention, distribution of condition‑specific biomarkers and vitals, avoidable admissions, task automation, gap‑closure velocity, and Stars performance. Results modeled on de‑identified data; actual outcomes depend on baseline, cohort mix, and program design.
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What daily operational benefits do care coordinators and providers realize with Maetra?
Care coordinators work prioritized queues, automate outreach, and generate audit‑ready reports, improving throughput. Providers see integrated clinical context, guideline‑aware plans, and coordinated follow‑ups - reducing swivel‑chair work, accelerating risk‑to‑action time, and enabling consistent, value‑based population health management.
