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Driving High-Touch, High-Performance Care:

How Matter Health Uses Ursa to Power Quality, RAF, and Operational Improvement

Overview

Matter Health is redefining what it means to deliver high-touch, high-value care to seniors living in affordable housing communities. Founded in 2022, the organization brings high-quality care directly into the homes and communities of older adults who have historically been underserved by the healthcare system. Their model focuses on proactive, relationship-centered care that improves outcomes, reduces avoidable utilization, and supports seniors with complex medical and social needs.

To support this mission, Matter Health required a unified data and analytics foundation capable of powering quality, utilization, risk adjustment, and operational performance—all while enabling a small team to move quickly.

According to Kristie Koch, Chief Performance Officer, “There is no way we would have the level of data transparency, the level of data access, or the ability to have actionable insights we have now if we had not found an organization like Ursa.”
Matter Health partnered with Ursa Health to build a flexible and transparent analytics environment that integrates claims, EHR, quality, and risk-adjustment data into a single, unified source of truth. The result is a robust platform that empowers clinical teams, supports program innovation, and enables Matter Health to achieve performance gains that fuel national growth.

The Challenge: Building a Data Foundation That Can Support a High-Touch Model

Matter Health’s model requires a level of real-time insight, operational coordination, and clinical precision that is difficult for most health organizations to achieve, let alone a young, rapidly scaling organization with a lean analytics team.

As a value-based care organization managing seniors within Medicare Advantage value-based contracts, Matter Health needed to:

  • • Unify and enrich diverse data sources, including EHR (Athena), external clinical feeds, and claims with quality gap files from multiple payors

  • • Track leading indicators like visit frequency, closed encounters, AWV-like touchpoints, and care model adherence

  • • Measure and improve HEDIS, Stars, and contractspecific quality metrics

  • • Identify and close chronic condition recapture gaps (HCC/RAF)

  • • Understand cost and utilization trends and direct resources where they would have the most significant impact

  • • Empower executives, clinical leaders, and care teams with curated reporting aligned to organizational goals

The Partnership: A Flexible, HighTransparency Analytics Platform

Matter Health partnered with Ursa Health early in its journey, relying on Ursa as both a data platform and an extension of its analytics and data engineering teams. Ursa became Matter’s central data warehouse, ingestion layer, and measurement engine, supporting a wide range of clinical and operational use cases.

Building Clinical Operations Metrics and Leading Indicators

One of the first joint initiatives was defining and operationalizing the metrics needed to support Matter Health’s high-touch model. Ursa helped build:

  • • Visit frequency and recency tracking

  • • Custom AWV-equivalent visit measures

  • • Encounter closure timeliness dashboards

  • • Patient engagement indicators

Ursa built the underlying logic, data model, and dashboards, enabling clinical leaders to understand variation, prioritize resources, and track improvement in real time.

Advancing Stars and Quality Performance

Matter Health and Ursa collaborated intensely on HEDIS and Stars measures, leveraging Ursa’s NCQA-certified measure logic. Together they developed:

  • • Real-time quality performance views

  • • Delta-to-next-Star-rating insights

  • • Patient-level chase lists for care gap closure

According to Kristie, this work directly contributed to Matter Health achieving a performance rating of greater than 4 Stars in 2024 and remaining on track for 2025.

Closing the RAF Gap and Reducing Avoidable Utilization

Matter Health also needed a rigorous, actionable risk-adjustment engine to support RAF recapture and burden-of-illness management. Ursa extended its HCC foundations to help Matter:

  • • Distinguish between documentation gaps vs. claims lag

  • • Prioritize the patients most in need of re-diagnosis

  • • Build a custom program to operationalize recapture efforts

This work enabled Matter Health to achieve:

  • • Significant improvements in RAF accuracy performance

  • • Corresponding decreases in acute utilization, including ED and inpatient use

Empowering Leaders Through Curated, Role-Based Data Boards

Ursa also enabled Matter Health to shift from static reporting to a self-service model tailored to organizational accountabilities. Executives now have a curated board in Ursa that aligns to their OKRs, such as TOC performance for the CMO or encounter closure metrics for the VP of Operations.

Results & Impact

Through its partnership with Ursa, Matter has:

  1. Achieved outstanding Stars and HEDIS results
    Greater than 4-Star performance in 2024, with strong momentum for 2025.

  2. Improved risk adjustment and RAF accuracy
    Significant improvements and a scalable process for ongoing RAF management.

  3. Reduced avoidable utilization
    Better chronic condition management has driven meaningful reductions in ED and inpatient use.

  4. Increased operational transparency
    Leaders now have aligned, curated reporting environments that surface actionable, role-specific insights.

  5. Accelerated innovation despite a lean analytics team
    As Kristie summarized, “We did not need to hire 15 data engineers. Instead, we were able to put those resources into frontline care, because we know we can lean on Ursa.”

Looking Ahead: Expanding Into Cost, Utilization, and End-of-Life Programs

With strong foundations in quality and RAF, Matter Health is now working with Ursa as a strategic partner to expand into new domains, including:

  • • End-of-life identification and palliative care programs

  • • Advanced care planning analytics

  • • Deeper cost-driver analyses to inform new clinical programs

  • • Operational workflows powered by Ursa data inside frontline systems like Salesforce and Athena

Conclusion: A True Partnership Enabling High-Touch, High-Impact Care

Throughout its growth, Matter Health has relied on Ursa not simply as a vendor, but as a partner deeply committed to shared success.

As Kristie emphasized, “Every time we talk to investors or payors about our tech stack, I tell them we made the right decision. Ursa was the right choice.”

Together, Matter and Ursa are proving that with the proper analytics foundation, a high-touch model can be both operationally disciplined and deeply compassionate, delivering measurable outcomes for some of the most underserved seniors in the country.

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Matter Health is a healthcare organization focused on bringing high-quality and high-value care closer to patients’ homes, particularly serving affordable housing communities for seniors with barriers to traditional access. They use an interdisciplinary team and a location-based care model to build long-term patient relationships, address complex health and social needs, and improve overall health outcomes.
 
Ursa Health is a data analytics software and professional services company that is reinventing how organizations use data to practice, make decisions, and innovate in healthcare. To learn more, reach out to us
 

Read additional success stories from some of our other clients:

 

  • Atlas Oncology Partners – we built precise scenario models and payor-specific logic to power full-risk, value-based oncology contracting with confidence.

 

  • IntoValue – we created a shared, demo-ready analytics environment to support direct contracting between health systems and self-insured employers.

 

  • HarmonyCares – we maintained analytics integrity through a complex EMR migration while sustaining top-tier ACO performance across MSSP and ACO REACH.

 

  • Altitude – we paired Ursa's data foundation with clinician activation tools to turn analytics into personalized, within-workflow actions that drive behavior change.

 

  • Cityblock – we built a multi-source quality engine to move beyond compliance and focus care teams on closing real gaps for complex Medicaid and Medicare populations.

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