Pega Care Management for Healthcare

PRODUCT OVERVIEW 7.21

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Pega Care Management for Healthcare

Document: Product Overview

Software Version: 7.21

Updated: October 2016

CONTENTS

Product overview............................................................................................... 1 Overview ....................................................................................................... 1 Key features .................................................................................................. 1

High-level functionality ..................................................................................... 2 Patient 360° view ........................................................................................... 2 Utilization management ................................................................................. 2 Population health management ..................................................................... 2 Assessment management ............................................................................. 2 Reporting ....................................................................................................... 3 Regulatory compliance .................................................................................. 3

Processes .......................................................................................................... 4 Standard processes ....................................................................................... 4

Portals ................................................................................................................ 5 User portal design.......................................................................................... 5 The utilization management portals ............................................................... 6 Care management portal ............................................................................... 7 Business analyst portal .................................................................................. 7 CMA fulfillment user portal ............................................................................. 8 Survey manager portal .................................................................................. 8 Developer’s configuration portal ..................................................................... 9

Pega Care Management for Healthcare Product Overview 1

Overview Healthcare organizations are bracing themselves for a care management tsunami fueled by growth in new, high-risk markets, and the global aging population. Stronger utilization control, efficacious disease and case management, and effective health and wellness strategies must be unified to reduce costs and garner improved health outcomes. Yet today’s care management efforts are suboptimal, performed in silos, constrained by traditional systems that lack interoperability, intelligence, and flexibility. Healthcare organizations are challenged to deliver appropriate care within the confines of inadequate technologies that cannot facilitate continuous refinement of clinical protocols and do not provide a synthesis of critical patient and population composite data. This results in highly skilled care professionals spending too much time working inefficiently—and often at odds with each other—rather than collaboratively delivering impactful healthcare services and improving outcomes.

Pega Care Management for Healthcare (CMA) is a rules-based, member-centric solution providing end-to-end care management capabilities across the care continuum spanning health and wellness, utilization, chronic disease, and acute episodic case management.

Key features Unified processes across utilization management, disease management, care management,

and health and wellness management.

Utilization and case management capabilities around prior-authorization/pre-certification management.

Care planning templates for business users to configure disease and wellness management protocols that are auto-executable.

Comprehensive member/patient profile including demographic, claims, authorizations, and clinical, visit history, incident history, audit trail, and notes data.

Aggregation of member/patient’s clinical data including vital signs, lab results, medications, and medical history.

Assessment tools that launch and recognize problem identification.

Configurable alerts for monitoring and responding to gaps in care, and out of range results.

Workflow embedded Integration with third-party clinical guidelines from McKesson and MCG that bring together state of the art clinical content with superior workflow capabilities.

Automated case management and control sends alerts, notifications, education, and correspondence to all involved parties, freeing the care manager from tedious letter creation.

Accelerators help program developers easily create and update the content of a care management program.

Real-time dashboards and ad-hoc reporting provide tools to monitor and balance workload.

Product overview

Pega Care Management for Healthcare Product Overview 2

Patient 360° view Pega’s Care Management application organizes all of the activities and participants around the core subject of all the work that needs to get done, namely, the patient. The Patient Profile captures detailed information including demographics, program enrollments, open requests, clinical data, recent claims, authorized contacts, care teams, associated visits, and associated incidents–and can also attach documents, notes, and other correspondence. The data in the fully-integrated, patient-centric platform can be updated and modified by the care manager or sourced directly from existing enterprise systems, or both.

Utilization management CMA offers a comprehensive utilization process that begins with prior authorization requests, denial opportunities for discussion, admission notification, concurrent review, discharge planning and transitions. CMA offers integration with National Clinical Guideline vendors that allow for clinical guideline review to be integrated fully within the workflow.

Population health management CMA provides processes for managing health and wellness management, disease management and care management processes from within a single platform. Wellness programs are typically population-focused, with preventative programs that help “healthy people stay healthy” and help at-risk people avoid future health problems. Disease management is typically for a subset population with a particular chronic disease (or diseases) that the payer or provider feel will be better served by engaging and implementing educational or other programs to improve the patient’s wellbeing and simultaneously minimizing the exacerbation of the disease. Case management relates to engagements with patients in pre or post-acute care or a complex medical scenario. Personal health planning provides an organization to focus on the patient’s goals, and barriers about their health, and leverage the patient’s motivations, alleviate medical and non-medical barriers, and drive health outside of standard protocols.

Assessment management Pega Care Management for Healthcare includes assessment and care plan templates which care teams can easily customize to meet their needs and accommodate their unique workflows. Care plans can include Pega’s best-in-class automated processing to improve consistency, accuracy and productivity. Visits can be scheduled between nurse care managers and patients to plan assessment and follow-up activities. Workflow activities can be easily configured to invite patients to participate and maintain on-going multi-channel engagements with them, including specific goals and tasks for every participant. This allows care teams to establish best practice workflows, schedules and tasks to optimize the patient care.

High-level functionality

Pega Care Management for Healthcare Product Overview 3

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Reporting CMA Reporting provides real time data through reports that can be viewed through a dashboard of active cases, operational reporting, as well as regulatory compliance. Reports can be automated to send to internal or external stakeholders.

Regulatory compliance Pega’s Care Management application is easily configured to route and escalate work to the right experts needed to make a decision or move a patient forward in their treatment. Decision rules can automate the approval of certain requested services while escalating other types of requests to utilization managers or medical staff for other requested services where human expertise or an individual review of the patient’s circumstances is necessary. As decisions are made by nurses and other experts or automatically by the software, Pega automatically routes the work to the next stakeholder who needs to perform a particular task, and can manage the entire set of activities against defined time frames, service level agreements (SLAs). Pega Care Management for Healthcare is designed to comply with industry standards such as HIPAA-compliant data usage and other standards.

Pega Care Management for Healthcare Product Overview 4

Standard processes This table lists the standard processes available with the Pega Care Management for Healthcare Application.

Process Description Pre-Authorization Request Process a request for authorization for coverage of services Outpatient Request Process request for coverage of Outpatient Services Inpatient Request Process request for coverage of Inpatient Services Pharmacy Request Process request for coverage of Pharmaceutical Services Referral Management Management of referral networks and service requests Duplicate Management Matching logic to bring awareness of possible duplicate authorization HIPAA 278 Processing for request for coverage via HIPAA 278 Admission Management Process for completing Admission Notification Concurrent Review Process for managing services while in flight Discharge Planning Planning and communication for proper transitions Appeal Processing Process of appeals for Medical necessity determinations Care Management Engagement and management of at risk Population Program Enrolment Enrollment and management of members in Care Management Programs Care Plan Management Managing and coordinating services with Care Teams Personal Health Plan New Plan of Care for managing patients without enrollment in a program Problem Management Set up and management of problems with member Goal Management Set up and management of Goals with member Task Management Set up and management of Tasks with member/provider/team Barrier Management Set up and management of Barrier with member Alert configuration Set up and design for Alerts and notifications based on clinical data Gaps in Care Management Set up and management notifications for gaps in care Fulfilment Management Set up and management of correspondence and fulfilment items Patient Profile Management Management of Patient data and details of care teams Care Team Management Management of Patient centric Care Teams User Management Administrative functions for bulk processing and management of work Clinical Data Management Documentation and integration of Clinical Data Reporting Real time and scheduled reports for operational efficiency and management Clinical Guideline Integration Integration with National Guidelines Vendors Visit Management Schedule and conduct visits and meetings between care managers and patients Incident Management Incident tracking for quality measures and regulatory reporting Assessment Offering Creation and management of Clinical and non-Clinical assessments which can result in

actionable activities.

Processes

Pega Care Management for Healthcare Product Overview 5

User portal design Pega Care Management for Healthcare includes a set of standard user portals to help manage various utilization and population health management activities.

Portal design features:

− Dashboards with configurable reports

The left panel describes recent work provided with patient context

Portals

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Easy access to pending work

Search features/user profile easily accessible in the top banner

Prioritized worklists

The utilization management portals Allow you to enter, and review referrals and authorizations. Integrated clinical vendor guidelines available for seamless embedded medical necessity review. Attachments easily managed and easy to find.

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Care management portal

The care management portal allows for the management of patient’s programs, and problems, providing a complete picture of the patient’s current and past health status. It provides a full 360 view of the patient, allows for the customization, tracking, and management of problems, goals, interventions, barriers, programs. It allows the aggregation of data to present a full 360 degree view of the patient in a single system.

Business analyst portal This portal allows a business analyst to configure care templates, define goals, alerts, programs, problems, to build a care plans and care programs. Streamlining the ability to launch care for subset of patients, and creating a framework from which care plan and program personalization can begin.

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CMA fulfillment user portal Though many fulfillment exercises can happen directly with e-mail, or portal responses, some educational material needs more manual support, sending physical mailers like a smart scale, a stress ball, or a pedometer will require the help of a fulfillment portal. In this portal the work associated with fulfillment is managed.

Survey manager portal Build assessment logic, and link survey answers to the creation of common care plan objects such as barriers to care, problems, or tasks. The survey helps to automate the patient’s current state with the next steps that an organization should take next to help the member/patient towards better health.

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Developer’s configuration portal