Pega’s Approach to Care Management

Pega’s Approach to Care Management

The American Care Management Association (ACMA), defines care management as: “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes.”

One of the most important aspects of this definition to Healthcare Payers is “quality cost effective outcomes”. There is no denying the adage, “An ounce of prevention is worth a pound of cure”, but with new regulation and competition in the healthcare insurance market, it is imperative that healthcare payers find ways to provide high quality care while still managing internal costs in order to stay competitive in this ever changing industry.

The Pegasystems Care Management Application (CMA) is uniquely suited to giving healthcare companies a strong head start into the development of a modern, dynamic application capable of changing to meet new regulations and initiatives. By utilizing the CMA, in conjunction with Pega’s powerful routing and workflow abilities it is possible to give a member streamlined and efficient care while allowing healthcare companies to only engage more expensive clinical resources when necessary, and to effectively use non-clinical care coordinators to complete many day to day tasks for the member. By properly balancing resource utilization, it is possible to provide a high level of interaction and care to a growing member population without needing to grow the number of clinical resources at the same rate.

In addition to managing work and tasks, with CMA and Pega it is possible to identify members with the highest probability of impact either through business rules created in Pega or through integration with third party healthcare stratification and predictive modeling tools. This allows Pega to weight and adjust urgency of cases to ensure that cases with the best chance for significant improvements to patient health and plan cost savings are presented to users quickly.

Having spent several months working on a care management application, I can see the dedication of the non-clinical care coordinators as well as the clinical staff, and I am excited at the prospects that a new system build on Pega presents to this customer, having participated in job shadowing of the current process I see that there is a tremendous opportunity using BPM to enhance current processes that already exist in Care Management and Disease Management and to leverage task routing to ensure that the right resources are doing the right work.

Leave a Reply