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Care Management - Creating Programs

Updated on September 25, 2019

The programs created in and used by the Care Management Framework are composed of multiple building blocks. A Program contains multiple care plans. Each care plan can contain objects such as Alerts, Tasks, and Goals. An Alert can contain Tasks and Goals, but Task and Goals can also be part of the Care Plan without being part of an Alert.

The diagram of a Diabetes program below will help put clinical context into the structure of a program.

This program contains 3 care plans.

  • Initial Risk Care Plan – this care plan contains a Task to schedule an call to the member to perform an initial risk assessment
  • Low Risk DM Care Plan – this care plan contains a Task to schedule a call to the member to monitor perform an routine assessment every 8 weeks, a Goal that all members who have this care plan should have HbA1c less than 7%, and an Alert that would detect a claim indicating that the member is a current tobacco smoker. Notice that the Alert embeds a Task to send some fulfillment to the member and a Goal that the member enrolls in a smoking cessation program. That Alert (and the embedded Task and Goal) would only execute for that member if a claim that meets the criteria of the Alert is met.
  • High Risk DM Care Plan – this care plan contains an Alert that embeds a Task that will notify the case owner when the Alert finds claims evidence that the member was hospitalized, a Task to schedule a call to the member to provide a routine assessment every 7 days, the same Goal as in the Low Risk DM Care Plan that members should have HbA1c < 7%, and an Alert that will trigger two tasks if the Alert detects a claim for the member with a diagnosis of Heart Failure. One of the tasks will notify the case owner that the member has a complication; the second task will schedule a call to the member’s PCP within 3 days.


Creating Program Building Blocks

Program building blocks listed below are created and maintained using the Care Management Wizards menu accessible from a portal menu.

  • Code Groups — define a selection of industry codes (such as CPT or ICD-9-CM) that represent the clinical criteria an Alert uses to evaluate a member"s claims and authorization requests
  • Correspondence — defines the letters and e-mail templates that Send Email and Send Letter Tasks use to communicate with the member or the member"s PCP
  • Assessments — define a set of questions that can be used to assess a member's health status and can also be used to populate clinical data in the Patient 360
  • Data Sources — identify the activity that retrieves the data that will be used by the Alerts
  • Programs — specify the name of the Programs
  • Fulfillment — stores brochures or other materials used in Programs
  • Tasks — define the type of work to be performed
  • Goals — define objectives the member should meet
  • Alerts — define the criteria that is evaluated against a member's claims or authorizations
  • Care Plans — define the risk level of the Care Plan and all of the Alerts, Tasks, and Goals for the Care Plan

For step by step information about how to design and create programs, see Creating and Maintaining Care Management Programs

Return to About the Care Management Framework





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