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Admission

Updated on January 4, 2022

An admission case is part of a medical record that documents the patient’s status, policy details, requesting and servicing provider details, facility information, admission type, level of care, member condition, admission dates, length of stay, diagnosis and procedure details.

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After the patient or member details are provided, the system checks if there are any active admission cases. It does not allow the case to proceed if there any active admissions. It also checks if the requested services require prior authorization and moves the case to the medical director’s workbasket if the prior authorization does not exist.

For more information, see Admission case management in the Pega Care Management Business Use Case Guide on the Pega Documentation home page.

The following list describes items that are related to the Admission Microjourney:

  • Data model for Admission
  • Configuring the observation days for an admission
  • Configuring the work group for medical directors
  • Modifying the skill-level settings for the medical director review
  • Associating work group operators with medical review skills
  • Configuring the work queue for medical directors
  • Configuring list of sources for admission case creation

Data model for Admission

In App Studio, you can view the Admission data model in Case types.

Click the Data model tab.

Configuring the observation days for an admission

Hospitals provide a limited amount of observation care for patients that is based on a well-defined set of specific, clinically appropriate services. These services include ongoing short-term treatment, assessment, and reassessment that are provided while a decision is being made about whether patients require further treatment as hospital inpatients or if they can be discharged from the hospital. You can configure the observation period for an admission case in Pega Care Management.

Before you begin: On the Pega Care Management Application configuration page, do the following:
  • Ensure that you have set values in the Admission work class and Admission notification work class fields in the Work classes tab.
  • Ensure that you have set values in the Medical directors work queue and the Medical directors work group in the Work queues tab.
  1. In the header of Dev Studio, click Configure Care Management Configuration.
  2. On the Care Management Application configuration page, click Other settings.
  3. In the Observation period for admission case (in days), enter a value.
  4. Click Save.
    The Resolved-Observation reason is validated against the admission date with the number of days configured for an observation period by using the ValidateDischargeDate validate rule.

Configuring the work group for medical directors

To ensure that the requests for authorization are routed correctly, configure a work group for the medical director review of an authorization. Ensure that you assign operators who have the medical doctors skills to the work group.

Before you begin: Ensure that you have a created work group. For more information, see Defining operator work groups, work queues, and schedules.
  1. In the header of Dev Studio, click ConfigureCare Management Configuration.
  2. Click the Work queues tab.
  3. In the Application workgroups section, in the Medical directors work group field, enter the name of the work group that your organization specified.
    For example: MDReview@MyHealthPlan
  4. Click Save.

Modifying the skill-level settings for the medical director review

You can change the work group in the Medical Director flow to correspond to the work queue that you specify on the Care Management Application configuration page. You can also change the skill level for the work group to meet the needs of your organization. For example, you might change the default skill level from 10 to 7.

For more information, see Medical Director review in the Pega Care Management Business Use Case Guide on the Pega Documentation home page.
  1. In the header of Dev Studio, enter and search for MedicalDirectorReview.
  2. Open the MedicalDirectorReview flow in the PegaHC-Care-Work-AuthRequest class.
  3. Click Save as and save the flow to your implementation layer ruleset.
  4. In the flow, double-click the Review authorization assignment.
  5. In the Assignment properties dialog box, in the Routing section, expand Parameters.
  6. Ensure that the work group corresponds to the work queue that you specified in the Configuring the work queue for medical directors task.
  7. To change the required skill, in the Routing section, perform the following steps:
    1. Click Update Skill.
    2. In the Level field, enter the value.
    3. Click Submit.
  8. Click Submit.
  9. Click Save to save the rule to your ruleset.

Associating work group operators with medical review skills

To ensure that the application can find an operator with the proper skills to route the authorization assignment, associate the skill and the appropriate level with the operator. For example, you might assign an operator with a specified skill to review out-patient authorizations or pharmacy authorizations.

  1. In an operator ID record, click the Work tab.
  2. In the Routing section, in the Skill field, select a skill or create one.
  3. In the Rating field, enter a value for the skill level.
  4. Click Save.
  5. Repeat these steps for each operator that you associate with a skill.
What to do next: You might want to modify the skill-level settings for the medical director review. For more information, see Modifying the skill-level settings for the medical director review.

Configuring the work queue for medical directors

To ensure that the requests for authorization are routed correctly, configure a work queue for the medical director review of an authorization.

Before you begin: Ensure that you have created a work queue. For more information, see Understanding project roles and personas.
  1. In the header of Dev Studio, click ConfigureCare Management Configuration.
  2. Click the Work queues tab.
  3. In the Medical directors work queue field, enter the name of the work queue that the system uses to route requests for authorization.
    For example: MDReview@MyHealthPlan
  4. Click Save.

Configuring list of sources for admission case creation

Based on your organization's requirements, you can provide other sources for use in admission case creation.

Rule nameRule typePurpose
NewAdmissionNotificationFlow actionNotifies the admission of a patient to a hospital or facility.
CreateMDReviewAdmissionCaseFlow action Checks if the prior authorization is required and routes the case to the medical director's work basket
IsPriorAuthRequiredData transformChecks if the requested services (procedure codes) are in the list of procedure codes that require prior authorization
D_PegaHCDataPriorAuthCodesListData page Fetches the configured list of procedure codes that require prior authorization
PegaHC-Data-PriorAuthCodesData typeMaintains procedure codes that require prior authorization
GetFieldvaluesReport definitionAdds or modifies complexity types; updates the field values with the Complexity field name .

Field name: Complexity

ServiceTypeCodeListReport definitionMaintains the supported service types for each request type in the PegaHC-Data-ServiceTypeCode data table.

Column name: AR (for admission)

GetFieldvaluesReport definitionReport for Clinical case types.

Field name: ClinicalCaseType

DiagnosisCodeTypesReport definitionFetches code set types.

Parameter is ServiceCodeType: pyWorkPage.Admission.ServiceTypeCode

AddCPContactsWrapperActivityAdds requesting or service provider details to a care provider team.
AddCPContactsActivitySaves a new contact, for example, a requesting or service provider

Key list rules for an admission case

Prompt list or local listPurpose
PrioritySource for the Priority list
AdmissionTypeCodeSource for the Admission type list
AdmissionSourceCode Source for the Admission source list
ConditionCodePatient Source for the Member Condition list
InpatientServiceLocationSource for the Level of care list
ProcedureCodeTypeSource for the Procedure code list

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