Pega Care Management case types and workflows
This section describes the standard Pega Care Management care items (also referred to
as case types), that are included with Pega Care Management and are available
for selection within the New Application wizard when you create your Care Management
application. Depending on your organization's needs, you might include all or a subset of
these case types in your application. These example case types represent some of the key features of Pega Care Management. Pega Care Management supports key roles that are associated with your
day-to-day use of the application. For more information, see Personas, access groups, and access roles. Data types that are used by Pega Care Management, are stored in external systems or,
where appropriate, internally to the Pega system.Case type Description Prior Authorization Request Case for prospective review and approval of a service or admission
that is needed for a member. Program referral Program enrollment allows patients to enroll in medical programs. It
also allows providers to request enrollment into programs on behalf of a
patient. Admission Case Case for creating member admission. Along with admission details
(admission date, length of stay, and admission type), the case captures
the diagnosis and procedure details. Discharge Plan This child case is automatically created from an admission case; it
is only created for inpatient members. The purpose of this case is to
capture the next steps for the care giver and member after
discharge. Discharge Worksheet This child case is automatically created from an admission case after
the concurrent review is completed or if concurrent review is not
required. The purpose of the discharge worksheet is to capture
medication detail, doctor and lab appointments, notes, and a review
summary. Concurrent Review This child case is automatically created from an admission case; it
is only created for inpatient members. It is automatically created based
on the length of stay or a certain diagnosis or procedure codes, or
both. Utilization managers can also add a review manually. The purpose
of the concurrent review is to manage a patient’s progression during the
hospital stay. Case conference A case created by a care manger to plan and conduct conferences among
care givers with or without the patient. A conference could be for visit
follow-up or utilization review. The purpose of a conference is to
capture the member's current issues and the care givers’ recommendations
to overcome those issues. Visit Visits are meetings between care managers and patients. Visits can
take place telephonically or in-person at a patient’s home. The Pega
Customer Service for Healthcare application allows schedulers to set up
these meetings. Scheduling is both triggered from and creates follow-up
work in the Care Management application. Medication Therapy Management (MTM) A case type to manage and enroll patients into Medication Management
Programs. The case walks through stages that are associated with the
Center for Medicare and Medicaid services expected protocols. Appeal A case type for raising an appeal and grievance on denial of
authorization or a grievance by the patient. Incident A case type for capturing an incident for the member. A care giver
captures the incident details (date, location, and incident type) along
with contact details of the person who reported the incident. UM Case A care manager can create this case to review the service and
utilization. It can be related to inpatient, outpatient, pharmaceutical,
or referral requests, as well as admission, concurrent, and
retrospective reviews. Care plan A case type for planning care for the patient. It can consist of
multiple child cases such as problems, goals, barriers, alerts, and
tasks to better manage members’ care. Alert An alert checks for the presence or absence of specific conditions
and notifies the care manager. Task A task is the basic element of a care plan that can be added to other
elements. Tasks can be of various categories and can be run once or
multiple times based on recurrence. Goal A case type to capture goals that need to be achieved as part of the
care plan for the patient. Goals can have barriers and interventions as
child cases. Barrier A case type to capture barriers that prevent the accomplishment of a
goal or completion of a care plan. There can be barriers directly tied
to the patient as well. Problem A case type to capture problems that a patient has and that needs to
be addressed while planning care for the patient. Intervention A case type to capture an intervention that is required to accomplish
a goal, mitigate a barrier, and complete a care plan for the
patient. General service request Used to address a customer issue when there are no service request
types more suitable for handling the situation. Customer service
representatives can select where to route the service request to
facilitate resolution. Interaction – chat Customer Chat interaction. Tracks interactions for this specified
channel and measures the duration, outcome, case history, and other data
that is related to the interaction. Interaction - inbound phone A phone call interaction with a member or provider. It tracks the
duration, outcome, case history, and other data that is related to the
interaction. Interaction – email Tracks inbound correspondence interactions for a member or provider
and measures the duration, outcome, case history, and other data that is
related to the interaction. Interaction - inbound social Interaction for a defined social channel. Tracks the conversations,
customer sentiment, topic, influence score, and other data that is
related to the interaction. Outbound phone interaction Phone call interaction with a member. Tracks the duration, outcome,
case history, and other data that is related to the interaction. Update patient profile Intent task to update the patient profile information including
address, phone, fax, email, and communication preferences. Code Group Used to define clinical concepts. Code groups are clinical building
blocks of important healthcare programs and initiatives. Code Set Used in inpatient settings for coding diagnoses and inpatient
hospital procedures and in physicians' offices and other outpatient
settings for diagnoses. Example case types
Example 1: Prior Authorization Request
Example 2: Program Referral
Example 3: Case Conference
Roles and portals in Pega Care Management
Primary data entities
Name Description System of record (SOR) Account role Role of the user Pega Accumulators – Family (Benefits) Records benefit accumulator data for a family. Benefits such as
annual out-of-pocket maximums and deductibles have certain limits
that are defined at the family level. All these limits are tracked
in accumulators. External Accumulators – Individual (Benefits) Records benefit accumulator data for an individual. Benefits such
as annual out-of-pocket maximums and deductibles have certain limits
that are defined at the individual level. All these limits are
tracked in accumulators. External Authorization Details Details of authorizations in the application Pega or External Business Entity Details of the business information held in the system Pega or External Care Team Contact Details for members of the patient’s care team Pega Claim Data Information that is related to claims submitted for a patient Pega or External Clinical Observation Data, received from external sources, that is related to clinical
data for a patient External Conference Type Case conference data for a conference that takes place in the
application Pega Contact Provides application access to contact data such as the name,
phone numbers, email address, account roles, social ID’s, and other
key data. Pega or External Conversation Logs Data captured from notes and Pulse and held in the Conversation
log section Pega Customer Address Provides application access to customer address data such as
address details (address lines 1-5, city, state, province, country,
and postal code), and related contact information such as contact
ID, first and last name, and other customer address data. Pega End Point Settings Stores end-point configurations Pega Insurance Contract Details on the insurance policies held Pega or External Late to Refill Reasons Maintains the late-to-refill reasons Pega LOINC Codes LOINC Codes that are used in the system Pega LOINC Units LOINC Units that are used in the system Pega Medical History Medical History for the patient or family, or both Pega or External Member Details about the patient Pega or External Member Incident Incidents for a patient External Member Notes Notes that are related to the patient cases Pega Member Risk Score The risk score that is identified for a patient External Medication Review Captures medication details such as drug-to-drug interaction,
side effects, and late-to-refill reason during a medication review Pega Medication Action Plan (MAP) The plan that is developed through MTM that helps patients
resolve problems that are related to their medical care and meet
specific health goals. This data entity is used to hold the data
that is related to the medication action plan Pega MTMMemberActionPlan The data class that holds data that is related to member action
items identified during the medication action plan Pega No Refill Reasons Stores reasons for not refilling a medication Pega Participant Type List of participants in visits and case conferences Pega Patient medications Stores details of the medications that are associated with a
member Pega or External Patient’s Allergy Information Details about a patient’s allergies External Patient’s Appointment Information Details about appointment information for a patient External Policy Policy information for the patient Pega or External Practitioner Details of the practitioners in the system Pega or External Prescription-Clinical Prescriptions and details for prescriptions for the patient External Product – Benefits List of benefits for the patient Pega or External Provider Affiliation Associations for providers and the organizations Pega or External Provider Contract Details of the contracts with the provider Pega or External Provider- Group/Facility Details of the contracts with the group or facility Pega or External Subscriber (Policy Holder) Details of the policy holder of the account External
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