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Population health management

Updated on January 11, 2022

Pega Care Management enables the user to manage health and wellness, disease, and care management processes from within a single platform. These processes are designed to follow industry guidelines by using stage-based programs which helps in delegating work depending on skill set for managing the care, that is, clinical and non-clinical staff. Through problem-oriented care plans, personalized health planning provides an organization to focus on the patient’s goals and barriers about their health, and leverages the patient’s motivations, informs and mitigates care gaps, alleviates medical and non-medical barriers, and drives health outside of standard protocols.

With integrations that use HL7 FHIR ® and other standard Pega integration tools, data from EMRs and IOT devices can be used to drive actions and communications to the care team and interested parties. Visits (home, telephonic or telehealth), either manual or automated, can be scheduled between nurse care managers/navigators and patients to plan, take assessments, and perform follow-up activities. Workflow activities can be easily configured to invite patients to participate in and maintain ongoing, multi-channel engagements, including review of specific goals and tasks for every participant. This allows care teams to establish best practice workflows, schedules, and tasks to optimize the patient care. For larger formal conferences, case conference scheduling, planning, and documentation are available.

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Care plan management

Pega Care Management provides full care plan documentation and management. With the wizard capabilities of the application, programs can be nested with goals, interventions, and tasks. This creates consistency at the outset of each program.

Customization of the care plan can take place through adding or removing items based on the preferences and engagement with the patient. Ad hoc problems, goals, and tasks can be created by the user when organizational offerings do not work for the patient and care manager. Reporting and workbasket configuration allow for monitoring of ad hoc items. Additionally, care plan elements can be identified through taking assessments. Items that are identified but not actively chosen to be on the care plan, are held within the program to allow the care manager and patient to return and review for appropriateness later.

Program referral

Pega Care Management provides a stage-based program referral process that can be initiated in various channels and routed to the appropriate resource for review and follow through. Upon completion of the Program referral, an organizational structured plan is generated for the manager and consumer.

Assessment management

Pega Care Management includes assessment and care plan templates that care teams can easily customize to meet their needs and accommodate their unique workflows. The authoring experience has been created to support the business analyst persona in authoring assessments, managing existing assessments, and previewing the assessment before publishing to the users.

The business analyst works closely with the development team for any detailed needs such as configurations that need to be created in the developer space. By using Pega Questonnaire, assessments use hide or showhow logic, scoring, and branching to support organizational requirements. Care plans can include the Pega best-in-class automated processing to improve consistency, accuracy, and productivity. Assessments can set up activities for the care team to act on or automated activities to facilitate communication among care team members. Clients who want to collect data but do not want to create care plans from the data, might consider using the core Pega Questionnaire that is located within the Dev Studio.

Mitigation of care gaps

Pega Care Management provides the ability to manage and mitigate identified care gaps. Effectively and proactively mitigating Care Gaps can significantly impact the quality of health of consumers, adherence with regulatory measures, and increased compliance with provider organizations.

Using Pega Customer Decision Hub (a separately licensed Pega product), organizations can utilize the healthcare xCAR to create campaigns, whether outbound or inbound to support informed decisions on closing these gaps. Benefits of mitigating care gaps include the following:

  • Compliance with regulatory requirements for care gap management
  • Proactively assisting consumers with addressing and closing care gaps
  • Decrease impact on providers to close gaps at the end of a business year through consistent mitigation
  • Increase quality health outcomes for consumers
  • Integration of data points (both clinical and demographic) to truly personalize and engage consumers for greater compliance

Identify and manage Social Determinants of Health

Pega Care Management supports identifying and managing Social Determinants of Health (SDoH), which are the non-clinical factors that impact a patient’s health.  Social determinants of health are conditions in the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. It is estimated that greater than 65% of people experience at least one social determinant of health.

Users can create barriers for the supported category of SDoH in the Business Analyst portal. The barriers that are related to SDoH categories are added directly to the member level, and an associated SDoH issue is flagged for the patient. The SDoH issues that are identified for the member are displayed in the header of patient profile.

Visit planning and scheduling through Microsoft Exchange integration

Pega Care Management provides an opportunity to plan, schedule, and conduct visits through the application. Visits can be telephonic or home-based. By using the Pega Mobile application, users can conduct visits on devices such as tablets while either connected or disconnected from the application. Additionally, during the scheduling stage, integration with Microsoft Exchange allows for visibility to the availability of key resources that are needed for the visit.

Care team management

Care teams are a primary part of the care of a patient. Knowing who to engage and when to engage is important to the relationship with the patient. Pega Care Management offers care team management for internal team members, external clinical team members, and personal support members.

Case Conference planning and conducting

Pega Care Management offers the ability to plan, schedule, and conduct case conferences within the application. By using data that is available on the Patient 360 and care plan, the case conference can be used to review important items that require follow-up and proper documentation. With Exchange integration, schedules can be checked to ensure that important resources can be available for the meeting. Next steps and assignment of actions are driven from the case conference.

Create and conduct a case conference
Shows where you create and conduct a case conference within the lifecycle

Integration with industry best practice guidelines

Pega Care Management offers certified workflow embedded integration with third-party clinical assessments with MCG’s Informed by MCG® for Disease Management which brings together state of the art clinical content with superior workflow capabilities. MCG’s Informed by MCG ® for Disease Management integrates fully with Pega Care Management, and assessments are delivered in the same manner as internally designed assessments.

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