HEALTHCARE

Care Management Solution

Unified Care Management Across the Continuum
The Challenge
Marketplace pressures and heightened government mandates are pushing healthcare organizations (HCOs) to deliver higher-quality, yet more cost-effective services. Todays inflexible and siloed care management systems, anchored by aging technology platforms and sluggish manual processes, are insufficient for the current challenge. This challenge is heightened by new delivery mechanisms such as Accountable Care Organizations (ACOs) and reform incentives which increase the need for unified care management.

Care Management Transformation

Health care organizations are bracing themselves for a care management tsunami fueled by growth in new, high-risk markets and the age wave of the U.S. populace. Physicians and nurses are at a premium and healthcare costs are climbing at ever higher rates, with some experts predicting it will reach 20% of GDP by 2017. Stronger utilization control, efficacious disease and case management, and effective health & wellness must be unified to reduce costs and garner improved health outcomes. Yet, todays care management efforts are suboptimal performed in silos, constrained by traditional systems that lack interoperability, intelligence and flexibility. Healthcare organizations are challenged to deliver appropriate care within the confines of inadequate technologies that cannot facilitate continuous refinement of clinical protocols and do not provided critical composite data. This results in highly skilled care professionals spending too much time working inefficiently and often at odds with each other rather than delivering impactful healthcare services and improving outcomes. In response, forward thinking companies are now creating strategic initiatives that apply business process improvement capabilities to create competitive advantage. These market leaders are investing in Pegas Build for Change technology to transform and unify their care management functions across the continuum of care.

The Solution
Pegas BPM-based Care Management Solution provides end-to-end, optimized care management spanning health & wellness and utilization, disease, and case management. Our clients have garnered: 5x faster delivery of health & wellness programs 12% increase in automated authorizations 3x faster enrollment in care management programs 30% reduction in training costs

Care Management Solution

Key Product Features

Highlights

Clinical Guideline Integration

Embedded McKesson CareEnhance Decisioning Embedded Milliman CareWebQI Decisioning Direct Data Transfer from Guidelines to Solution

360 Person-centric Views Personalized Care Planning Payer / Provider Collaboration Guided Survey Assessments 5010 / ICD-10 Compliance Automated Authorization Processing Built-in Accelerators & System Management

Unified Care Management across

Adaptive, Pre-configured Portals Care Manager Provider Person Custom User Dynamic Case Management Enterprise Agility for Ever-changing Conditions Personalized Interactions & Processes Instant Response to Critical Conditions Direct Links to Related Pega Solutions Award-winning Customer Relationship Manager Appeals & Grievances Predictive & Adaptive Analytics Mobile Support Appeals & Grievances adds Intend-led, Streamlined Appeal & Grievance data capture Multi-level Appeal Process Directed Web-access External Feedback Auto-generated A&G Correspondence Object-Oriented Data Model Person-centric Pre-loaded Code Sets ICD-9 ICD-10 CPT HCPCS NCD GCN Industry Compliance X12 4010 / 5010 Messaging ICD-9 / ICD-10 Coding Support

Utilization Management Disease Management Case Management Health & Wellness

Utilization Management, including

Pre-certification Authorization Prior Authorization Referral Management Utilization Review Concurrent Review Discharge Planning

Disease Management, including

Care Plan Assessment Problem List Tasks Goals Alerts

Case Management, including

Personalized Care Plan Personalized Assessment Problem List Personalized Tasks Personalized Goals Authorization Requests

For more information, please contact your Pegasystems representative, visit us on the Web at www.pega.com, or email us at info@pega.com. Copyright 2011 Pegasystems. All rights reserved. 2011-6