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Pega Care ManagementImplementation Guide

7.4

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Pega Care Management Implementation Guideii

Document: Pega Care Management Implementation Guide

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Pega Care Management Implementation Guideiii

Contents

Contents

Application overview.................................................................................................................................................................................6Implementation delivery methodology....................................................................................................................................................6

Initiation stage...............................................................................................................................................................................6Delivery stage................................................................................................................................................................................ 7

Prerequisites................................................................................................................................................................................................ 8Initiation stage.............................................................................................................................................................................................8

Creating your application............................................................................................................................................................ 8Optimizing properties...................................................................................................................................................................9Creating a ruleset for Business Analyst templates................................................................................................................10Generating specification documents....................................................................................................................................... 10

Delivery stage...........................................................................................................................................................................................12Defining requirements............................................................................................................................................................................. 12

Mapping your application data................................................................................................................................................ 13External data sources................................................................................................................................................................ 13Defining integration....................................................................................................................................................................13Defining the case type modifications and attributes............................................................................................................ 16Configuring printers for bulk printing of authorization reviews..........................................................................................17Application data model..............................................................................................................................................................18Defining the security model and organization structure.....................................................................................................19Customizing the user experience.............................................................................................................................................23Definition of application components..................................................................................................................................... 23Defining the fields on the Incident report..............................................................................................................................26Defining options for a case conference.................................................................................................................................. 27Defining reporting requirements..............................................................................................................................................27Implementing the Pega Care Management mobile app.......................................................................................................27Uploading code sets...................................................................................................................................................................28Defining sample code group modifications............................................................................................................................28Defining parameters for an intervention logic flow.............................................................................................................. 28

Building features.......................................................................................................................................................................................29Updating your application settings..........................................................................................................................................29Assigning the workbasket for medical directors....................................................................................................................29Modifying the class structure................................................................................................................................................... 30Implementing the security model............................................................................................................................................30Modifying the user interface.....................................................................................................................................................30Creating your application components................................................................................................................................... 31Intervention logic........................................................................................................................................................................ 41Integrating your application with external systems.............................................................................................................. 42Extending your application........................................................................................................................................................43Reports......................................................................................................................................................................................... 49Building the Pega Care Management mobile app.................................................................................................................49Distributing the mobile app......................................................................................................................................................49

Testing a new application........................................................................................................................................................................49Testing your application in the Build environment............................................................................................................... 50Testing in the Test or Production environments....................................................................................................................50Testing in the UAT environment...............................................................................................................................................51Testing the connectors...............................................................................................................................................................52

Packaging a new application...................................................................................................................................................................52

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Merging application changes.................................................................................................................................................... 52Packaging an application for migration.................................................................................................................................. 53Importing the packaged application........................................................................................................................................53Multitenancy deployment considerations...............................................................................................................................53

Production maintenance and monitoring............................................................................................................................................54Business rule maintenance in the Production environment..............................................................................................................54Application health monitoring................................................................................................................................................................ 54Identifying and reporting issues.............................................................................................................................................................55

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Application overview

Application overviewPega Care Management provides organizations with the opportunity to manage patients through thelife cycle of engagement. Pega Care Management now uses Pega Customer Service for Healthcare as afoundational application that provides clients access to many Customer Service workflows and functions.The Pega Care Management application optimizes the creation and management of care and care plansfor patients through automated integration and workflow rules. You can quickly start using the applicationfor one area of care such as managing disease states or offering wellness campaigns and then easilyexpand to also support utilization management or case management for patients.

The application provides a unified approach that uses the value of highly skilled care-managementprofessionals to ensure that optimal care is delivered to both populations and individuals across chronicand acute conditions.

With Pega Care Management, organizations can build and manage programs and support caremanagement across all functions by providing a complete view of each patient including Internet ofThings (IoT), clinical information, assessments, and analytics. The application also enables care teams toconfigure programs that comply with industry standards, such as HIPAA-compliant data usage and otherstandards.

• Implementation delivery methodology

• Prerequisites

• Initiation stage

Implementation delivery methodologyIn most cases, use a scrum-based, Agile delivery model for a Pega application implementation. In the rarecases where a waterfall-based implementation methodology is better suited, use Pega’s Iterative Waterfallapproach. These two implementation methodologies help break down the work into manageablecomponents that you can deliver to production faster. The Pega delivery approach has the followingprimary stages:

• Initiation stage

• Delivery stage

Initiation stageIn the Initiation stage, the implementation teams build the foundation or baseline of the application andprepare for the work that is necessary to configure the first production release and subsequent extendedproduction releases. Keep in mind that the first production release is the minimal required scope to golive into production. Other capabilities can be added as part of the extended production releases. Buildinga strong foundation to support expansion and reuse is key to the success of an implementation.

The Initiation stage is further organized into the following sub-stages:

PlanAlign the vision and roadmap to establish the foundation for the implementation. The Plan sub-stageincludes the following tasks:

• Defining the production release milestone

• Refining scope alignment

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Application overview

Set upValidate and review the Pega-provided features and capabilities to see if they meet your requirements andexpectations. This sub-stage includes the following tasks: 

• Establishing environments and processes

• Reviewing application feature descriptions (in Designer Studio, click Application > Overview)

• Reviewing Application Guides for first production release setup information (in Designer Studio, clickResources > Application Guides)

• Creating the baseline application

• Loading customer data

• Demonstrating the baseline application

• Reviewing artifacts from the solution assessment

• Reviewing business needs and outcomes

PreparePrepare for the delivery of Pega Care Management by completing the following tasks:

• Confirming resources

• Enabling team members

• Establishing governance

At the conclusion of the Initiation stage, the scope of the work for the first production release is clearlydefined. For Scrum, the scope of the work is represented in an initial backlog. For Iterative Waterfall, aspecification list and schedule are prepared and finalized.

Delivery stageThe Delivery stage is dependent on the methodology selected (Scrum or Iterative Waterfall). Duringthis stage, the delivery team designs, builds, configures, and tests the application by using the selectedimplementation methodology. The goal is to accomplish the tasks that are described in this documentby organizing the Application Feature backlog so that the delivery team can configure the applicationincrementally with the result being a fully tested and performance-tuned application in production.

The Delivery stage is organized into the first production release and the extended production releasetypes.

First production releaseThis release includes only the essential features that are defined during the solution proposal stage andare required for the first release into production. The first production release should be implemented in90 days or less, depending on the scope of the essential features. This release type includes the followingfeatures:

• Core Pega-provided features

• Extended features considered essential for your business

• Key integrations with your systems to get data that you require

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Application overview

Extended production releaseThis release includes the non-essential features that are defined during the solution proposal stage. Thefollowing features are implemented incrementally after the first production release:

• Non-essential Pega-provided features

• Extended features that you have identified as required for your business

This guide provides information to support both Scrum and Iterative Waterfall implementationmethodologies during the first production release and the extended production release.

PrerequisitesBefore you start your Pega Care Management deployment, be sure that you understand the support forvarious browser versions. See the Platform Support Guide.

Initiation stageDuring this stage, the implementation teams build out the foundation or baseline of the application andprepare for the work that is necessary to configure the first production release and subsequent extendedproduction releases. For more information, see Implementation delivery methodology.

The Initiation stage includes the following tasks:

• Creating your application

• Optimizing properties

• Creating a ruleset for Business Analyst templates

• Generating specification documents

Creating your applicationTo meet your organization needs, create your application on which your extended application will be built.Use the New Application wizard to create your new application.

1. Log in by entering an administrator user name and password. If you have enabled a sampleadministrative operator for this application, optionally log in using that operator ID.

2. In the Designer Studio header, click the name of your current application and click New Application tostart the wizard.

3. Follow the New Application wizard instructions.For more information, see Creating an application.

4. Enter the operator names or email addresses to invite users to work with your new application, andselect the corresponding role for each operator you set up.It is a best practice to create at least one operator in the application-specific administrator role for usein completing the implementation.

5. Optional: To fully set up your application, in the upper-right corner of Designer Studio, clickResources > Application Guides and follow the setup steps.

The New Application wizard creates the application class structure for you. You can reuse the classesand rulesets that are created by the wizard in future applications that you create. As you implementthis application and future applications, you can apply class hierarchy and inheritance principles to help

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Application overview

you decide where in the class structure to create your rules to improve the maintainability and overallefficiency of your application.

For more information, see Class layers.

Optimizing propertiesAfter you run the Application Wizard and create a new application, the exposed columns for page-levelproperties from the framework work tables are not cloned properly. In an environment where user-defined functions (UDF) are disabled, the report definitions that fetch the specified properties will not run.

Framework class Property

PegaHC-Care-Work-Program .CMCareplan.pyCategory

PegaHC-Care-Work .CMTask.StartDateTime

.CMTask.RecurrenceLogic

.Appointment.Starttime

.Appointment.Endtime

.Appointment.MeetingType

.Appointment.ConferenceType

.Member.CustomID

PegaHC-Care-Work-AuthRequest .Authorization.RequestDate

.Authorization.RequestCategoryCode

.Authorization.ServiceTypeCode

.Authorization.ActionCode

.Authorization.RejectReasonCode

PegaHC-AG-Work-Appeal .RequestingProvider.ProviderName

.Urgency

.AppealReason

PegaHC-Care-Work-Visit .Appointment.Starttime

.Appointment.Endtime

.Appointment.MeetingType

.Appointment.ConferenceType

.Member.CustomID

PegaHC-Care-Work-CaseConference .Appointment.Starttime

.Appointment.Endtime

.Appointment.MeetingType

.Appointment.ConferenceType

.Member.CustomID

PegaHC-Care-Work-Task .Member.pyFirstName

.Member.pyLastName

.PCP.pyFullName

To correct this issue, use the information in the table above and follow the steps below for each propertylisted in the table.

1. In the Explorer panel of Designer Studio, enter the class name in the Search field.

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Application overview

2. Click Data Model  > Property.

3. Click the property name that corresponds to the specified class and follow the steps in Exposingproperties and populating database columns.

Creating a ruleset for Business Analyst templatesYou need to create a ruleset to store the care templates that you create in the Business Analyst portal.

1. Create a new ruleset by completing these steps:

a) In Designer Studio, click Application > Definition.

b) In the Application ruleset section, click Add ruleset.

c) Enter a name and click the Open rule icon.

d) Follow the steps in Creating a ruleset.

2. Click Designer Studio > Care Management Configuration.

3. Click the Other settings tab.

4. In the Ruleset field, enter the name of the template ruleset.

5. In the Ruleset version field, enter the version number for your care template ruleset.

6. Click Save.

Generating specification documentsTo avoid duplicating existing features, review the following documents to familiarize yourself with thedefault rules and rulesets of your application. During the solution assessment, a number of requirements,specifications, and other artifacts are captured to represent the scope of the work. If they are capturedin the Pega Platform, these artifacts can be reused to streamline the first production release scopeidentification.

You can export application specification and requirements artifacts from the Pega Platform, and thenimport them into your new baseline application so that you can build on the content that has alreadybeen created. For more information, see Exporting specifications and requirements and Importingspecifications and requirements.

Follow these procedures to generate documents that define what is contained within your application:

• Generating the Application profile

• Generating the Application document

• Generating the Specification document

Generating the Application profileThis document is created during the Sales stage and includes the process stages and steps, case types,reports, requirements, specifications, participants, collaborators, and actors that are associated with theimplementation of your application. It is a document that defines the scope of the application, and it alsoincludes the results of the presale gap analysis.

When you generate this document, you can include process flow diagrams.

To generate the document, log into your application by entering your newly created credentials, andfollow the procedure in Generating an application profile document.

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Application overview

Generating the Application documentThis document and its associated controls provide the ability to customize the presentation of theapplication information based on the document's intended audience. When you run the ApplicationDocument tool, you can include or exclude content by selecting and clearing various options.

During an implementation, this document reflects the current state of your application. The ApplicationDocument tool automatically updates the content of your document as you modify and extend yourapplication to reflect additional requirements. If you have not yet built anything, the content of thisdocument is the same as the application profile.

To generate the document, log into your application by entering your newly-created credentials, andfollow the procedure in Generating an application document.

Generating the Specification documentThis document shows all of the specifications and linked requirements associated with your applicationat the time that you generate the document. You can generate this document at any point during theimplementation life cycle to include any updates to the application's specifications and requirements.

Review this document before and after each sprint by using the available filters to tailor the content tomeet the business requirements of your implementation.

To generate the document, log into your application by entering your newly-created credentials, andfollow the procedure in Generating a specification document.

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Delivery stage

Delivery stageDuring this stage, the delivery team designs, builds, configures, and tests the application by using theselected implementation methodology. For more information, see Implementation delivery methodology.

The Delivery stage includes the following tasks:

• Defining requirements

• Building features

• Testing a new application

• Packaging a new application

Defining requirementsTo ensure that you stay on target for a successful deployment, use a structured approach for yourimplementation methodology. You will need to prepare for your implementation and determine keyaspects of the design that will affect the behavior of your application. Defining requirements for animplementation includes the following tasks:

• Reviewing extension requirements

• Refining customizations and determining the availability of required data and integrations

• Prioritizing, for example, revising the solution backlog, re-estimating the effort for extensions andcustomizations, and confirming the project scope

Defining your requirements also involves DCO sessions and incorporating those requirements into theapplication design. During these sessions, you review each of the case types and process flows that theapplication already provides.

Update the Application Specifications with planned changes as described in Specifications.

The Implementation Planning Workbook helps you capture decisions as you define your requirements. Youcan download the Implementation Planning Workbook from the Pega Care Management product page.

To define requirements, review the topics in the following sections:

• Mapping your application data

• External data sources

• Defining integration

• Defining the case type modifications and attributes

• Configuring printers for bulk printing of authorization reviews

• Application data model

• Defining the security model and organization structure

• Customizing the user experience

• Definition of application components

• Defining the fields on the Incident report

• Defining options for a case conference

• Defining reporting requirements

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• Implementing the Pega Care Management mobile app

• Uploading code sets

• Defining sample code group modifications

• Defining parameters for an intervention logic flow

Mapping your application dataThe application data types provide a default set of properties for your use. You can add or removeproperties from these data types depending on your requirements. You can also add new data types.

Use the "Data model" worksheet in the Implementation Planning Workbook to record your decisions duringthis procedure.

1. In the Designer Studio Explorer panel, click Data.

2. Click the data type that you want to modify.

3. On the Data model tab, determine the properties to add, remove, or leave unchanged. For moreinformation about data types, see Viewing data type details. Repeat these steps for any other datatypes, as necessary.

External data sourcesPega applications come with data types that you configure to point to a site's data. This helps you tobring information such as patient information or clinical data from external sites into the Pega CareManagement application. You configure these data types to integrate the site's data source into theapplication. Data types that should point to external data are marked with the Simulated data source icon.This replaces the provided sample data sources.

For more information, see Viewing external data entities.

Defining integrationInventory the external applications that exist at your site and plan how to connect to them.

An example is determining how the member profile information will be integrated.

Note: Identify integration points as early in your planning as possible. If a connection to anexternal data source is required and either the data does not exist or the interface to that datadoes not exist, you must account for the time to publish these data sources and the time toconfigure the interface for this application.

The External Data Entities landing page lists the application data types and shows the source for that data.

To record your decisions during this procedure, use the "Integration" worksheet in the ImplementationPlanning Workbook.

1. Identify all integration points for your application.

2. Identify which data is needed from each system of record, if you have not already done so .

3. Determine whether an interface to that system of record already exists and how to connect to it.

• Integration points

Integration pointsBased on your needs, you can integrate your care management application.

• Patient 360 profile

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• Change Healthcare Interqual

• MCG CareWebQI

• MCG Disease Management

• Microsoft Exchange Web Services

• Defining types of integration information using FHIR

Patient 360 profileYou must plan how to integrate systems that provide the data for the Patient 360 profile. Some of thedata that populates the profile comes from external systems, user interactions, and data collected fromthe application itself. Also, some of the data, such as membership information, can flow from PegaFoundation for Healthcare.

The Patient 360 profile has these sections:

• Patient banner

• Patient information

• Five tabs of patient information

To record your decisions about additional information that you want to add to the profile, use the"Customizing the Patient 360 profile" worksheet in the Implementation Planning Workbook on the PegaCare Management product page.

The Patient 360 profile displays a banner that includes a patient summary with recent notes, contactinformation, a list of healthcare policies, recent conditions and medications, patient-enrolled programs,and barriers for the patient. You can add information to this summary. For example, you might add linksto special programs that you offer to your patients or members.

The patient score is related to a patient's wellness and includes blood pressure, weight, pulse and glucosereadings. The value of the score can come from integration with third-party systems. A To do list has thepatient assignments and scheduled appointments. The Last engagement section includes a list of notesfrom patient interactions.

The Patient 360 profile also includes tabs of information that is related to the patient. Some of the datacomes from user interactions and data collected from the application itself. You can integrate with avariety of data sources. For example, you can integrate your claims system with your care managementapplication. For more information, see Integration services.

The following tabs of information appear in the patient summary.

• Care

• Patient care including goals, problems, barriers, intervention logic, interventions, and related tasks

• Clinical

• Laboratory results

• Information about vital signs

• Medications

• Allergies

• History

• Timeline of patient events such as case conferences or tasks

• Medical history

• Family history

• Completed assessments

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• Attached documents and correspondence

• Administrative

• Details of the care team members, including those who provide personal support

• Admissions

• Utilization management

• Authorizations

• Appeals and grievances

• Claims

• Programs

• Conversations

• Incidents

• Declined programs

• Appointments

• Case conferences

• Home visits

• Phone calls

Change Healthcare InterqualThe Pega Change Healthcare Interqual® Integration Solution is bundled with the Pega Care Managementand is referred to as a connector. It integrates your care management application with ChangeHealthcare's CareEnhance® Review Manager Application. This capability is licensed separately anddepends on a subscription service with Change Healthcare Interqual.

This connectivity allows you to use Change Healthcare InterQual directly from within the Pega Platformand have real-time, bi-directional interaction with the InterQual system.

Features of the connector include:

• Interqual book view for research on guideline subsets from the patient portal

• Seamless integration of Interqual guidelines during a UM Review

• Dynamic submission of Pre-Cert information for targeted criteria search

• Hospital stay concurrent review

• Automated Pre-Cert decision-based Interqual criteria met status

• The Review Manager case associated with Pre-Cert request

For additional information, see the following references:

• Integration with external systems

• Pega Integration Solution for Change Healthcare Interqual® Installation Guide on the Pega CareManagement product page.

MCG CareWebQIThe Pega Integration Solution for MCG CareWebQI integrates Pega Care Management with the MCGCareWebQI application to give you access to evidence-based best practices and guidelines so that you candocument your utilization man re comprehensive, consistent, utilization management practices.

For additional information, see the following references:

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• Integration with external systems

• Pega Integration Solution for MCG CareWebQI Installation Guide on the Pega Care Management productpage.

MCG Disease ManagementThe Pega Integration Solution for MCG Disease Management integrates Pega Care Management withthe Informed by MCG for Disease Management solution to provide chronic care assessments and careplanning tools for use in patient care. With real-time access to chronic care guidelines, care managerscan integrate these services into their workflows and rapidly build, document, and share care plans. Themodular guidance makes it easy to provide patients with education and self-care. This helps to reducethe incidence of emergency care utilization, 30-day readmissions, and preventable adverse outcomes forindividuals with chronic disease and other complex conditions.

For additional information, see the following references:

• Integration with extrenal systems

• Pega Integration Solution for MCG Disease Management Installation Guide on the Pega Care Managementproduct page.

Microsoft Exchange Web ServicesOptionally, you can integrate your application with Microsoft Exchange Web Services to scheduleappointments, check the availability of the participants, and also send them invitations to the meeting forvisit planning.

For information about the preconfigured SOAP web services for integrating with Microsoft ExchangeWeb Services, see the Pega Foundation for Healthcare Implementation Guide on the Pega Foundation forHealthcare product page.

Defining types of integration information using FHIRFast Healthcare Interoperability Resources (FHIR) is a next-generation standards framework created by theHealth Level 7 (HL7) organization. FHIR supports the interoperability and exchange of healthcare-relatedinformation between organizations. This includes clinical, administrative, public health, and research data.

With the Pega FHIR APIs in Pega Foundation for Healthcare, you can integrate your application withexternal electronic medical or health record (EMR/EHR) systems and other clinical data repositories.By using a FHIR API, you can obtain specified information about the patients that are managed in yourapplication. For example, you might want all new referrals or authorization records for a patient from athird-party system. Or once you have the initial policy information for a patient, you might want to receiveupdated policy records on demand.

1. Identify the FHIR APIs that will be used for integration with your care management application.For additional information, see Pre-configured REST APIs in the Pega Foundation for HealthcareImplementation Guide on the Pega Foundation for Healthcare product page.

2. Complete the "Integrating with your application by using FHIR" worksheet in the ImplementationPlanning Workbook on the Pega Care Management product page to record your decisions during thisprocedure.

Defining the case type modifications and attributesYour application includes a set of predefined case types. A case is defined as a service case or a servicerequest, which is a process that your staff will execute to service your customers.Each case contains oneor more processes that will be extended or created to meet your business requirements. If you do not seean existing case type, you can create one during your planning process.

• Updating case types

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• Adding case types

Updating case typesIf an existing case type is close to meeting your business requirements, you can modify it and use it.

1. In the Designer Studio Explorer panel, click Cases.

2. Click the case type that you want to modify.

3. Update the settings for a case type.

4. Update the processes associated with the case type.In addition, you can add processes by using the Case Designer.

5. Repeat these steps for any other case types, as necessary.

Adding case typesIf you require a case type that is not similar to an existing case type, create a new one that meets yourbusiness requirements.

For a list of the Pega Care Management case types, see Pega Care Management case types on the Pega CareManagement product page.

1. In the Designer Studio Explorer panel, click Cases.

2. Click Add a case type.

3. Enter the Name for the new case type.

4. Click Advanced Settings.

5. Select the Derived from (Directed) class.

6. Select the Derives from (Pattern) class.

7. Select the appropriate Ruleset and Ruleset version.

8. Click Submit.

9. Define a life cycle for the case type.

10. Click Finish.

Configuring printers for bulk printing of authorization reviewsCare management users need to be able to print or review cases for subsets of authorization reviews. Forexample, they need to print legal reviews, appeal reviews, diagnosis reviews, scheduled regulatory andaccrediting audits, or a random audit by date, as part of audit activities.

With the bulk printing of authorization reviews feature, you can move from printing single documents toprinting multiple reviews at a time.

As an implementer, you need to plan with the client for the number of printers that will be configured.The printers must be on the same server where your care management application resides.

Consider the following items:

1. Determine the number of printers that will be available for bulk printing of authorizations.

2. Configure the printers, and verify that the configured printers are displayed in the Print Options dialogbox that appears when you are bulk uploading authorization reviews.

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Application data modelThe application provides a set of data types, data pages, and sample data, which you can use to beginimplementing your application.

Data modeling involves creating a conceptual model of how data items relate to each other in anapplication. In the Pega Platform, the data model refers to a set of rules that work together to populatethe data in your application. The system displays this data to help you process the information and canhelp you make decisions in your sales processes. The following rule types constitute your data model:

Data typesData type is another name for a class in your application. It holds data that the application uses. A datatype has one or more data pages and several property definitions associated with it.

PropertiesProperties define the format and visual presentation of data in your application.

Data pagesData pages define the content of a clipboard page. Data pages also control the loading of that data froma source system, as shown here.

A related concept to data pages is integration. Integration controls how the data is retrieved from thesystems of record to populate your application data pages. Data mapping rules determine how the datafrom the system of record corresponds to your application data model.

Pega Care Management and the underlying Pega Foundation for Healthcare provide a robust industry-standard model that is used in the application and can be used for additional extensions.

When planning your data model, work with the data modeling resource at your site to understand theattributes of the data types that need to be supported by your application.

Note: Pega Care Management uses the Pega Platform system of record for application data.Optional: You can integrate your application data with your Pega Platform system of record.

For additional information, see the Product Overview on the Pega Care Management product page.

• Adding properties to data types

Adding properties to data typesData types categorize the data that your application uses. The data types that come with your applicationhave one or more data pages associated with them. Add properties to a data type to further customize it,for example, by adding contact information to a data type that represents a user of your application.

1. In the Designer Studio Explorer panel, click Data.

2. Click the data type that you want to modify.

3. On the Data model tab, scroll to the bottom.

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4. To add a property, click Add field. Add as many properties as your application requires. Repeat thesesteps for any other data types, as necessary.

For more information about data types, see Data type management.

For information about data pages, see Data pages.

For information about adding data types, see Creating a new data type.

Defining the security model and organization structureSecurity planning involves defining authorization and authentication strategies for your application.

AuthenticationProves to the application that you are who you say you are.

AuthorizationDetermines the functions that you can perform in the application. This corresponds to access group androle configuration.

Security planning also involves setting up the organization structure and operator attributes. Theapplication provides security in the form of access settings and denial rules. Many integration rules alsoincorporate authentication.

For more information about the additional aspects of security, enroll in the Lead System Architect course onPega Academy and cover the Security lessons that correspond to the following topics:

• Authentication schemes

• Defining your authentication scheme

• Defining your authorization scheme

• Defining your organization structure

• Defining the operator attributes

• Access groups and users

• Access roles and privileges

• Settings for the Medical Director work group

• Associating work group operators with Medical Review skills

Authentication schemesThe Pega Platform offers the following authentication types:

PRBasicBased on passwords in the Operator ID data instances and the login form. This is defined by the HTML@baseclass.Web-Login rule, which your application can override.

PRSecuredBasicSimilar to PRBasic, but passes credentials using Secure Sockets Layer (SSL) using Basic HTTPauthentication. The login form is defined by the HTML @baseclass.Web-Login-SecuredBasic rule,which your application can override.

PRCustomSupports access to an external LDAP directory or a custom authentication scheme.

PRExtAssignSupports external assignments (Directed Web Access).

J2EEContext

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Specifies that the application server in which the Pega Platform is deployed uses JAAS to authenticateusers.

Defining your authentication schemeYour site can use a centralized, automated means of maintaining operator data instead of maintaining itmanually in your care management application.

To record your decisions during this procedure, use the "Security Model" worksheet in the ImplementationPlanning Workbook.

1. Discuss Authentication schemes with your site's security and application server teams.

2. Determine the appropriate authentication type.

For more information on authentication scheme planning, see Authentication in Pega Platform.

Defining your authorization schemePega Care Management application comes with a predefined set of access groups, roles, and privileges.You can use the application roles as a starting point, but you should create your own application-specificaccess groups and roles to avoid any future problems when upgrading.

Other rule types such as sections, flow actions, and activities use roles and privileges to allow access tothese rules at run time.

Note: You can review the Pega Care Management access groups and roles in Pega Express.

Defining your organization structureUse the organization structure for routing and reporting within the application. Typically, the applicationorganization structure does not map operators exactly to the site's organization chart but instead, it mapsthe work that those operators do.

Tip: For design guidance, see Organization landing page.

Use the "Organization structure" worksheet in the Implementation Planning Workbook to record yourdecisions during this procedure.

1. Click Designer Studio > Org & Security > Organization > Organizational Chart.

2. Review the existing structure.

3. Determine the organization, division, and unit levels of the hierarchy.

Defining the operator attributesAn operator's access group affects what the operator can do in the application. In addition to the accessgroup, the following fields in the operator record influence how the application handles assignment ofwork to the user:

• Work group

• Skills

• Calendar

Tip: In many implementations, it is more efficient for the application to set values in the operatorrecord during the authentication process than it is to have an administrator manually maintainthese records. These rules must be configured as part of the authentication mechanism for yoursite. For more information, see Authentication Services.

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For more information, see Operator IDs.

• Defining the operator work group

• Defining the operator skills

• Defining the operator calendar

Defining the operator work groupThe work group setting in the operator record affects how your application delivers work to the operator.Review the Operator record and determine the rules for assigning a work group to an operator or the rolethat multiple operators hold.

To record your decisions during this procedure, use the "Organization structure" worksheet in theImplementation Planning Workbook.

1. Click Designer Studio > Org & Security > Organization > Operators.

2. Select an operator ID.

3. On the Work tab, review the work group information for the operator record.

4. Determine your policy for assigning a work group to an operator or the role that multiple operatorshold.

For more information, see Work settings tab on the Operator ID form.

Defining the operator skillsSkill settings in the operator record affect how the application routes work to the operator. Skill settingsalso affect how the application gets the most appropriate work when using the Get Next Work feature.You must determine the skills that are appropriate for your application and operators.

Read the Expert Assist Tech Note on the Customer Service page to learn how to use operator skill settingsfor Expert Assist.

To record your decisions during this procedure, use the "Organization structure" worksheet in theImplementation Planning Workbook.

1. Define the skills that are needed for the application.

2. Determine which operator records or roles should be associated with those skills.

Defining the operator calendarThe application calendar affects date calculations within the application, such as the date betweenbusiness days calculation, and the SLA goal and deadline date calculation. The calendar on the operatorrecord is relevant only if you have users who are not working in the same time zone as the rest of theorganization. Otherwise, the application uses the calendar on the organization record and you can skipthis step.

Operator calendars will have an impact on chat availability. If a chat request comes in after or beforethe business hours defined in the specified calendar, then the requestor receives "Off-hours behavior"message.

To record your decisions during this procedure, use the "Organization structure" worksheet in theImplementation Planning Workbook.

1. Determine the calendar instances that are needed for your application.

2. Determine which operator roles need a distinct calendar.

3. Determine the operator location.

For more information, see More about Calendar data instances.

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Access groups and usersYour care management application includes access groups and users.

To view the access groups and users, click Designer Studio > Application > Structure > Access Groupsand Users.

Access roles and privilegesPega Care Management includes a set of predefined access roles and privileges for the standardapplication user roles. For information, see Pega Care Management access roles and privileges on the PegaCare Management product page.

For information about creating your own access roles and privileges, see Creating an access role name.

Settings for the Medical Director work groupBy default, the following settings determine the assignment of authorizations that have a skill level greaterthan 10.

Type of authorization Skill required

Inpatient AdmissionReview

Outpatient HealthServices

Referral SpecialtyCare

You assign a name to the Medical directors workbasket. See Assigning the workbasket for medicaldirectors.

To modify the skills required for a review of an authorization request, see Modifying the skills for a reviewof an authorization request.

To change the work group or skill level in the Medical Director flow, see Overriding the Medical Directorflow settings.

To associate operators with Medical Review skills, see Associating work group operators with MedicalReview skills.

Associating work group operators with Medical Review skillsYou need to associate at least one operator in the Medical Review work group with each skill that has alevel greater than 10 so that the application is able to find at least one operator to route the authorizationassignment.

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. For additional information, see the Operator ID form- Completing the Work tab.

4. Click Save.

5. Repeat these steps for each operator that you associate with a skill.

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Customizing the user experienceWhile Pega Care Management is fully functional immediately after installation, you may change portionsof the user experience (UX) to meet the needs of the users at your site. Pega Care Management includesthe latest UI tool kit.

To design the user experience, complete the steps in the following topics:

• Designing portals

• Designing an application skin and styles

• Designing for screen performance

Designing portalsReview the content of the Business Analyst portal to ensure that only relevant data is presented.

To record your decisions during this procedure, use the "Portals" worksheet in the ImplementationPlanning Workbook.

1. Click Designer Studio > Launch web interface > CM Care Manager Portal.

2. Review each of the portal sections.

Designing an application skin and stylesYour site very likely has user experience (UX) standards for the appearance of your applications. Your taskis to determine which styles have to change to adhere to those standards. To record your decisions duringthis procedure, use the "Skinning" worksheet in the Implementation Planning Workbook.

1. Click Designer Studio > User Interface > Skins, interfaces, & templates.

2. On the Skins tab, double-click the CMA skin.

3. Click the Component Styles tab.

4. Review each component.

Note: As you plan your application styles, consider using mixins to provide incremental stylechanges. For more information, see Using mixins in the skin to drive consistency and efficiency.

Designing for screen performanceYou want your application to respond immediately as your end users interact with customers. As youdesign your user interface, complete the following steps:

1. Review transactional service level agreements. For example, the customer details must be available inone second or less while a representative is on the phone with the customer.

2. Review service performance, such as how long it takes back end systems to gather the data needed todisplay customer details.

3. Review data requirements to determine which fields contain the information that the representativesabsolutely need for the task that they need to perform.

4. Determine if any network configuration could cause latency, for example, if there are representativeslogged in through a corporate VPN or in a remote location.

Definition of application componentsYour care management application provides a guided process to help you define components that areneeded for care plans, programs, and the personal health plan.

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The dashboard in the Business Analyst portal provides a system administrator or a business analystaccess to instances of configured rules such as goals, tasks, interventions, and alerts for the managementof chronic conditions and wellness and preventative programs. Each rule type has its own templatefor creating and maintaining these instances. At run time, when these rules are called in the contextof a patient’s care plan, a work object is created. With these reusable components, you can create andmaintain care plans to manage programs that are based on the needs and designs to meet your businessobjectives.

You must plan for and create the instances of the following rule types to meet your business needs:

Program categorySpecifies the name of the clinical category in which the program is being managed, such as CareManagement, Disease Management, and Health and Wellness.

ProgramSpecifies the name of the clinical condition or chronic disease program that is being managed such asDiabetes, Asthma, Smoking Cessation, Post-Discharge or Re-Admission Prevention, Falls Risk, and High-Risk Maternity. The programs are categorized as Disease Management, Case Management, or Healthand Wellness programs.

Care planSpecifies the name of the clinical condition or chronic disease program that is being managed such asDiabetes, Asthma, Smoking Cessation, Post-Discharge or Re-Admission Prevention, Falls Risk, and High-Risk Maternity. The programs are categorized as Disease Management, Case Management, or Healthand Wellness programs.

TaskDefines the automated and manual user actions such as scheduled phone calls, scheduled riskassessments, sending fulfillment, sending correspondence (emails and letters), and interventions.

GoalDefines an objective to be met by the patient within a given time frame, for example, achieve HbA1clevels <7.

AlertDefines the automated queries against claims and authorizations data sources that are used formonitoring changes, that is, the presence or absence of clinical events.

ProblemDefines issues that are associated with the patient that need to be addressed.

FulfillmentRefers to documents, brochures, or educational materials that are sent to a patient or a patient'sPrimary Care Physician (PCP). By selecting this rule, you can attach these files to the associated programand program category.

BarrierDefines situations that prevent a patient from completing a goal.

InterventionPromotes behavior to improve mental and physical health or discourage or redirect those with healthrisks.

Intervention logic templatesIdentifies observations or changes in patient data and defines automated actions.

For additional information, see the Diabetes example.

To create the components, see Creating your application components.

• Program enrollment care plan

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• Diabetes program example with three care plans

Program enrollment care planA care plan is a set of activities that are identified to manage the care of a patient. A care plan can containproblems, goals, barriers, tasks, and interventions.

Additionally, patients can be enrolled in condition-specific programs that contain alerts, goals,interventions, and tasks within the program (You configure these items in the Business Analyst portal).Within the care plan, users can filter on a specific program in order to see the care plan elements thatare associated with that program. For example, during an assessment, answers to a specific question, orseries of questions, results in the triggering of tasks and goals for the patient. In working with a patient, acare manage can also personalize the care plan with other problems, goals, and tasks as agreed to by thepatient.

The following example shows that a patient is assessed for diabetes and then is enrolled into one of thethree Diabetes Programs, based on the assessment.

Initial Risk assessmentThis type of care plan is used to schedule an initial risk assessment task.

Low Risk diabetes managementThis type of care plan is used to manage a low-risk diabetic.

High Risk diabetes managementThis type of care plan is used to manage a high-risk diabetic with more active management.

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Diabetes program example with three care plansThe following example shows that a Diabetes Program is managed with three care plans.

Initial Risk Assessment Care PlanThis type of care plan is used to schedule an initial risk assessment task.

Low Risk DM Care PlanThis example shows the types of alerts, goals, and tasks that can be set up to manage a low-riskdiabetic.

High Risk DM Care PlanThis example shows the types of alerts, goals, and tasks that can be set up to manage a high-riskdiabetic with more active management.

Defining the fields on the Incident reportYou create incident reports when an unexpected event occurs, including situations when a patient makesa complaint, a medication error occurs, or a medical device malfunctions.Your application provides anIncident report that you can use as is or customize it to meet your business needs. For example, youmight want to add another person who can report the incident to the Relationship list on the report.

1. To view an Incident report, log in to the CM Care Manager portal.

2. In the Care Management header, click Patients and select a patient.

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3. Click Actions > New > Report incident.

4. Use the "Defining additional fields for an Incident report" worksheet in the Implementation PlanningWorkbook on the Pega Care Management product page to view the sections where you can add fieldsand record your decisions about additional fields.

5. Configure the additional settings. See Extending the Incident report.

Defining options for a case conferenceA case conference is held with care team members and other interested parties to discuss and documentthe coordination of the care and follow-up for a patient. You can extend the application-provided caseconference to add options to meet your business needs.

1. To record your decisions during this procedure, use the "Defining Case Conference options" worksheetin the Implementation Planning Workbook on the Pega Care Management product page.

2. Configure your options by following the steps in Extending the case conference from a specified launchpoint.

Defining reporting requirementsBased on your login and portal, your application provides numerous pre-configured reports to monitorcase and work inventory as well as monitor workforce productivity and quality. These standard reportsare driven by the case and work object life-cycle infrastructure as well as the work and assignment-levelservice level rules for goals and deadlines used in managing the life cycle of a case.

For additional information, see the Pega Care Management Business Use Case Guide on the Pega CareManagement product page.

Implementing the Pega Care Management mobile appThe Pega Mobile Client is a service that enables the quick building of mobile apps from the Pega Platformapplication. You need a license for the Pega Mobile Client.

To implement the Pega Care Management mobile app, review the following items:

1. Verify that Pega Platform settings are complete.These settings are configured during the system configuration phase by the Pega Platformadministrator in your organization. If they are not configured, contact the administrator to verify thatyour organization has been licensed to use the Pega Mobile Client app building feature. If you do nothave a license, contact your account executive.

2. Determine if the organization needs to customize the mobile app.

For information about the Pega Mobile Client API, see Pega Mobile Client API reference and Using thePega Mobile Client API within a Pega application.

If you are planning to build a mobile app, consider configuring your mobile app’s functionality withsupport of device-specific features, such as a barcode scanner.

3. Make sure that you have a certificate set for the Android or iOS mobile platform. A certificate setdefines various settings which identify the Android or iOS application that you are creating.

For information about the certificate set for the Android platform, see Creating an Android certificateset.

You need to generate the iOS certificate set in the Apple Developer Portal ahead of time. SeeGenerating mobile certificates for the iOS platform.

4. Determine if the organization wants to brand the mobile app.

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You can customize the branding of your mobile app to serve the organization's specific requirementsand needs. You can upload your own images for the splash screen and menu icon to the Pega Platformduring the app customization process. If you do not provide custom assets, a default Pega Platformbranding is applied. For additional information, see Preparing custom branding assets.

For more information, see Building the Pega Care Management for Healthcare mobile app.

Uploading code setsA code set includes codes that are used for encoding data elements, such as tables of terms, medicalconcepts, medical diagnosis codes, or medical procedure codes. Based on your business requirements,you must upload the code sets to Pega Foundation for Healthcare.

For example, the industry-standard ICD-10 code sets consist of two parts.

• ICD-10-CM diagnosis coding that is used in all United States healthcare environments

• ICD-10-PCS inpatient procedure coding that is used in United States hospital environments

Follow the steps that describe how to upload code files in the Pega Foundation for Healthcare CommonCodes Solution Business Use Case Guide on the Pega Foundation for Healthcare product page.

Defining sample code group modificationsBy using the Healthcare Common Codes solution that is provided by Pega Foundation for Healthcare, youcan modify sample code groups or establish new code groups to fit your business needs.

Your application includes the following two code groups to establish the need for concurrent review.

• Diagnosis codes for mandatory concurrent review

• Procedure codes for mandatory concurrent review

To record your decisions during this procedure, use the "Defining sample code groups" worksheet in theImplementation Planning Workbook on the Pega Care Management product page.

1. Log in to the Code Manager portal of your application by using the credentials that you specified forPega Foundation for Healthcare. For additional information, see the Pega Foundation for Healthcareproduct page.

2. In the Code Manager Portal header, click Code Groups.

3. In the Search field on the Code groups page, enter Diagnosis codes for mandatoryconcurrent review and click Search.

4. In the results list, select and open the specified code group, and discuss the codes that you want toadd. Use the "Defining sample code groups" worksheet in the Implementation Planning Workbook torecord your decisions about additional codes.

5. In the Search for field, enter Procedure codes for mandatory concurrent review and clickSearch.

6. Repeat step 4.

7. To modify the sample code groups, see Modifying code groups for a concurrent review.

Defining parameters for an intervention logic flowBy using intervention logic, you can define one or more algorithms to identify observations or changesin patient data and initiate automated actions. For example, a cardiac patient submits their weight daily.Based on an identified percentage of change over a period of time, your care management applicationtriggers predetermined actions such as making an appointment with a doctor, or contacting a nutritionist.

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An intervention logic template is the mechanism for examining one or multiple data points that your caremanagement application compares against the defined algorithm. You define the actions in the template,which are based on the specified algorithm. According to the information received, the application triggersthe algorithm and initiates actions for the patient. The information that your application receives might bewhen an electronic medical record provides a new observation or some data, a care team member entersinformation in the patient record, or a third-party source provides information.

To use intervention logic, perform the following steps:

1. Define the parameters and record your decisions by using the "Defining parameters for interventionlogic " worksheet in the Implementation Planning Workbook on the Pega Care Management productpage.

2. In Designer Studio, create a flow for each intervention logic template that you define. For additionalinformation, see Creating a flow for an intervention logic template.

3. In the Business Analyst portal, create an intervention logic template that corresponds to the flow thatyou create in step 2. For additional information, see Creating an intervention logic template.

Building featuresTo build your application features, complete the steps in the following topics:

• Updating your application settings

• Assigning the workbasket for medical directors

• Modifying the class structure

• Implementing the security model

• Modifying the user interface

• Creating your application components

• Integrating your application with external systems

• Extending your application

• Reports

• Building the Pega Care Management mobile app

• Distributing the mobile app

Updating your application settingsThe key application configuration settings are maintained on the Care Management Applicationconfiguration page in the Designer Studio menu. Settings include information that is related to work, rule,data, and accelerator classes status for work objects. These settings populate the Declare_CM_Env datapage. The application references this data page to set work and data class names at run time.

If you update data types, classes, or rules, update the configuration page.

1. Click Designer Studio > Care Management Configuration.

2. Update the settings as you implement your solution.

3. Click Save to save the settings.

Assigning the workbasket for medical directorsYou need to assign a workbasket for the Medical Director review of an authorization request so that therequests are routed correctly.

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1. In Designer Studio, click Designer Studio > Care Management Configuration.

2. Click the Workbaskets tab.

3. In the Medical directors workbasket field, enter a name.

4. Click Save to save the settings.

Modifying the class structurePega Care Management automatically creates your class structure. When you modify the structure, followthe correct naming conventions. For more information, see Classes.

Implementing the security modelAfter you review the existing groups and roles to determine additional groups and roles that you need,create them by clicking Designer Studio > Org & Security > Groups and Roles. Make sure that you arelogged in as an administrator. For information on configuring groups and roles, see Groups and Roles andrelated topics.

Modifying the user interfaceTo modify the user interface, complete the steps in the following topics:

• Determining which part of the user interface to modify

• Locating the user interface element to change

• Adding properties to sections

• Adding sections

• Updating the skin

Determining which part of the user interface to modifyWhen you first access your application portal, you see the dashboard, which typically contains informationabout the patient. The content of the dashboard is customizable and displays any data that you integrateinto your application.

You can also customize the Patient view.

Locating the user interface element to changeTo determine which user interface element to modify to implement your change, use the Live UI featureof the Pega Platform.

1. In Designer Studio, launch a portal.

2. Click the Live UI icon.

3. Select an element to observe. When selected, the Live UI icon provides the information about the UIelement. You can see the sections and harnesses of the element.

4. To update the rule, click the Open in Designer Studio icon.

Adding properties to sectionsPega Care Management uses standard Pega Platform user interface components, so the update process isthe same as any Pega Platform application.

1. In Designer Studio, click Live UI and determine the section that you want to modify.

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2. To open the rule in Designer Studio, click the Magnifying glass icon.

3. In the Application Explorer, locate the property that you want to add to the section and drag it into thatsection.

4. Click Save as and then save the rule to the default Applies To class and make sure that the ruleset is foryour application.

5. Click Create and open and click Save.

Adding sectionsPega Care Management uses standard Pega Platform user interface components. Whether you areupdating the dashboard, Patient 360 view, or the portals, you follow the same procedure as you do for anyPega Platform application.

1. In Designer Studio, click Live UI and locate the section where you want to add another section.

2. To open the rule in Designer Studio, click the Magnifying glass icon.

3. In the Application Explorer, locate the section that you want to add and drag it into your specifiedsection.

4. Click Save as and save the rule to the default Applies To class. Make sure that the ruleset is for yourapplication.

5. Click Create and open and then click Save.

Updating the skinYou can update the look and feel of your application to reflect the color scheme of your organization. Theapplication uses the standard Pega Platform skinning features in your application.

For more information about skins, see Creating a skin and Skin inheritance.

1. In Designer Studio, click Application Name > Skin.

2. Update the options as needed, and then click Save as.

3. Click Create and open.

4. If you give your skin a different name, update the application to reflect it by performing the followingsteps:

a) In Designer Studio, click Application Name > Open Application.

b) Change the value in the Skin field to the name of the skin that you created.

5. Click Save.

Creating your application componentsCreate your components in the Business Analyst portal by using the information that you specified duringthe Define stage.

For examples of programs, see Program example and Diabetes program example. Also, see Definition ofapplication components.

• Creating goal templates

• Creating barrier templates

• Configuring intervention templates

• Creating task templates

• Creating alert templates and specifying the data source

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• Selecting codes, goals, and tasks for an alert

• Creating care plan templates

• Configuring problem templates

• Creating fulfillment templates

• Creating program templates

Creating goal templatesTogether, patients and clinicians agree on the goals that they want to achieve to help with disease andhealth management. These goals can be part of standard programs and standard problems or can beadded directly to a patient's personal health plan.

In the case of goals, the follow-up for achieving goals can be associated with service level agreements(SLAs). Before you create goals in the CM Business Analyst portal, ensure that you create the SLAs tosupport them.

Goals can be created in an ad-hoc manner at the level of the personal health plan.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Goal and enter a name for the goal.

4. Complete the details in the wizard by selecting options from lists, clicking buttons to indicate a choice,selecting a check box when appropriate, and entering text when needed.

5. Click New to create a new goal or Copy from existing goal. If you are copying an existing goal, selectthe goal from the list.

6. Click New to create a new SLA or Select existing SLA. If you are copying an existing SLA, select the SLAfrom the Select Existing SLA list.

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

8. Click Next to add one or more interventions to the goal.

9. Select the intervention category and the intervention from the lists. Click Add intervention.

10. Repeat step 8 for each intervention that you are adding.

11. Click Next to review the information.

12. When you complete the review, click Finish.

Creating barrier templatesWithin the context of a care management case and goal achievement, a barrier is anything that prevents apatient or a member from completing the goals that are documented in the system.

If you have glucose self-monitoring as a goal and you have not been taught the self-monitoring process,then you have a barrier. In this example, if you are also blind, that might change the way that theeducation is delivered.

You can create barriers in an ad-hoc manner at the level of the personal health plan.

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1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified.

2. Click Launch web interface > CM Business Analyst

3. In the navigation panel, click New > Barrier and enter a name for the barrier.

4. Complete the details in the wizard by selecting options from lists, clicking buttons to indicate yourchoices, selecting a check box when appropriate, and entering text when needed.

5. Click New to create a new barrier or Copy from existing barrier. If you copy from an existing barrier,select it from the Copy from existing barrier list.

6. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

7. Click Continue to add one or more interventions. For additional information, see Configuringinterventions.

8. Click Continue to review the information and then click Finish.

Configuring intervention templatesA health intervention is an effort that promotes behavior to improve mental and physical health ordiscourage or redirect those with health risks.

An intervention template can be created in an ad-hoc manner at the level of the personal health plan. Thecare template manager can create an intervention template as a rule in the Business Analyst portal. Anintervention template is part of the problem, goal, and barrier hierarchy and can be assigned an outcome.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Intervention and enter a name for the intervention.

4. Complete the details in the wizard by completing the fields.

5. Click New to create a new SLA or Select existing SLA. To create a new SLA:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

6. Select an option from the Select starting flow list to start the processes that occur during anintervention.

7. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

8. Click Continue to advance to the Add tasks step.

9. Select your options and click Add task.

10. Click Continue to advance to the Review information step.

11. Click Finish after you review the information.

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Creating task templatesA task defines automated or manual actions such as scheduled phone calls, scheduled risk assessments,sending fulfillment, sending correspondence (emails and letters), and interventions that are performed bymedical personnel.

These actions include the following task types:

• Creating a notification task template

• Creating a task for an MCG assessment template

• Creating a record observation task template

• Creating a schedule assessment task template

• Creating a schedule call task template

• Creating an email task template

• Creating a fulfillment task template

• Creating a send letter task template

Creating a notification task templateYou can create a task to automatically send an email to the case owner.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select NotifyCaseOwner.

5. Click New to create a new task or Copy from existing task to reuse existing information. Complete theremaining fields.

6. Select the Auto resolve check box to indicate that no manual intervention is required.

7. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

8. Click Create and then click Close.

Creating a task for an MCG assessment templateYou can specify the scheduling of an MCG assessment when you create a task. This task type provideseasy access to industry-leading, evidence-based best practices and assessments so that you can supportclinical decision-making.

You must have installed Informed by MCG for Disease Management solution. For more information, seethe Pega Integration Solution for MCG Disease Management Installation Guide on the Pega Care Managementproduct page.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select Schedule MCG Assessment.

5. Click New to create a new task or Copy from existing Task to reuse existing task information.

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6. Click New to create a new SLA or Select Existing SLA to use an existing SLA.

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

8. Click Create and then click Close.

Creating a record observation task templateA care manager creates a record observation task for a patient to monitor a condition. For example, if apatient experiences higher than normal blood pressure, the care manager creates a task for the patientto take blood pressure readings three times a day for a month to obtain more information related to thecondition.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select RecordObservation.

5. Click New to create a new task or Copy from existing Task to reuse existing task information.

6. Click New to create a new SLA or Select Existing SLA to use an existing SLA. To create a new SLA,follow these steps:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. Select the Execute once check box to indicate that you want the task performed once.

When the case manager adds the task to the care plan, and the value entered in the End after fieldexceeds the default value, an agent handles the recurrence process. For example, if the default valueset by the administrator is 10 recurrences and the care manager schedules 100 recurrences, an agenthandles the processing due to performance reasons. The care manager needs to close the case forapproximately two minutes so that the agent can create the recurring tasks.

8. If you clear this check box because you want the task to occur multiple times, complete the recurrenceinformation:

a) Enter a value in the Every field and click the appropriate button.

b) Enter values in the Frequency and End after fields.

9. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

10. Click Create and then click Close.

Creating a schedule assessment task templateA care manager schedules a phone call to a patient to perform an assessment and associates aquestionnaire with this task.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

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2. Click Launch > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select ScheduleAssessment.

5. Click New to create a new task or Copy from existing Task to reuse existing task information.

6. Click New to create a new SLA or Select Existing SLA to use an existing SLA. To create a new SLA,follow these steps:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. In the Recurring task creation mode section, click one of the options to create and schedule allinstances now or create the next instance when the previous one is complete.

8. Select the Execute once check box to indicate that the task is performed only once.

If you clear this check box, enter a value in the Every field and click the appropriate button. Then, entera value in the End after field.

When the case manager adds the task to the care plan, and the value entered in the End after fieldexceeds the default value, an agent handles the recurrence process. For example, if the default valueset by the administrator is 10 recurrences and the care manager schedules 100, an agent handles theprocessing due to performance reasons. The care manager needs to close the case for approximatelytwo minutes so that the agent can create the recurring tasks.

9. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

10. Click Create and then click Close.

Creating a schedule call task templateA care manager creates a task to schedule a phone call to a patient or the patient's primary carephysician.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select ScheduleCall.

5. Click New to create a new task or Copy from existing Task to reuse existing information.

6. Click New to create a new SLA or Select Existing SLA to use an existing SLA. To create a new SLA,follow these steps:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. In the Recurrring task creation mode section, click one of the options to create and schedule allinstances now or create the next instance when the previous one is complete.

8. Select the Execute once check box to indicate that the task is performed only once. 

9. If you clear this check box because you want the task to occur multiple times, complete the recurrenceinformation:

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a) Enter a value in the Every field and click the appropriate button.

b) Enter values in the Frequency and End after fields.

When the case manager adds the task to the care plan, and the value entered in the End after fieldexceeds the default value, an agent handles the recurrence process. For example, if the default valueset by the administrator is 10 recurrences and the care manager schedules 100, an agent handles theprocessing due to performance reasons. The care manager needs to close the case for approximatelytwo minutes so that the agent can create the recurring tasks.

10. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

11. Click Create and then click Close.

Creating an email task templateYou can generate a pre-configured email to a patient or a patient's primary care physician.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select SendEmail.

5. Click New to create a new task or Copy from existing Task to reuse existing information.

6. Click New to create a new SLA or Select Existing SLA. To create a new SLA, follow these steps:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. Select the Auto resolve check box to indicate that no manual intervention is required.

8. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

9. Click Create and then click Close.

Creating a fulfillment task templateWhen you create this task, the application automatically sends fulfillment, such as brochures oreducational materials, to a patient or a patient's primary care physician.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select SendFulfillment.

5. Click New to create a new task or Copy from existing Task to reuse existing information.

6. Click New to create a new SLA or Select Existing SLA. To create a new SLA, follow these steps:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

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7. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

8. Click Create and then click Close.

Creating a send letter task templateWhen you create this task, the application automatically generates a pre-configured letter to either apatient or a patient's primary care physician.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Task and enter the name of the task.

4. In the Category list, select SendLetter.

5. Click New to create a new task or Copy from existing Task to reuse existing information.

6. Click New to create a new SLA or Select Existing SLA. To create a new SLA, follow these steps

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

7. Select the Auto resolve check box to indicate that no manual intervention is required.

8. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

9. Click Create and then click Close.

Creating alert templates and specifying the data sourceAlerts can scan information such as patient claim history to check for the inclusion or absence of certaininformation, such as a claim’s primary diagnostic code, that help determine whether a particular careprogram may be relevant for the plan member. You can configure alerts to run on a regular basis byscanning the member base and creating a follow-up set of activities to inform those prospects about thecare plan and tracking their enrollment and participation.

Before you create an alert template, have the code groups available, and create tasks and goals and makethem available.

To enter the alert information and specify the data source for the template:

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified.

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Alert and complete the fields.

4. Click New to create a new goal or Copy from existing alert to reuse existing information.

5. Click New to create a new SLA or Select Existing SLA. To create a new SLA:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

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6. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

7. Click Continue to select the data source for the alert.

8. Complete the fields in this step and click Continue to select the codes.

Selecting codes, goals, and tasks for an alertAfter you enter the alert information and specify the data source, perform the following steps to select thediagnostic codes and configure goals and tasks for an alert.

1. In the Select codes step, complete the fields for the Code group and Code list sections.

2. Select the Restrict to primary check box to indicate that the primary diagnosis is key for codeselection.

3. Click Continue to add goals to the alert template.

4. Based on your category selection, select an option from the Goal list.

5. Add the goal and repeat the steps for each goal that you add.

6. Click Continue to add tasks to the alert.

7. Based on the category selection, select an option from the Task list.

8. Add the task and repeat the steps for each task that you want to add.

9. Click Continue to review the alert information.

10. After you review the information, click Finish.

Creating care plan templatesA care plan template defines the pre-configured combination of tasks, goals, alerts, and intervention logicthat you use to manage a care program. You configure workflow activities to invite patients to participatein and maintain ongoing multi-channel engagements, including specific goals and tasks.

Be sure that you created an intervention logic template and corresponding flow. See Creating anintervention logic template and Creating a flow for an intervention logic template

You can create multiple care plan templates for a given program, such as Low Risk Diabetes or High RiskDiabetes.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Care plan and enter a name for the care plan.

4. Select options for the duration of the care plan, the program category, and the name of the program.

5. Click New to create a new care plan or Copy from existing care plan.

6. In the Initial assessments section, click the Add assessment link and add one or more assessments.

7. Check the Default care plan check box to automatically assign a default care plan template.If you do not select the Default care plan check box, the Risk level list becomes available and youcan select the appropriate care plan template.

8. To make this template available for use, select the Active check box.For example, this means that a care manager can find the template when searching or a businessanalyst can use it when attaching tasks to an intervention in the Business Analyst portal.

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9. Complete the remaining fields in this step, and click Continue to advance to the Add alerts step.If you encounter an error, you need to either select a default care plan or select another program.

10. Complete the fields for the remaining steps of the wizard to add goals, tasks, and interventions. ClickContinue at the end of each step.

11. After you review the information, click Finish.

Configuring problem templatesA problem is a component that supports your care plan. It consists of issues that are associated with apatient and need to be addressed, for example, a medical condition such as diabetes. A problem is madeup of goals to address the problem and a task to mitigate the problem and address the goals.

Problems can be created in an ad-hoc manner at the level of the personal health plan.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Problem and enter the name of the problem.

4. Complete the details in the wizard by selecting options from lists, clicking buttons to indicate a choice,selecting a check box when appropriate, and entering text when needed.

5. Click New to create a new SLA or Select existing SLA. To create a new SLA:

a) Enter a name in the New SLA field, and click the Add icon.

b) In the Create a new SLA window, complete the fields and click Submit. For information about thesefields, see Setting goals and deadlines on the Service-level agreement form.

6. To make this template available for use, select the Active check box. For example, this means that acare manager can find the template when searching or a business analyst can use it when attachingtasks to an intervention in the Business Analyst portal.

7. In the Add goals step, select a goal category, a goal, and click Add goal.

8. Repeat this step for each goal that you need and then click Continue.

9. In the Add tasks step, select a task category, a task, and click Add task.

10. Repeat this step for each task that you need and then click Continue to review your information.

11. After you review the information, click Finish,

Creating fulfillment templatesA fulfillment represents brochures or educational materials that can be sent to a patient or the provider.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Fulfillment.

4. In the Program category list, select the clinical category to which the fulfillment applies.

5. In the Program list, select the program with which the fulfillment is associated.You can add programs in Designer Studio.

6. Enter a description of the fulfillment and the fulfillment file name. Then upload the file.

7. Click Create.

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Creating program templatesYou can create programs to meet your organization's needs.

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified.

2. Click Launch web interface > CM Business Analyst.

3. In the navigation panel, click New > Program.

4. Click Add program.

5. Enter a name for the program.

6. In the Category list, select the clinical category in which the program is managed.

7. Click Create.

Intervention logic

Creating a flow for an intervention logic templateTo monitor new incoming patient data in your application, create a flow that compares a patient's dataand runs a specified algorithm. Use the information that you define in the "Defining parameters for anintervention logic flow" worksheet in the Implementation Planning Workbook.

1. In the Designer Studio Explorer panel, click App and search for PegaHC-Care-Work-InterventionLogic.

2. Click Process > Flow.

3. Right-click Flow and click Create.

4. On the Create Flow page, complete the fields and click Create and open.

5. Complete the flow and click Save. For additional information, see Creating a flow.

6. To display the name of the flow in the intervention logic template that you define in the BusinessAnalyst portal, click the History tab.

7. In the Custom fields section, click the Add field link.

8. In the Name field, enter pyCategory.

9. In the Value field, enter Yes and click Submit.

Creating an intervention logic templateIn the Business Analyst portal, create an intervention logic template to identify observations or changes inpatient data and define automated actions. For example, when a patient submits data through a RecordObservation task, Care Management looks for intervention logic cases that are monitoring the specifiedobservation, and runs the algorithm that you defined in the related flow.

Ensure that you create the flows that Care Management calls when observations take place or data isreceived. See Creating the flow for the intervention logic template.

To create an intervention logic template:

1. Log in to the application by entering the user name for the Business Analyst operator and thepassword that you specified. 

2. Click Launch web interface > CM Business Analyst.

3. In the left navigation panel, click New > Intervention Logic.

4. Enter the name of the task and the information that is required to define the intervention logic.

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5. To indicate that the task is available for use by case managers during a search or a business analystwhen attaching tasks to an intervention in the Business Analyst portal, select the Active check box andclick Continue.

6. In the Define Outcomes steps:

a) In the When list, select a rule. For example, with a weight condition, you might have separate rulesfor a 5% and 10% increase in weight.

b) In the Care Template type list, select either Task or Intervention logic to indicate a task or therunning of another algorithm. For example, if there was a 5% increase in weight, you might choosea task which indicates that the patient contact a nutritionist for a consultation. If there was a 10%increase in weight, you might select Intervention logic to run an algorithm to review other datapoints, such as pulse.

c) In the Select Value list, select a value and click Add.

7. Click Finish.

Integrating your application with external systemsYou can integrate with other applications or systems. The following topics describe integration with yourapplication:

Be sure that you review the planning items that are described in Integration points.

• Pega Integration Solution for Change Healthcare Interqual

• Pega Integration Solution for MCG CareWebQI

• Pega Integration Solution for MCG Disease Management

Pega Integration Solution for Change Healthcare InterqualFor information about Pega Integration Solution for Change Healthcare Interqual with Pega CareManagement, see:

• Integration with external systems

• Pega Integration Solution for Change Healthcare Interqual Installation Guide on the Pega CareManagement product page.

Pega Integration Solution for MCG CareWebQIFor information about integrating the Pega Integration Solution for MCG CareWebQI lwith Pega CareManagement, see the following:

• Integration with external systems

• Pega Integration Solution for MCG CareWebQI Installation Guide on the Pega Care Management productpage.

Pega Integration Solution for MCG Disease ManagementFor information about integrating the Pega Integration Solution for MCG Disease Management with PegaCare Management, see the following:

• Integration with external systems

• Pega Integration Solution for MCG Disease Management Installation Guide on the Pega Care Managementproduct page.

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Extending your applicationYou can extend your care management application to meet your business needs. You can perform thefollowing tasks:

• Extending the care team list

• Extending the print case summaries

• Extending the case conference from a specified launch point

• Extending the header status in the member profile

• Extending the Incident report

• Extending the patient timeline of events

• Extending your program enrollment case

• Changing the number of tasks displayed on a care plan

• Modifying code groups for a concurrent review

• Changing the event order in the Last engagement section

• Overriding the Medical Director flow settings

• Modifying the skills for a review of an authorization request

• Configuring the assessment setting for discharge plans

• Configuring the default assessment for the HRA program

• Changing the setting for locking patient notes

• Changing the source on the Patient Risk Score data page

Extending the care team listYour application includes a list of existing internal care team member roles. During implementation, youmight have added more user roles. To meet your business needs, you can extend the internal care teamlist on the Pega Care Management configuration page when you identify additional roles who need tointeract with a patient. For example, your non-clinical care management representatives might be askedto engage with patients. In this example, you would add the existing role of CM User Rep to the internalcare team.

In the application, a user role is not available to be added to the internal care team unless the role isassociated with a user profile. Make sure that the user role is associated with a user profile.

1. In Designer Studio, click Designer Studio > Care Management Configuration.

2. On the Care Management Application configuration page, click the Drop-down arrow next to Closeto display additional tabs.

3. On the Access roles for internal team tab, click the Add a row icon below the Access role field.

4. In the Access role field, select a name from the list.

5. Click Save. An individual must be assigned to the specified access role in order for the access role to bedisplayed in the Pega CM Care Manager portal. For additional information, see More about Access Rolerules

Extending the print case summariesYou can extend the print case summaries to include additional information for printing.

1. Update the Print harness with the additional information that you want printed.

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2. Click the Scripts & styles tab.

3. In the Scripts section, insert two rows.

a) In the first row, enter harness_print in the Name column. Select js as the type.

b) In the second row, enter harness_print_post_activity in the Name column. Select js as thetype.

4. To customize the printing behavior, save the PrintMemberDetails activity to your ruleset and modifythe activity as needed.

5. Click Save.

Extending the case conference from a specified launch pointA case conference is held with care team members and other interested parties to discuss and documentthe coordination of the care and follow-up for a patient.

You can extend the application-provided case conference by adding conference types and launch pointsthat meet your specific business needs. For example, you might add a 45-day follow-up case conferencethat you want launched from the Patient 360. You can view this new option only in the Patient 360.

1. Log in to the application by entering the credentials for a Business Analyst and clicking webinterface > CM Business Analyst.

2. At the bottom right of the portal, click Edit.

3. On the Conference type page, scroll to the bottom of the list and click +Add record.

4. Enter the name of the conference type that you are adding in the first field. Then enter the launchpoint in the second field.

5. Repeat steps 4 and 5 for all your additions.

6. Close the window.

Extending the header status in the member profileWhen a patient is discharged from the hospital, the patient status on the patient profile header isdisplayed for 90 days. You can modify the when rule to specify a different number of days.

1. In Designer Studio, enter IsDischargeDuration in the header search text field.

2. On the When:IsDischargeDuration page, change the numerical value to reflect the number of daysthat you want the message to display in the header.

3. Click Save as.

For additional information about When rules, see When Condition rules.

Extending the Incident reportAfter you record your decisions about additional fields that you want included in the Incident report,configure the additional fields. For example, you might want to add more options that describe the impactof the incident.

1. In the Designer Studio Explorer panel, click Cases.

2. Click Incident.

3. Follow the steps in Updating existing case types.

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Extending the patient timeline of eventsA patient timeline of events tracks patient experiences including authorization requests, admissions, andincidents that occur. It provides a visual presentation of the different engagements. A patient timelineappears on the History tab of a Patient 360 profile. By default, the following events appear on thetimeline:

• Admission case

• Visit

• Authorization request

• Task

• Case conference

You can choose to display or hide the events in a patient timeline. You also can remove an event or addanother event for all patient timelines. To meet your organization's needs, you might add another event,for example, you might add an intervention event to the timeline.

1. In Designer Studio, click Designer Studio >  > Care Management Configuration.

2. On the Care Management Application configuration page, click the Drop-down arrow next to Closeand select Patient events.

3. In the Timeline events section in the Work class column, click to display a list of class names for casetypes. For example, if you are adding an intervention event to the timeline, select the PegaHC-Care-Work-Intervention class to display the Show intervention label on the timeline.

4. In the Display name column, click to display a list of properties related to the class that you selectedin step 3. For the intervention example, you might select . CMIntervention.pyLabel to display thename of the intervention on the timeline.

5. In the Display date column, click to display a list of properties related to the selection in step 4.For example, you might select . StartDate to display the point when the intervention starts on thetimeline.

6. Click Save.

See the video that shows how to add an incident report to a patient timeline.

Extending your program enrollment caseYou can extend your program enrollment case to avoid duplicate enrollments.

1. In the Explorer panel, click Case types

2. Scroll down to Program referral and click it to open the case

3. On the Workflow tab, in the Referral stage, click +STEP to add a step.

4. Click More > Utilities > Duplicate search.

5. Adjust the flow according to your case. For more information, see Case types.

Changing the number of tasks displayed on a care planYou might want to change the number of tasks that are displayed on a care plan at one time. Bydefault, the Pega Care Management application sets the display to seven days of tasks. Based on yourorganization's needs to change the display, follow these steps.

1. In the Designer Studio header search box, enter pyLoadMyCasesNestedOneWP.

2. Click the report definition in the PegaHC-Care-Work class to open it.

3. Click Save as and save the change to your implementation-layer ruleset.

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4. On the Report Definition page, scroll to the Edit filters section.

5. In row C (Column Source : .CMTask.StartDateTime), click Select values next to the Value column.

6. In the Select Values list, scroll to the Day section and select an option, for example, 30 Days.

7. Click Submit.

8. Click Save and then click Check in.

Modifying code groups for a concurrent reviewYour care management application includes the following two code groups that you can modify to make aconcurrent review that meets your business needs.

• Diagnosis codes for mandatory concurrent review

• Procedure codes for mandatory concurrent review

1. Log in to the Code Manager Portal of your application by entering theCodeManager@PegaHealthCodes operator ID and the password that you specified.

2. Make sure that you have an open ruleset. For additional information, see the Pega Foundation forHealthcare Business Use Case Guide on the Pega Foundation for Healthcare product page.

3. In the Code Manager Portal header, click Search > Code Group.

4. In the Search for field, enter Diagnosis codes for mandatory concurrent review and clickSearch.

5. In the results list, select and open the specified code group. Use the decisions that you recorded inDefining the sample code group modifications. See the Pega Foundation for Healthcare Business Use CaseGuide on the Pega Foundation for Healthcare product page.

6. In the portal header, click Search > Code Group.

7. In the Search for field, enter Procedure codes for mandatory concurrent review and clickSearch.

8. Repeat step 5.

Changing the event order in the Last engagement sectionThe CM Care Manager Portal displays a Last engagement section for each patient in their patient profile.This section contains events such as out-of-range lab results, phone visit, patient notes updated, homevisit follow-up, and authorization.

Based on the priorities of your organization, you can change the order of the events in the Lastengagement section.

1. Launch your application by entering the administrative credentials that you specified.

2. In Designer Studio, click Designer Studio > Care Management Configuration.

3. On the Care Management Application configuration page, click the Drop-down arrow next to Closeand select Patient events.

4. In the Recent Activity section, in the Display order column, modify the numbers to reflect the orderof events for display.

5. Click Save.

Overriding the Medical Director flow settingsYou might have to change the work group in the Medical Director flow to correspond to the workbasketthat you specified on the Care Management Configuration page. You also might want to change the skill

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level required for the work group to meet the needs of your organization. For example, you might changethe default level from 10 to 7.

1. In Designer Studio, search for and select the MedicalDirectorReview flow.

2. To make changes to this flow, click Save as and save it to your implementation-layer ruleset.

3. In the flow, click the Review authorization assignment.

4. In the Assignment properties dialog box, expand Parameters.

5. Make sure that the work group corresponds to the workbasket that you specified in the Assigning theworkbasket for medical directors task.

6. To change the required skill, in the Routing section, click Update Skill.

7. Change the value in the Level field, and click Submit.

8. Click Submit in the Assignment properties dialog box.

9. Click Save and check in the rule.

Modifying the skills for a review of an authorization requestYou might want to change the skills required for a review of an authorization request to meet yourorganization's needs. For example, you might add an authorization type of Pediatrics with a skill ofexperience with the age-related group.

1. In the Designer Studio Explorer panel, click App, and in the search field, enter class PegaHC-Care-Work-AuthRequest.

2. Click Decision and expand Decision Tree.

3. Click GetAuthSkill.

4. On the Decision Tree page, click Save as and save the rule to your implementation-layer ruleset.

5. Click Create and open.

6. Make your changes. For information on the decision tree, see Decision Tree form - Completing theDecision tab (Advanced format).

7. Click Save and check in your rule.

Configuring the assessment setting for discharge plansThe business must determine the default assessment setting that is used for discharge plans, forexample, a Pre-discharge assessment. After you configure this setting on the application configurationpage, the discharge plan for patients is automatically updated with the specified assessment at the timeof patient admission.

Be sure that you have already created a Pre-discharge assessment. For information, see Creating tasks.

To configure the assessment setting for discharge plans, perform the following steps:

1. Click Designer Studio > Care Management Configuration.

2. Click the Other settings tab.

3. In the Pre-Discharge Assessment field, select the assessment option that corresponds to theassessment that you created.

4. Click Save.

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Configuring the default assessment for the HRA programAn organization can choose the questionnaire that will be part of Health Risk Assessment (HRA) whena patient is referred to a program. You configure this setting on the Care Management Applicationconfiguration page.

After you configure this setting, the program referral for patients is automatically associated with thespecified assessment at the time of referral and is run if the patient confirms the enrollment.

1. Click Designer Studio > Care Management Configuration.

2. Click the Other settings tab.

3. In the Default Assessment for HRA field, select the assessment option that corresponds to theassessment that you want to associate with the HRA programs.

4. Click Save.

Changing the setting for locking patient notesBy default, in your care management application, a care team member can edit their patient notes for aperiod of three days and then the notes are locked and are unavailable for editing. You can change thedefault number of days to meet your organization's needs. For example, your organization might have aprotocol of being able to update information in records for a period up to seven days.

1. In Designer Studio, search for and select the MemberNotesEdit report definition rule in the PegaHC-Data-MemberNotes class.

2. Click Save As > Specialize by class or ruleset to your implementation-layer ruleset.

3. On the MemberNotesEdit page, go to the Edit filters section.

4. In the Condition B row, in the Relationship list, select a value and change the number in the Valuefield that meets your organization's needs.

5. Save and check in the rule.

Changing the source on the Patient Risk Score data pagePatient risk scores are calculations that are used to identify the risk levels of patients. Typically, patientsare classified as high, medium, or low risk. Additionally, risk scores are created to review risks in variousareas such as readmission risk or future risk of an event happening in a certain time period, for example,three, six, or 12 months. The consistent use of the score helps organizations segment their populationinto manageable categories. Low and medium-risk members might be managed by using email, tests,or electronic coaching. High-risk members need person-to-person interaction with a care manager. Therisk level determines the level of management. Risk scores are dynamic and case managers can measureprogress through the decrease or increase in a risk score.

You modify the source on the Patient Risk Score data page to indicate how your organization calculatespatient risk scores.

1. Log in to your application by entering the CMSysAdmin@MyHealthPlan operator ID and the passwordthat you specified.

2. In the Designer Studio Explorer panel, click App and then enter PegaHC-Data-RiskScore in thesearch field.

3. Click Data Mode > Data Page > > D_PatientRiskScore > ..

4. In the Data sources section, in the Source field, select the method by which you will populate thepatient risk score information in your application. For example, if the patient risk scores will come froman external system, you might select a connector or a data transform.

5. Save the data page to your implementation-layer ruleset. For additional information, see Data pagerules.

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6. Based on the Source method that you select, update the fields to describe how you are gettinginformation or calculating information for the patient risk score.For additional information, see the following topics:

• Data Transforms

• Integration Connectors landing page

• Data page rules

• Activities

ReportsIn addition to the library of Pega Platform reports, your application provides several pre-configuredreports that are customized for the various work objects, cases, and business processes used in theapplication. These reports provide you with real-time insights into case inventories and aging so thatyou can respond with the agility that is needed to comply with your internal and external service levelagreements as well as compliance mandates.

For more information about reports, see Pega Care Management reports.

To create other reports, see Reporting.

Building the Pega Care Management mobile appAfter you determine the organization's needs in the Implementing Pega Care Management the mobile appsection, you can build your mobile app.

1. Configure and upload certificates.

2. Optional: Prepare your assets for branding the mobile app. See Uploading branding assets and custommodules.

3. Optional: Upload custom modules. See Pega Mobile Client API reference and Using the Pega MobileClient API within a Pega application.

4. If you do not use Pega Care Management as shipped, and you extend the application, ensure that thecases are available and enabled for mobile.

5. Build your mobile app:

• For the Android platform, see Building an Android app.

• For the iOS platform, see Building an iOS app.

Distributing the mobile appAfter you build the mobile app, you can distribute it. See Distributing mobile apps.

Testing a new applicationTesting a new application includes the following procedures:

• Testing your application in the Build environment

• Testing in the Test or Production environments

• Testing in the UAT environment

• Testing the connectors

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Testing your application in the Build environmentTest a new application in the Build environment before migrating the new application to a Test orProduction environment. Testing in the Build environment enables you to verify that basic functionalityand interfaces work correctly and also that performance is acceptable.

1. Run functional tests to test specific features from the end-user perspective.

2. Test features used by all service intents, such as: security, eligibility, search, and loading of data. For thisunit testing, automated scripts are recommended but not required.

3. Run automated unit tests to test features such as security, eligibility, search, and loading of data.

4. Use the Performance tool to measure the performance of the application. For information about thePerformance tool, see About the Performance tool.

• Prior to extending your site-specific Pega implementation, establish a performance benchmark(baseline) using the Performance tool. This allows subsequent, iterative performance testsagainst the established baseline to help identify any degradation in performance resulting fromdevelopment efforts.

• Use the Performance tool to check the performance of the following features:

• Search

• Account selection

• Loading of components

• Kickoff of all service intents. For this unit testing, automated scripts are recommended but notrequired.

• Save the test results so that you can compare them to future test results to determine whether anapplication update has a performance impact.

5. Verify that the Pega-provided reports and your custom reports run successfully, and that they showyour implementation layer data, rather than the default demonstration data. This can be an automatedtest.

6. Test all integrations, both independently and with associated integrations. 

Test integrations for any optional Pega Care Management components and other applications thatyou plan to use. See the product documentation for the component or application to determine whichproduct components to test.

For Pega Call, check the following pieces of moving infrastructure:

• Switch

• Provider software

• Connectivity (network)

• CTI engine

• Integration to the CTI engine

In addition, check all delegated rules (for example, coaching tips).

7. Test security. Test the most common roles to ensure that the required access groups are configuredand point to the correct software version.

Testing in the Test or Production environmentsAfter you import the application to a Test or Production environment, test the application in the newenvironment to verify that it works correctly in that environment.

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Note: For a multitenancy configuration, run tests in each tenant region. The testing performed inthe Test environment should include usability testing to ensure that the application meets the UIstandard.

1. Verify that the source and the destination files are the same.

2. Run functional tests to test specific features from the end-user perspective.

3. Test features used by all service requests, such as security, eligibility, search, and loading of data. Forthis unit testing, automated scripts are recommended but not required.

4. Run automated unit tests to test features such as security, eligibility, search, and loading of data.

5. In the Test or Production environment, run the Application Guardrails Compliance Score to ensure thatthe application meets guardrails.

6. Verify that there is an open Production ruleset so that managers will be able to edit dialogs, coachingtips, and knowledge content in the Test and Production environments, and so that they can sharethose changes. Rulesets are typically locked during migration; you will need to unlock the ruleset aftermigration.

7. Verify that the Pega-provided reports and your custom reports run successfully, and that they showyour implementation layer data, rather than the default demonstration data. This can be an automatedtest.

8. Test all integrations, both independently and with associated integrations.

Test integrations for any optional Pega Care Management components and other applications thatyou plan to use. See the product documentation for the component or application to determine whichproduct components to test.

For Pega Call, check the following pieces of moving infrastructure.

• Switch

• Provider software

• Connectivity (network)

• CTI engine

• Integration to the CTI engine

In addition, check all delegated rules (for example, coaching tips).

9. Verify that the integrations point to the correct system of record, and not to the system of record forthe Build environment.

10. Test security. Test the most common roles to ensure that the required access groups are configuredand point to the correct software version. Use these common roles in your smoke tests (see next step).

11. Run a smoke test to compare the source and destination environments. Verify that all tests that passin the Build environment also pass in the Test or Production environment. If anything fails, comparethe environments to determine whether a difference in environment could cause the test to fail. Ifthe environment caused the failure, either fix the issue that caused the failure or adjust the test asappropriate for the new environment.

12. Run performance tests to verify that performance meets expectations. Pega recommends automatedperformance testing. Save the results so that you can compare them to future performance test resultsto determine whether an application update has a performance impact.

Testing in the UAT environmentAfter you complete testing in a Test environment, it is common for large call centers to perform UserAcceptance Testing (UAT) in a designated UAT environment, which could be a pre-production environment.UAT ensures that end users will be able to successfully complete work and meet business objectives.

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Note: Organizations that use Scrum for application development will complete less formal UAT aspart of each sprint cycle.

1. Verify the integrity of the UAT environment.

2. Have the end-users (or business analysts acting the role of end-users) run scripts to test all scenariosincluding boundary and exception testing. The end-users (that is, the trainers, managers, anddirectors), perform the following steps during UAT:

a) Verify that there are no major issues.

b) Review changes in order to better understand the features.

c) Customize the delegated rules (for example, coaching tips) as needed.

Testing the connectorsAfter you install and configure the connector software in your environment and update the securityparameters, you can test and validate the connector.

See the testing sections in the following resources for each of the connectors:

• Pega Integration Solution for Change Healthcare Interqual

Pega Integration Solution for Change Healthcare Interqual Installation Guide on the Pega CareManagement product page

• Pega Integration Solution for MCG CareWebQI

Pega Integration Solution for MCG CareWebQI Installation Guide on the Pega Care Management productpage

• Pega Integration Solution for MCG Disease Management

Pega Integration Solution for MCG Disease Management Installation Guide on the Pega Care Managementproduct page

Packaging a new applicationTo migrate a new application to a different environment, you must first package the application so that itcan be imported to the new environment.

Packaging and importing a new application includes the following procedures:

If deployment is to a Multitenancy environment, see Multitenancy deployment considerations.

• Merging application changes

• Packaging an application for migration

• Importing the packaged application

• Multitenancy deployment considerations

Merging application changesIf you developed your application features in separate branches, use the Merge Branches wizard to mergethe branches before you package the application. The wizard shows any merge conflicts so that you cancorrect them before you merge the branches.

For more information about using Merge Branches wizard, see Branch development.

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Packaging an application for migrationBefore you can migrate a new application to a different environment, you must package the relevant datainstances and rulesets into a product rule. The product rule is an instance of Rule-Admin-Product, andit is referred to as the RAP file.

1. Click Designer Studio > Application > Distribution > Package to start the Application Packagingwizard. For information about using the wizard, see Application Packaging wizard.

2. Complete each page of the Application Packaging wizard.

3. On the last page of the wizard, click Preview.

4. Review the contents of the generated RAP file.

5. On the last page of the wizard, click Modify to make any changes.

6. When the RAP file is complete, click Export. The wizard creates a .ZIP file in the ServiceExportdirectory on the current application server node.

Importing the packaged applicationTo deploy a new application to a different environment, import the .ZIP file that contains the packagedapplication to the new environment.

1. Click Designer Studio > Application > Distribution  > Import.

2. Use the Import Gadget to import the target .ZIP file. For more information, see Import wizard landingpage.

For information about how to swap the database connection pointers to your Production database afteran import to a Production environment, see the Pega Platform Upgrade Guide at Deployment Guides.

Note: For an on-premises Pega Co-Browse integration, be sure to update the data transform ruleto point to the correct Pega Co-Browse server if necessary.

Multitenancy deployment considerationsIn a multitenancy environment, the shared application components are deployed only to the sharedenvironment, and the tenant-specific components are deployed only to the tenant region.

For information about how to package and deploy a shared application or a tenant-specific application,see the Multitenancy Administration Guide.

A deployment to a multitenancy environment has the following requirements.

• The package for the tenant layer should include production rule sets for that tenant. The package forthe shared layer should not include production rule sets.

• The package for the tenant layer should include the tenant-specific Pega Call configuration settings,such as sample operators, service packages, CTI links, and call objects. The package for the sharedlayer should include the global Pega Call configuration settings that apply to all tenants, such as PegaCall rules.

• The package for the tenant layer should include the table definitions for that tenant.

Note: Multitenancy is not supported for Pega Social.

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Production maintenance and monitoring

Production maintenance and monitoringProduction maintenance and monitoring includes the following procedures:

• Business rule maintenance in the Production environment

• Application health monitoring

• Identifying and reporting issues

Business rule maintenance in the ProductionenvironmentAs a manager, you can update Dialogs, and Coaching Tips in the Production environment using theTools > Configuration option available in each process action of the case type. This feature allowsmanagers to change these options without having to wait for a rule deployment. Managers must have thesame privileges associated with the PegaCA:Manager role in order to maintain these rules.

Note: Skills instances need to be created in order for them to be available in the selection ofavailable Expert Skills.

Managers can also create reports in the My Reports section of the portal. For more information, seeReport Browser features.

You can give managers the ability to update other rule types in the Production environment. For example,managers can update the Goals and Deadline for a certain case type. These rules must be delegated inDesigner Studio first. After the rule has been delegated, you can access it in the Interaction Portal byclicking Profile menu > My rules. For more information on rule delegation, see Delegating a rule or datatype.

Managers can also create reports in the Reports section of the portal. For more information, see ReportBrowser features.

Application health monitoringPega Autonomic Event Services is an application that automatically monitors, retrieves, and organizes thealert data from one or more clustered systems throughout the enterprise. Pega also provides the PegaPredictive Diagnostic Cloud, which allows you to benefit from Pega Autonomic Event Services withoutinstalling it locally. Pega Predictive Diagnostic Cloud is a Software as a Service offering of Pega AutonomicEvent Services.

Implementing the following best practices in your application can help to ensure optimal response timesand overall application health:

• Segment application agent processing to a dedicated JVM (Java Virtual Machine). This configurationensures that end users do not have to share resources with background processes.

• Monitor integration response time. Over time, slow integration points can cause average handle timesto increase. When queues start to grow, it becomes very difficult to recover, which might require usageof offline services or a backup application.

• Regularly perform a Layer 7 health check. Layer 7 is the application layer of the OSI model. Havingvisibility into the details of a connection can allow you to filter out unwanted traffic from entering yourcall center, such as for example, in the form of a DDoS attack. It can also help with load balancing.

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Having visibility into call details also provides information that is needed to more intelligently route thecall.

• Regularly perform a health check on the CTI layer. Periodically check to ensure that the application cancommunicate with the switch. Periodically call the application to make sure it can get through an entireprocess.

• Monitor social accounts (for example, your Facebook and Twitter accounts) to ensure that they do notexpire.

Identifying and reporting issuesAs with any application, your users will encounter issues that they need to report as they begin to usethe application. When deploying your application to the production environment, complete the followingsteps:

1. Identify operational staff who will be responsible for responding to issues reported in the productionenvironment.

2. Establish procedures with those resources to triage, respond to, and escalate issues.

3. Determine procedures for delivery of changes to the production environment.

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