Care Management (CM)
Care Management (CM) supports the administration of clinical, behavioral, and social programs for members across all risk profiles. It enables program-based interventions, task orchestration, and multi-channel member engagement driven by real-time data signals and intelligent rules.
Key Features
Task-Driven Case Management
Member interactions and other case supporting activities are managed through tasks, which are generated based on workflows, program rules, and user actions.
Tasks are units of work, such as call member, complete assessment, review lab. CM includes support for tasks, including the following:
Due dates and reminders
Task escalation and re-assignment
Task pause and resume
Tasks can be created manually or generated via:
Program logic
Clinical Intelligence Engine rules
External API triggers
Program Configuration
CM includes support for condition-specific and population-wide programs, including support for overlapping, mutually exclusive, or staged programs. It also features a rules engine for determining eligibility and triggers based on diagnosis, utilization, and behavioral patterns. Program logic includes entry and exit criteria, auto-close rules, and activity triggers.
Programs can be configured for:
Chronic condition management (e.g., diabetes, COPD)
Maternity care
Behavioral health and substance use
Post-discharge follow-up
Social determinants of health (SDOH) screening and referral
Assessments and Clinical Content
CM includes configurable, logic-based assessments supporting eligibility screening, behavioral health evaluations, and follow-up risk assessments. CM supports scored and unscored assessments, and available configurable logic includes branching questions, conditional scoring, and threshold-triggered alerts.
Outreach and Engagement
CM features guided care journey orchestration through a next-best-action model driven by data triggers and historical engagement. CM supports both digital and telephonic programs – or a hybrid approach – as well as the ability to pause and resume a journey.
Outreach occurs via call, SMS, email, or portal-based interaction across channels that include the following:
Phone call tasks with documentation templates
SMS/email via campaign engine
In-app educational content
Content includes assessments, reminders, education, and next-best-action nudges. Automated nudging is based on a behavioral science-informed journey builder that provides always-on outreach campaigns. Triggers for automated nudges include event timing, data signals, and historical engagement.
Roles and Teams
CM allows you to configure access and workflow logic for such roles as care managers, supervisors, behavioral health clinicians, and social workers. You can create team-based assignment rules and reassignment workflows, along with integrated alerts and notifications for collaboration.
Reporting and Monitoring
CM includes the following features for reporting and monitoring:
Member reach rate and engagement outcomes
Task completion trends and SLA adherence
Program effectiveness and enrollment KPIs
Risk segment performance and case complexity scoring
Compliance and Security
CM is designed with compliance and security in mind. All actions are logged in an audit trail. PHI access is governed by role-based controls. All messaging is encrypted. Assessment and documentation storage meets HIPAA and HITECH compliance regulations.
Additional Features and Capabilities
CM also includes the following features and capabilities:
Comprehensive Person View (CPV): Centralized view of all tasks, authorizations, interactions, and assessments.
Timeline: Chronological visual history of interventions, documentation, and data triggers.
Smart Alerts: Notifies care teams of gaps, needs, or conditions requiring outreach.
Real-Time Data Reaction: New claims, labs, or admission-discharge-transfers (ADTs) can activate new tasks or reroute journeys.
Custom Programs: Ability to set up custom program logic, assign resources, and define clinical content.