Care Management

Care management is a program of coordinated clinical care delivered to individuals with serious or long-term health problems, based on health and wellness objectives jointly identified by the patient and his or her healthcare providers. The ultimate objectives of care management are to improve the well-being of the patient and to control costs through careful planning, coordination among providers, and elimination of duplicative or wasteful expenditures.


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Although not new, this approach to clinical care administration and delivery has grown in importance as the Affordable Care Act has pushed healthcare providers and payers to adopt a more ambitious form of care management marked by closer collaboration and closer monitoring of patients and program effectiveness. Chief among the challenges that this reform mandate presents to health plans is the need to identify and deploy healthcare software systems that facilitate the degree of multi-party coordination, operational efficiency, and highly informed decision-making called for by this ambitious new vision of care management.

Pega’s Intelligent, Agile Platform for Care Management

Pegasystems’ Better Business Software® technology enables organizations to achieve operational excellence across all their front- and back-office operations. Pega healthcare solutions are the business process and customer service platforms of choice for 13 of the 14 largest U.S. healthcare payers and more than half of the Blues plans.

The Pega Care Management solution provides health plans a unified platform for member-centric healthcare management across case, utilization, disease, chronic illness, and wellness programs. This unified Pega health management system delivers all the technological capabilities that payers need to meet the demands of the new care management paradigm, including:

  • Support for easy, timely coordination across all the personnel associated with each case, using seamless multi-channel communications.
  • Automated workflow management, queue management, authorizations and pre-authorizations, alerts and notifications, and correspondence generation.
  • Automated role-specific guidance for care coordinators, discharge nurses, and other program participants.
  • Standards-based integration with legacy health information systems.
  • The ability to easily change care management applications in response to changing circumstances or regulatory requirements, without any need for programming.

Pega Care Management Solutions Drive Customer Success

Healthcare organizations adopting Pega healthcare management solutions are consistently able to reduce operating costs and boost operating performance. For example, Alere Health—with more than 25 million patients in its care management programs—used Pega technology to implement its new CareAlerts program which:

  • Reduced HEDIS gaps by 63%
  • Improved medication adherence by 56%
  • Achieved a 96% global satisfaction rating.

Learn more about how Pega healthcare solutions can help your organization deliver personalized member programs and services.