PegaWorld 2026: Modivcare's 42-day Digital Transformation: Speed Meets Impact

This is the first Healthcare Blueprint delivered success. And so we are honored to have Ken and Heather share this success with you. Thank you. Thank you. Hey. Good afternoon. Good afternoon everyone. There's plenty of seats. You can come sit in the front if you'd like. You know, on an intimate group. But we'll make this. We'll make this fun. So not sure how much you all know about Modivcare or our non-emergency medical transportation business, but let me give you a few minutes of context so you understand what our business is and who we serve. So non-emergency medical transportation is an absolutely critical part of the health care experience. What we do is we help people get access to the care that they need. So we treat those that are underprivileged, or those that don't have financial means gain access to care. Enabling them to live in their home, being able to move to the doctor and to be able to get that access to care in a seamless way.

So. This kind of treatment or this type of services is essential. Um little story. My father in law, my father in law was um, both medically and financially in need of support. So we took, we took him in. Right. So my wife and I took him into our home and we were then responsible for caring for his entire medical situation. Now this was an individual that had significant mobility issues. He had the the challenges of a wheelchair and not being able to get up out of the lower level where we had him living to get to a vehicle. So there were significant barriers, just the fact that he had to be able to get from a lower level to a, you know, a slightly elevated area in the driveway was a massive problem for him to get to his care. So when he couldn't get up the hill, like when it snowed in New England, he couldn't go to his appointment.

Right. And that became a barrier of care and barrier to access. So for us, what we do is we're able to connect, whether it's curb to curb or whether it is, you know, a situation like a hospital facility or a medical facility, get them to the care that they need through the mode of transportation that they have. And with that, they're enabled to get access, to go to the appointments reliably, to be able to, um, have that discipline and that care. We navigate an extremely complex environment. So non-emergency medical transportation today is broken up into a bunch of different personas that we service. First, think about our clients. We sell our services directly to, um, health plans, right. So you think, um, you know, Cerner and CVS Aetna, you think about um, UnitedHealthCare, etc. those Mcos are our clients as well. Are our Medicaid states, right?

So the state of new Jersey or the state of Maine. And we then have to manage all of the complexities that those clients need in terms of the care for that population and whether that is various modes of transportation, you know, whether they want to offer a mass transit opportunity or they want to offer, um, a mileage reimbursement or leveraging our fleet of commercial vehicles. We are now working to match their needs for their modes of transportation to their vast network of transportation providers that we create. And in that, there's plenty of planned rules and state requirements and reporting requirements, etc. and as a broker, we handle that. We also have to think about the member. And then again, this is an individual that, um, you know, might not have mobility issues, might have mobility issues, whether that's a wheelchair or a stretcher, whether that's a bariatric wheelchair or an electric wheelchair, whether that person needs to have a personal care assistant, maybe their wife is accompanying them.

Maybe we're in a situation where a mom is transporting with their child that needs to go to a methadone treatment center. So we have all of these variabilities that we have to account for in this broker client relationship. And then we have this vast network of commercial of commercial transportation options. Of course, we partner with the Ubers and the Lyft's, but we also leverage a network of mom and pop, you know, kinds of companies that might have five wheelchairs and five wheelchair vehicles in their fleet. Or maybe we have access to, you know, someone that needs a stretcher, right? So we as Modivcare are bringing this massively into a separate network of challenges together into a seamless broker client relationship. And we're helping those that need it the most get access to the care that they require. So that's what we do. So the challenge that we faced in this particular use case, and this dates back about this time last year, a little bit earlier than this time last year, is we were dealing with a, an MCO that was handling our population in Hawaii.

Now, if you've had the privilege of going to Hawaii, you know that that geography is very different. If you're going to go to the road to Hana and this is Windy Switchback Road all the way north, right in a really remote area that's very different than being on a seven lane highway in Honolulu, right? You have to be able to say, if someone that is on an island that doesn't have access to maybe an advanced medical facility and needs to come to Honolulu for care. Now we have air transportation that we have to bring in. And now if you're going to do air transportation, well, someone's scheduled for a surgery. Well, maybe they need a hotel. So now we have to start reimagining what is the entire life cycle of that transportation look like to be able to get someone that is in this either remote or separated part of these, of these islands to the care that they need.

And the challenge that we faced is that we had to be able, in a very short time frame to meet this client need come up with a solution that was scalable and automated. Now, non-emergency medical transportation is largely a you know, it's sort of a decentralized network, right? You think about now trying to do air transportation on a on a, you know, Maui, that group of people might be different than the Big Island, right? So now you have different groups of cohorts of people you have to be able to manage. We also had to make sure that the rules were being enforced. If we're going to spend money on transportation for a husband and a wife, for an airplane ticket, for a hotel, for meals, you know, the we wanted to make sure or we needed to make sure that the rules were being enforced consistently.

So those were the challenges that we were facing as we had to bring all this multi-variant kind of information into a clean and scalable, repeatable system and do so on a very, very fast horizon. And so that's where Heather go for it. Okay, so as Ken mentioned, we had a lot of issues to solve for in a very short amount of time. So thankfully, early on, we identified that we could use some existing out of the box Pega Pega capabilities. So we didn't have to completely start from scratch and recreate the wheel. However, what helped us most of all was the use of Blueprint. And as we all saw today, Blueprint is extremely intuitive. It is very user friendly. And so it allowed us to quickly, um, bring together our product and business and technology teams all together and walk through all of our end to end workflows, identify our user journeys and personas and map our integrations.

And that allowed us to then provide our business partners with visual requirements that they could very easily look at and see. Yes, this is exactly what I wanted. This is exactly what I meant. Or no, we need to tweak that a little bit in removing that ambiguity from the requirements early on in the process made moving to development and then later to a scalable production system a lot easier and faster. So what happened in the 42 days? Well, on April 7th, 2025, we had our first kickoff call. And at that time we had four personas that we had to take into consideration. We had our facility providers, we had our mode of care reviewers, we had our client payer approvers and our mode of care logistics coordinators that actually scheduled the transportation. And within all of those personas, there were incredibly complex workflows and handoffs that we had to consider in our solution.

So in addition to removing the ambiguity from our requirements and the out of the box solutions that we were able to use. We also leveraged our agile delivery framework, so we had daily stand ups. We maintained constant communication with across all of the different teams that we worked with. And we got continuous feedback from users to make sure that we all stayed aligned. We all maintained momentum all the way through, and that allowed us to start development 15 days later on April 22nd. And then of course, 27 days after we started development, we were able to go live on June 3rd. So what did we learn? So the first thing is start right. Use Blueprint. So obviously as I mentioned, that allowed us to to remove ambiguity from the requirements early on, which made sure that we were all aligned before we ever started development.

We defined those integrations early. This allowed us to avoid costly rework downstream, especially after we'd already gone to production and obviously reusing the Pega out of the box capabilities. We don't need to rebuild what already exists. Building with people. This was the second thing that we learned. So we made sure to keep our user journeys at the forefront at all times, and not just the business logic. So we always had to consider that what we were building was going to meet the needs of our users. We involved the personas in our testing early, so we didn't wait until just right before production or after production, obviously, to test. We tested all the way through as we were building, not just after, and then also maintaining that cross-functional engagement across all of the teams and with the different personas allowed us to drive adoption at scale.

Last move fast, but stay aligned. So establishing strong governance meant that we were able to execute with faster delivery. We also had frequent demos and that helped build trust with our users and with our stakeholders. And we had tight feedback loop with all of our users in early system testing. That meant we were able to deliver quality at speed. So at the end of the day, the success story isn't that mode of care delivered in 42 days. The real success story is that Blueprint helped us deliver a reliable, quick solution for prior authorization that enabled our clients members to get access to care faster, with less friction and with more confidence. Thank you. So how many? By a show of hands. How many people have used Blueprint before? Yeah. So it's interesting you think about this. 15. 16 months ago. Anyone here doing AI AI DLC kind of mobbing sessions, that type of thing?

No. Okay, so what's very interesting about this is that nearly 15 months ago, we were using this concept of AI to be able to start organizing our jobs to be done. We had multiple personas that you saw. We have someone that is a some in the facilities, and it's going to be submitting in that prior authorization. We have people that are, um, the expediters that are going to have to schedule on a, you know, a Hawaiian Airlines or a JetBlue, the actual logistics and coordination, etc. you have exceptions management to make sure that the rules were being filed, filed. What that really was, is the foundation for the jobs to be done to make that particular business process possible. And what we've done now, nearly 15 months later is we're in a full blown adoption of what we refer to as our AI DLC. So instead of using a software development lifecycle, we're now in AI lifecycle.

And what we're doing is we are synthesizing all of these types of rules and requirements and variability into a clear spec, and Blueprint acts as the bridge to distill all of this information down into those jobs to be done, the processes to follow, the skills that have to be executed, and that provides the framework now for us to create this spec. And then that spec can get loaded into, you know, codex or clod or whatever, or even, you know, even Pega capabilities that we saw today and now greatly accelerate the ability to translate to value. So the experiments and the work that we were doing even 15 months ago has provided a foundation. For now, all of our scrum teams to be using this kind of spec driven development AI thinking and the creation of value of what we we do now. If I dream a little bit further, where we're going next is imagine us looking at all of our jobs to be done across our organization.

Our our business is 27 years old, right? And we've, we have all these different roles and skills and manual processes that are there. Now, I'm not going to talk about a whole organizational transformation in this chat, but the ability to begin to distill all of these jobs to be done, the kinds of skills that you need, what becomes an AI worker versus a human worker, that is all now foundationally available in the capabilities that we have. We did that, you know, 15 months ago, right? In this use case, in a very short, compressed time frame. But the learnings from that allow us to also flywheel that to the rest of our operations and begin reimagining our workforce as a result. So it's pretty powerful capability when you really start studying or thinking about how do you run a modern organization and redesign that organization to really complement a human and AI worker environment?

So any questions so far? We've left them stunned. So, so great story. And the question was around the concept of repeatability. And if we wanted to do this again in another part of the business or an extension of the existing application, what would be the non-negotiables on day zero in order to get started and to be able to move again in 42 days or less? Yeah. So I would start with making sure that the representative personas are present and relevant, right? You have a bunch of different in our business, Especially you have, you know, we're weighing constantly whether it is in need of an internal operations or, you know, the client need or a transportation network or the member need. Right. So you need the persona in the room. What are the kinds of goals that they're trying to be able to realize? What are their pain points?

What are their what are the jobs to be done, if you will, like having that organizationally represented in the room, whether that's through initial documentation or, you know, the problem to be solved, that is a critical so that we can zoom out and look at a holistic view of the problems we're solving. That's sort of number one, right? Then you can bring it into your gonna later to crush, you know, put all the different pieces together and say, now I can begin rationalizing what's an optimal flow for that. So the persona representation is critical. I would say. Um, two and I wouldn't say we had this at the time, but moving forward, it's also you have to be really intentional about what is your source of truth and sort of your foundational architecture. Where are you going to make sure that if you're going to build a new set of skills, you're not creating multiple skills and different systems and different methods all over the company.

So having an enterprise architecture footprint, we didn't have it in here. But to answer your question, to have a footprint, to be really clear on what are the core foundational principles of your architectural design, I think that's a must because now you can then say, okay, I have these skills I'm bringing in, where do they belong? Where do they get orchestrated? Where do they, where are they going to live in our, in our repository? So we're not creating a Frankenstein version. Um, and then in today's world, especially if I fast forward got to run a mobbing session, right? So the idea of bringing together product and operations and our engineering and architectural partners to literally look at the problem in an intense, focused session really work to declare a strong spec write that has the clear boundaries of what you want that problem to become, and then iterating rapidly through that spec with AI Co assistance.

Right. And then that gets us to faster iterative development, um, moving forward. Anything else Dan. No, that's why I have you answer the questions. Hi. It's Mark from Australia. Bupa from Australia. Um, firstly, apologies, I missed the start of your presentation, but um, I take it you've implemented the Pega Healthcare Platform. Yeah, parts of it. Yeah. Parts of it. Just wondering if you've added the, I guess, smart claims engine on top of it or if you have any plans to do so. Not yet. Um, if you have experience in that, I'd love to chat, but at present, no, we haven't brought in our smart claims, Henry. You're not aware of anything that we've done there yet, right? No. We're in the process of implementing it, so I was. Yeah, yeah. Keen to see if you guys had already gone down that path. But. Yeah. So what we are doing right now, and this is where, where the Pega workflow piece has become very interesting.

If you think about our world, we're really managing an end to end trip lifecycle, right? So when you come from intake through to rules and decisioning, we're assigning the right mode of transportation. We're then fulfilling that right and tracking to make sure that the pickup and drop off was right. And then you have all the digital evidence that flows through. And then you have the claims and the reporting. Like we have a full continuum of every single trip that we have to power. So we are actively looking at, well, one, we're modernizing that entire stack. And then two, being able to leverage accelerators like probably what you're referring to so that we can do that more seamlessly, that specific capability we have not used yet, it though. I'd just like to add a little more. Um, the smart claims engine and what Modivcare uses Customer Service for Healthcare and some other assets.

They all share a common Healthcare industry foundation and an object model that you guys use a lot. There's a lot of objects that are used, like the notion of a member, the notion of an entity, a provider. All of those are available in the foundation model and those are the reusable. I wouldn't call or go as far as skills, but those are the reusable assets that you can use regardless of whether you're deploying a claims journey, prior authorization journey, or a customer journey, because the member is still the same member, and the integrations and the connections that you have done for that member or that patient with your sources of truth still remains the same. Great. Thank you. Any other questions? Okay. Well, that was wonderful. Ken Heather, thank you so much for sharing the success. Okay. Thanks for coming, everyone. Oh, yeah. Sorry. The most important one.

Yeah. Questions? Advance the slide, please. Heather. Oh, there you go. So, um, my name is Scott Holtz. I'm part of the Blueprint delivery team and part of the adoption team. And, uh, you know, we're really, really proud of of what you were able to accomplish in 42 days. I think it's a fantastic example of exactly what we're hoping all of our clients will be able to do to get faster, better outcomes, you know, with, with Pega, with Blueprint. And so I want to present this award to the Nemt team at Modivcare. This is the the first year we're giving these awards and we haven't given very many of them. So it's a an honor to be able to share it with you. Appreciate it. Thank you. Thank you. Thank you. So I just want to say I want to say thank you to the team.

Um, this time last year when they brought this problem to us, um, and the timeline, which was like only five months, um, they said, can you do it? Can you help us? And I said, are you ready to get uncomfortable. And because this is a new process. And they said yes. And we went through that process and it was successful. And I think the things that made it successful was everybody was ready to get outside of their comfort zone. Um, you did a really great job at sticking to, uh, the scope that we had defined and not letting that grow. And you just executed very well. And just getting that piece out the door, uh, quickly and efficiently. And it was a really great project. So congratulations. Thanks. Thank you. Great. Appreciate it. Thank you. Heather. I think we're coming in. Thank you. Thanks, everybody.