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Case study
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Healthcare case study

Health plan streamlines accreditation process with CareAdvance

Physicians Health Plan jumpstarts NCQA case management accreditation process with agile CareAdvance implementation by Cognizant.

At a glance

Industry
Healthcare

Location
US

Challenge
Meeting accreditation agency requirements

Products and Services
TriZetto Clinical CareAdvance

Success Highlights

  • Achieved early go-live date and came in 16% under budget
  • Optimized processes
  • Received NCQA accreditation

The challenge

Our client, Physicians Health Plan (PHP), elected to earn the National Committee for Quality Assurance (NCQA) accreditation for case management to help improve operating efficiencies through evidence-based best practices. PHP would complete a gap analysis and identify improvement areas for each of its members. Earning NCQA accreditation would also showcase the quality of PHP's programs and align its goals to case management practices across the country.

Working with a consultant, PHP learned its case management documentation methodology did not meet NCQA requirements. As prerequisite to the accreditation, PHP would have to implement a new case management system and create a new complex case management (CCM) program. 

Minimal time and resources

PHP set a very tight deadline for these projects so its case managers could become familiar with the new systems and program details before the NCQA look-back period began. However, PHP is a lean organization with few additional resources for implementing the new system and program.

Our approach

PHP accepted Cognizant’s proposal for a six-month agile implementation of the TriZetto® Clinical CareAdvance® Case Management module and its standard assessments, which meet NCQA requirements out of the box. Using our agile implementation methodology, PHP and Cognizant teams achieved an early go-live date, beating the already short timeline by 19%.

Because the implementation was completed ahead of schedule, PHP case managers spent additional time working with NCQA consultants to perform three mock chart review sessions before the start of the NCQA look-back period. This was invaluable, enabling the PHP clinical team to incorporate recommendations from the chart reviews prior to the NCQA survey. "Cognizant's team was focused and engaged to ensure we met our project metrics. Post go-live, Cognizant was very responsive in assisting us to improve workflow processes," said Kellie Banko, Manager, Case & Disease Management, PHP.

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"Without the implementation happening in under six months, we would not have been able to apply for the NCQA accreditation."

Walter Briggs IV, Director of Information Technology and Project Development, PHP

Business outcomes

PHP had already implemented the TriZetto Clinical CareAdvance Utilization Management (UM) module. CareAdvance modules integrate with PHP's core administration platform, TriZetto Facets which shares real-time claims, benefits and membership details with CareAdvance UM and CM to enrich collaboration between our client's UM and CM departments.

In addition to the cearly go-live date and coming in under budget by more than 16%, the CareAdvance Case Management implementation has enabled PHP to:

  • Automate identification campaigns that enable PHP to target at-risk populations
  • Conduct systematic, patient-centered NCQA-compliant assessments
  • Monitor a patient's progress to track care planning goals to maintain or improve member health and wellness
  • Standardize complex case management enrollment, documentation, processes and reporting
  • Enable case managers to manage members between care settings and ensure access to qualified, evidence-based case management programs

PHP's new case management processes help the team anticipate the needs of its members and populations and engage them proactively to improve health outcomes. These new processes also led to the client receiving NCQA accreditation for case management.

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About PHP

At Physicians Health Plan, we exist to improve people’s lives by making healthcare more accessible for the diverse communities we serve. Together with our extensive network of provider partners and hospitals, we provide our members access to high-quality, affordable healthcare so they can live their best lives. PHP is owned by two of Michigan’s top health systems, University of Michigan Health and Covenant HealthCare, and offers healthcare plans to individuals, employers, and Medicare beneficiaries throughout Michigan.