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Configuring MTM

To track the progress of any Social Determinants of Health (SDoH) issues and use SDoH information and activities for optimum health and wellness for members, you must configure the settings in Pega Care Management™.

Pega Care Management supports the identification and management of SDoH, which are the non-clinical factors that impact a patient’s health. It is estimated that more than 65 percent of people experience at least one social determinant of health. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. You add these "barriers" to supported categories of SDoH in the Business Analyst (BA) portal. Barriers in SDoH categories are added directly at the member level, and then associated SDoH issues are flagged for the patient. The SDoH issues that are identified for the member are displayed in the header of their patient profile.

  1. In the header of Dev Studio, click Configure > Care Management Configuration.
  2. Click the SDoH Categories tab.
  3. Select the checkbox for each SDoH category for which you want to enable tracking.

    The system displays the selected categories in patient profiles.

  4. Click Save SDoH to save your selections.
  5. Click Save to update the configuration page.
SDOH Categories

Configuring MTM eligibility criteria

Medication Therapy Management (MTM) consists of a range of services that are provided to individual patients to optimize their therapeutic outcomes and detect and prevent costly medication problems. Configure these settings to set the criteria by which patients who are enrolled in Medicare Part D are evaluated for enrollment in MTM.

Tip:  Before you begin: Ensure that you install the Snomed codes in Pega Foundation for Healthcare.
  1. Log in to the application as a Business Analyst. 
  2. Click Launch portal > CM Business Analyst.
  3. In the navigation pane, click MTM config.
  4. In the MTM program eligibility criteria window, enter values in the following fields to set the thresholds by which qualified members are evaluated:
    Drug cost
    The annual drug cost must be greater than this value for the patient to be eligible for the program
    Medication count
    The number of medications that a patient needs to be eligible for the program [COE inline review: Perhaps "is taking" instead of "needs"? This sounds a bit odd.]
    Late to refill days
    The number of days for which a medication refill is considered late
    Chronic condition count
    Indicates the number of chronic conditions that a patient must have to be eligible for the program
  5. In the Chronic conditions section, in the Code field, select the code representing the condition from the list, and then in the Name field, enter the name of the condition.
  6. Repeat step 5 for each condition that you add.
  7. In the Social Determinant Assessment list, select the appropriate assessment.
  8. In the MTM program list, select the appropriate program.
  9. Click Save.

The following figure shows an example of eligibility criteria settings:

MTM Config

Check your knowledge with the following interaction:

Extending the rules in Medication Therapy Management

To meet your organization's needs, you can extend rules in MTM such as coverage, additional questionnaires, and calculation of delay in refills.

The following table shows the extendable rules in MTM:

Rule name Purpose Additional information Example
CalculateRefillDelayDays
The calculation of this rule is based on the system date and the next refill date. Clients can extend this rule based on their requirements.
Data Transform A business organization might want to modify its refill calculation strategy.
CheckMemberPlanCoverage Add a plan in a line of business other than Medicare. Data Transform A business organization might want to include the Commercial line of business as a check for enrollment in MTM.
EvaluateMemberExpenses Evaluate the total expense of pharmacy claims for a member by using the TotalPaidValue property for the calculation. Data Transform
A business organization might use the value of the TotalChargeValue property for a calculation of the total amount instead of the paid amount.
ValidateDuplicateInterventionInListExt Used for additional validation when adding interventions to the flow. Validate Rule
Clients might want to configure additional validations, for example, to validate a duplicate intervention based on the combination of category and the name of the intervention.
ValidateDuplicateBarrierListExt
Used for additional validation when adding barriers to the flow
Validate Rule Clients might want to configure additional validations, for example, to validate a duplicate barrier based on the combination of category and the name of the barrier.
SetSpawnedInterventionAgentData Sets and passes the required values to a business analyst for creating interventions. Data Transform A business organization might want to skip any validation or populate values for additional fields for intervention creation.
InitializeSdohAssessmentDetails Add another questionnaire Data Transform In addition to the Social Determinants of Health questionnaire, a provider might add another survey, for example Health Risk Health Risk Assessment (HRA)
DrugToDrugInteraction Integration for drug-to-drug interaction information. Flows
A business organization might integrate with a third-party application that describes drug-to-drug interactions.

Check your knowledge with the following interaction:

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