Adaptive case management: Process takes a detour

Business process management (BPM) software has been highly successful in improving the efficiency and consistency of many business processs. However, the requirement to be consistent also has limited its applicability to work processes that vary significantly.

Adaptive case management (ACM, also called dynamic case management) takes a different view, one in which the case rather than the process is the focus of the work. It brings together the information needed to resolve a case, allowing for variability in the sequence and type of actions needed to achieve the goal. That makes adaptive case management well suited to knowledge workers, whose tasks require expertise and judgment.

Because so much work is unpredictable, it seems surprising that the emergence of enabling software solutions took such a long time, but several obstacles needed to be overcome. "As process thinking evolved over the past three decades," says Connie Moore, VP and research director at Forrester Research, "people focused on the concept of automation and coming up with the best way to carry out a process. This mental model posed a barrier to a more flexible view of process." In addition, the technical challenges were considerable. "It takes a lot of sophistication to support the many different information states that are present in unpredictable processes," Moore adds.

One leading health care company saw adaptive case management as a good match for managing care for its senior citizens, including its Medicare patients. This market segment is growing rapidly, and the medical issues its patients have are often unpredictable. In addition, medical care for seniors entails many regulations, which often change in ways that affect patient care and insurance payments.

Having used solutions from Pegasystems to develop other BPM applications, the company opted to extend its use of that platform into adaptive case management. One of the early BPM applications was an authorization process with very sophisticated decision trees containing thousands of embedded business rules.

Other capabilities were added, such as integration points for fax, correspondence generation, automated mailing, image repositories, and Web self-service. After these rollouts, process improvement achieved high visibility within the company, and management encouraged the development of other applications, such as the use of process analytics for detecting fraud and abuse. 

Adaptive and agile

The streamlining achieved through the BPM applications was beneficial and aided the company's efficiency, but for senior care, an approach was needed that was adaptive as well as agile. Agility entails a quick and vigorous response in terms of process, while adaptability means being able to respond in a nonstandard way.

Seniors often have chronic medical conditions that require collaboration among multiple teams of caretakers, for example, but not necessarily the same teams. Many cases require research and discussions based on a large collection of medical information. Modeling all of the options would be difficult if not impossible. Adaptive case management allows each case to move forward in a unique path with relevant information being collected along the way.

A key part of Pegasystems' case management solution is that it provides visualization of each case, as well as the ability to aggregate cases. "Users can see all of the elements of a case together," says Emily Burns, principal for product marketing at Pegasystems. This includes the sub-cases, identification of who owns each one and all the associated content. "Knowledge workers don't want a screen that says yes or no," she says. "They want to evaluate the data in the context of the case and make a decision."

The ability to tag cases on an ad hoc basis helps in understanding trends prior to formal analyses. "Users can tag according to any criteria they want," Burns explains. "For example, an insurance processor might start tagging cases that are associated with a natural disaster that has just occurred, before it appears as a category." The tag cloud would then begin to indicate a trend before any systematic reporting had occurred. However, Pegasystems' platform also has a full set of analytics that provide a variety of metrics within and across cases. 

A cloud solution

psHEALTH was founded with the intent of developing case management solutions for healthcare providers in the United Kingdom. Aware that it was going to be making a big investment in time and money, the company carried out an extensive investigation into the available BPM platforms. Ingolv Urnes, principal at psHEALTH, says, "We wanted a cloud solution with a human-centric approach, and well designed user interfaces." psHEALTH decided on the Appian BPM Suite and built a framework for solutions in three primary areas: occupational health and rehabilitation, home healthcare and social care.

The service offered by psHEALTH includes design of the system for each client, along with technical support. "We incorporate a great deal of user engagement during the design and development process," Urnes says. "Within a few weeks, we start presenting working prototypes, and based on user feedback, we modify the system frequently for several more weeks or until it meets the client's requirements." Because all the solutions are provided via a software-as-a-service (SaaS) model, the client does not need to invest in any additional infrastructure or install software, and the time to rollout is quite short.

Walsall Council is a government organization that provides residents with many types of services, including "reablement," an intense process during which the patient receives support and training geared toward fostering independence. Studies of reablement indicate that it can significantly increase quality of life while reducing the need for homecare by up to 60 percent. To better manage its reablement cases, Walsall Council began using psHEALTH's eABLE, which tracks the patient from referral through assessments and outcome.

Most healthcare processes are a combination of structured and unstructured activities, and adaptive case management allows a smooth transition between them. "The initial referral procedure for a patient follows a predictable path and therefore can be standardized," Urnes says. However, during the care cycle, medical experts will, within certain parameters, make clinical decisions, and therefore a flexible approach is needed. "The challenge is to get the balance right between delivering evidence-based processes and automation, while using the skills and judgment of the healthcare worker where appropriate," Urnes explains. 

Productivity boost

Productivity in healthcare is notoriously difficult to measure, but the information that is gathered during case management provides insights into the value of treatment. Unlike transactional BPM, productivity in case management does not depend just on the speed of completing the process, but also on whether the patient improves. "Often, no one is tracking patient outcomes," Urnes says, "and no one knows what each portion of medical care really costs. This lack of information can lead to an inefficient system of care."

In a study using data from eABLE, Walsall Council found patients had, on average, experienced considerable improvement as measured by an activities-of-daily-living (ADL) index, and experienced an 80 percent reduction in care needs. The study also revealed that the duration of the treatment period was not correlated with improvement, and that service teams differed widely in their productivity as measured by the combination of improvement and use of resources.