Opening the conversation: who we are meeting today

• Tell me briefly how your care management organization is structured today, including roles, average caseloads, and primary responsibilities
• On a typical shift, how many minutes does a nurse care manager spend on direct member outreach versus documentation and administrative tasks Options: <60 minutes outreach, >180 minutes documentation, 60-120 minutes outreach, 120-180 minutes documentation, 120-180 minutes outreach, 60-120 minutes documentation, >180 minutes outreach, <60 minutes documentation, I don't have exact timing
• Which care team roles currently own outreach, transition-of-care calls, and utilization review respectively Options: Nurse care managers, Social workers, Transitions specialists, Utilization management nurses, Third-party vendors, Combination
• How many active high-acuity members does a typical care manager carry right now Options: <40, 40-79, 80-119, 120-199, 200+
• Walk me through a recent weekday when your highest-risk member received a timely outreach and it prevented an ED visit, what happened step by step

Where the workflow frictions actually live

• If nurse care managers are spending half their day on documentation, what practical things stop them from doing proactive outreach to high-risk members
• How often in the last 90 days have you identified a missed intervention that directly preceded an avoidable ED visit Options: Weekly, Biweekly, Monthly, Quarterly, We have not tracked this
• When you trace a recent avoidable ED visit, which part of the workflow most commonly failed, triage, scheduling, outreach attempts, or data signal Options: Triage, Scheduling, Outreach attempts, Data signal delay or inaccuracy, Multiple failures
• Who on your team is the first to learn when a top-risk member is not engaging with outreach, and what happens next
• Which reporting gap makes leadership feel least confident about program performance Options: Attribution to outreach, Timeliness of ADT alerts, Risk stratification accuracy, Cost per member, Other
• Which single operational gap would make you stop a vendor pilot immediately if it could not be resolved

Assumptions that could derail a rollout

• What assumptions about your claims and clinical data readiness are most likely to be wrong and would derail the first integration sprint
• Are real-time ADT feeds currently available from your provider network or hospital partners Options: Fully available, Partially available, Planned but not available, Not available
• Who owns the API or data integration work internally and can that person commit dedicated hours during deployment
• How many full time equivalents in IT and operations could you allocate to integration and testing in the next 8 weeks Options: None, 1 FTE, 2-3 FTEs, 4-6 FTEs, 7+ FTEs
• If an integration requires mapping non-standard EHR fields from a major provider, what is your expectation for the timeline and who will fund that work Options: We will supply mapping resources and funding, Provider will supply mapping, We need vendor to map and fund, Unsure
• Is there any single compliance, legal, or contractual approval that would block data sharing for a pilot Options: Yes, No, Unsure
• If the answer to the previous question is yes, who is the decision maker and what is the earliest date they could approve data sharing

How success would actually show up in your day-to-day

• If your team hit the target of reducing avoidable ED visits by 15% in 12 months, what would have to be different about daily care manager work
• Which single metric does finance need to see to consider the program a success, 12-month PMPM reduction, reduction in ED visits, or net cost saving Options: 12-month PMPM reduction, Avoidable ED visits reduction, Total cost of care reduction, Improved quality scores/NCQA readiness
• How soon after go-live do you expect to see measurable changes that would satisfy the finance team, 3 months, 6 months, 12 months, or longer Options: 3 months, 6 months, 12 months, Longer than 12 months, Unsure
• What success evidence would make clinical leadership comfortable certifying this program during a Medicaid contract renewal audit
• If a pilot demonstrates the agreed success signal, what internal approvals would be required to scale to the full cohort and who can give that approval

The other options on your desk right now

• Who are the incumbent systems, vendors, or internal projects you are actively comparing against for this work Options: Incumbent case management platform, Other third-party vendors, Home-grown solution, Consulting firm, Replacing staff model, Not yet evaluated options
• What would have to be true about your current approach for you to keep it instead of moving to an outside platform
• Has anyone internally proposed building the functionality yourself instead of buying, and if so, who owns that proposal Options: Yes, IT owns it, Yes, clinical ops owns it, Yes, a cross-functional team, No internal proposal
• Which competitive feature or capability would make you choose another vendor over an outside platform partner Options: Faster integrations, Lower total cost, Better clinician UX, Proven outcome evidence, Stronger compliance controls
• If the incumbent committed to delivering real-time ADT, integrated claims, and automated outreach within 90 days, would you stay with them Options: Yes, No, Depends on proof and contract, Unsure
• What single answer from an incumbent would make you walk away from exploring external platforms today

Operational readiness and gating constraints

• If production-quality feeds for claims, ADT, and pharmacy are not available, which part of the proposed rollout is most likely to fail first Options: Risk stratification accuracy, Timely outreach, Pilot measurement, Provider notification
• Which source systems must be integrated for a minimal pilot, choose all that apply Options: Claims platform, Core EHR, Hospital ADT stream, Pharmacy claims, Lab results repository, SDOH screening tool
• Are APIs or HL7 feeds available for those systems or will custom integration be required Options: APIs available, HL7 feeds available, Custom integration required, Combination, Unsure
• Who is the single technical owner we should coordinate with for data mapping and testing, and can they commit to weekly integration sprints
• Do you have a documented data dictionary for claims and ADT fields we can use for mapping Options: Yes, comprehensive, Yes, partial, No, but we can produce one, No
• Are there regulatory approvals or legal reviews that must finish before any data leaves your environment Options: Yes, privacy/legal approvals, Yes, security review, No approvals required, Unsure
• If legal or security approval is required, what is the expected lead time in weeks Options: <2 weeks, 2-4 weeks, 5-8 weeks, 9-12 weeks, 12+ weeks, Unsure

Clinician adoption, training, and day-one experience

• What about the current tools or workflows makes clinicians most resistant to change
• Walk me through the last time clinicians pushed back on a workflow change, what were their specific concerns and who ultimately resolved them
• Which training formats work best for your care managers, pick all that apply Options: Live classroom, Remote instructor-led, Recorded micro-lessons, Shadowing and role play, Super-user mentoring
• How many super-users or champions would you commit to train before pilot launch Options: None, 1-3, 4-6, 7-10, 10+
• If frontline clinicians refuse to participate in the pilot, will leadership still permit a technical go-live for a subset of features Options: Yes, No, Only with incentives, Unsure
• What immediate change to the platform or workflow would make nurses more willing to try it for 30 days

Decision triggers, pilot design, and acceptance criteria

• What single pilot outcome would make your CFO sign for a full rollout within 30 days
• Which population should we pilot with to get the fastest, most attributable signal, choose one Options: Top 1% highest risk, Top 5% risk stratified by claims, Post-discharge transition cohort, Frequent ED utilizers, Behavioral health high utilizers
• What primary acceptance criteria would you require for pilot success, pick up to three Options: % reduction in avoidable ED visits, Timeliness of outreach within X hours, Risk stratification precision, Clinician adoption rate, PMPM cost reduction
• Who has final authority to sign the pilot acceptance and commit budget for scale
• What reporting cadence and audience would you want during the pilot to make go/no-go decisions Options: Weekly ops to clinical leads, Biweekly to exec stakeholders, Monthly CFO review, Ad hoc as issues arise
• If the pilot fails to meet one acceptance metric but exceeds others, who decides whether to iterate or stop

Practical next steps and timeline alignment

• If we agreed to a 90-day pilot starting once integrations are validated, what is your preferred kickoff week in the next quarter Options: First week, Second week, Third week, Fourth week, Unsure
• Who will be the project sponsor and who will be the day-to-day project lead from your side
• Which resources can you commit in the first 4 weeks, pick all that apply Options: Integration engineer hours, Clinical workflow SME, Data steward, Training coordinator, Executive sponsor time
• What reporting or dashboard must be available at the end of pilot week 4 to keep your leadership engaged Options: Daily outreach volume and outcomes, Risk stratification snapshots, Engagement and no-show rates, Initial cost per outreach estimate
• If the pilot proves the acceptance criteria, what internal steps would be required to budget and schedule full deployment and how fast could you move Options: Sign within 2 weeks, 1 month, 2-3 months, Longer
• Finally, what outstanding risk or concern, not yet discussed, would cause you to pause moving to a pilot

• Clinical Workflow Experience Session

• Confirm the current state and its cost
• You confirm the demonstrated workflow eliminates the documentation rework that consumes half a care manager day.
• Provide three representative high-risk member scenarios including ADT timeline, claims events, and SDOH notes for sandbox testing.
• Map a care manager day with Scenario A
• You confirm the proposed outreach cadence and reporting provide the evidence needed to link earlier interventions to fewer avoidable ED visits and PMPM improvement.
• Run the two provided anonymized member scenarios through the seller sandbox and deliver the scenario timelines and simulated outcome snapshots before the pilot kickoff.
• Run an end-to-end platform proof with Scenario B
• Identify care manager participants and available training windows for the pilot cohort.
• You and the seller agree the data feeds and pilot acceptance criteria required to produce decision-grade results within the agreed timeline.
• Confirm the owners and expected delivery dates for ADT and claims data feeds needed for the pilot.
• Confirm data and integration assumptions
• Validate this matches your need
• Agree next evidence and pilot steps

• Clinical Workflow Experience Session
• Clinical Workflow Experience Deck
• Clinical Workflow Solution Brief

• meeting
• slides
• document

• Ingest real-time ADT alerts
• Integrate payer claims and pharmacy feeds
• Integrate lab and diagnostic results
• Consolidate SDOH screening and referral data
• Migrate legacy case records and trackers
• Configure unified care manager workspace
• Configure evidence-based clinical protocols
• Deploy predictive risk stratification models
• Integrate with provider EHR systems
• Automate member outreach and notifications
• Activate utilization and transition-of-care workflows
• Train care team on platform workflows
• Enable outcomes and PMPM cost dashboards
• Provide post-go-live data operations and support

Ingest real-time ADT alerts

• Which ADT event types do you need ingested (for example A01 admit, A03 discharge, A08 update)? Options: A01 Admit, A03 Discharge, A08 Update/Transfer, A04 Registration, Other
• Do you currently receive ADT feeds in HL7 v2, FHIR subscription, or a vendor-specific stream? Options: HL7 v2 over MLLP, FHIR Subscription/API, Vendor push (SFTP/HTTP), No existing feed
• How quickly must an ADT event be specific in the care manager workspace (latency SLA and proof required)? Options: < 5 minutes, < 15 minutes, < 60 minutes, Within 24 hours
• Provide the expected average and peak daily ADT event volume for the populations in scope (events/day).
• Identify the sending system(s) for ADT feeds (senders such as hospital LIS/ADT broker or HIE) and the technical owner for each.

Integrate payer claims and pharmacy feeds

• Which claims feed formats do you provide or expect (for example X12 837, 277, 835 or CSV extracts)? Options: X12 837 Professional/Institutional, 835 Remittance, EDI via clearinghouse, CSV/extract, Other
• Do pharmacy claim records include National Drug Code (NDC) values and days-supply fields required for adherence checks? Options: Yes, NDC and days-supply present, Partial (NDC only), No
• Specify the preferred file transfer method for claims and pharmacy (SFTP, API, clearinghouse push) and any vendor gateway details. Options: SFTP, REST API, Clearinghouse push, Other
• What is the typical claims adjudication lag you expect to rely on for risk scoring and PMPM reporting (for example 30/60/90 days)? Options: 30 days, 60 days, 90 days, Custom (describe)
• List required mapping rules or business logic for claims (for example mapping internal benefit IDs, member identifiers, or PCP assignment).

Integrate lab and diagnostic results

• Which lab result types must be ingested (for example chemistry panels, CBC, microbiology, or imaging reports)? Options: Chemistry panels, CBC/Hematology, Microbiology/culture, Imaging/radiology reports, Pathology
• Are lab results coded with LOINC or delivered as unstructured PDF/attachment from the sending LIS/EHR? Options: LOINC-coded discrete results, PDF attachments only, Mixed (both)
• Specify the delivery standard you can provide for results (HL7 ORU, FHIR DiagnosticReport/Observation, or SFTP files). Options: HL7 ORU v2, FHIR DiagnosticReport/Observation, SFTP file drops, Other
• Provide the expected latency requirement for lab results used in care workflows (for example stat results within 1 hour, routine within 24 hours). Options: Stat <1 hour, Same day <8 hours, Within 24 hours, No SLA
• Identify the lab vendor or laboratory information system (LIS) sending results and the technical contact for testing.

Consolidate SDOH screening and referral data

• Which SDOH screening instruments do you use (for example PRAPARE, AHC-HRSN, internally developed forms)? Options: PRAPARE, AHC-HRSN, Internal screening form, Other
• Do referrals to community-based organizations include a standardized taxonomy or referral outcome codes that we must ingest? Options: Yes, standardized taxonomy, Partial mapping required, No standard taxonomy
• How do you capture referral outcomes today (callback, CBO portal, care manager update) and what evidence of closure must be stored? Options: CBO portal confirmation, Care manager documentation, Phone callback log, Other
• Specify consent, data-sharing, or state-unique privacy constraints for SDOH data (for example member opt-in, state consent form).
• Provide a list of community partners or referral endpoints and whether they can accept inbound electronic referrals or require a manual handoff.

Migrate legacy case records and trackers

• Identify the legacy systems and trackers to migrate (for example Excel trackers, legacy case management database, or faxed PDFs).
• How many case records and attachments require migration and what date range should be included (for example last 12 months)? Options: <1,000, 1,000-10,000, 10,000-50,000, 50,000+
• What migration completeness threshold will you accept as evidence of success (for example 95% of active cases with attachments verified)? Options: 95% complete, 90% complete, 80% complete with prioritized backlog, Other
• Specify which data fields must be preserved during migration (for example care plans, outreach notes, consent status, PCP assignment).
• Who will validate migrated record accuracy and provide sign-off (title or role, for example data owner or care management director)?

Configure unified care manager workspace

• Which workspace tabs or modules are essential for day-to-day work (for example ADT queue, risk roster, outreach tasks, documentation panel)? Options: ADT queue, Risk roster, Outreach tasks, Documentation/notes panel, Reports
• Do you require role-based custom views (for example RN care manager vs social worker dashboards)? Options: Yes, No
• How should outreach tasks be prioritized and surfaced in the workspace (for example by risk score, recent ED visit, or time-since-last-contact)? Options: By risk score, By recent ED/ADT event, By time-since-last-contact, Custom rule
• Specify required integrations inside the workspace (for example in-line medication lists from claims, lab results view, EHR chart link).
• Provide examples of two typical patient scenarios we should use to validate workspace workflows during testing.

Configure evidence-based clinical protocols

• Provide the specific clinical protocols or pathways you require (for example heart failure transition protocol, diabetes titration pathway, or high-risk care plan templates).
• Are the protocols mapped to any external standards or accreditation guidance (for example NCQA HEDIS measures or state Medicaid protocols)? Options: NCQA/HEDIS-aligned, State Medicaid protocol, Locally developed only
• Which fields should be required for protocol adherence documentation (for example vitals, medication reconciliation, SDOH screening result)?
• Who has authority to edit or approve protocol content within your organization (role/title)?
• Describe how exceptions to protocols are currently documented and what evidence must be retained for audits.

Deploy predictive risk stratification models

• What model performance targets will you accept as sign-off (for example sensitivity, positive predictive value, or AUC thresholds)? Options: Sensitivity target, PPV target, AUC target, Custom (describe)
• Do you require local retraining or calibration of models using your claims and ADT history before go-live? Options: Yes, full retrain, Partial calibration, No, use out-of-the-box model
• Specify the risk strata definitions you want surfaced (for example top 1% high risk, top 10% elevated risk) and any action tied to each strata.
• How often should risk scores refresh (daily, weekly, monthly) and which data sources must trigger a score refresh (ADT, claims, pharmacy)? Options: Daily, Weekly, Monthly, Event-driven
• Provide the input data elements required for the model (for example 12 months of claims, 1 year of ADT history, medication fills).

Integrate with provider EHR systems

• Identify the provider EHR systems and versions for integrations (for example Epic, Cerner, Athena) and number of provider sites.
• Which integration standard do you prefer for each EHR (for example FHIR API, HL7 v2, CCDA, or custom API)? Options: FHIR R4 API, HL7 v2, CCDA/CCD, Custom API
• How will patient identity matching be handled across systems (for example deterministic using MRN + DOB, probabilistic match, or master patient index)? Options: Deterministic (MRN+DOB), Probabilistic matching, Master Patient Index (MPI), Other
• Specify the scope of write-back or messaging to the EHR (for example posting notes, task creation, or updating problem lists). Options: Notes only, Notes + tasks, Problem list updates, No write-back
• Provide test environment access and a technical contact for each EHR integration during validation.

Automate member outreach and notifications

• Which outreach channels should be automated (for example SMS, IVR, telephony, secure portal message, email)? Options: SMS, IVR/Phone, Secure portal message, Email, Letter
• Do you require documented member consent for SMS or automated calls per state regulations and your consent records format? Options: Yes, consent required, Consent on file for some members, No
• How should outreach cadence be configured for high-risk members (for example 3 attempts over 7 days, escalation on no response)? Options: 1 attempt, 3 attempts over 7 days, Weekly cadence, Custom cadence
• Specify required message templates, scripts, or language for clinical outreach and escalation pathways (for example after ED discharge).
• Provide opt-out and Do Not Contact handling rules and the expected source of truth for opt-outs.

Activate utilization and transition-of-care workflows

• Which utilization events should trigger workflows (for example ED visit, inpatient admission, observation stay, post-discharge follow-up)? Options: ED visit, Inpatient admission, Observation stay, Discharge to home health
• Do you require prior authorization or utilization review checks integrated into the workflow and from which system (for example UM system or PA vendor)? Options: Yes, integrate UM system, Manual PA process, No
• How should transition-of-care handoffs be routed (for example to assigned RN, to PCP inbox, or to a transition team), and what SLA applies? Options: Assigned RN, PCP inbox, Transition team, Other
• Specify escalation rules and time thresholds for unresolved utilization events (for example escalate after 24 hours without outreach).
• Provide two example discharge-to-home scenarios and the desired workflow steps we should automate for validation.

Train care team on platform workflows

• What target training completion rate is required before go-live (for example 90% of active care managers certified)? Options: 100%, 95%, 90%, Custom
• Which roles require formal certification or assessment (for example RN care manager, social worker, supervisor)? Options: RN care manager, Social worker, Supervisors, Data operations
• How many training sessions and what duration do you prefer (for example four 90-minute sessions, half-day workshop)? Options: Two 2-hour sessions, Four 90-minute sessions, Half-day workshop, Other
• Specify how you want training completion tracked and evidence provided (for example LMS completion, quiz pass, signed attestation). Options: LMS completion, Quiz/assessment, Signed attestation, Other
• Provide preferred training windows and blackout dates we must avoid for live sessions.

• Non-Disclosure Agreement (NDA)
• Master Services Agreement (MSA)
• Subscription Order Form
• Statement of Work (SOW)
• Data Processing Agreement (DPA) / HIPAA Business Associate Addendum (BAA)
• Data Use & Sharing Agreement
• Service Level Agreement (SLA)
• Acceptance & Success Criteria Agreement
• Governance & Steering Committee Charter
• Change Order Agreement
• Termination, Data Return & Transition Addendum

• Go-live Health Check (Weeks 1-4)
• First Outcomes Measurement (Weeks 4-10)
• Acceptance Gate Review (Day 90)
• Monthly Operational Review — Hypercare (Months 4-6)
• Quarterly Success Review

• Deliver targeted training modules for care managers identified with low weekly active usage.
• Produce a documented acceptance decision for each Solution Scope criterion and capture the buyer signatory where applicable.
• Agree remediation plans with timelines for any failed acceptance items so the loop is closed.
• Confirm the incumbent system status and the plan for final decommission or read-only retention and data archiving.
• Publish the acceptance decision record including pass/fail per criterion and the buyer signatory statement where required.
• Create and publish remediation tasks with deadlines and the specific evidence required for re-evaluation.
• Execute the incumbent decommission checklist and produce an archive report confirming data migration or read-only retention.
• Operational dashboards and incidents
• Reduce ADT alert acknowledgment-to-action time toward the target established in Solution Scope.
• Increase weekly active care manager usage to the target percentage and close critical adoption gaps.
• Prioritize the operational backlog so high-impact items are scheduled for resolution within the hypercare window.
• Resolve the top three operational incidents affecting ADT processing and report completion status before the next review.
• Re-confirm success criteria and owners
• Publish an updated operational runbook including escalation paths and SLAs for integrations.
• Quarterly outcomes vs Solution Scope targets
• Confirm whether the avoidable ED visit rate and PMPM for the high-risk cohort are meeting or moving toward the Solution Scope targets.
• Identify the top clinical or operational drivers requiring intervention next quarter.
• Agree a concise measurement plan and the evidence package for the next quarterly review.
• Publish the quarterly outcomes dashboard and the quarter-over-quarter analysis to the shared channel.
• Run a targeted detailed review analysis on any cohort with worsening avoidable ED visit rates and document recommended fixes.
• Schedule and prioritize enhancement requests that materially affect the agreed quarterly priorities.
• Confirm key data feeds and integrations are delivering expected records and test cases passed.
• Surface and document all high-severity blockers with remediation windows.
• Verify that a baseline of users can access and perform core workflows for the high-risk cohort.
• Publish a deployment validation report summarizing feed status, failed test cases, and next steps.
• Log each open blocker in the shared channel and record the agreed remediation window.
• Schedule targeted refresh sessions for care managers whose access or workflows are incomplete.
• Present first measurement vs targets
• Determine whether the avoidable ED visit rate and documentation time are trending toward the Solution Scope targets or require remediation.
• Agree the top 3 root causes for any metric gaps and the testable changes to address them.
• Confirm the evidence package required for the Acceptance Gate meeting.
• Deliver a data snapshot and methodology note showing how the avoidable ED visit rate and documentation time were calculated.
• Implement agreed short-term workflow adjustments and schedule a follow-up data pull for the next measurement window.
• Fix any identified integration or mapping errors and report when corrected data is available for re-analysis.
• Restate acceptance criteria and targets
• Adoption and training gaps
• Present outcome data against each criterion
• Diagnose root causes for gaps
• Deployment and data feed validation
• Clinical outcome breakdown by cohort
• Enhancement requests and backlog triage
• Early adoption signals and usage patterns
• Document pass/fail and capture formal decision
• Operational adjustments and short-term experiments
• Financial performance and cost drivers
• Open SLA and integration issues
• Open issues, remediation status, and enhancement requests
• Data quality and integration issues
• Remediation plan for any failed criteria
• Blockers, defects, and escalation paths
• Incumbent system wind-down checklist
• Confirm timeline to Acceptance Gate
• Agree short-term operational tasks
• Agree priorities and measurement plan for next quarter
• Agree immediate remediation actions