Care Management Implementation Best Practices for Regulatory Compliance Agility

The Imperative for Regulatory Compliance Agility for Health Plans

Health plans face mounting pressure from multiple directions, requiring a proactive approach to compliance. Key challenges include:

• Expanding Oversight: CMS and NCQA are increasing requirements for transparency, reporting, and audit readiness.

• State Mandates: States like New York and California are leading the way with more frequent and complex mandates.

• Audit Expectations: Regulators now expect built-in audit readiness and comprehensive documentation within technology platforms.

To navigate this environment, health plans must partner with a technology vendor that embeds compliance into its solutions from the start, offering configurable platforms, audit-ready reporting, and seamless data integration.

Nascentia Health's Transformation with HealthEdge GuidingCare

Nascentia Health, a New York-based Managed Long-Term Care (MLTC) plan, faced significant challenges with its legacy care management system. A patchwork of disconnected tools and manual workflows created administrative strain, compliance risks, and staff burnout.

The Challenge: Legacy Systems and Compliance Risk

The health plan’s outdated system could not adapt to frequent state regulatory changes, such as updates to the Uniform Assessment System (UAS) or Person-Centered Service Plans (PCSPs). These inefficiencies required duplicative data entry and manual effort, resulting in delayed compliance responses.

The Solution: A Partnership for Modernization

To modernize its operations and enhance agility, Nascentia Health partnered with HealthEdge to implement GuidingCare®. Operating under a unified "one-team" model, the joint implementation was completed in just nine months.

Measurable Outcomes and Operational Impact

The partnership with HealthEdge delivered immediate and lasting results, demonstrating improvements in multiple areas:

• 9-month go-live timeline.

• Saved 6–7 FTEs, enabling these resources to focus on high-value work.

• Trained 20 internal champions to foster strong adoption and sustain momentum.

• Achieved a 15% increase in nurse capacity, optimizing care delivery.

• Managed 90% of system changes internally, ensuring real-time adaptability to updates from the NY DOH.

• Delivered <30-minute support turnaround, significantly reducing burnout among care management teams.

Five Proven Practices for Successful Care Management Implementation

Nascentia Health’s success highlights five key practices for building regulatory compliance agility. By engaging compliance teams from day one and partnering with an experienced vendor, the health plan built a scalable model for continuous improvement.

1. Start with compliance on day one

2. Build shared accountability with your vendor.

3. Strengthen internal capacity early.

4. Choose a partner with deep regulatory expertise.

5. Track and share early wins

For a deeper dive into these practices, explore the blog post detailing Nascentia Health's success story.

The HealthEdge Framework for Compliance and Implementation Success

HealthEdge’s proven, compliance-first approach was central to Nascentia’s success. This structured model embeds regulatory alignment, collaboration, and measurable outcomes into every phase of deployment.

A Compliance-First Implementation Methodology

HealthEdge’s collaborative implementation begins with an Assessment Phase where compliance and transformation teams work together to align goals and define success measures. This approach, detailed in the Nascentia Health case study, minimizes rework and ensures a shared roadmap for long-term success.

Four Pillars of the HealthEdge Regulatory Strategy

A dedicated regulatory strategy forms the foundation of the HealthEdge implementation approach, ensuring customers remain audit-ready and aligned with evolving requirements.

• Regulatory Change Management: Continuously tracks and interprets state, federal, and accreditation mandates.

• Regulatory Risk Management: Documents, analyzes, and mitigates compliance risks through transparent processes.

• Operational Standards: Maintains a central policy library and a customer-facing Trust Portal for transparency.

• Industry & Customer Advocacy: Proactively engages with industry groups and customers to anticipate and influence policy.

Partnering for Lasting Regulatory Compliance Agility

By embedding compliance into technology and strategy, health plans can modernize care management, streamline operations, and build lasting readiness for an evolving regulatory landscape. The partnership between HealthEdge and Nascentia Health demonstrates that with the right partner and platform, organizations can adapt confidently, maintain compliance, and focus on improving member outcomes.

Learn more about how GuidingCare helps health plans strengthen compliance agility and deliver superior results.