How UPMC Uses Helios to Unify Its LTSS Operating Model and Deliver Significant Productivity Gains.

Member Story

Dorothy is 81 years old and lives alone in a row house in Pittsburgh. She has moderate mobility limitations, manages a
chronic heart condition, and receives home health services through Pennsylvania’s Community HealthChoices
program. She gets by, mostly — but her service coordinator has been concerned. Dorothy mentioned at her last visit
that she’d been skipping meals. Not because she couldn’t afford food, but because getting to the grocery store had
become impossible and she didn’t know where to ask for help.

During Dorothy’s next scheduled assessment, her coordinator pulls up her profile in Helios, identifies food insecurity as
an unmet need, and submits a referral to a local meal delivery program directly through the platform, without opening
a second system, logging into a separate portal, or looking up a phone number. The referral goes to FindHelp, which
connects Dorothy with a community provider. When the service is confirmed, the loop closes back in Helios, and
Dorothy’s care plan reflects the new support.

That interaction — a coordinator identifying a need, acting on it in the moment, and connecting a member to support
without breaking the workflow — is one example of what LTSS coordination looks like in practice. UPMC Health Plan
supports thousands of members like Dorothy, with complex medical, functional, social, and service needs that span
both facility-based and home- and community-based settings. Helios® by Elligint Health provides the platform
infrastructure that helps UPMC manage that complexity at scale.

Disclaimer – The member described here is fictional and created for illustrative purposes only. Any resemblance to an actual person is coincidental.

Value-based care for populations with complex functional needs is difficult to manage, and Long-Term Services and Supports (LTSS) is one of the clearest examples of why. In an acute or subacute setting, a care team controls the environment: shifts for staff, equipment, protocols, and appropriate oversight are built into the walls of the facility. The work is organized around a defined encounter with a beginning and an end. Supporting LTSS requires health plans to manage that same level of complex need without any of the built-in structure in the member’s own home and on the member’s own terms, for as long as support is needed (versus the defined encounter). Health plans serving LTSS members must provide the ability to coordinate medical, functional, social, provider, caregiver, and compliance needs across members’ homes and communities often over years, and without the direct observation a facility setting provides. For the University of Pittsburgh Medical Center (UPMC) Health Plan, that challenge includes supporting approximately 64,000 LTSS members as part of its much broader Community Health Choices (CHC) population. Across CHC, the telephonic member services team handles more than 2,500 calls each day, requiring an operating model that can support intake, assessment, service planning, authorizations, compliance monitoring, and service delivery oversight at scale. UPMC Health Plan has met that challenge by deploying Helios® by Elligint Health — a comprehensive care management and utilization management platform — as its dedicated system for LTSS even as other clinical management functions use other platforms. LTSS requires a purpose-built combination of platform configurability, unified care and utilization management capabilities, and expert partnership to manage complex functional needs, long-duration services, provider coordination, and compliance demands that general clinical systems are not designed to replicate.

Why Populations with Complex Needs Make LTSS Different from Traditional Care Management

Most care management programs focus on clinical coordination: managing diagnoses, closing gaps in care, supporting transitions, and reducing avoidable utilization. LTSS requires those capabilities within a much broader operating model — one that must also coordinate functional support, caregivers, community providers, service delivery, and regulatory obligations over periods that may extend for years.

In an acute or subacute setting, the setting itself does much of the work of managing complexity. A hospital or skilled nursing facility (NF) supplies trained staff around the clock, standardized protocols, equipment, and a physical environment designed for care delivery. Documentation happens in real time because the care team is present. The relationship has a natural endpoint: the patient is discharged, and the episode closes.

None of that structure exists in a member’s home. The health plan does not control the physical environment, cannot guarantee caregiver availability, and cannot directly observe whether a scheduled visit happened as planned. The same member who might receive continuous nursing oversight in a facility instead depends on a rotating cast of home health aides, family caregivers, and community providers to manage bathing, meals, mobility, and medication support — all coordinated remotely, over years, by a care team that is rarely physically present. Managing complex needs in this setting is not simply “acute care management, but longer.” It is a fundamentally different discipline: one built around sustaining a person’s life in place rather than treating an episode within a controlled setting.

LTSS encompasses a broad range of non-medical supports that allow individuals with complex functional needs to live safely and independently in their homes and communities. That means coordinating not only medical and behavioral health services, but also personal care, home health, caregiver supports, meal programs, transportation, and other community-based services. It means monitoring needs that may shift gradually over months or years, maintaining compliance with highly specific program requirements, and documenting not only what services were authorized, but whether they were delivered as planned and remain aligned with each member’s goals, circumstances, and functional needs.

The regulatory landscape adds further complexity. LTSS programs operate under Medicaid requirements, state waiver rules, person-centered planning standards, service authorization requirements, quality reporting obligations, and fraud, waste, and abuse oversight frameworks, including requirements and standards established by CMS, NCQA, and URAC. As Medicaid programs continue to emphasize care in home- and community-based settings, the operational and documentation demands on coordinating health plans have grown substantially.

Managing this environment requires more than a clinical documentation system. Care teams need integrated support for functional assessments, person-centered service plans, authorization workflows, provider coordination, caregiver needs, reassessment scheduling, budget oversight, service delivery monitoring, and ongoing compliance tracking, all within a workflow that supports the way LTSS programs actually operate.

These two populations sit at different points on the same spectrum of complexity. NF members receive LTSS within a facility that provides staffing, structure, and quality care in a safe environment. UPMC’s coordination efforts under this model therefore focus on supporting members who want to return to the community by identifying and mitigating barriers to discharge, while also ensuring that members who remain in long-term care have their medical, social, and LTSS needs met.

HCBS members face many of the same complex functional needs and regulatory requirements, but with fewer built-in supports. For these members, UPMC’s care management platform must help provide the coordination infrastructure that a facility would otherwise provide — bringing providers, caregivers, and services together around the member in their home and community.

At the scale UPMC operates, the logistics of intake, assignment, assessment, service planning, authorization, and ongoing monitoring are formidable and require more than just adding LTSS workflows to a conventional care management system. UPMC previously relied on a system that proved difficult to scale as the LTSS program grew. That experience underscored the need for a platform built specifically to handle complexity — one that could flex with the program and adapt to evolving state requirements. For the last six years, UPMC has used Helios® by Elligint Health as a configurable, purpose-built foundation to manage LTSS across a large, multifaceted program.

Notably, UPMC uses another vendor for medical management functions across the organization. The decision to retain Helios specifically for LTSS reflects a deliberate decision to support complexity: LTSS requires workflow infrastructure, compliance tooling, assessment capabilities, automation, and long-duration authorization. When LTSS complexity increases, purpose-built infrastructure matters.

Why Helios for LTSS

Helios is designed to support whole-person care within the context of daily life — whether in an NF, at home or in the community — in coordination with the caregivers and providers who surround that member and across the services that must continue functioning between encounters over time. That distinction explains why UPMC will continue to use Helios for their LTSS population.

The Helios platform’s configurability and automation are central to that decision. Workflows vary by population, setting, assessment requirements, service authorization rules, provider networks, budget parameters, and state-specific compliance obligations. Helios allows UPMC to tailor workflows around the way its LTSS program actually operates, including using different management models for NF and HCBS members. Within the same unified platform, UPMC can support embedded assessments, automated service planning, authorization creation, and ongoing care and utilization management activities.

How UPMC Uses Helios: An End-to-End Walkthrough

UPMC’s LTSS workflow, as supported by Helios, extends across one connected operating model: from initial member intake, case management, and assessment through to service planning, authorization, budget oversight, service delivery monitoring, and ongoing compliance tracking. Helios provides end-to-end continuity and reduces fragmentation across the LTSS life cycle.

Intake & Case Assignment

New LTSS member records are automatically loaded into Helios, providing care teams with a centralized starting point for intake and ongoing care management. Once records are available in the platform, UPMC assigns them to service coordinators based on established operational processes and caseload considerations.

Care Management & Outreach

UPMC staff, including health plan nurses and service coordinators, receive system-generated outreach tasks and documentation prompts in Helios so that phone outreach, in-home visits, assessments, and other member interactions can be directly tracked in the platform. In LTSS, where timely outreach and follow-up can affect service continuity, member safety, and compliance, that automation is especially valuable, helping care teams stay organized while reducing manual coordination and administrative burden.

Helios also supports the distinct LTSS care management models required for NF and HCBS members within a single platform. This gives UPMC a consistent LTSS infrastructure while allowing workflows to reflect the needs and realities of each population. Care teams can manage facility-based and community-based members, as well as transitions between settings, without relying on separate systems, duplicative processes, or manual workarounds.

Helios also supports UPMC’s telephonic member services team, which includes approximately 125 staff and handles nearly 3,000 member calls each day. By enabling member services staff to access member records, review authorizations, check case notes, and schedule transportation in a single platform, UPMC can resolve more member needs during the initial call. This focus on one-call resolution helps improve the member experience while limiting repeat inquiries that would increase call volume and place additional demands on member services staff.

Integrated Assessments & Member-Centric Services

Within Pennsylvania’s Community HealthChoices program, functional eligibility and service needs for LTSS members are assessed through the Functional Eligibility Determination (FED), a state-specific instrument drawn from the interRAI Home Care assessment. The FED helps establish NF level-of-care eligibility and determine the services and supports needed for members receiving LTSS in the community.

The interRAI assessment is fully embedded within Helios, rather than linked externally, allowing service coordinators to complete assessments without leaving their workflow. Elligint Health incorporated the instrument directly into the platform for UPMC under its existing interRAI license, as this type of deployment requires the client organization to hold the appropriate licensing. Working with UPMC’s LTSS SMEs, Elligint Health also supported the transition to interRAI V10 and the configuration of a more streamlined assessment workflow that brings together interRAI and UPMC-specific assessment and service planning requirements within Helios.

UPMC’s assessment workflow now brings together components that previously required separate assessment and service planning activities. InterRAI identifies the member’s clinical and functional needs, while Service Planning & Allocation (SPA) translates those needs into services, tasks, and allocated time. As assessments are completed, Helios generates key outputs such as risk scores, recommended services, service frequency guidance, and prompts for the member’s personal goals to fill care gaps that help inform the LTSS service plan. By capturing that information within a single connected workflow, Helios creates a stronger source of truth for the person-centered service plan, authorizations, outbound files, and future direct state submission while reducing duplicate entry and administrative effort.

UPMC recently completed a major overhaul of its core LTSS needs assessment within Helios, reducing it from nearly 900 questions to approximately 370 — cutting the length by more than half. The reduction was possible because redundant data collection could be eliminated: information previously gathered through the assessment questionnaire was already captured elsewhere in the system and available for back-end reporting.

Assessments that previously took a full day, now take 3 – 4 hours

What formerly required 2 home visits, now only takes 1

With UPMC conducting approximately 1,500 assessments per week, the operational impact has been significant. Service coordinators report that assessments that previously took a full day now take three to four hours and include the development of a care plan and service plan. What formerly required two home visits can now be completed in one. Participants have noticed the difference as well, commenting that visits feel faster and less burdensome. Formal outcome data is still emerging — the redesign launched approximately one month prior to publication — but UPMC expects to see improvements in assessment completion timeliness, grievance and appeal rates, and member satisfaction scores.

Just as importantly, Helios allows care managers to apply frontline judgment within the workflow. Care managers can adjust risk levels and recommended services based on real-world observations. UPMC also uses multiple supplementary tools they developed within Helios to support additional services like employment opportunities, transportation, and requests for medical care management.

This balance is critical in LTSS. Standardized assessments provide structure, consistency, and compliance support, while service coordinator observations help ensure that the service plan reflects the member’s lived experience, home environment, caregiver support, and changing needs. Assessment data does not sit apart from the LTSS workflow; it flows into the service plan, authorization process, and ongoing monitoring. That matters for organizations trying to improve timeliness, reduce rework, and maintain compliance across large LTSS populations.

Service Planning, Authorizations & Budget Management

Helios uses assessment data and integrated member information to help guide the creation of a comprehensive person-centered service plan that care managers can refine based on the member’s circumstances, preferences, and evolving needs. These plans include services and frequencies, assigned providers, care schedules such as bathing or meal preparation, emergency preparedness plans for events such as natural disasters or power outages, and backup provider plans required for regulatory compliance.

LTSS authorizations are created within the same care planning workspace, leveraging functionality that automatically cascades information from one section to the next. Rather than requiring staff to re-enter member information into intermediate screens, Helios carries relevant data forward into the person-centered service plan, authorizations, and outbound files. This helps improve consistency, reduce duplicate entry, and establish the completed assessment as a shared source of truth across downstream LTSS processes.

Service Delivery Monitoring

For health plans managing LTSS in home- and community-based settings, maintaining visibility into whether services are being delivered as planned is one of the more operationally challenging aspects of the work. Unlike a facility, where care is observable and documentation happens in real time, a member’s home offers no default visibility. The health plan has to create it.

Helios supports service delivery monitoring through the combination of documentation workflows, automated tasking, and reassessment scheduling that run throughout the LTSS life cycle. Care managers document member interactions — phone outreach, in-home visits, service updates — directly in the platform, creating a running record of engagement that member services staff, supervisors, and quality teams can access in real time. When follow-up is due, the system generates the task. When a care plan milestone approaches, the system flags it. That continuous workflow automation means gaps in service delivery are more likely to surface as actionable alerts than as missed items discovered after the fact. The service plan itself also functions as an ongoing monitoring tool. As circumstances change — a member’s health status shifts, a caregiver becomes unavailable, or service provider changes — the plan can be updated and the authorization record revised to reflect current needs.

Why Helios Matters for UPMC

For UPMC Health Plan, Helios provides the infrastructure and configurability needed to support its real-world LTSS operating model rather than forcing a complex program into a generic care management workflow. The platform can accommodate the distinct requirements of LTSS while supporting both care management and utilization management within a unified environment.

Helios supports UPMC’s LTSS program across intake, assessment, service planning, authorization, and ongoing compliance monitoring in a single, integrated solution, giving UPMC staff access to a unified foundation that reduces fragmentation across the member journey. That integration matters. At UPMC’s scale, even small gaps between systems can create administrative burden and compliance risk as well as delay the identification of unmet needs.

The most significant value for UPMC is the ability to support its complex LTSS operating model within a single configurable platform. By connecting assessment, service planning, care management, authorizations, and downstream processes, Helios helps information captured at one stage of the member journey remain useful throughout the next. That shared foundation helps UPMC manage LTSS complexity at scale while keeping the focus where it belongs: on the members who rely on LTSS to remain safe, supported, and connected to their communities.