Quality Improvement

    Program Purpose

    CareSource PASSE™ is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. Our Quality Improvement (QI) program is comprehensive and inclusive of both clinical and non-clinical services. CareSource PASSE monitors and evaluates the quality and safety of the care and service delivered to our members, emphasizing:

    • Accessibility to care
    • Availability of services and practitioners
    • Quality of care and member safety
    • Medical and behavioral health services
    • Internal monitoring, review and evaluation of program areas, including utilization management, care management and pharmacy services

    Member and provider satisfaction and health outcomes are monitored through:

    • Quality improvement activities
    • Routine health plan reporting
    • Annual Health Effectiveness Data and Information Set (HEDIS®)
    • Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
    • Member surveys
    • Accessibility and availability standards
    • Utilization trends

    CareSource PASSE assesses our performance against goals and objectives that are in keeping with industry standards. We complete an annual evaluation of our QI program.

    CareSource PASSE will seek accreditation by the National Committee for Quality Assurance (NCQA).

    Program Scope

    The CareSource PASSE Quality Improvement program governs our quality assessment and improvement activities.

    To maintain a robust QI program, our scope includes:

    • Advocating for members across settings including review and resolution of quality of care concerns
    • Meeting member access and availability needs for physical and behavioral health care
    • Determining interventions for overall HEDIS® rates to improve preventive care scores and facilitate support of members’ acute and chronic health conditions and other complex health, safety or welfare needs
    • Using the annual member CAHPS® survey to capture member perspectives on health care quality and establish interventions based on results
    • Demonstrating enhanced care coordination and continuity across settings
    • Meeting members’ cultural and linguistic needs, encompassing the social determinants of health
    • Ensuring CareSource PASSE is effectively serving members with complex health needs
    • Assessing member population characteristics and needs
    • Assessing the geographic availability and accessibility of primary care providers and specialists
    • Monitoring important aspects of care to ensure the health, safety and welfare of members across health care settings
    • Determining practitioner adherence to clinical practice guidelines
    • Supporting care coordination in meeting member needs
    • Partnering collaboratively with network providers, practitioners, regulatory agencies and community agencies
    • Ensuring regulatory and accrediting agency compliance, including:
      • All federal requirements as outlined in 42 CFR Part 438, Managed Care
      • HEDIS® compliance audits and performance measurement
      • NCQA accreditation standards
    • Meeting the quality requirements of CareSource PASSE’s contract with the Arkansas Department of Human Services

    On an annual basis, CareSource PASSE makes information available about our QI program to providers on our website.

    Quality Strategy

    CareSource PASSE seeks to advance a culture of quality and safety throughout the organization, beginning with our senior leadership. CareSource PASSE utilizes the Institute of Healthcare Improvement (IHI) framework to optimize health system performance, as well as the Centers for Medicaid & Medicare Services’ (CMS) National Quality Strategy, which is a national effort to align public and private sector stakeholders to achieve better health and health care.

    Institute for Healthcare Improvement Triple Aim for Populations

    CareSource PASSE aligns with the Institute for Healthcare Improvement Triple Aim (IHI) framework to:

    • Improve the member experience of care (including clinical quality and satisfaction)
    • Improve the health of populations
    • Reduce the per capita cost of health care

    Centers for Medicare & Medicaid Services’ National Quality Strategy

    CareSource PASSE aligns with the Centers for Medicare & Medicaid Services (CMS) National Quality Strategy to optimize health outcomes by leading clinical quality improvement and health system transformation. The CMS Quality Strategy vision for improving health care delivery can be summed up in three words: better, smarter healthier.

    The strategy corresponds to the six priorities from the Agency for Healthcare Research & Quality’s National Quality Strategy. Each of these priorities is a goal in the CMS Quality Strategy:

    • Make care safer by reducing harm caused while care is delivered:
      • Improve support for a culture of safety
      • Reduce inappropriate and unnecessary care
      • Prevent or minimize harm in all settings
      • Help patients and their families be involved as partners in their care
    • Promote effective communication and coordination of care
    • Promote effective prevention and treatment of chronic disease
    • Work with communities to help people live healthier lives
    • Make care affordable

    CMS employs the four foundational principles outlined to assist in meeting their stated goals:

    • Eliminate racial and ethnic disparities
    • Strengthen infrastructure and data systems
    • Enable local innovations
    • Foster learning organizations

    Quality Measures

    CareSource PASSE continually assesses and analyzes the quality of care and services offered to our members. This is accomplished by using objective and systematic monitoring and evaluation to implement programs to improve member outcomes.

    CareSource PASSE uses HEDIS to measure the quality of care delivered to members. HEDIS is developed and maintained by NCQA. The HEDIS tool is used by America’s health plans to measure important dimensions of care and service and allows for comparisons across health plans in meeting state and federal performance measures and national HEDIS benchmarks. HEDIS measures are based on evidence-based care and address the most significant areas of care. Potential quality measures include the following:

    • Wellness and prevention
    • Preventive screenings (breast cancer, cervical cancer and chlamydia)
    • Well-child care
    • Adolescent care
    • Chronic disease management
    • Comprehensive diabetes care
    • Controlling high blood pressure
    • Prenatal and postpartum care
    • Behavioral health
    • Follow-up after hospitalization for mental illness
    • Antidepressant medication management
    • Follow-up for children prescribed attention deficit/hyperactivity disorder (ADHD) medication
    • Safety
    • Use of imaging studies for low back pain

    Providers can log in to our Provider Portal to access our Clinical Practice Registry and historical medical and pharmacy data.

    Member Health, Safety & Welfare

    A top priority for CareSource PASSE is ensuring the health, safety and welfare of our members. The purpose of the CareSource PASSE Health, Safety and Welfare initiative is to ensure CareSource PASSE provides quality and safe health care and services to prevent medical errors, avoid adverse events and provide an avenue for addressing those social determinants of health that impact health status. CareSource PASSE understands that many social determinants contribute to a member’s health status, ability to seek preventive services and manage chronic health conditions.

    Quality of Care Reviews

    CareSource PASSE ensures the provision of safe and quality care to members by investigating and mitigating potential quality of care concerns, that include:

    • Inappropriate or inconsistent treatment
    • Delay in receipt of care
    • Compromising member health, safety or welfare
    • Having the potential to limit functional abilities on a permanent or long-term basis

    To properly assess quality of care concerns, CareSource PASSE Enterprise Quality Improvement initiates contact with providers to request medical records using established processes and timelines. As per our policies and provider contracts, we are authorized to ask for protected health information for health care operations, which includes quality issue reviews. Medical record requests are forwarded to providers via mail, email or fax and may be returned to CareSource PASSE via these same mechanisms as detailed in the medical record request document.

    All providers are expected to return medical record requests related to quality of care concerns within 14 days from initial receipt of the request, unless otherwise defined by program guidelines or state or federal law requirements. In the event that a state, federal or regulatory agency makes a request, or if the health and safety of a member requires that medical records must be submitted under a shorter timeframe, providers are expected to comply with the shorter turnaround time.

    Providers and facilities that utilize third party health information management vendors are responsible for providing medical records to CareSource PASSE or facilitating delivery of medical records to CareSource PASSE by the identified contractor. We are legally bound to interact with providers only and CareSource PASSE is not subject to any fees charged by health information management companies for medical record retrieval or submission.

    Your health partner representative may contact you if medical records are not received within the 14-day timeframe to ensure you received the request. In addition, our market Chief Medical Officer may also be in contact to facilitate and ensure receipt of the required medical records to complete the quality of care reviews. Providers or facilities who repeatedly fail to return requested medical records are reported to the Credentialing Committee and may face other directed intervention or penalties up to and including contract termination.

    Preventive and Clinical Practice Guidelines

    CareSource PASSE approves and adopts evidence-based nationally recognized standards and guidelines and promotes them to practitioners to help inform and guide clinical care provided to members. Member health resources are available on the website and cover a broad range of wellness, preventive health and chronic disease management tools. Guidelines are reviewed at least every two years or more often as appropriate and updated as necessary.

    The use of these guidelines allows CareSource PASSE to measure their impact on member health outcomes. Review and approval of the guidelines are completed by the Market CareSource PASSE Provider Advisory Committee (PAC). The CareSource PASSE Enterprise PAC and Quality Enterprise Committee (QEC) are notified of guideline approval. Topics for guidelines are identified through analysis of member population demographics and national or state priorities. Guidelines may include, but are not be limited to:

    • Behavioral health (e.g., depression)
    • Adult health (e.g., hypertension and diabetes)
    • Population health (e.g., obesity and tobacco cessation)

    Guidelines may be promoted to providers through one or more of the following: newsletters, our website, direct mailings, provider manual and through focused meetings with CareSource PASSE Provider Engagement Specialists. Information regarding clinical practice guidelines and other health information are made available to members via member newsletters, the CareSource PASSE member website or upon request.

    Value-Based Reimbursement

    Your success is important to us. We offer a series of value-based reimbursement (VBR) programs for our providers. These programs provide a progressive approach along a continuum of payment programs that will reward you as you attain higher levels of quality.

    Our flexible approach will enable you to participate in VBR programs at an initial level and grow to successively higher levels of reimbursement. Under the guidance of the CareSource PASSE Quality Management and Performance Improvement program, you are rewarded for providing better value for services and achieving better health outcomes for our members.

    Contact Us

    If you would like more information about CareSource PASSE Quality Improvement, please call Provider Services, Monday through Friday, 8 a.m. to 5 p.m. Central Time (CT) at 1-833-230-2100.

    HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
    CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).