Quality Improvement

    Program Purpose

    CareSource PASSE™ is committed to providing quality 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 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.

    HEDIS Coding Guides

    To ensure HEDIS measures are captured when billing CareSource. Please review the following HEDIS coding guidelines for children and adults and use the appropriate ICD-10 and certified procedural terminology (CPT) codes.

    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
    • CareSource uses 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 seeks to advance a culture of quality and safety that begins with our senior leadership and is cultivated throughout the organization. CareSource utilizes the Institute of Healthcare Improvement (IHI) framework to optimize health system performance, known as the IHI Quadruple Aim.

    The Quadruple Aim focuses on:
    • Improving the health of populations – preventing and managing prevalent, costly, and chronic diseases
    • Improving the patient experience of care (including quality and satisfaction) – motivating and engaging patients to play an active role
    • Reducing the per capita cost of health care – reducing resource utilization and readmissions while assuming greater risk
    • Improving provider satisfaction – providing access to tools and resources to address provider burden and burnout

    In addition, CareSource utilizes Lean Six Sigma tools, when indicated, to focus on improving member experience, member safety and ensuring our processes consistently deliver the desired results.

    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.

    Patient Safety Program

    CareSource recognizes that patient safety is the cornerstone of high-quality health care, contributing to the overall health and welfare of our members. Our CareSource Patient Safety Program evaluates patient safety trends with the goal of reducing avoidable harm. The patient safety program is developed in the context of our Population Health Management approach and includes regulatory/accreditation, policies/procedures, training/implementation, continuous monitoring, program evaluation and improvement initiatives.

    The Program also includes a well-defined health, safety, welfare (HSW) component. The purpose of the HSW Program is to ensure CareSource and our network of providers are identifying and remediating those social determinants of health that often contribute to negative member health outcomes.

    Safety events are monitored through retrospective review of Quality of Care Concerns and real time reporting of Claims data.  Data analysis of our provider and health system network ensures situational risks can be identified in a timely manner, reviewed and mitigated by proactive corrective action or performance improvement steps. 

    Cultural Competency

    CareSource (PASSE) has a long-standing commitment to addressing the need for culturally competent care in our member populations, including exploring the social determinants of health that impact member health outcomes and quality of life.  CareSource (PASSE) considers providing equitable and culturally competent care and services a core value of our organization.  CareSource (PASSE) is committed to promoting health equity principles and developing programs which focus on identifying and addressing health disparities. 

    We encourage you to access the 2023 CareSource PASSE Cultural Competency & Health Equity Plan Summary Document to learn more about our Cultural Competency and Health Equity efforts. 

    CLAS Standards:  National Culturally and Linguistically Appropriate Standards

    The Office of Minority Health (U.S. Department of Health & Human Services, 2018), created National Culturally and Linguistically Appropriate Standards (CLAS) to provide a blueprint for implementing culturally and linguistically appropriate services for health and health care organizations to:

    • Advance Health Equity
    • Improve Quality
    • Help Eliminate Health Disparities

    CareSource (PASSE) recognizes language and cultural differences have the potential to negatively impact interactions between providers, members and employees. 

    CareSource adheres to the National Culturally & Linguistically Appropriate Standards (CLAS), which serve as a blueprint for health care providers and organizations to implement culturally and linguistically appropriate services.

    Network providers must ensure that:

    • Members understand that they have access to free medical interpreter services in their native language, including sign language, at no cost. TDD/TTY services are available to facilitate communication with hearing impaired members.
    • Health care is provided with consideration of the members’ cultural background, encompassing race/ethnicity, language and health beliefs. Cultural considerations may impact/influence member health decisions related to preventable disease or illness.
    • The provider office staff makes reasonable attempts to collect race and language-specific member data. Staff is available to answer questions and explain race/ethnicity categories to a member, to assure accurate identification of race/ethnicity for all family members.
    • Treatment plans are developed based on evidence-based clinical practice guidelines with consideration of the member’s race, country or origin, native language, social norms, religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation and other characteristics that may result in a different perspective or decision-making process.
    • Participating providers must also meet the requirements of all applicable state and federal laws and regulations as they pertain to provision of services and care.

    CareSource prohibits its providers or partners from refusing to treat, serve or otherwise discriminate against an individual because of race, color, religions, national origin, sex, age, gender orientation (i.e., intersex, transgendered and transsexual) or disability. In consideration of cultural differences, including religious beliefs and ethical principles, CareSource will not discriminate against providers who practice within the permissions of existing protections in provider conscience laws, as outlined by the U.S. Department of Health and Human Services (HHS).

    CareSource encourages our participating providers to visit the Office of Minority Health, Cultural Competency Resources website found at: www.ThinkCultureHealth.hhs.gov for toolkits and educational resources. Included on the site is a free 9-credit continuing medical education (CME) course, A Physician’s Practical Guide to Culturally Competent Care. This self-directed e-learning program equips providers to better understand and treat diverse populations.

    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.

    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).