Quality Improvement

Program Purpose

Your care means a lot to us. Humana – CareSource® continually reviews the quality of care and service offered to our members. We implement programs to improve how we work internally, our delivery of health care services and our members’ health outcomes.

In order to ensure a structure, key processes and a culture of continuous improvement, Humana – CareSource has implemented a comprehensive Quality Improvement (QI) program. The program has evolved from managing individual episodes of illness to oversight of the entire continuum of care to include wellness, prevention and disease and case management.

This is an evolving program that is responsive to the needs of our members, drawing and analyzing information from a variety of sources that impact your care. We always look at standards set by the medical community through practicing providers’ input, regulators and accrediting bodies.

A written evaluation of the Quality Improvement program is conducted annually. This helps to determine how well the QI activities are working. It is submitted to appropriate regulatory and accrediting bodies as required. A cross-functional team participates in the evaluation process.

Program Scope

Humana – CareSource supports an active, ongoing, and comprehensive quality improvement program. The scope of the Quality Improvement program includes:

  • Advocating for members across settings
  • Meeting member access and availability needs for physical and behavioral healthcare
  • Determining interventions for the Healthcare Effectiveness Data and Information Set (HEDIS®) overall rate improvement that increase preventive care rates and facilitate support of members’ acute and chronic health conditions and complex needs
  • Determining interventions for the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) rate improvement that enrich member and health partner experience and satisfaction
  • Demonstrating enhanced care coordination and continuity across settings
  • Meeting members’ cultural and linguistic needs
  • Monitoring important aspects of care to ensure the safety of members across health care settings
  • Determining practitioner adherence to clinical practice guidelines
  • Supporting member self-management efforts
  • Partnering collaboratively with network partners, practitioners, regulatory agencies and community agencies
  • Ensuring regulatory and accrediting agency compliance

Quality Measures

Humana – CareSource 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 outcomes.

Humana – CareSource uses HEDIS to measure the quality of care delivered to members. HEDIS is one of the most widely used means of health care measurement in the United States. HEDIS is developed and maintained by The National Committee for Quality Assurance (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 pressing areas of care. Potential quality measures for Humana – CareSource are:

  • Wellness and Prevention
    • Preventive Screenings (breast cancer, cervical cancer, chlamydia)
    • Well-Child Care
  • Chronic Disease Management
    • Comprehensive Diabetes Care
    • Controlling High Blood Pressure
  • Behavioral Health
    • Follow-up After Hospitalization for Mental Illness
    • Antidepressant Medication Management
    • Follow-up for Children Prescribed ADHD Medication
  • Safety
    • Use of Imaging Studies for Low Back Pain
NavigateView Our Latest HEDIS Survey Results

Humana – CareSource uses the annual member survey, CAHPS surveys, to capture member perspectives on health care quality. CAHPS is a program overseen by the United States Department of Health and Human Services―Agency for Healthcare Research and Quality (AHRQ). Potential CAHPS measures for the plan uses are:

  • Customer Service
  • Getting Care Quickly
  • Getting Needed Care
  • How Well Doctors Communicate
  • Ratings of All Health Care, Health Plan, Personal Doctor, Specialist
NavigateView Our Latest CAHPS Survey Results

Preventive Guidelines and Clinical Practice Guidelines

Humana – CareSource recommends nationally accepted standards and guidelines to help inform and guide the clinical care provided to Humana – CareSource members. Guidelines are reviewed at least every two years or more often as appropriate, and updated as necessary. The use of these guidelines allows Humana – CareSource to measure the impact of the guidelines on outcomes of care.  Review and approval of the guidelines are completed by the CareSource Clinical Advisory Committee every two years or more often as appropriate. The guidelines are then presented to the Humana – CareSource Quality Assurance Committee. Topics for guidelines are identified through analysis of members. Guidelines may include, but are not be limited to:

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

Information about clinical practice guidelines and health information are made available to Humana – CareSource members via member newsletters, the Humana – CareSource member website, or upon request. Preventive guidelines and health links are available to members and providers via the website or hard copy.

Your Health is Important

Here are some ways that you can maintain or improve your health:

  • Establish a relationship with a health care provider.
  • Make sure you and your family have regular checkups with your health care provider.
  • Make sure if you have a chronic condition (such as asthma or diabetes) that you see your doctor regularly. You also need to follow the treatment that your doctor has given you. Make sure that you take the medications that your doctor has asked you to take.
  • Remember the 24-Hour Nurse Advice Line is available to help you. You can call the number on your member ID card 24/7/365.
  • Humana – CareSource has programs that can help you maintain or improve your health. You can call the following number for more information about these programs: 1-855-852-7005 (TTY: 1-800-648-6056 or 711).

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).