Quality Improvement Program

This page explains the CareSource Georgia Quality Management and Improvement program. This section includes medical and technical terms. If you need help understanding this section, please call Member Services at the number listed at the bottom of the page.

Purpose

Your care means a lot to us. The purpose of the CareSource Georgia Quality Management and Improvement program is to ensure that CareSource Georgia has the resources needed to:

  • Coordinate care
  • Promote quality
  • Ensure performance and efficiency on an ongoing basis
  • Improve the quality and safety of clinical care and services provided to CareSource members

There are two guiding principles for the program: 

  • Our mission, which is our heartbeat, is to make a lasting difference in our members’ lives by improving their health and well-being. Our vision is to transform lives through innovative health and life services.
  • The Institutes for Healthcare Improvement’s Triple Aim:  Simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing the per capita cost of care for the benefit of communities.

The CareSource Georgia Quality Management and Improvement Program includes both health and non-health services and is revised as needed to quickly respond to member needs, provider feedback, standards of care and business needs. 

Goals and Objectives

CareSource Georgia works every day to be a top performing national health plan. Performance goals are determined and aligned with national benchmarks where available.

The goals and objectives of the program include:

  • National Committee for Quality Assurance (NCQA) Excellent Accreditation
    • Compliance with NCQA accreditation standards
  • NCQA Health Plan Rating of 5
    • High level of HEDIS performance
    • High level of CAHPS performance
    • Comprehensive population health management program
    • Comprehensive provider engagement program

Scope

The CareSource Georgia Quality Management and Improvement program governs quality assessment and improvement activities. The scope includes:

  • Meeting the quality requirements of the Centers for Medicare and Medicaid Services (CMS)
  • Meeting the requirements of the CareSource Georgia contract with the Department of Community Health
  • Establishing safe clinical practices throughout the network of providers
  • Providing quality oversight of all clinical services
  • Compliance with NCQA accreditation standards
  • HEDIS compliance audit and performance measurement
  • Monitoring and evaluation member and provider satisfaction
  • Managing all quality of care and quality service complaints
  • Developing organizational competency of the Institute of Healthcare Improvements Model for Improvement
  • Ensuring that CareSource is effectively serving members with culturally and linguistically diverse members
  • Ensuring that CareSource is effectively serving members with complex health needs
  • Assessing the characteristics and needs of the member population
  • Assessing the geographic availability and accessibility of primary and specialty care providers

The CareSource Georgia Quality Management and Improvement program is overseen by the Georgia Medical Director, and implementation is facilitated by the Vice President, Quality Improvement and Performance Outcomes. On an annual basis, CareSource Georgia makes information available about the CareSource Georgia Quality Management and Improvement program to members on the CareSource Georgia member website.

Quality Metrics

CareSource Georgia 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.

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 NCQA. HEDIS 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 are:

CareSource also 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 include:

  • Customer service
  • Getting care quickly
  • Getting needed care
  • How well doctors communicate
  • Ratings of all health care, health plan, personal doctor, specialist

Preventive Guidelines and Clinical Practice Guidelines

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

  • Preventive health
  • Behavioral health (e.g., depression, ADHD, substance use disorder)
  • Chronic condition management (e.g., hypertension, diabetes, cardiovascular disease, cerebrovascular disease and chronic obstructive pulmonary disease)
  • Population health (e.g., obesity, tobacco cessation)

Information about clinical practice guidelines and health information are made available to CareSource Georgia members via member newsletters, this 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 CareSource24® is available to help you. You can call the number on your member ID card 24/7/365.
  • CareSource has programs that can help you maintain or improve your health. You can call 1-800-479-9502 (TTY for the hearing impaired: 1-800-750-0750 or 711) for more information about these programs. 

If you would like more information on CareSource Quality Improvement, please call Member Services at 1-855-202-0729 (TTY 800-255-0056 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).