Primary Care Provider Roles & Responsibility
All CareSource® members choose or are assigned to a PCP upon enrollment in the plan. Members have the option to change to another participating PCP as often as needed. Members initiate the change by calling our Member Services department at 1-833-230-2020.
PCPs should help facilitate a medical home for members. This means that PCPs will help coordinate health care for the member and provide additional health options to the member for self-care or care from community partners.
In addition, providers are expected to administer patient care in a culturally competent manner. Resources are provided below.
Roles and Responsibilities
PCP care coordination responsibilities include at a minimum, the following:
- Assisting with coordination of the member’s overall care, as appropriate for the member.
- Serving as the ongoing source of primary and preventive care.
- Recommending referrals to specialists, as required.
- Triaging members.
- Participating in the development of case management care treatment plans, and notifying CareSource of members who may benefit from case management.
In addition, CareSource PCPs play an integral part in coordinating health care for our members by providing:
- Availability of a personal health care practitioner to assist with coordination of a member’s overall care, as appropriate for the member.
- Continuity of the member’s total health care.
- Early detection and preventive health care services.
- Elimination of inappropriate and duplicate services.
PCPs are Responsible For
- Treating CareSource members with the same dignity and respect afforded to all patients. This includes high standards of care and the same hours of operation.
- Identifying the member’s health needs and taking appropriate action.
- Providing phone coverage for handling patient calls 24 hours a day, 7 days a week. Members select a PCP from our health plan’s Provider Directory.
- Following all referral and prior authorization policies and procedures as outlined in this manual.
- Complying with the quality standards of our health plan.
- Providing 30 days of emergency coverage to any CareSource patient dismissed from the practice.
- Maintaining clinical records, including information about pharmaceuticals, referrals, inpatient history, etc.
- Obtaining patient records from facilities visited by CareSource patients for emergency or urgent care if notified of the visit.
- Ensuring demographic and practice information is up-to-date for directory and member use.
CLAS Standards: National Culturally and Linguistically Appropriate Standards
We recognize language and cultural differences have a significant impact on member health care experience and outcomes. Consistent with federal mandate 42 CFR 438.206 (2), Access and Cultural Considerations, CareSource participates in efforts to promote the delivery of services in a culturally competent manner to all members. Participating providers must also meet the requirements of this mandate and any applicable state and federal laws or regulations pertaining to provision of services and care.
In addition to our focus on health disparities and their impact on member health outcomes, it is important for our providers and team members to understand how a lack of cultural competency may negatively impact member health outcomes. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy.
We offer staff education and training through our CareSource University learning management system. In addition, CareSource developed an Equity Council to promote diversity within the organization, including the development of Employee Resource Groups to foster a diverse and inclusive workplace.
CareSource provides our participating providers with cultural competency resources available from the Office of Minority Health, Cultural Competency Resources website found at: www.ThinkCulturalHealth.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. In addition, CareSource encourages its participating providers to complete the U.S. Department of Health and Human Services Physician’s Practical Guide to Culturally Competent Care, which is a free on-line accredited educational program.
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. CLAS consists of 15 standards that encompass the following topic areas:
- Principal Standard: Provision of effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs
- Governance, Leadership, and Workforce
- Communication and Language Assistance
- Engagement, Continuous Improvement & Accountability
Network providers must ensure that:
- Members understand that they have access to free medical interpreter services in their native language, including Sign Language. 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 of 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, religion, 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).
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 program is developed in the context of our Population Health Management approach and includes regulatory/accreditation, training/implementation, continuous monitoring, program evaluation and improvement.
The Safety Program recognizes the importance of identifying health, safety and welfare issues that may result from the social determinants of health (SDOH) which contribute to health disparities. SDOH may negatively impact member health status, ability to seek preventive services and manage chronic health conditions.
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.
We are dedicated to the communities in which we serve and making a positive impact in the lives of our members by eliminating health disparities, supporting our organization’s Health Equity initiatives, partnering with community stake holders to carry out this much needed work. Our Enterprise Life Services Department is dedicated to serving marginalized communities and making a positive impact in the lives of diverse member populations to eliminate health disparities
Enterprise Life Services is taking an integrated approach to Health Equity and embedding it across CareSource. As a result, we have developed our objectives based on Pillars of Life Services outlined below.
- Workforce Development: promote long-term employment opportunities, financial literacy, connection to job training and increasing assets, such as home ownership
- Housing: increase the quality of safe & affordable housing, enhanced financial tools to develop & preserve housing units & improved affordability of housing
- Food & Nutrition: regular & consistent access to healthy foods, education on nutrition & overall health impacts, addressing food deserts and inequalities
- Health Equity: pursuit of Health Equity for Black, Indigenous and People of Color (BIPOC), LGBTQIA, & complex populations, elimination of health disparities; partnerships with outside organizations; drive policy & advocate for change.