Quality Improvement

Quality Improvement Program

CareSource’s Quality Improvement (QI) program design is to ensure the organization delivers on all aspects of care delivery for D-SNP members based on their unique needs.
The overarching QI program goals are aligned with the Institute for Healthcare Improvement Quadruple aim of:

Improving health outcomes of members and populations
Improving member and provider experience with care and services
Reducing per capita cost of care and
Advancing health equity.

We monitor, analyze and identify opportunities for improvement across the comprehensive span of health care continuum using standardized metrics such as:

HEDIS
CAHPS
Provider satisfaction survey results
Health Outcomes Survey
Over and underutilization patterns and trends

On an annual basis, we formally evaluate our QI program and performance metrics against set goals. Our formal results inform our QI strategy for the following year.

We are committed to delivering high quality care and services and are accredited by the National Committee for Quality Assurance (NCQA).

CareSource is accredited by the National Committee for Quality Assurance (NCQA).

Quality Measures

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 member 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 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 clinical guidelines and address the most significant areas of care. We collect and monitor performance for population specific measures, such as, but not limited to:

Wellness and prevention
- Preventive screenings (breast cancer, colorectal cancer screenings)
- Annual wellness visit
Chronic disease management
- Diabetes recommended screenings and tests
- Controlling high blood pressure
Behavioral health
- Follow-up after ER or hospitalization for mental illness or substance use
- Antidepressant medication management
Safety
- Use of imaging studies for low back pain
Transitions of care
- Timely and appropriate provider follow up after an acute inpatient stay
- Medication reconciliation post discharge
- Time and appropriate provider follow up after ER utilization for people with multiple high risk chronic conditions

CareSource Commitment to Health Equity

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

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.

Patient Safety Program

Ensuring the health, safety and welfare of our members is top priority at CareSource. Our organization seeks to build a culture in which all leaders and the workforce understand basic principles of patient safety science, and it is essential that all CareSource employees understand that member safety is their responsibility. HSW Program goals are:

Foster an organizational environment that emphasizes the use of quality tools to improve quality, safety and member outcomes.
Ensure the provision of appropriate, evidence-based, safe, quality care to all CareSource members through the reduction of avoidable medical errors by developing and implementing safeguards, systems and processes that detect, prevent and mitigate harm and/or risk factors.
Ongoing improvement in care and safety through use of quality of care methodologies, such as the IHI Quadruple Aim and Six Sigma.
Develop relevant policies and procedures and ensure staff education on identification of at-risk situations and medical error.
Establish procedures to mitigate risks.
Ensure reporting to appropriate CareSource Quality Committees, as well as to CareSource Departments, such as Compliance or Program Integrity, when indicated.

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

Clinical and Preventive Guidelines

CareSource 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 topics. Guidelines are reviewed at least every two years or more often as appropriate, and updated as necessary. They may be found at www.caresource.com > Providers > Education > Patient Care > Health Care Links.

If you would like more information on CareSource Quality Improvement, please call Provider Services.

Quality of Care Reviews

CareSource 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 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, e-mail or fax and may be returned to CareSource 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. If a state, federal or regulatory agency, 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 or facilitating delivery of medical records to CareSource by the identified contractor. We are legally bound to interact with providers only and CareSource 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 time frame 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.

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) code:

Participation in CMS and HHS Quality Improvement Initiatives

CareSource encourages providers to participate in CMS and Health and Human Services (HHS) quality improvement initiatives.

If you would like more information on CareSource Quality Improvement, please call Provider Services at 1-833-230-2176.

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).

Quality Improvement