Quality Improvement

Program Purpose

CareSource® is committed to providing evidence-based care that is safe, effective, efficient, timely, equitable and member-centric. The scope of the CareSource Quality Improvement program is comprehensive and includes both clinical and non-clinical services.

CareSource monitors the quality and safety of care provided to members through tracking and trending of all providers, including utilization management, care management and pharmacy programs.  

Member satisfaction and health outcomes are monitored through routine health plan reporting, annual HEDIS and Qualified Health Plan (QHP) Enrollee Experience Survey scores, assessment of provider and member satisfaction and review of accessibility and availability standards, utilization trends and quality improvement activities. Performance is assessed against goals and objectives that are in keeping with industry standards. Annually, CareSource completes an evaluation of our QI program.

In 2019, CareSource will seek an accreditation status of Interim Accreditation by the National Committee for Quality Assurance (NCQA). This accreditation status shows the commitment to service and clinical quality that meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement as we work to improve members’ health care.

Program Scope

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

  • Member advocacy across all settings
  • Meet member access and availability needs for medical and behavioral health care 
  • Determine interventions for HEDIS overall rate improvement that increase preventive care rates and facilitate support for members with acute and chronic health conditions and complex health care needs
  • Determine interventions for Qualified Health Plan (QHP) Enrollee Survey rate improvement that enrich member and provider experience and satisfaction
  • Demonstrate enhanced care coordination and continuity across settings
  • Meet the cultural and linguistic needs of our diverse member populations
  • Monitor care measures to ensure the health, safety and welfare of members across all  health care settings
  • Determine provider adherence to clinical practice guidelines
  • Support development of member self-management skills
  • Partner collaboratively with network providers, regulatory agencies and community agencies
  • Ensure regulatory and accrediting agency compliance

Quality Measures

CareSource continually assesses and analyzes the quality of care and services offered to our members using recognized quality methodologies, such as the Triple Aim from Institute for Healthcare Improvement. CareSource uses 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. 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 standards of care and address the most pressing areas of need, such as diabetes care and preventive screenings. Potential quality measures for the Health Insurance Marketplace are:

  • Wellness and prevention
    • Preventive screenings (breast cancer, cervical cancer, chlamydia)
  • Chronic disease management
    • Comprehensive diabetes care
    • Controlling high blood pressure
  • Behavioral health
    • Follow-up after hospitalization for mental illness
    • Antidepressant medication management
  • Member health, safety and welfare

CareSource uses the annual member survey, the QHP Enrollee Survey, to capture member perspectives on health care quality. The QHP Enrollee Survey assesses enrollee experience with Health Insurance Exchange plans. The survey includes questions that address areas of care and service.  

Preventive and Clinical Practice Guidelines

CareSource recommends nationally accepted standards and guidelines to help inform and guide the clinical care provided to 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 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 CareSource Quality Enterprise 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 chronic health conditions (e.g., hypertension or diabetes)
  • Well child health (i.e.. immunizations, age appropriate screenings)
  • Population health (e.g., obesity or tobacco cessation)

Guidelines are promoted to providers through newsletters, the CareSource website, direct mailings, the provider manual and through focused meetings with CareSource Provider Engagement Specialists.  Information about clinical practice guidelines and member health resources are available to members via member newsletters, the CareSource member website and upon request.

CareSource Health Equity Commitment (CHEC)

As a non-profit, mission driven, member-centric organization, CareSource seeks to provide high quality, appropriate, effective, evidence-based health services for all members. Social determinants of health are increasingly recognized as significant contributors to member health outcomes and quality of life. Providing equitable and culturally competent care and services is a core value of CareSource. 

Georgia Safety Program

A top priority for CareSource is assuring the health, safety and welfare of our members. The purpose of the Georgia Safety Program (GSP) is to ensure CareSource provides quality, safe, evidence-based health care and services to prevent medical errors, avoid adverse events and provide an avenue for addressing those social determinants of health that impact health status and contribute to health disparities.  CareSource understands that a number of social determinants contribute to a member’s health status, ability to seek preventive services and manage chronic health conditions.  The GSP provides a systematic, coordinated approach to member health, safety and welfare.  

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:

Contact Us

If you would like more information about CareSource Quality Improvement, please call Provider Services Monday through Friday, 8 a.m. to 6 p.m. Eastern Standard Time (EST) at 1-833-230-2155.

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).