Quality Improvement

• Advocate for members across settings, including review and resolution of quality of care concerns
• Meet member access and availability needs for physical and behavioral health care
• Determine interventions for HEDIS^® overall rate improvement that improve preventive care scores and facilitate support of members’ acute and chronic health conditions and other complex health, safety or welfare needs
• Determine interventions  based on Enrollee QHP results that enrich member and provider experience and satisfaction
• Demonstrate enhanced care coordination and continuity across settings
• Meet members’ cultural and linguistic needs encompassing the social determinants of health
• Monitor important aspects of care to ensure the health, safety, and welfare of members across health care settings
• Determine practitioner adherence to clinical practice guidelines
• Support member self-management skills
• Partner collaboratively with network partners, practitioners, regulatory agencies and community agencies
• Ensure regulatory and accrediting agency compliance

• Wellness and prevention
  • Preventive screenings (breast cancer, colon cancer, cervical cancer, chlamydia)
  • Well-child care
  • Immunizations
• Chronic disease management
  • Comprehensive diabetes care
  • Controlling high blood pressure
• Behavioral health
  • Follow-up after hospitalization for mental illness
  • Antidepressant medication management
• Safety
  • Use of imaging studies for low back pain

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

In order to properly assess quality of care concerns CareSource Enterprise Quality Improvement 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. In the event that 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 timeframe 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.

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 and 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.

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

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. Our Patient Safety Program is developed in the context of our Population Health Management approach and includes:

• Regulatory/Accreditation
• Policies & Procedures
• Training & Implementation
• Continuous Monitoring
• Program Evaluation & Improvement

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.