Quality Improvement

Program Purpose

CareSource is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. The scope of our CareSource quality improvement (QI) program is comprehensive and includes clinical and non-clinical services.

CareSource monitors and evaluates the quality of care, encompassing the safety and service delivered to our members with an emphasis on accessibility to care, availability to care, availability of services and physical and behavioral health care delivered by network practitioners and providers. CareSource also monitors the quality and safety of member services through review of practitioner, provider, hospital, utilization management, care management and pharmacy program results.

Member satisfaction and health outcomes are monitored through routine health plan reporting, annual Healthcare Effectiveness Data and Information Set (HEDIS®). In addition, Marketplace members complete the annual Quality Health Plan (QHP) Enrollee Survey to capture member perspectives on health care quality. The QHP Enrollee Survey is a consumer experience survey that assesses the enrollee experience with plans offered through Marketplace plans. The survey includes a set of core questions that address key areas of care and service provided to members.

CareSource was awarded initial National Committee for Quality Assurance (NCQA) accreditation in 2015 and achieved renewals in 2017 and 2019. 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. The scope of the Quality Improvement program includes:

  • Advocate for members across settings
  • Meet member access and availability needs for physical and behavioral health care
  • Determine interventions for HEDIS overall rate improvement that increase preventive care rates and facilitate support of members’ acute and chronic health conditions and complex needs
  • Determine interventions for CAHPS rate improvement that enrich member and provider experience and satisfaction
  • Demonstrate enhanced care coordination and continuity across settings
  • Meet members’ cultural and linguistic needs
  • Monitor important aspects of care to ensure the safety of members across health care settings
  • Determine practitioner adherence to clinical practice guidelines
  • Support member self-management efforts
  • Partner collaboratively with network partners, practitioners, regulatory agencies and community agencies
  • Ensure regulatory and accrediting agency compliance

CareSource Quality Strategy

CareSource seeks to advance a culture of quality and safety that begins with our senior leadership and is cultivated throughout the organization. CareSource utilizes the Institute of Healthcare Improvement (IHI) framework developed to optimize health system performance, as well as the Centers for Medicare & Medicaid Services’ (CMS) National Quality Strategy, which is a national effort to align public and private sector stakeholders to achieve better health and health care.

CareSource aligns with the IHI Triple Aim framework to:

  • Improve the member experience of care (including clinical quality and satisfaction)
  • Improve the health of populations
  • Reduce the per capita cost of health care

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 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 care and address the most pressing areas of care. Potential quality measures for the Health Insurance Marketplace are:

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

Preventive and Clinical Practice 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 tools. 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 their impact on member health outcomes. Review and approval of the guidelines are completed by the Market CareSource Physician Advisory Committee (PAC). The CareSource Enterprise PAC and Quality Enterprise Committee (QEC) are notified of guideline approval. Topics for guidelines are identified through the analysis of member populations demographics and national or state priorities. Guidelines may include, but are not limited to:

  • Behavioral health (e.g., depression)
  • Adult health (e.g., hypertension or diabetes)
  • Population health (e.g., obesity or tobacco cessation)

Guidelines may be prompted to providers through one or more of the following: newsletters, our website, direct mailings, provider manual, and through focused meetings with CareSource Provider Engagement Specialists. Information regarding clinical practice guidelines and other health information are made available to members via member newsletters, the CareSource member website, or upon request.

If you would like more information on CareSource quality improvement, please call Provider Services.

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 1-866-286-9949.

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).