Quality Improvement

Program Purpose

CareSource® is committed to providing care that is safe, effective, member-centered, timely, efficient and equitable. The scope of the CareSource quality improvement program is comprehensive and includes both clinical and non-clinical services.

CareSource monitors and evaluates quality of care, safety and service delivered to our members, with emphasis on accessibility to care, availability of services, and physical and behavioral health care delivered by network practitioners and providers. CareSource also monitors member services through practitioners, providers, hospital, utilization management, care management and pharmacy programs.

Member satisfaction and health outcomes are monitored through routine health plan reporting, annual Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) 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 2015, CareSource was awarded 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. 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

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

CareSource uses the annual member CAHPS surveys to capture member perspectives on health care quality. CAHPS is a program overseen by the United Stated Department of Health and Human Services―Agency for Healthcare Research and Quality (AHRQ). Potential CAHPS measures for the Health Insurance Marketplace include:

  • Customer service
  • Getting care quickly
  • Getting needed care
  • How well doctors communicate
  • Ratings of all health care, health plan, personal doctor, specialist

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 health (e.g., hypertension or diabetes)
  • 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 Relations representatives. Information about clinical practice guidelines and health information is available to Just4Me members via member newsletters, the CareSource member website and upon request.

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).