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 the CareSource Quality Management and Improvement Program (QMIP) is comprehensive, inclusive of both clinical and non-clinical services, and health, safety and welfare concerns. CareSource monitors and evaluates the quality and safety of the care and service delivered to our members, emphasizing:

    • Accessibility to care
    • Availability of services and practitioners
    • Medical and behavioral health services
    • Internal monitoring, review and evaluation of program areas, including utilization management, care management and pharmacy

    Member and provider satisfaction and health outcomes are monitored through:

    • Quality improvement activities
    • Routine health plan reporting
    • Annual Health Effectiveness Data and Information Set (HEDIS) – measures the quality of our health plan
    • Consumer Assessment of Healthcare Providers and Systems (CAHPS) – measures patient experience with the health care system
    • Member surveys
    • Review of accessibility and availability standards
    • Utilization trends

    CareSource assesses our performance against goals and objectives that are in keeping with industry standards. Annually, we complete an annual evaluation of our QMIP.

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

    The purpose of the CareSource Quality Management and Improvement Program (QMIP) is to ensure that CareSource Indiana has the necessary infrastructure to:

    • Coordinate member care and services to improve health outcomes
    • Promote the use of evidence-based best practice for the treatment of member health conditions
    • Ensure high-performing and efficient systems for delivery of care
    • Address the health, safety and welfare concerns of CareSource members and implement appropriate interventions.

    The QMIP is revised as needed:

    • To remain responsive to member needs
    • Based on feedback received from our providers and other health partners
    • In response to changes in nationally recognized practice standards and evidence-based research
    • To meet CareSource business needs

    Program Scope

    CareSource supports an active, ongoing and comprehensive quality improvement program across the organization. Performance goals are developed to measure the components of our program, including performance against national benchmarks.

    CareSource uses HEDIS as one measure to determine 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 measure are based on evidence-based research and address significant health priorities in the United States.

    CareSource uses the annual member survey, Consumer Assessment of Healthcare Providers and Systems (CAHPS), to capture how a member views the quality of health care received. CAHPS is a program overseen by the United States Department of Health and Human Services―Agency for Healthcare Research and Quality (AHRQ). Potential CAHPS measures include:

    • Helpful, courteous customer service
    • Getting care quickly, for example, getting care of illness/injury when needed
    • Ease of access in obtaining needed care
    • Provider ability to communicate and show respect to member
    • Ratings of all health care, health plan, personal doctor and specialists

    The CareSource Quality Management and Improvement Program (QMIP) oversees quality improvement and assessment activities for our CareSource Healthy Indiana Plan and Hoosier Healthwise members to maintain a robust QMIP Program, our scope includes:

    • Ensure regulatory and accrediting agency compliance, including:
      • All federal requirements as outlined by CMS and in 42 CFR Part 438, Managed Care
      • Perform HEDIS® compliance audit and performance measurement
      • Ensure compliance with NCQA accreditation standards
    • Establish safe clinical practices throughout our network of providers
    • Provide quality oversight of all clinical services, including addressing all quality of care concerns
    • 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 increase preventive care rates and facilitate support of member acute and chronic health conditions and other complex health, safety or welfare needs
    • Use the annual member CAHPS® survey to capture member perspectives on health care quality and establishes interventions based on results to enrich member and provider experience and satisfaction. Use the Institute for Healthcare Improvement (IHI) model for improvement methodologies to evaluate initiatives and effect change
    • Ensure CareSource is effectively serving our members with cultural and linguistic needs, as well as identified disparities that may impact member receipt of health care services and achieving positive member outcomes
    • Monitor important aspects of care to ensure the health, safety and welfare of members across healthcare settings Ensure e that CareSource is effectively serving members with complex health needs
    • Ongoing assessment of member population health characteristics
    • Regularly assess the geographic availability and accessibility of primary and specialty care providers
    • Monitor important aspects of care to ensure the health, safety and welfare of members across health care settings
    • Partner collaboratively with network providers, practitioners, regulatory agencies and community agencies

    Our commitment to the Quality Management and Improvement Program is aligned with the Indiana Family Social Services Administration (FSSA) Office of Medicaid Policy and Planning’s (OMPP) expectations for Managed Care Entities (MCEs), as emphasized in the State’s Medicaid Managed Care Quality Strategy Plan 2020:

    Hoosier Healthwise Initiatives

    • Improvements in the number of children and adolescents receiving well-care
    • Increase participation in Early Periodic Screening, Diagnostic & Treatment (EPSDT) services
    • Increase seven (7) day follow-up post hospital discharge for behavioral health conditions
    • Reduce the number of emergency department visits
    • Assure and increase the number of children who receive blood lead testing by their second birthday
    • Increase the frequency of prenatal visits for pregnant members
    • Increase medication management for people with asthma
    • Participate in the Right Choices Program (RCP), which assures quality health care through health care management
    • 30-day appointment for all children ages 6 to 12 who are new to starting ADHD medication

    Healthy Indiana Plan Initiatives

    • Ensure members have access to a primary care provider within a maximum of 30 miles of the member’s residence; at least two providers of each specialty type within 60 miles of member’s residence
    • Ensure members have access to dental care within a maximum of 60 miles a member’s residence
    • Increase the number of members who receive a preventive exam during the year (POWER Account Roll-Over)
    • Reduce Emergency Department Admissions
    • Increase seven (7) day follow-up post hospital discharge for behavioral health conditions
    • Increase seven (7) and thirty (30) day follow-up after Emergency Department visit for substance use
    • Increase the timeliness of prenatal and postpartum care for pregnant members
    • Increase the referral of pregnant women who smoke to the Indiana Tobacco Quitline for smoking cessation services
    • Increase completion of health needs screen within 90 days of new member enrollment
    • Participate in the Right Choices Program (RCP), which ensures quality health care through health care management

    CareSource collaborates with OMPP and other MCEs in attaining the goals of the Indiana Medicaid Quality Strategy Plan.

    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 to optimize health system performance, known as the IHI Quadruple Aim.    

    The Quadruple Aim focuses on:

    1. Improving the health of populations
    2. Improving the patient experience of care (including quality and satisfaction)
    3. Reducing the per capita cost of health care
    4. Improving provider Satisfaction

    In addition, CareSource utilizes Lean Six Sigma tools, when indicated, to focus on improving member experience, member safety and ensuring our processes consistently deliver the desired results.

    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 5 p.m. Eastern Standard Time (EST) at 1-844-607-2831.

    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).