Quality Improvement

Program Purpose

The purpose of the CareSource® Quality Management and Improvement program is to ensure that CareSource has the necessary infrastructure to:

  • Coordinate care
  • Promote quality
  • Ensure performance and efficiency on an ongoing basis
  • Improve the quality and safety of clinical care and services provided to members

The CareSource Quality Management and Performance Improvement program includes both clinical and non-clinical services and is revised as needed to remain responsive to member needs, provider feedback, standards of care and business needs.

Quality Strategy

Our quality strategy aligns with the Institute for Healthcare Improvement’s (IHI’s) Triple Aim and the National Quality Strategy. The three tenets of the strategy are:

  • Better health for populations
  • Better care for individuals
  • Lower per capita costs

The strategy focuses the direction for:

  • Continuous quality improvement efforts
  • Establishing a culture of improving quality of care and services for CareSource Healthy Indiana Plan and Hoosier Healthwise members

Goals and Objectives

CareSource strives to be a top performing health plan nationally. Performance goals are determined and aligned with national benchmarks where available.

The goals and objectives of the program are:

  • Ensuring the health, safety, and welfare of members
  • National Committee for Quality Assurance (NCQA) Excellent Accreditation
    • Compliance with NCQA accreditation standards
    • High level of Healthcare Effectiveness Data and Information Set (HEDIS®) performance
    • High level of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) performance
    • Comprehensive population health management program
    • Comprehensive provider engagement program
  • NCQA Health Plan Rating of 5

Program Scope

The CareSource Quality Management and Performance Improvement program governs the quality assessment and improvement activities. The scope includes:

  • Meeting the quality requirements of the Centers for Medicare and Medicaid Services (CMS) as outlined in CMS’s Medicare Managed Care Manual, Chapter 5, Quality Assessment; and 42 CFR§422.152
  • Establishing safe clinical practices throughout our provider network
  • Providing quality oversight of all clinical services
  • Ensuring compliance with NCQA accreditation standards
  • Performing HEDIS compliance audit and performance measurement
  • Monitoring and evaluating member and provider satisfaction
  • Managing all quality of care and quality service complaints
  • Developing organizational competency of the Institute for Healthcare Improvement (IHI) Model for Improvement
  • Ensuring that CareSource is effectively serving members with culturally and linguistically diverse needs
  • Ensuring that CareSource is effectively serving members with complex health needs
  • Assessing the characteristics and needs of our member population
  • Assessing the geographic availability and accessibility of primary medical providers (PMPs) and specialists

Our commitment to the Quality Management and Improvement Program is well aligned to the Office of Medicaid Policy and Planning’s (OMPP’s) expectations of managed care entities (MCEs), as emphasized in the state’s Medicaid Managed Care Quality Strategy Plan 2019:

  • Improve overall health outcomes for the population
  • Foster personal responsibility and healthy lifestyles with our members
  • Increase consumer knowledge of health care by increasing health care literacy
  • Provide price and quality transparency
  • Improve access to health care services
  • Engage in provider and member outreach regarding preventive care, wellness and a holistic approach to better health
  • Develop innovative utilization management (UM) techniques that incorporate member and provider education to facilitate the right care, at the right time, in the right location

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

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 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 attention-deficit/hyperactivity disorder (ADHD) medication
  • Safety
    • Use of imaging studies for low back pain

CareSource also uses the annual member CAHPS survey to capture member perspectives on health care quality. CAHPS is a program overseen by the AHRQ. Potential CAHPS measures include:

  • Customer service
  • Getting care quickly
  • Getting needed care
  • How well doctors communicate
  • Ratings of all health care, health plans, personal doctors and specialists

Preventive and Clinical Practice Guidelines

CareSource approves and adopts nationally accepted standards and guidelines and promotes them to practitioners and members to help inform and guide clinical care provided to Healthy Indiana Plan and Hoosier Healthwise members. CareSource quality and clinical staff regularly and routinely monitors evidence-based practices evaluated by federal agencies, such as the Agency for Healthcare Research and Quality (AHRQ), US Preventive Services Task Force (USPSTF), National Quality Forum and professional medical associations. In addition, our network providers, care managers, members and advocacy groups are often important information resources for identifying and validating evidence-based practice recommendations.

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 Provider Advisory Committee every two years or more often as appropriate. The guidelines are then presented to the CareSource Enterprise Physician Advisory Committee (E-PAC). If new evidence-based clinical practices can be implemented or more effectively deployed in the field by care management staff and network providers, those practices are discussed with OMPP and other MCEs and recommended for deployment across the Healthy Indiana Plan and Hoosier Healthwise programs. Topics for guidelines will be identified through analysis of CareSource Healthy Indiana Plan members. Guidelines may include, but are not be limited to:

  • Behavioral health (depression)
  • Adult health (hypertension, diabetes, cardiovascular disease, cerebrovascular disease and chronic obstructive pulmonary disease)
  • Population health (obesity, tobacco cessation)
  • Well-child care

Guidelines are promoted to providers through newsletters, the website, direct mailings, provider manual, and through focused meetings with CareSource Provider Relations representatives. Information about clinical practice guidelines and health information will be made available to CareSource Healthy Indiana Plan and Hoosier Healthwise members via member newsletters, the CareSource member website, or 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 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).