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 for 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, CAHPS, to capture how 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 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
  • CareSource uses 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

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 developed to optimize health system performance, as well as the CMS National Quality Strategy, which is a national effort to align public-and private-sector stakeholders to achieve better health and health care.

The Institute for Healthcare Improvement Triple Aim for Populations

CareSource aligns with the IHI 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

Centers for Medicaid & Medicare Services National Quality Strategy

CareSource aligns with the CMS National Quality Strategy to optimize health outcomes by leading clinical quality improvement and health system transformation. The CMS Quality Strategy vision for improving health care delivery can be summed up in three words: better, smarter, healthier.

The strategy corresponds to the six priorities from the Agency for Healthcare Research & Quality’s National Quality Strategy. Each of these priorities is a goal in the CMS Quality Strategy:

  • Make care safer by reducing harm caused while care’s delivered
    • Improve support for a culture of safety
    • Reduce inappropriate and unnecessary care
    • Prevent or minimize harm in all settings
  • Help patients and their families be involved as partners in their care
  • Promote effective communication and coordination of care
  • Promote effective preventon and treatment of chronic disease
  • Work with communities to help people live healthily
  • Make care affordable

CMS employs the four foundational principles outlined to assist in meeting their stated goals:

  • Eliminate racial and ehtnic disparities
  • Strengthen infrastructure and data systems
  • Enable local innovations
  • Foster learning organizations

Quality Measures

CareSource adheres to the following quality measures as part of our QMIP:

  • Achieve and maintain National Committee for Quality Assurance (NCQA) accreditation
  • Assure compliance with NCQA accreditation standards
  • Receive scores on Healthcare Effectiveness Data and Information Set (HEDIS) that reflect a high level of performance
  • Receive scores on Consumer Assessment of Healthcare Providers and Systems (CAHPS) that reflect a high level of performance
  • Develop and maintain a comprehensive population health management program
  • Develop and maintain a comprehensive provider engagement program
  • Assure CareSource is meeting all OMPP requirements for a quality improvement and management program

CareSource continually assesses and analyzes the quality of care and services provided to our members, through use of objective and systematic monitoring and implementation of quality improvement initiatives.

Member Health, Safety & Welfare

A top priority for CareSource is ensuring the health, safety and welfare of our members. The purpose of the CareSource Health, Safety and Welfare initiative is to ensure CareSource provides safe, evidence-based health care and services to prevent medical errors, avoid adverse events and provide an avenue for addressing those social determinants of health that impact health status and contribute to health disparities. CareSource understands that a number of social determinants contribute to a member’s health status, ability to seek preventive services and manage chronic health conditions.

Clinical Practice Guidelines & Preventive 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 needed, and updated as necessary. They may be found at www.caresource.com > Providers > Education > Patient Care > Health Care Links.

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 Provider Advisory Committee (PAC). The CareSource Enterprise PAC and Quality Enterprise Committee (QEC) are notified of guideline approval. Topics for guidelines are identified through analysis of member population demographics and national or state priorities. Guidelines may include, but are not be limited to:

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

Guidelines may be promoted 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 our Quality Management and Improvement Program, please visit www.caresource.com > Provider Overview > Education > Quality Improvement or call Provider Services at 1-844-607-2831.

Quality Measures

CareSource adheres to the following quality measures as part of our QMIP:

  • Achieve and maintain NCQA accreditation
  • Assure compliance with NCQA accreditation standards
  • Receive scores on HEDIS that reflect a high level of performance
  • Receive scores on CAHPS that reflect a high level of performance
  • Develop and maintain a comprehensive population health management program
  • Develop and maintain a comprehensive provider engagement program
  • Assure CareSource is meeting all quality improvement and management program

CareSource continually assesses and analyzes the quality of care and services provided to our member, through use of objectives and systematic monitoring and implementation of quality improvement initiatives.

Member Health, Safety & Welfare

A top priority for CareSource is ensuring the health, safety and welfare of our members. The purpose of the CareSource Health, Safety and Welfare initiative is to ensure CareSource provides safe, evidence-based health care and services to prevent medical errors, avoid adverse events and provide an avenue for addressing those social determinants of health that impact health status and contribute to health disparities. CareSource understands that a number of social determinants contribute to a member’s health status, ability to seek preventive services and manage chronic conditions.

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).