Quality Improvement Program
CareSource is committed to providing evidence-based care in a safe, effective, member-centered, timely, efficient and equitable manner. The scope of the CareSource Quality Improvement (QI) program is comprehensive and includes both clinical and non-clinical services. CareSource monitors and evaluates quality of care, encompassing safety and service delivered to our members, with an emphasis on accessibility 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 practitioners, providers, hospital, utilization management, care management and pharmacy programs. Member satisfaction and health outcomes are monitored through routine health plan reporting, annual Health Effectiveness Data and Information Set (HEDIS) and Qualified Health Plan (QHP) Enrollee Experience Survey 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.
CareSource supports an active, ongoing and comprehensive QI program across the enterprise. The scope of the QI program is to:
- Advocate for members across settings.
- Meet member access and availability needs for physical and behavioral health care.
- Determine interventions to positively impact HEDIS, overall improvement rates that increase utilization of preventive care services and facilitate support for members with acute and chronic health conditions and other complex health, welfare or safety needs.
- Determine interventions for improvement that enrich member and provider experience and satisfaction with our CareSource products and services.
- Demonstrate enhanced care coordination and continuity across setting.
- Meet members’ cultural and linguistic needs, encompassing the social determinants of health.
- Monitor important aspects of care to ensure the health, safety and welfare of members across health care settings.
- Determine practitioner adherence to clinical practice guidelines.
- Support the development of member self-management skills.
- Partner collaboratively with network providers, practitioners, regulatory agencies and community agencies.
- Ensure regulatory and accrediting agency compliance.
On an annual basis, CareSource makes information available about its quality program to providers on the web. CareSource gathers and uses provider performance data to improve quality of care and service provided.
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 Medicaid & Medicare Services’ (CMS) National Quality Strategy, which is a national effort to align public and private sector stakeholders to achieve better health and health care.
Institute for Healthcare Improvement Triple Aim for Populations
CareSource aligns with the Institute for Healthcare Improvement Triple Aim (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 Medicare & Medicaid Services’ National Quality Strategy
CareSource aligns with 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 prevention and treatment of chronic disease
- Work with communities to help people live healthy
- Make care affordable
CMS employs the four foundational principles outlined to assist in meeting their stated goals:
- Eliminate racial and ethnic disparities
- Strengthen infrastructure and data systems
- Enable local innovations
- Foster learning organizations
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 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 significant areas of care. Potential quality measures we use include:
- Wellness and prevention
- Preventive screenings (breast cancer, cervical cancer and chlamydia)
- 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
- Use of imaging studies for low back pain
Health Equity Commitment
Health equity enables everyone to achieve their full health potential. This requires addressing:
- Historical and contemporary injustices
- Removing obstacles to health such as poverty, discrimination, and their consequences:
- Including powerlessness
- Lack of access to good jobs with fair pay
- Quality education and housing
- Safe environments and
- Health care (The Health Policy Institute of Ohio (HPIO), 2018).
We recognize language and cultural differences have a significant impact on member health care experience and outcomes. Consistent with federal mandate 42 CFR 438.206 (2), Access and Cultural Considerations, CareSource participates in efforts to promote the delivery of services in a culturally competent manner to all members. Participating providers must also meet the requirements of this mandate and any applicable state and federal laws or regulations pertaining to provision of services and care.
Health, Safety & Welfare Program
A top priority for CareSource is assuring the health, safety and welfare of our members. The purpose of the CareSource Health, Safety and Welfare (HSW) program is to ensure CareSource provides quality, 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. The HSW program provides a systematic, coordinated approach to member health, safety and welfare.
Clinical and 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 appropriate, 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 Physician 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 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:
Participation in CMS and HHS Quality Improvement Initiatives
CareSource encourages providers to participate in CMS and Health and Human Services (HHS) quality improvement initiatives.
If you would like more information on CareSource Quality Improvement, please call Provider Services at 1-833-230-2176.
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).