Quality Improvement

    Program Purpose

    The purpose of the HAP CareSource™ Quality Assessment and Performance Improvement (QAPI) program is to ensure that HAP CareSource has the necessary infrastructure processes to:

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

    The HAP CareSource Quality Assessment 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.

    Goals and Objectives

    HAP 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:

    • Obtaining a high level of performance in Healthcare Effective Data and Information Set (HEDIS).
    • Earning a high rating on member, practitioner, and provider satisfaction survey results.
    • Obtaining National Committee for Quality Assurance (NCQA) Accreditation through the set up and implementation of infrastructure, processes/systems and people.
    • Carrying out a comprehensive Population Health Management Program to address member needs, including social determinants of health that contribute to health disparities.
    • Serving members with complex health needs through the development of targeted interventions and focused programs.
    • Fostering partnerships among members, caregivers, practitioners, providers, and the community to promote grassroots efforts for effective health management, health education, disease prevention, and overall improved health and quality of life.
    • Ensuring a high-quality practitioner and provider network through a comprehensive credentialing, peer review, and contracting process.
    • Seeking to improve member health through the development of targeted innovative initiatives.
    • Ensuring adequate and appropriate resources are available to maintain and enhance ongoing QI Programs.
    • Collaborating with practitioners and providers to implement strategies to improve coordination and continuity of care.
    • Improving patient safety and monitoring outcomes through the use of patient safety indicators.
    • Implementing programs that address the social determinants of health that promote quality of life, employment and independence.

    Program Scope

    The HAP CareSource Quality Assessment and Performance Improvement program governs the quality assessment and improvement activities and is comprehensive.

    The HAP CareSource Quality Assessment and Performance Improvement program is overseen by the Michigan Chief Medical Officer, in conjunction with the Quality Improvement Director, and the CareSource Vice President, Quality Improvement and Performance Outcomes. On an annual basis, HAP CareSource makes information available about our Quality Assessment and Improvement program to providers on our website or provider-preferred communication channels. HAP CareSource gathers and uses provider performance data to improve quality of services.

    Measuring Member Experience

    HAP 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

    Quality of Care Reviews

    HAP CareSource ensures the provision of safe and quality care and services to members by investigating and mitigating potential quality of care concerns, that include:

    • Inappropriate or inconsistent treatment
    • Delay in receipt of care
    • Compromising member health, safety or welfare
    • Having the potential to limit functional abilities on a permanent or long-term basis

    In order to properly assess potential quality of care concerns HAP CareSource Enterprise Quality Improvement initiates contact with providers to request medical records using established processes and timelines. As per our policies and provider contracts, we are authorized to ask for protected health information for the purpose of health care operations, which includes potential quality issue reviews. Medical record requests can be forwarded to providers via mail, e-mail or fax and may be returned to HAP CareSource via these same mechanisms as detailed in the medical record request document.

    All providers are expected to return medical record requests related to potential quality-of-care concerns within 14 days from initial receipt of the request, unless otherwise defined by program guidelines or state or federal law requirements. In the event that a state, federal or regulatory agency, or if the health and safety of a member requires that medical records must be submitted under a shorter timeframe, providers are expected to comply with the shorter turnaround time request. Providers and facilities that utilize third party health information management vendors are responsible for providing medical records to HAP CareSource or facilitating delivery of medical records to HAP CareSource by the identified contractor and within the requested time frames. We are legally bound to interact with providers only and HAP CareSource is not subject to any fees charged by health information management companies for medical record retrieval or submission.

    Your health partner representative may contact you if medical records are not received within the 14-day time frame to ensure you received the request. In addition, our market Chief Medical Officer may also be in contact to facilitate and ensure receipt of the required medical records to complete the potential quality-of-care reviews. Providers or facilities who repeatedly fail to return requested medical records are reported to the Credentialing Committee and may face other directed intervention or penalties up to and including contract termination.

    Preventive and Clinical Practice Guidelines

    HAP CareSource approves and adopts evidence-based nationally recognized standards and guidelines to help inform and guide the clinical care provided to HAP CareSource members. Guidelines are adopted from organizations that develop or promulgate evidence-based clinical practice guidelines and include professional medical associations, voluntary health organizations and the National Institute of Health (NIH) Centers and Institutes. In the absence of scientific evidence, the guidelines will be determined by board-certified practitioners from appropriate specialties. HAP CareSource submits to MDHHS for review and prior approval and as updated thereafter all clinical practice guidelines. Provider utilization of guidelines allows for the measurements of member health outcomes. 

    Evidence-based clinical practice and preventive health guidelines are established for acute and chronic medical and behavioral health care conditions that are relevant to the HAP CareSource membership. The topics for these guidelines are identified through analysis of the enrolled membership. These guidelines are the clinical basis for the prevention, wellness, disease management and care management programs.

    HAP CareSource will adopt Clinical Practice and Preventive Guidelines as follows:

    • Be based on the condition prevalence representative of the population served.
    • Be based on at least two behavioral health conditions with at least one that addresses children and adolescents.
    • Be based on perinatal care, care for children up to 24 months of age, care for children 2-19 years of age, care for adults 20-64 years of age and care for adults 65 years of age or older.
    • Be based on the health needs and opportunities for improvement identified as part of the HAP CareSource Quality Assessment and Performance Improvement program.
    • Be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field.
    • Consider the needs of the members.
    • Be adopted in consultation with network providers.

    The review and update process against clinical evidence will be completed for each guideline at least every two years or more frequently if the guideline changes.

    Value-Based Purchasing

    Your success is important to us. We offer a series of value-based purchasing (VBP) programs for our providers. These programs provide a progressive approach along a continuum of payment programs that will reward you as you attain higher levels of quality.

    Our flexible approach will enable you to participate in VBP programs at an initial level and grow to successively higher levels of reimbursement. Under the guidance of the HAP CareSource Quality Assessment and Performance Improvement program, you are rewarded for providing better value for services and achieving better health outcomes for our members.

    Contact Us

    If you would like more information about HAP CareSource Quality Improvement, please call Provider Services, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET) at 1-833-230-2102.

    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).