Quality Improvement Program

This page explains the CareSource Quality Management and Improvement program.  This section includes medical and technical terms. If you need help understanding this section, please call Member Services at the number listed at the bottom of the page.

Your Care Means a Lot to Us

CareSource continually reviews the quality of care offered to our members. We implement programs to improve how we work internally, our delivery of health care services and our members’ health outcomes.

In order to ensure a structure, key processes and a culture of continuous improvement, CareSource has implemented a comprehensive Quality Improvement (QI) program. It has evolved from managing individual episodes of illness to oversight of the entire continuum of care to include wellness, prevention and disease and case management.

This is an evolving program that is responsive to the needs of our members, drawing and analyzing information from a variety of sources that impact your care. We always look at standards set by the medical community through practicing providers’ input, regulators and accrediting bodies.

In 2012, the CareSource Medicaid HMO was accredited by the National Committee for Quality Assurance (NCQA). This demonstrates that our quality meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement as we work to improve your health care.

Healthcare Effectiveness Data and Information Set (HEDIS®) is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. Annual HEDIS scores are one indicator for CareSource to evaluate how we’re doing with our QI program and where key opportunities exist to improve the quality of health care we provide for our members.

Our Quality Report Card summarizes how we are doing with care and treatments in a variety of categories. Each year we prioritize areas and ensure we have plans in place that give us the best chance for improvement in areas that matter the most, including physical, mental and emotional health. Typically, for HEDIS, we look at things like well-child care, follow-up after discharge for mental illness, prenatal and post-partum concerns, high blood pressure, diabetes indicators and appropriate medications for asthma conditions.

View our 2015 – 2017 HEDIS Survey Results and 2015 – 2017 CAHPS Survey Results

To meet the objectives of the program, activities are focused in the following areas.

Improving the health status of our members, including those with complex health needs

Preventive health programs, including:

  • “Care reminder” alert system that reminds members of preventive care services at points of member contact
  • Preventive Health Guidelines and Health Care Links available to members and providers via the website or a printed copy is available by calling Member Services.
  • Educational articles on preventive services in member and provider communications, such as newsletters
  • Disease management programs for members with long-term health conditions, including asthma and diabetes
  • Case management for members with special and/or complex medical needs

Evaluating over- and under-utilization of health care services

  • Continuous monitoring of total utilization statistics to identify possible areas where services are being used too much or too little
  • Quality of care issue review and resolution specific to inappropriate use of services
  • Evaluation of HEDIS rates for preventive health services among CareSource members

Ensuring quality of care and services provided to members

  • Review and resolution of quality of care concerns, clinical quality of care grievances or member risk, issues in coordination with involved providers

Identifying and implementing appropriate safety and error avoidance initiatives in collaboration with our providers

  • Implementation of the Medication Therapy Management (MTM) program
  • Articles contained in member newsletter mailings such as medication adherence, medication interaction and questions to ask your doctor
  • Creating and sending out preventive and clinical practice guidelines relevant to our members to support delivery of appropriate health care

Improving the coordination and continuity of member health care

  • Care Transitions program coordinates transitions in level of care for CareSource members

Evaluating the access and availability of care and service

  • We look at our whole network of providers for access to primary, specialty and ancillary care each quarter of the year
  • Annual provider appointment and after hours availability surveys
  • Continuous monitoring of Member Services call statistics and call quality to ensure results are within standards

Overseeing member and provider satisfaction measurement and improvement activities

  • Annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) member satisfaction survey results reviewed, analyzed and work plan developed

Evaluation of the effectiveness of QI activities in producing measurable improvement in the care and service provided to our members

  • A written evaluation of the Quality Improvement program is conducted annually. This helps to determine how well the QI activities are working. It is submitted to appropriate regulatory and accrediting bodies as required. A cross-functional team participates in the evaluation process.
  • CareSource shares a summary of the care and services provided to its membership with an annual Quality Report Card, available, and also highlighted in CareSource newsletters periodically.

Your health is important. Here are some ways that you can maintain or improve your health:

  • Establish a relationship with a health care provider.
  • Make sure you and your family have regular checkups with your health care provider.
  • Make sure if you have a chronic condition (such as asthma or diabetes) that you see your doctor regularly. You also need to follow the treatment that your doctor has given you. Make sure that you take the medications that your doctor has asked you to take.
  • Remember CareSource24® is available to help you. You can call them at 1-866-206-0554.
  • CareSource has programs that can help you maintain or improve your health. You can call Member Services for more information.

If you would like more information on CareSource Quality Improvement, or to get a copy of our program description, you can contact our Member Services department.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Member Services: 1-800-488-0134 (TTY: 1-800-750-0750 or 711), Monday – Friday 7 a.m. – 7 p.m.