Quality Improvement

CareSource is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. The scope of our CareSource quality improvement (QI) program is comprehensive and includes both clinical and non-clinical services.

CareSource monitors and evaluates the quality of care, encompassing the 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 practitioner, provider, hospital, utilization management, care management and pharmacy program results.

Member satisfaction and health outcomes are monitored through routine health plan reporting, annual Health Effectiveness Data and Information Set (HEDIS)®, Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, 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 is accredited by the National Committee for Quality Assurance (NCQA) for our Indiana Medicaid and Marketplace plans. 

Program Scope

CareSource supports an active, ongoing and comprehensive quality improvement 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

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 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

Quality Metrics

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 the 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 National Committee for Quality Assurance (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 for the Health Insurance Marketplace are:

  • 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
  • Safety
    • Use of imaging studies for low back pain

CMS uses a five-star quality rating system to measure Medicare beneficiaries’ experience with their health plan and the health care system. Star ratings are based on measures of the health plan’s rating across five categories:

  • Staying healthy (screenings, tests and vaccines): Includes whether members received various screening tests, vaccines and other checkups that help them stay healthy.
  • Managing chronic conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
  • Member experience with the health plan: Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals.

For health plans covering drug services, the overall score for quality of those services covers many different topics that fall into four categories:

  • Drug plan customer service: Includes how well the plan handles member appeals.
  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.

Tools are available for providers via the CareSource Provider Portal to determine services and recommended routine screening tests needed and historical medical and pharmacy data.

Health Equity Commitment

CareSource has a long-standing commitment to addressing the need for culturally competent care in our member populations, as well as looking at the social determinants that impact member health outcomes and quality of life. CareSource considers providing equitable and culturally competent care and services a core value of our organization. Our CareSource Commitment to Health Equity, in conjunction with our Life Services programs, focuses identifying health disparities and resulting inequities that impact our members.

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 accepted standards and guidelines and promotes them to practitioners and members 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 CareSource Physician Advisory Committee (PAC) every two years or more often as appropriate. The CareSource Enterprise PAC and Quality Enterprise Committee (QEC) are notified of guideline approval. Topics for guidelines are identified through analysis of Marketplace plan members. 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 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 may be 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).