Quality Improvement

CareSource is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. Our CareSource Quality Improvement (QI) Program is comprehensive and inclusive of both clinical and non-clinical services. CareSource monitors and evaluates the quality and safety of the care and service delivered to our members emphasizing:

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 practitioners, medical and behavioral health services and 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 and 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 and utilization trends. 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). 

Program Scope

CareSource supports an active, ongoing and comprehensive quality improvement program across the organization. To maintain a robust QI program, our scope includes:

  • 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 improvement to improve preventive care scores and facilitate support of members’ 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
  • 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. CareSource also utilizes Lean Six Sigma tools, when indicated, to focus on improving member experience, member safety and ensuring our processes consistently deliver the desired results.

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

Quality Measures

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 member 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 D-SNP are:

  • Wellness and prevention
    • Preventive screenings (breast cancer, colorectal cancer screenings)
  • 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.

CareSource Commitment to Health Equity

We are dedicated to the communities in which we serve and making a positive impact in the lives of our members by eliminating health disparities, supporting our organization’s Health Equity initiatives, partnering with community stake holders to carry out this much needed work. Our Enterprise Life Services Department is dedicated to serving marginalized communities and making a positive impact in the lives of diverse member populations to eliminate health disparities

Enterprise Life Services is taking an integrated approach to Health Equity and embedding it across CareSource. As a result, we have developed our objectives based on Pillars of Life Services outlined below.

  • Workforce Development: promote long-term employment opportunities, financial literacy, connection to job training and increasing assets, such as home ownership
  • Housing: increase the quality of safe & affordable housing, enhanced financial tools to develop & preserve housing units & improved affordability of housing
  • Food & Nutrition: regular & consistent access to healthy foods, education on nutrition & overall health impacts, addressing food deserts and inequalities
  • Health Equity: pursuit of Health Equity for Black, Indigenous and People of Color (BIPOC), LGBTQIA, & complex populations, elimination of health disparities; partnerships with outside organizations; drive policy & advocate for change

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.

Patient Safety Program

Ensuring the health, safety and welfare of our members is top priority at CareSource. Our organization seeks to build a culture in which all leaders and the workforce understand basic principles of patient safety science, and it is essential that all CareSource employees understand that member safety is their responsibility. HSW Program goals are:

  • Foster an organizational environment that emphasizes the use of quality tools to improve quality, safety and member outcomes.
  • Ensure the provision of appropriate, evidence-based, safe, quality care to all CareSource members through the reduction of avoidable medical errors by developing and implementing safeguards, systems and processes that detect, prevent and mitigate harm and/or risk factors.
  • Ongoing improvement in care and safety through use of quality of care methodologies, such as the IHI Triple Aim and Six Sigma.
  • Develop relevant policies and procedures and ensure staff education on identification of at-risk situations and medical error.
  • Establish procedures to mitigate risks.
  • Ensure reporting to appropriate CareSource Quality Committees, as well as to CareSource Departments, such as Compliance or Program Integrity, when indicated.

We are dedicated to the communities in which we serve and making a positive impact in the lives of our members by eliminating health disparities, supporting our organization’s Health Equity initiatives, partnering with community stake holders to carry out this much needed work. Our Enterprise Life Services Department is dedicated to serving marginalized communities and making a positive impact in the lives of diverse member populations to eliminate health disparities

Enterprise Life Services is taking an integrated approach to Health Equity and embedding it across CareSource. As a result, we have developed our objectives based on Pillars of Life Services outlined below.

  • Workforce Development: promote long-term employment opportunities, financial literacy, connection to job training and increasing assets, such as home ownership
  • Housing: increase the quality of safe & affordable housing, enhanced financial tools to develop & preserve housing units & improved affordability of housing
  • Food & Nutrition: regular & consistent access to healthy foods, education on nutrition & overall health impacts, addressing food deserts and inequalities
  • Health Equity: pursuit of Health Equity for Black, Indigenous and People of Color (BIPOC), LGBTQIA, & complex populations, elimination of health disparities; partnerships with outside organizations; drive policy & advocate for change

Clinical and Preventive Guidelines 

CareSource approves and adopts evidence-based nationally accepted 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 topics. 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) and the CareSource Enterprise PAC. The 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 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.

Quality of Care Reviews

CareSource ensures the provision of safe and quality care 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

To properly assess quality of care concerns 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 health care operations, which includes quality issue reviews. Medical record requests are forwarded to providers via mail, e-mail or fax and may be returned to CareSource via these same mechanisms as detailed in the medical record request document.

All providers are expected to return medical record requests related to 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. If 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. Providers and facilities that utilize third party health information management vendors are responsible for providing medical records to CareSource or facilitating delivery of medical records to CareSource by the identified contractor. We are legally bound to interact with providers only and 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 timeframe 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 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.

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).