Quality Improvement

Program Purpose

CareSource is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. The scope of the CareSource quality improvement 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 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 results program.

Member satisfaction and health outcomes are monitored through routine health plan reporting, annual Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores, assessment of provider and member satisfaction and review of 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.

Program Scope

CareSource supports an active, ongoing and comprehensive quality improvement program. The scope of the QI program includes:

  • Advocate for members across settings
  • Meet member access and availability needs for physical and behavioral health care
  • Determine interventions for HEDIS overall rate improvement that increase preventive care rates and facilitate support of members’ acute and chronic health conditions and complex needs
  • Determine interventions for CAHPS rate improvement that enrich member and provider experience and satisfaction
  • Demonstrate enhanced care coordination and continuity across settings
  • 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 member self-management skills
  • Partner collaboratively with network partners, 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 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 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 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 pressing areas of care. Potential quality measures are:

  • Wellness and prevention
  • Preventive screenings (breast cancer)
  • Flu vaccinations
  • 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

CareSource uses the annual member CAHPS surveys to capture member perspectives on health care quality. CAHPS is a program overseen by the United Stated Department of Health and Human Services―Agency for Healthcare Research and Quality (AHRQ). Potential CAHPS measures include:

  • Customer service
  • Getting care quickly
  • Getting needed care
  • How well doctors communicate
  • Ratings of all health care, health plan, personal doctor, specialist

We’ve recently shared our evaluation on how we are performing against our Model of Care (MOC).

Preventive and Clinical Practice 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. Evidence-based preventive health guidelines and clinical practice guidelines are established for acute and chronic medical and behavioral health care and are relevant to the membership.

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 or diabetes)
  • Population health (e.g., obesity or 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:

  • Medicare

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

CareSource 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 on 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.

CLAS Standards: National Culturally & Linguistically Appropriate Standards

CareSource adheres to the National Culturally & Linguistically Appropriate Standards (CLAS), which serve as a blueprint for health care providers and organizations to implement culturally and linguistically appropriate services. CLAS consists of 15 standards that encompass the following topic areas:

  • Principal Standard: Provision of effective, equitable, understandable, and respectful quality care and services that are response to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs
  • Governance, Leadership, and Workforce
  • Communication and Language Assistance
  • Engagement, Continuous Improvement & Accountability

Network providers must ensure that:

  • Members understand that they have access to free medical interpreter services in their native language, including Sign Language. No cost TDD/TTY services are available to facilitate communication with hearing impaired members.
  • Health care is provided with consideration of the members’ cultural background, encompassing race/ethnicity, language and health beliefs. Cultural considerations may impact/influence member health decisions related to preventable disease or illness.
  • The provider office staff makes reasonable attempts to collect race-and language-specific member data. Staff is available to answer questions and explain race/ethnicity categories to a member, to assure accurate identification of race/ethnicity for all family members.
  • Treatment plans are developed based on evidence-based clinical practice guidelines with consideration of the member’s race, country of origin, native language, social norms , religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation and other characteristics that may result in a different perspective or decision-making process.
  • Participating providers must also meet the requirements of all applicable state and federal laws and regulations as they pertain to provision of services and care.

CareSource prohibits its providers or partners from refusing to treat, serve or otherwise discriminate against an individual because of race, color, religion, national origin, sex, age, gender orientation (i.e. intersex, transgendered and transsexual) or disability. In consideration of cultural differences, including religious beliefs and ethical principles, CareSource will not discriminate against providers who practice within the permissions of existing protections in provider conscience laws, as outlined by the U.S. Department of Health and Human Services (HHS).

CareSource encourages our participating providers to visit the Office of Minority Health, Cultural Competency Resources website found at: www.ThinkCulturalHealth.hhs.gov for toolkits and educational resources. Included on the site is a free 9 credit Continuing Medical Education (CME) course, A Physician’s Practical Guide to Culturally Competent Care. This self-directed e-learning program equips providers to better understand and treat diverse populations.

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:

Contact Us

If you would like more information about CareSource Quality Improvement, please call Provider Services at 1-800-488-0134 Monday through Friday, 8 a.m. to 6 p.m. Eastern Standard Time (EST).

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).