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 of care and services, encompassing the safety and service delivered to our members, with emphasis on accessibility to care, availability of services and practitioners, quality of care and member safety, medical and behavioral health services and internal monitoring, review and evaluation of program areas, including Utilization Management, Care Management and Pharmacy. 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 and provider satisfaction and health outcomes are monitored through quality improvement activities, routine health plan reporting, annual Healthcare Effectiveness Data and Information Set (HEDIS®), measures the quality of our health plan, Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores, member surveys, 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 supports an active, ongoing and comprehensive quality improvement program across the organization. The scope of the QI program 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 rate 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 settings
- Assess member population characteristics and needs
- Meet members’ cultural and linguistic needs encompassing the social determinants of health
- Assess the geographic availability and accessibility of primary care providers and specialists
- Monitor important aspects of care to ensure the health, safety and welfare of members across health care settings
- Ensure CareSource is effectively serving members with complex health needs
- 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, including:
- All federal requirements as outlined in 42 CFR Part 438, Managed Care
- Perform HEDIS® compliance audit and performance measurement
- Ensure compliance with NCQA accreditation standards
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.
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
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.
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 HEDIS® to measure the quality of care delivered to members. HEDIS® is developed and maintained by 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 include the following:
- Wellness and prevention
- Preventive screenings (breast cancer)
- Chronic disease management
- Comprehensive diabetes care
- Controlling high blood pressure
- Behavioral health
- Follow-up after hospitalization for mental illness
- Antidepressant medication management
- 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).
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.
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 Provider 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:
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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.
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.
Patient Safety Program
CareSource recognizes that patient safety is the cornerstone of high-quality health care, contributing to the overall health and welfare of our members. Our CareSource Patient Safety Program evaluates patient safety trends with the goal of reducing avoidable harm. Our patient safety program is developed in the context of our Population Health Management approach and includes regulatory/accreditation, policies/procedures, training/implementation, continuous monitoring, program evaluation and improvement initiatives.
Our CareSource Patient Safety Program has a well-defined health, safety, welfare (HSW) component. The purpose of the HSW program is to ensure out of network providers are identifying and remediating those social determinants of health that often contribute to negative member health outcomes.
Safety events are monitored through retrospective review of Quality of Care concerns and real time reporting of claims data. Data analysis of our provider and health system network ensures situational risks can be identified in a timely manner, reviewed and mitigated by proactive corrective action or performance improvement steps. In addition to our focus on health disparities and their impact on member health outcomes, it is important for our providers and team members to understand how a lack of cultural competency may negatively impact member health outcomes. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy.
We offer staff education and training through our CareSource University learning management system. In addition, CareSource developed an Equity Council to promote diversity within the organization, including the development of Employee Resource Groups to foster a diverse and inclusive workplace.
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:
- 2022-2023 Adult HEDIS Coding Guide
- 2022-2023 Child and Adolescent HEDIS Coding Guide
- 2022-2023 Behavioral Health HEDIS Coding Guide
- 2022-2023 HEDIS Quality Companion Guide
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).