Quality Improvement Program

Purpose

Your care means a lot to us. CareSource continually reviews the quality of care and service 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. The program 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.

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.

In 2015, CareSource (then CareSource Just4Me) was awarded an accreditation status of Accredited by the National Committee for Quality Assurance (NCQA). This accreditation status shows the commitment to service and clinical quality that meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement as we work to improve members’ health care.

Scope

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

  • Advocate for members across settings
  • Meet member access and availability needs for physical and behavioral health care
  • Determine interventions for Healthcare Effectiveness Data and Information Set (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 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) rate improvement that enrich member and health partner experience and satisfaction
  • Demonstrate enhanced care coordination and continuity across settings
  • Meet members’ cultural and linguistic needs
  • Monitor important aspects of care to ensure the safety of members across health care settings
  • Determine practitioner adherence to clinical practice guidelines
  • Support member self-management efforts
  • Partner collaboratively with network partners, practitioners, regulatory agencies, and community agencies
  • Ensure regulatory and accrediting agency compliance

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 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 for the Health Insurance Marketplace are:

  • Wellness and Prevention
    • Well-Child Care
    • Preventive Screenings (breast cancer, cervical cancer, chlamydia)
  • Chronic Disease Management
    • Comprehensive Diabetes Care
    • Controlling High Blood Pressure
  • Behavioral Health
    • Follow-Up After Hospitalization for Mental Illness
    • Antidepressant Medication Management
    • Follow-Up for Children Prescribed ADHD Medication
  • 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 for the Health Insurance Marketplace include:
  • Customer Service
  • Getting Care Quickly
  • Getting Needed Care
  • How Well Doctors Communicate
  • Ratings of All Health Care, Health Plan, Personal Doctor, Specialist

Clinical and Preventive Guidelines

CareSource approves and adopts nationally accepted standards and guidelines and promotes them to practitioners and members to help inform and guide clinical care provided to CareSource members. Guidelines are reviewed at least every two years or more often as appropriate, and updated as necessary. The use of these guidelines allows CareSource to measure the impact of the guidelines on outcomes of care. Review and approval of the guidelines are completed by the CareSource Clinical Advisory Committee every two years or more often as appropriate. The guidelines are then presented to the CareSource Quality Enterprise Committee. Topics for guidelines are identified through analysis of CareSource members. Guidelines may include, but are not be limited to:

  • Behavioral Health (e.g., depression)
  • Adult Health (e.g., hypertension, diabetes)
  • Population Health (e.g., obesity, tobacco cessation)

Information about clinical practice guidelines and health information are made available to CareSource members via member newsletters, the CareSource member website or upon request. Clinical & Preventive Guidelines and Health Links are available to members and providers on the website or on paper.

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 the number on your member ID card 24/7/365.
  • CareSource has programs that can help you maintain or improve your health. You can call 1-855-202-0622 (TTY: 1-800-982-8771 or 711) for more information about these programs.

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).