Primary Care Provider Roles & Responsibility

 

All CareSource members may choose a PCP upon enrollment in the plan. PCPs should help facilitate a medical home for members. This means that PCPs will help coordinate health care for the member and provide additional health options to the member for self-care or care from community partners.

In addition, providers are expected to administer patient care in a culturally competent manner. Resources are provided below.

Roles and Responsibilities

PCP care coordination responsibilities include the following:

  • Assisting with coordination of the member’s overall care, as appropriate for the member.
  • Serving as the ongoing source of primary and preventive care.
  • Recommending referrals to specialists, as required.
  • Triaging members.
  • Participating in the development of case management care treatment plans and notifying CareSource of members who may benefit from case management. Please see the “Member Support Services and Benefits” section on how to refer members for case management.

In addition, CareSource PCPs play an integral part in coordinating health care for our members by providing:

  • Availability of a personal health care practitioner to assist with coordination of a member’s overall care, as appropriate for the member
  • Continuity of the member’s total health care
  • Early detection and preventive health care services
  • Elimination of inappropriate and duplicate services PCPs are responsible for:
    • Treating CareSource members with the same dignity and respect afforded to all patients. This includes high standards of care and the same hours of operation.
    • Identifying the member’s health needs and taking appropriate action.
    • Providing phone coverage for handling patient calls 24 hours a day, seven days a week.
    • Following all referral and prior authorization policies and procedures as outlined in this manual.
    • Complying with the quality standards of our health plans outlined in this manual.
    • Providing 30 days of emergency coverage to any CareSource patient dismissed from the practice.
    • Maintaining clinical records, including information about pharmaceuticals, referrals, inpatient history, etc.
    • Obtaining patient records from facilities visited by CareSource patients for emergency or urgent care if notified of the visit.
    • Ensuring demographic and practice information is up-to-date for directory and member use.

Cultural Competency

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 responsive 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, at 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 or 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, religions, 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.ThinkCultureHealth.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.