Quality Improvement

CareSource PASSE develops, approves, and adopts evidence-based, nationally recognized Clinical Practice Guidelines (CPGs) and best practices standards of care based on valid and reliable clinical evidence or a consensus of health care professionals in a particular field. Resource sites may include, for example:

• American Academy of Pediatrics
• American College of Obstetrics & Gynecology
• American Heart Association
• American Society of Addiction Medicine
• Centers for Disease Control and Prevention
• National Institutes of Health
• National Comprehensive Cancer Center

CareSource selects guidelines using member analytics, including claims data based on population health conditions in each Market. In addition, guidelines may be selected based on state or national priority areas, such as the Department of Health & Human Services Health People 2030 or the Arkansas Department of Human Services (DHS) priorities.

CPGs are reviewed every two years, or more often if required, e.g., new guidelines are issued. The Provider Advisory Committee (PAC) members, inclusive of Market Chief Medical Officers (CMOs) and Market Medical Directors evaluate current CPGs and make recommendations for revision and/or addition of new guidelines. CPGs are then voted on and approved by each individual Market Provider Advisory Council (PAC). Once all Markets have voted and approved the CPGs, the Enterprise PAC issues final approval.

CareSource PASSE’s goal is to make available the most up-to-date CPGs and best practice information to providers to ensure delivery of quality health care resulting in positive member health outcomes. CareSource PASSE promotes CPGs to providers to inform and guide the clinical decision-making for care provided to our members. Guidelines may be promoted to providers through any of the following methods: CareSource PASSE Provider Manual and website, provider newsletters, Provider Advisory Council activities, or provider trainings.

View CareSource PASSE CPGs

CareSource (PASSE) has a long-standing commitment to addressing the need for culturally competent care in our member populations, including exploring the social determinants of health that impact member health outcomes and quality of life. CareSource (PASSE) considers providing equitable and culturally competent care and services a core value of our organization.

CareSource PASSE is committed to addressing the need for culturally competent care in our member populations, including provision of culturally and linguistically appropriate services and exploring the social determinants of health that impact member health outcomes and quality of life.

The commitment to cultural competency and health equity is expressed in the CareSource PASSE Cultural Competency and Health Equity Plan. The Plan is evaluated and updated annually. A provider summary of the Plan is on this website, but the complete Plan is available upon request.

We encourage you to access the current CareSource PASSE Cultural Competency & Health Equity Plan Summary Document to learn more about our Cultural Competency and Health Equity efforts.

Learn more about CareSource PASSE’s commitment to Health Equity and Cultural Competency, available trainings and resources, and more by visiting the Health Equity webpage.

CareSource PASSE 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 PASSE uses Healthcare Effectiveness Data and Information Set (HEDIS^®) to measure the quality of care delivered to members. 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.

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

HEDIS^® Measures and 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) codes.

• 2024-2025 HEDIS Coding Guide
• 2022-2023 Behavioral Health HEDIS Coding Guide
• 2022-2023 Adult HEDIS Coding Guide
• 2022-2023 Child/Adolescent HEDIS Coding Guide
• 2022-2023 HEDIS Quality Companion Guide

CareSource PASSE Focus Measures

CareSource PASSE has identified specific HEDIS^® measures relevant to physical and behavioral health conditions of its membership. These health conditions and their relevant measures are of special interest in developing performance improvement projects and interventions, strategic population health management interventions, quality improvement activities, and value-based reimbursements for providers.

The current measures of focus are listed below. Details about each measure can be found in the HEDIS^® Coding Guide.

Other Quality Measures

Other potential quality measures and quality improvement activities may focus on areas other than those included in HEDIS^® measures, such as chronic disease management, inpatient admissions, re-admissions, and length of stay, moving children out of foster care, avoidable emergency department encounters, federal and state priorities, and wellness and prevention activities.

The CareSource PASSE Incident Reporting process is a means to ensure the health and safety of individuals who are enrolled in the CareSource PASSE program and is part of the PASSE’s efforts to prevent, detect, and remediate critical incidents. Its purpose is to diminish or eliminate potential incidents that put the health and safety of members at risk and to allow immediate steps to be taken to ensure members are protected from further harm when an incident occurs.

CareSource PASSE has implemented this Incident Reporting process that complies with the requirements outlined in the DHS PASSE Provider Agreement and aligns with the Minimum Licensing Standards for HCBS Providers. Incident Reports are completed by PASSE Staff and are received from providers. Reportable events are submitted to the DHS Quality Assurance Unit within required timeframes and critical incidents are identified. Care Coordinators and Complex Health Population leaders and management, as well as the Medical Director, are informed of incidents. CareSource PASSE monitors, tracks, and trends all incidents in its efforts to ensure members’ health, safety, and welfare.

Incident reports are reviewed internally for potential quality of care concerns and health, safety, or welfare concerns that must be escalated according to internal protocols and appropriate referrals are made.

Patient Safety Program

CareSource PASSE recognizes that patient safety is the cornerstone of high-quality health care, contributing to the overall health and welfare of our members. Our CareSource PASSE Patient Safety Program evaluates patient safety trends with the goal of reducing avoidable harm. The 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.
The Program also includes a well-defined health, safety, welfare (HSW) component. The purpose of the HSW Program is to ensure CareSource and our network of 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.

Providers Required to Report Incidents and Where to Submit the Reports

HCBS Providers are required as part of their state certification to submit Incident Reports to the PASSE and to the DHS Quality Assurance Unit.

PRTF Providers are required as part of their contract with CareSource PASSE to submit Incident Reports to CareSource PASSE.

AR DHS has developed a DHS DDS Incident Reporting Portal for electronic submission of Incident Reports via an online portal. Providers must work directly with DHS in order to have access to the Portal.

When submitting Incident Reports, providers with access to the DHS Portal, should utilize that method of report submission. For providers without access to the DHS Portal, reports are submitted via encrypted email to addresses identified on the Incident Reporting Form.

• Incident Reporting Form

Reportable Events and Timeframes

1. Death of a member*
2. Use of restrictive interventions:
   • HCBS Providers: Use of any restrictive interventions, including seclusion, physical, chemical or mechanical restraint
   • PRTF Providers: Use of any restrictive interventions where there is harm or alleged harm to the member, alleged during or subsequent to the intervention
3. Suspected maltreatment or abuse of a member
4. Any injury to a member that:
   • Requires attention of EMT, paramedic, MD
   • May cause death
   • May result in substantial, permanent impairment*
   • Requires hospitalization
5. Threatened or attempted suicide
6. Arrest or commission of any crime
7. Member has eloped or disappeared for more than two (2) hours
8. Any event where a staff member threatens a member
9. Unexpected occurrence involving actual or risk of death or serious physical or psychological injury
10. Medication errors made by staff that cause or have the potential to cause injury or illness
11. Any violation of a member’s rights that jeopardize the health, safety or quality of life of the member
12. Any incident involving property destruction by the member
13. Vehicular accidents
14. Biohazard incidents
15. Arrest or conviction of a staff member providing direct care services
16. Possession of a non-prescribed medication or illicit substance
17. Rape or any suspected sexual abuse
18. An incident that would be of interest to the media.*

*Must be reported to CareSource PASSE and DHS within one hour of becoming aware of the event.

Except as otherwise provided above, all reportable incidents must be reported to CareSource PASSE, using the appropriate Incident Report Form, via secure e-mail no later than two days following the incident. Any incident that occurs on a Friday is still considered timely if reported by the Monday immediately following.

Provider Training for Incident Reporting

CareSource PASSE developed a training module for reporting incidents and it is available on this website.

• Provider Education Series: Incident Reporting

Member and provider satisfaction and health outcomes are monitored through:

• Quality improvement activities
• Routine health plan reporting
• Annual Health Effectiveness Data and Information Set (HEDIS^®)
• Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) survey
• Member surveys
• Accessibility and availability standards
• Utilization trends

CareSource PASSE assesses our performance against goals and objectives that are in keeping with industry standards. We complete an annual evaluation of our QI program.
Consumer Assessment of Healthcare Providers and System (CAHPS®) Surveys are conducted annually to assess member experience. The first survey was conducted in 2023. Results are aggregated and disseminated for review and action if required. Programs and processes may be implemented or revised to meet member needs and assist in continuous quality improvement and member satisfaction.

Provider surveys are conducted, with results analyzed to develop quality activities and to enhance providers’ experience with CareSource PASSE.

Feedback from members through the Consumer Advisory Council and from providers through the Provider Advisory Committee is also utilized for quality improvement in programs and processes.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

CareSource PASSE, per our policies and provider contracts, is authorized to ask for protected health information for health care operations. Pursuant to Provider Agreements with CareSource PASSE and as outlined in the Provider Manual, providers are required to facilitate the provision of information and record exchanges necessary to comply with our Quality Improvement Program. HIPAA privacy regulations allow for sharing of PHI for purposes of making decisions around treatment, payment, or health plan operations.

The purposes for which member medical, clinical, and/or service records (“medical records”) may be used include, but are not limited to collection of data for:

• Reporting requirements
• Healthcare Effectiveness Data and Information Set (HEDIS^®) and other outcome measures 
• Quality improvement activities, such as performance improvement projects 
• Quality of Care (QOC) reviews 
• Care coordination
• Special reviews, audits, or investigations by CareSource or by state, federal or regulatory agencies
• Utilization management
• Claims payment

Record Requests

CareSource PASSE initiates contact with providers to request medical records using established processes and timelines. Medical record requests are forwarded to providers via mail, email or fax.

CareSource PASSE may also request remote access to electronic member records and access to and copies of records at the provider site.

Submission of Requested Records

Records may be returned to CareSource PASSE via mail, email or fax as detailed in the medical record request document. In general, all providers are expected to return medical record requests within 14 days from initial receipt of the request, unless otherwise defined by program guidelines or state or federal law requirements. In the event that a state, federal or regulatory agency makes a request, 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.

Third-Party Health Information Management Vendors

Providers and facilities that utilize third-party health information management vendors are responsible for providing medical records to CareSource PASSE or facilitating delivery of medical records to CareSource PASSE by the identified contractor. We are legally bound to interact with providers only and CareSource PASSE is not subject to any fees charged by health information management companies for medical record retrieval or submission.

Medical Records Not Received

A CareSource PASSE representative may contact your office if medical records are not received within the required timeframe to ensure you received the request. In addition, our market Chief Medical Officer (CMO) may facilitate contact 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 may be reported to the Credentialing Committee and may face other directed intervention or penalties up to and including contract termination and referral to applicable state and federal agencies.

Health outcomes are improved utilizing data collected from various sources, such as population health data, HEDIS® measures, Arkansas SHARE health information exchange, provider and member experience surveys and participation on advisory councils, and results of DHS-required metrics. Data collected and analyzed is utilized for quality improvement initiatives, performance improvement measures, and performance improvement projects, as well as work plans, roadmaps, strategies, and program development, all for the purpose of driving high quality health outcomes for all PASSE members.

CareSource PASSE Quality Improvement activities improve the quality of care provided to its members as defined in 42 CFR § 438.330 and its improvement as an organization. These activities are designed to:

1. Improve health quality.
2. Meet specified quality performance measures.
3. Increase the likelihood of desired health outcomes in ways that are capable of being objectively measured and/or producing verifiable results and achievements.
4. Be directed toward individual members incurred for the benefit of specified segments of members or provide health improvements to the population beyond those enrolled in coverage as long as no additional costs are incurred due to the non-members.
5. Be grounded in evidence-based medicine, widely accepted best clinical practice, or criteria issued by recognized professional medical associations, accreditation bodies, government agencies or other nationally recognized health care quality organizations.

Current PIPs

PIPs are specific projects designed to increase the quality of services to members. CareSource PASSE conducts Performance Improvement Projects (PIPs) in clinical and nonclinical areas, in accordance with the DHS-PASSE Agreement and federal protocols.

For 2024, CareSource PASSE has developed three PIPs. The interventions for each are under development and will be published upon completion.

1. Improving Metabolic Monitoring for Children and Adolescents on Antipsychotics

According to the Agency for Healthcare Research and Quality (AHRQ), the safe and judicious use of antipsychotic medication is a critical issue for children and youth, especially vulnerable children in Medicaid and foster care.

Antipsychotics are powerful medications that are indicated for treating a limited range of children’s mental health problems and come with a potential for serious side effects that have life-long consequence. A review of clinical trials using atypical antipsychotic agents with children and adolescents revealed that these medications can cause:

• Weight gain and obesity
• Drowsiness
• An increased risk of developing:
  • hyperglycemia (high blood glucose/sugar)
  • hyperlipidemia (abnormally high concentration of fats or lipids in the blood, such as cholesterol and triglycerides, that can deposit in blood vessel walls and restrict blood flow, creating a risk of developing coronary heart disease)
  • hyperprolactinemia (higher than normal levels of prolactin, a hormone that is mainly responsible for the development of mammary glands within breast tissue, milk production and lactation)
  • diabetes, and
  • cardiovascular concerns

Without appropriate metabolic monitoring while taking antipsychotic medications, members are at risk of developing chronic health conditions affecting both the quality and longevity of life for the member.

This PIP Performance measure is based on HEDIS® specifications for appropriate medication use. It is acknowledged that there are published practice standards for this metabolic monitoring that are stricter than those put forth by HEDIS® and are intended to be applied to patients receiving even one antipsychotic medication; however, for the purposes of this project, the HEDIS® measurement guidelines were chosen based upon ability to collect and analyze data.

• Performance Measure: The percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and who received both blood glucose and cholesterol testing.

Explanation of the requirements to meet this HEDIS® APM Measure is outlined in the HEDIS^® Coding Guide.

2. Improving Member Safety by Increasing the Percentage of Psychiatric Residential Treatment Facility (PRTF) Providers Submitting Incident Reports

According to a report in 2023 by Performance Health Partners, the number one benefit of incident reporting to healthcare providers—and their patients—is improved quality of care and patient safety.

Incident Reporting by healthcare providers within their organization helps the provider to detect and mitigate patient harm. The Institute for Healthcare Improvement notes that incident reporting helps the provider to identify opportunities for harm to occur by identifying both individual and system issues that contribute to occurrences of reportable events. This identification can then be utilized by the organization to evaluate and improve clinical processes and patient-related operations.

In addition to the benefits within the provider organization, submitting Incident Reports to the CareSource PASSE allows for timely follow-up with the member and the provider by the member’s care coordinator and other appropriate/needed responses from the CareSource medical and quality improvement/quality of care teams.

Report submission also provides opportunities for identification of patient safety and quality of care issues and trends that can be addressed by the PASSE. Incident Reports are flagged for potential quality of care/patient safety issues and reviewed weekly by an Incident Reporting/Quality of Care workgroup for provider quality of care and patient safety issues and trends.

• Performance Measure: The percentage of PRTF providers submitting Incident Reports during the measurement year.

3. Reducing the Rate of PRTF Readmissions Six Months Following Discharge from PRTF

This PIP was a priority for and required by AR DHS. There are three performance measures for which data will be collected and reported:

• Performance Measure 1: Percentage of readmissions to PRTF in the 6 months following discharge
• Performance Measure 2: Percentage of enrollees receiving BH treatment in the 30 days prior to PRTF readmission
• Performance Measure 3: Percentage of BH enrollees who had follow up outpatient services within 14 days of discharge

CareSource PASSE 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.

CareSource’s Clinical Quality and Health Safety team ensures systems are in place to review, investigate and resolve Quality of Care concerns and health, safety and welfare events identified and referred through the Incident Reporting process, through grievances, record reviews, other internal processes, external entities, and CareSource staff.

To assess quality of care concerns, CareSource PASSE 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. Learn more about our member records requests here.

Upon referral, Enterprise Clinical Quality nurse analysts, in conjunction with Chief Medical Officers (CMOs) and Medical Directors, investigate and evaluate quality of care and patient safety concerns, inclusive of overall member health and welfare concerns and physical and mental health issues. Appropriate actions follow, based on the severity of the quality of care or safety concern. Peer review and remediation activities, such as corrective action plans and/or performance improvement plans, may be implemented with individual providers and/or facilities.