Quality Improvement

CareSource’s Quality Improvement (QI) program design is to ensure the organization delivers on all aspects of care delivery for D-SNP members based on their unique needs.

The overarching QI program goals are aligned with the Institute for Healthcare Improvement Quadruple Aim of:

  1. Improving health outcomes of members and populations,
  2. Improving member and provider experience with care and services,
  3. Reducing per capita cost of care, and
  4. Advancing health equity.

We monitor, analyze and identify opportunities for improvement across the comprehensive span of health care continuum using standardized metrics such as:

  • Healthcare Effectiveness Data and Information Set (HEDIS)
  • Customer Assessment of Healthcare Providers and Systems (CAHPS)
  • Provider satisfaction survey results
  • Health Outcomes Survey
  • Over and underutilization patterns and trends

On an annual basis, we formally evaluate our QI program and performance metrics against set goals. Our formal results inform our QI strategy for the following year.

We are committed to delivering high quality care and services.

Quality Measures

CareSource uses the 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. Potential quality measures for the D-SNP are:

  • Wellness and prevention
    • Preventive screenings (breast cancer, colorectal cancer screenings)
  • Chronic disease management
    • Comprehensive diabetes care
    • Controlling high blood pressure

CMS uses a five-star quality rating system to measure Medicare beneficiaries’ experience with their health plan and the health care system. Star ratings are based on measures of the health plan’s rating across five categories:

  • Staying healthy (screenings, tests and vaccines): Includes whether members received various screening tests, vaccines and other checkups that help them stay healthy.
  • Managing chronic conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
  • Member experience with the health plan: Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan’s performance:
    • Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals.

For health plans covering drug services, the overall score for quality of those services covers many different topics that fall into four categories:

  • Drug plan customer service: Includes how well the plan handles member appeals.
  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.

Tools are available for providers via the CareSource Provider Portal to determine services and recommended routine screening tests needed and historical medical and pharmacy data.

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.

    Patient Safety Program

    Ensuring the health, safety and welfare of our members is top priority at CareSource. Our organization seeks to build a culture in which all leaders and the workforce understand basic principles of patient safety science, and it is essential that all CareSource employees understand that member safety is their responsibility. HSW Program goals are:

    • Foster an organizational environment that emphasizes the use of quality tools to improve quality, safety and member outcomes.
    • Ensure the provision of appropriate, evidence-based, safe, quality care to all CareSource members through the reduction of avoidable medical errors by developing and implementing safeguards, systems and processes that detect, prevent and mitigate harm and/or risk factors.
    • Ongoing improvement in care and safety through use of quality of care methodologies, such as the IHI Quadruple Aim and Six Sigma.
    • Develop relevant policies and procedures and ensure staff education on identification of at-risk situations and medical error.
    • Establish procedures to mitigate risks.
    • Ensure reporting to appropriate CareSource Quality Committees, as well as to CareSource Departments, such as Compliance or Program Integrity, when indicated.

      Clinical and Preventive Guidelines 

      CareSource approves and adopts evidence-based nationally accepted 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 topics. 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.

      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 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 time frame 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.

        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:

        Participation in CMS and HHS Quality Improvement Initiatives 

        CareSource encourages providers to participate in CMS and Health and Human Services (HHS) quality improvement initiatives. 

        If you would like more information on CareSource Quality Improvement, please call Provider Services at 1-833-230-2176.

        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).