Quality Improvement Program

The Quality Improvement (QI) program ensures a structure, key processes, and a culture of continuous improvement within CareSource. The program has evolved from managing individual episodes of illness to the entire continuum of care, which includes wellness, prevention, and disease and case management.

This is an evolving program that responds to our members’ needs, analyzing information from many sources that affect your care. We 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 completed annually. This helps us determine see how well our QI activities are working. It is submitted for review to the appropriate regulatory and accrediting bodies as required. A cross-functional team participates in the evaluation process.

To get more information about our Quality Improvement program visit the web page, check your Member Handbook or call Member Services.

In 2018, CareSource 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

We have an active and comprehensive quality improvement program. The scope of the program includes:

  • Advocate for members across health care settings
  • Meet member access and availability needs for physical and behavioral health care
  • Determine interventions for Healthcare Effectiveness Data and Information Set (HEDIS®) overall increase for 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 with network practitioners, regulatory agencies, and community agencies
  • Ensure regulatory and accrediting agency compliance

Quality Measures

We continually assess and analyze the quality of care and service offered to our members. We do this by objectively monitoring our efforts to implement programs to improve outcomes.

We use HEDIS to measure the quality of care delivered to members. HEDIS is one of the most widely used means of health care quality measurement in the United States. HEDIS is developed and maintained by the NCQA (National Committee for Quality Assurance). The HEDIS tool is used by America’s health plans to measure important dimensions of care and service and allows us to compare to other 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 important 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, prostate)
  • Chronic Disease Management
    • Comprehensive Diabetes Care
    • Controlling High Blood Pressure
  • Behavioral Health
    • Follow-Up After Hospitalization for Mental Illness
    • Antidepressant Medication Management
  • 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, Substance Use Disorder )
  • 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.

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).