CareSource

CareSource, a leading nonprofit managed care organization based in Dayton, Ohio, has been living its mission to make a lasting difference in members' lives by improving their health and well-being for more than 30 years. CareSource serves 1.26 million members in Ohio. CareSource's membership includes: (1) Medicaid consumers, including families with low income, children, pregnant women, adoption and foster kids, those who are aged, blind or disabled, 2) Medicaid consumers who are eligible for Home and Community Based services through execution of an annual Provider Agreement with the Ohio Department of Medicaid ("ODM"), (3) Dually eligible consumers for Medicare and Medicaid through Ohio's Dual Demonstration program, MyCare, (4) Medicare Advantage consumers, (5) a Qualified Health Plan offered through the Federal Health Insurance Marketplace, providing low-cost comprehensive coverage for individuals and families, and (6) Community Transition Program consumers who are transitioning from the Ohio Department of Rehabilitation and Correction back to the community through a grant from the Ohio Department of Mental Health and Addiction Services. CareSource Program Services: 1) CareSource Ohio Medicaid: CareSource pioneered Ohio's first mandatory Medicaid managed care program in 1989 and is now one of the largest Medicaid managed care plans in the country. CareSource's years of experience in managing Medicaid managed care programs and member-focused approach to care have allowed it the opportunity to forge strong, positive regulatory relationships with state agencies, including departments of insurance. CareSource has earned 52.6% of the statewide Medicaid managed care market share, with the highest voluntary enrollment rate and the lowest voluntary disenrollment rate of all Ohio participating Medicaid Managed care plans. CareSource focuses on prevention with a goal of improving member health, the quality of health care services received, and accessibility of health care services for Medicaid members. CareSource has made an organizational commitment to make evidence-based investments towards improving health outcomes for members. CareSource's approach is one that blends the recommendations of the Triple Aim framework and principles of population health management best practice, while leveraging emerging technological and analytic solutions to make measurable positive impacts in the health of the communities we serve. CareSource also has significant focus on creating social based partnerships with providers and community organizations to support a longitudinal health management effort for members. Providers have the most control and influence on members and thus provide the best opportunity to help capitalize on cost, quality, and experience. Partnering with providers allows us to collaborate on population health strategies such as emergency department diversion, patient-centered medical home implementation, and performance management. Engaging our high-risk members' primary care and specialty providers is particularly critical to achieving successful care management. CareSource has a broad, statewide network of more than 45,000 providers, including primary care and specialist physicians, hospitals, nursing facilities, home health care agencies and other medical providers who provide medical services as well as assist in the coordination of member care. To further drive quality and achieve health outcomes targets, CareSource incentivizes certain providers through a value-based incentive model. CareSource focuses efforts on creating incentives and reimbursement options to support models that recognize quality at the provider level. CareSource created a program that provides additional incentives to providers for delivering quality based services that impact Healthcare Effectiveness Data and Information Set ("HEDIS") measures. CareSource created a shared savings model that rewards providers for attaining quality targets while sharing savings. In this particular model, CareSource established "filters" such that providers have to meet or exceed quality metrics before being eligible to share in cost savings. Value-based incentive models ultimately result in improved member health outcomes as providers continue to deliver quality service with the member's health and safety at the forefront. Effective high-risk case management alone is not sufficient to improve the overall population's health or decrease costs. Therefore, CareSource has created a robust care management infrastructure that consists of three levels of member care to accelerate care transformation for each and every member. Members are assigned to self-management, rising risk, or high-risk based on their unique member risk stratification. CareSource can then tailor the care coordination program to meet those members' needs. Members receive enhanced care coordination services based on their complex physical, behavioral and social health needs. The fluidity of this design allows CareSource to focus on preventing lower-risk and rising risk members from escalating to high-risk over time, while still tending to the one-to-one care management needs of high-risk populations. CareSource collaborates with community partners and providers such as the Area Agencies on Aging ("AAA"), Community Mental Health Centers, local pharmacies, and Federally Qualified Health Centers ("FQHCs") to ensure members receive the services they need. Additionally, CareSource's Enterprise Quality team helps drive improved clinical outcomes for members through a number of HEDIS targeted interventions including member engagement, education and disease management programs. To further enhance our HEDIS metric initiatives, CareSource has an established dedicated Quality team which works hand-in-hand with our Enterprise team as well as across all departments that impact quality clinical outcomes for our members. CareSource offers a 24/7 Nurse Advice Line staffed by Registered Nurses to help members access appropriate care and divert unnecessary emergency department visits. CareSource's commitment to quality is demonstrated through the organization's National Committee for Quality Assurance ("NCQA") accreditation. CareSource is accredited by NCQA for its qualified Health Insurance Marketplace and Medicaid Health plans. Accreditation demonstrates CareSource's commitment to quality and enhances CareSource's ability to improve the health and well-being of those we serve. CareSource utilizes the NCQA disease management definition and ensures the policy of CareSource to conduct appropriate disease management member identification and risk stratification, offering the appropriate interventions and education to the member. Through these efforts, the disease management programs focus simultaneously on achieving health and maintaining wellness to the highest level possible for each member. Any given member may be eligible for more than one condition. CareSource will engage members with the conditions of interest, or the parents/guardians of children with conditions of interest, through disease-specific and preventive care population-based interventions. The Disease Management program contains the following: program resources, program integration, provider notification and involvement, curriculum and content, NCQA requirements, and annual evaluation. The CareSource Women and Children's Health program is part of the corporate Care4U model of care and utilizes a population-based approach to meet the clinical and social needs of the women and children CareSource serves. The goal of the Care4U Women and Children's Health program is to maximize the quality of life and health outcomes of women, infants, children, and their families. The program employs a multi-faceted, evidence-based approach to achieve the best possible health outcomes by utilizing predictive analytics, case management, member incentive and educational programs, and community and provider partnerships. The Women and Children's Health program objectives include reducing the number of preterm births, reducing the risk of maternal and infant mortality and pregnancy-related complications, and reducing complications of health and development in infancy and early childhood. Elements of the program include: (1) Babies First - Babies First is available for all pregnant members. The program provides financial incentives for the completion of timely and ongoing prenatal, postpartum, and well-baby care, allowing the mother the opportunity to earn money for completion of doctor visits for both her infant and herself. Babies First requires that members must complete 5-7 prenatal visits, a post-partum visit within 21-56 days after delivery, the first 6-7 well baby visits prior to 15-18 months, and a lead screening by 15 months of age to receive incentives, and (2) Early and Periodic Screening, Diagnostic, and Treatment ("EPSDT"). The EPSDT benefit provides comprehensive and prevent