Caresource Ohio Inc

TO MAKE A LASTING DIFFERENCE IN OUR MEMBERS' LIVES BY IMPROVING THEIR HEALTH AND WELL-BEING. CARESOURCE OHIO INC. IS A NONPROFIT HMO LICENSED BY THE STATE OF OHIO.

CARESOURCE OHIO INC. ("CSOH"), 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 THIRTY-ONE YEARS. CSOH SERVES MORE THAN 1.5 MILLION MEMBERS IN OHIO. CSOH'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, AND (5) A QUALIFIED HEALTH PLAN OFFERED THROUGH THE FEDERAL HEALTH INSURANCE MARKETPLACE, PROVIDING LOW-COST COMPREHENSIVE COVERAGE FOR INDIVIDUALS AND FAMILIES. CSOH PROGRAM SERVICES: 1) CARESOURCE OHIO MEDICAID: CARESOURCE OHIO INC. 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. CSOH'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. CSOH HAS EARNED 50.7% 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. CSOH 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. CSOH HAS MADE AN ORGANIZATIONAL COMMITMENT TO MAKE EVIDENCE-BASED INVESTMENTS TOWARDS IMPROVING HEALTH OUTCOMES FOR MEMBERS. CSOH'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. CSOH 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. CSOH HAS A BROAD, STATEWIDE NETWORK OF MORE THAN 52,000 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, CSOH INCENTIVIZES CERTAIN PROVIDERS THROUGH A VALUE-BASED INCENTIVE MODEL. CSOH FOCUSES EFFORTS ON CREATING INCENTIVES AND REIMBURSEMENT OPTIONS TO SUPPORT MODELS THAT RECOGNIZE QUALITY AT THE PROVIDER LEVEL. CSOH CREATED A PROGRAM THAT PROVIDES ADDITIONAL INCENTIVES TO PROVIDERS FOR DELIVERING QUALITY BASED SERVICES THAT IMPACT HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET ("HEDIS") MEASURES. CSOH CREATED A SHARED SAVINGS MODEL THAT REWARDS PROVIDERS FOR ATTAINING QUALITY TARGETS WHILE SHARING SAVINGS. IN THIS PARTICULAR MODEL, CSOH 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, CSOH 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 CSOH 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. CSOH 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, CSOH'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, CSOH 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. CSOH'S COMMITMENT TO QUALITY IS DEMONSTRATED THROUGH THE ORGANIZATION'S NATIONAL COMMITTEE FOR QUALITY ASSURANCE ("NCQA") ACCREDITATION. CSOH IS ACCREDITED BY NCQA FOR ITS QUALIFIED HEALTH INSURANCE MARKETPLACE AND MEDICAID HEALTH PLANS. ACCREDITATION DEMONSTRATES CSOH'S COMMITMENT TO QUALITY AND ENHANCES CSOH'S ABILITY TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. CSOH HAS IMPLEMENTED AN INTEGRATED CARE MODEL TO EMPOWER MEMBERS TO BECOME ENGAGED AND ACTIVELY PARTICIPATE IN THEIR HEALTH AND WELL-BEING. THE CARESOURCE INTEGRATED CARE MANAGEMENT PROGRAM IS BOTH MEMBER-CENTRIC AND RESOURCES-SPECIFIC AND SUPPORTS A MEMBER'S HOLISTIC PHYSICAL AND BEHAVIORAL HEALTH NEEDS. THE INTEGRATED CARE MANAGEMENT PROGRAM HAS INTEGRATED DISEASE MANAGEMENT, HIGH RISK OBSTETRICS, AND CONDITION-MANAGEMENT PROGRAMS TO ADDRESS MEMBER PHYSICAL AND BEHAVIORAL HEALTH NEEDS. CSOH FOLLOWS EVIDENCE-BASE PROTOCOLS TO IDENTIFY MEMBERS WITH BOTH HEALTH NEEDS AND CHRONIC CONDITIONS TO CONDUCT INTERVENTIONS AT THE APPROPRIATE LEVEL OF CARE. DISEASE MANAGEMENT OCCURS AT EVERY PROGRAMMATIC LEVEL TO ENSURE APPROPRIATE INTERVENTIONS AND EDUCATION OF THE MEMBER TARGETED TO THEIR UNIQUE NEEDS. THROUGH TARGETED PROGRAMS LIKE DISEASE MANAGEMENT, BEHAVIORAL HEALTH, AND TRANSITIONS OF CARE, WE FOCUS SIMULTANEOUSLY ON ACHIEVING HEALTH AND MAINTAINING WELLNESS TO THE HIGHEST LEVEL POSSIBLE FOR EACH MEMBER. ANY GIVEN MEMBER MAY BE IDENTIFIED WITH MORE THAN ONE PROGRAM. THE CARESOURCE INTEGRATED CARE MANAGEMENT PROGRAM INCORPORATES SPECIALTY PROGRAMS SUCH AS WOMEN AND CHILDREN'S HEALTH, HEALTH MANAGEMENT, AND TRANSITIONS OF CARE. IN CONJUNCTION WITH OTHER GROUPS WITHIN CSOH SUCH AS QUALITY, NETWORK, AND ANALYTICS, THE INTEGRATED CARE MANAGEMENT PROGRAM UTILIZES A POPULATION-BASED APPROACH TO MEET THE CLINICAL AND SOCIAL NEEDS OF OUR MEMBERS. 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. AN EXAMPLE OF THE POPULATION HEALTH APPROACH IS THE WOMEN AND CHILDREN'S HEALTH PROGRAM. THROUGH COLLABORATION BETWEEN QUALITY, CLINICAL, NETWORK, AND ANALYTICS, CSOH HAS ESTABLISHED A PROGRAM TO TARGET OBJECTIVES INCLUDING A REDUCTION IN 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, A PROGRAM AVAILABLE TO ALL PREGNANT MEMBERS TO PROVIDE 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. (2) HIGH RISK OBSTETRICS, A PROGRAM TO SUPPORT AT RISK PREGNANCY AND ENSURE PREGNANT MEMBERS RECEIVE HIGH-TOUCH CASE MANAGEMENT SUPPORT THROUGHOUT THEIR PREGNANCY. (3) EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT ("EPSDT"), TO PROVIDE COMPREHENSIVE AND PREVENTATIVE HEALTH CARE SERVICES FOR CHILDREN UNDER AGE 21. ALL ELIGIBLE MEMBERS RECEIVE EPSDT REMINDER LETTERS THAT COINCIDE WITH THE APPROPRIATE HEALTH CARE TREATMENT BASED ON THEIR AGE. MEMBERS WHO ARE CASE MANAGED AND PARTICIPATE IN OUR PRENATAL EDUCATI