In the first section of this chapter we present three Master Measure Mapping Tables, one for each perspective—Patient/Family, Health Care Professional(s), and System Representative(s). In the second section of this chapter, we present specific measure mapping tables for each individual measure and profiles detailing information about each measure.
Master Measure Mapping Tables
Tables 7, 8, and 9 are Master Measure Mapping Tables for the three care coordination perspectives— Patient/Family, Health Care Professional(s), and System Representative(s), respectively. The tables indicate which measures focus on each of the care coordination domains for each perspective. The measure numbers seen in the Master Measure Mapping Tables correspond to the numbers assigned to each measure in Table 10.
Table 7. Care Coordination Master Measure Mapping Table, Patient/Family Perspective†
| Measurement Perspective: Patient/Family |
|
|---|---|
| Care Coordination Activities | |
| Establish accountability or negotiate responsibility | 3, 4a, 4b, 4c, 6, 9b, 11a, 13, 14, 16c, 17a, 17b, 26, 32, 37, 40, 42, 45, 48, 64, 68, 69, 73 |
| Communicate | 3, 4a, 4b, 4c, 4d, 4e, 6, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 24, 25, 26, 29, 30, 31, 32, 33, 37, 38a, 45, 48, 51, 65, 66, 68, 70, 72, 73 |
| Interpersonal communication | 3, 4a, 4b, 4c, 6, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 33, 35, 36, 37, 38b, 39, 40, 41a, 41b,42, 45, 48, 51, 64, 66, 67, 68, 69, 70, 72 |
| Information transfer | 3, 4a, 4b, 4c, 6, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 24, 26, 29, 30, 31, 32, 33, 35, 36, 37, 38a, 38b, 39, 40, 41a, 41b, 42, 45, 48, 49, 51, 65, 67, 68, 69, 70 |
| Facilitate transitions‡ | |
| Across settings | 4d, 4e, 9a, 9b, 13, 14, 16c, 17a, 17b, 21, 26, 31, 32, 37, 38a, 38b, 40, 42, 51, 64, 65, 67, 68, 70, 72, 73 |
| As coordination needs change | 11a, 14, 24, 68 |
| Assess needs and goals | 3, 4a, 4b, 4c, 4d, 4e, 6, 9a, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 24, 25, 26, 30, 31, 32, 33, 35, 37, 38a, 38b, 40, 41a, 41b, 42, 45, 65, 66, 68, 69, 70, 73 |
| Create a proactive plan of care | 6, 9b, 10, 11a, 16c, 21, 24, 37, 38a, 40, 65, 66, 67, 68, 69 |
| Monitor, follow up, and respond to change | 3, 4a, 4b, 4c, 4d, 4e, 6, 9b, 10, 11a, 13, 16c, 17a, 17b, 21, 24, 25, 26, 29, 31, 32, 33, 36, 37, 39, 40, 41a, 45, 64, 65, 67, 68, 69, 70, 72 |
| Support self-management goals | 4a, 4b, 4c, 6, 9a, 9b, 10, 11a, 13, 16c, 17a, 17b, 21, 24, 25, 26, 29, 31, 32, 33, 35, 36, 37, 38a, 38b, 40, 41a, 41b, 64, 65, 66, 67, 68, 70, 72 |
| Link to community resources | 10, 11a, 16c, 17b, 21, 24, 31, 33, 38a, 38b, 64, 65, 67, 70, 73 |
| Align resources with patient and population needs | 6, 11a, 14, 16c, 17a, 17b, 31, 38a, 38b, 51, 65, 73 |
| Broad Approaches Potentially Related to Care Coordination | |
| Teamwork focused on coordination | 6, 11a, 16c, 24, 25, 29, 30, 35, 36, 39, 40, 65, 68, 69, 70, 73 |
| Health care home | 4a, 4b, 4c, 4d, 4e, 16c, 17a, 17b, 45, 51 |
| Care management | 11a, 14, 21, 51 |
| Medication management | 4a, 4b, 4c, 4d, 4e, 6, 9a, 9b, 10, 17a, 17b, 21, 32, 35, 36, 37, 38a, 38b, 42, 48, 65, 66, 70 |
| Health IT-enabled coordination | 4a |
† A key to measure numbers can be found in Table 10: Index of Measures.
‡ All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).
Table 8. Care Coordination Master Measure Mapping Table, Healthcare Professional(s) Perspective†
| Measurement Perspective: Health Care Professional(s) |
|
|---|---|
| Care Coordination Activities | |
| Establish accountability or negotiate responsibility | 5, 7a, 7b, 11b, 18, 20, 22b, 38c, 38d, 38e, 43, 46, 62, 74, 77 |
| Communicate | 5, 7a, 7b, 11b, 12a, 12b, 17d, 22b, 23, 38e, 38f, 43, 46, 62, 74, 77 |
| Interpersonal communication | 7a, 7b, 8, 11b, 12a, 12b, 17d, 18, 22b, 28, 43, 74, 75, 77 |
| Information transfer | 5, 8, 11b, 12a, 12b, 17d, 18, 20, 22b, 23, 27, 38c, 38d, 38e, 38f, 62, 74, 75, 77 |
| Facilitate transitions‡ | |
| Across settings | 5, 17d, 22b, 27, 43, 38c, 38d, 38e, 38f, 74, 75, 77 |
| As coordination needs change | 11b, 22b |
| Assess needs and goals | 5, 11b, 12a, 12b, 17d, 20, 23, 27, 38d, 38e, 38f, 43, 46, 74 |
| Create a proactive plan of care | 5, 7b, 8, 11b, 12a, 22b, 23, 27, 38e, 38f, 62 |
| Monitor, follow up, and respond to change | 5, 11b, 12a, 12b, 17d, 20, 22b, 23, 74, 75, 77 |
| Support self-management goals | 5, 8, 11b, 17d, 20, 22b, 38d, 38e, 38f, 74 |
| Link to community resources | 5, 11b, 17d, 22b, 27, 38e, 74 |
| Align resources with patient and population needs | 5, 8, 11b, 17d, 20, 38d, 38e, 74 |
| Broad Approaches Potentially Related to Care Coordination | |
| Teamwork focused on coordination | 7a, 7b, 11b, 12a, 12b, 18, 23, 27, 28, 43, 46, 62, 74 |
| Health care home | 17d, 74 |
| Care management | 5, 11b, 22b, 27 |
| Medication management | 17d, 18, 20, 38c, 38e, 38f, 63 |
| Health IT-enabled coordination | 12a, 17d, 75 |
† A key to measure numbers can be found in Table 10: Index of Measures.
‡ All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).
Table 9. Care Coordination Master Measure Mapping Table, System Representative(s) Perspective†
| Measurement Perspective: System Representative(s) |
|
|---|---|
| Care Coordination Activities | |
| Establish accountability or negotiate responsibility | 1, 2, 15, 16a, 16b, 57, 58, 59, 60, 63, 71, 73, 76, 78, 79, 80 |
| Communicate | 1, 16a, 16b, 17c, 22a, 34, 71, 73, 76, 80 |
| Interpersonal communication | 17c, 22a, 52, 71, 76, 78, 79 |
| Information transfer | 1, 2, 15, 16a, 17c, 22a, 34, 44, 49, 50, 52, 53, 54, 56, 57, 58, 59, 60, 63, 71, 73, 76, 79, 80 |
| Facilitate transitions‡ | |
| Across settings | 15, 16a, 17c, 22a, 49, 50, 55, 57, 58, 59, 60, 63, 71, 73, 76, 78, 80 |
| As coordination needs change | 16a, 16b, 22a, 73, 76 |
| Assess needs and goals | 1, 16a, 16b, 17c, 44, 49, 73, 76, 79, 80 |
| Create a proactive plan of care | 1, 16a, 16b, 22a, 49, 52, 55, 58, 59, 60, 73, 76, 80 |
| Monitor, follow up, and respond to change | 1, 2, 3, 17c, 19, 22a, 44, 49, 54, 58, 59, 60, 61, 63, 71, 73, 76, 78, 79, 80 |
| Support self-management goals | 1, 16a, 17c, 19, 22a, 34, 49, 71, 73, 76, 79, 80 |
| Link to community resources | 1, 16a, 17c, 22a, 44, 52, 73, 80 |
| Align resources with patient and population needs | 1, 2, 16a, 16b, 17c, 19, 49, 52, 73, 76, 79, 80 |
| Broad Approaches Potentially Related to Care Coordination | |
| Teamwork focused on coordination | 1, 44, 52, 76, 79, 80 |
| Health care home | 2, 3, 16a, 16b, 17c, 19, 47, 71, 76, 80 |
| Care management | 15, 16a, 16b, 22a, 49, 76, 79, 80 |
| Medication management | 2, 3, 17c, 57, 58, 60, 63, 71, 76, 78 |
| Health IT-enabled coordination | 1, 16a, 17c, 19, 34, 44, 50, 71, 73, 76, 79, 80 |
† A key to measure numbers can be found in Table 10: Index of Measures.
‡ All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).
Measure Profiles
This section contains measure mapping tables specific to each individual measure. Each individual measure mapping table is followed by a measure profile designed to provide more detailed information on the measure's purpose, format and data source, perspective, validation and testing, links to outcomes, applications, and key sources. The measure profiles also identify the specific measure items (i.e., survey questions or measure components) that map to each domain. Table 10 below is an index to the measure numbers (far left column) cited in the Master Measure Mapping Tables and the order in which the individual measure mapping tables and profiles appear.
* An additional version of this measure was added to this update.
† At the request of the measure developer, the title of this measure was changed from that which appeared in the original Atlas.
