Care Coordination Measures Atlas Update

Measures 4a-4e

Measure #4a. Consumer Assessment of Healthcare Providers and Systems (CAHPS) — Adult Primary Care 1.0

Care Coordination Measure Mapping Table

	Measurement Perspective:
	Patient/Family	Health Care Professional(s)	System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility	□
Communicate	■
Interpersonal communication	■
Information transfer	■
Facilitate transitions
Across settings
As coordination needs change
Assess needs and goals	■
Create a proactive plan of care
Monitor, follow up, and respond to change	□
Support self-management goals	■
Link to community resources
Align resources with patient and population needs
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination
Health care home	□
Care management
Medication management	□
Health IT-enabled coordination	□

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

Consumer Assessment of Healthcare Providers and Systems (CAHPS) – Adult Primary Care 1.0

Purpose: To measure adult consumers' experiences with a specific primary care physician and practice.

Format/Data Source: Survey comprised of 31 core items with an additional 64 supplemental items specific to adult primary care. Supplemental items focus on additional aspects of care, including: (1) after hours care, (2) costs of care, (3) doctor role, (4) doctor thoroughness, (5) health improvement, (6) health promotion and education, (7) help with problems or concerns, (8) other doctors, (9) provider communication, (10) provider knowledge of specialist care, (11) doctor recommendation, (12) shared decisionmaking, (13) wait time, (14) care received from specialists, and (15) most recent visit. All questions were answered on a 4-point frequency scale. Responses covered experiences in the last 12 months and were compiled into a nationally available database.¹

Date: Measure released in 2008.¹

Perspective: Patient/Family

Measure Item Mapping:

• Establish accountability or negotiate responsibility: 2
• Communicate:
  • Between health care professional(s) and patient/family: 14, 15, AE1, AE2, OD2, C2, SD2
• Interpersonal communication:
  • Between health care professional(s) and patient/family: COC3, COC5, OD3-OD5, C1, C5, C7, C8, SD3, SC3, RV3-RV5
  • Participants not specified: 18
• Information transfer:
  • Between health care professional(s) and patient/family: 10, 12, 22, OD8, C9
  • Across health care teams or settings: PK2, SC6
  • Participants not specified: RV6
• Assess needs and goals: DT2, HPC1, SD1, SD2, RV7
• Monitor, follow up, and respond to change: 22
• Support self-management goals: 17, HI1, HP1-HP6, HPC1
• Health care home: 1, 2
• Medication management: COC1, COC3
• Health IT-enabled coordination: AE1, AE2

Development and Testing: Several rounds of revision of the draft instrument (all versions) were based on literature review and feedback from extensive field tests with various health care organizations, cognitive interviews, and stakeholders.¹ The final instrument is endorsed by the National Quality Forum as well as the Ambulatory Care Quality Alliance (AQA).

Link to Outcomes or Health System Characteristics: The CAHPS survey questions and data have been used for evaluating patient experiences with care delivery.² Measure scores related to communication and care coordination were shown to be higher (more favorable) for patients seen by physicians in large, integrated medical groups compared with other practice settings.³ Study populations enrolled in care management programs also showed trends toward higher ratings of patient experience with provider communication via the CAHPS.⁴

Logic Model/Conceptual Framework: None described in the sources identified.

Country: United States

Past or Validated Applications*:

• Patient Age: Adults
• Patient Condition: General Population/Not Condition Specific
• Setting: Primary Care Facility

*Based on the sources listed below.

Notes:

• The final survey includes 3 variations of a multi-item instrument: (1) Adult Primary Care 1.0, (2) Adult Specialty Care 1.0, and (3) Child Primary Care 1.0, which has a beta adaptation (Child Primary Care 2.0). Core question items are the same across the non-beta versions, but wording (patient vs. child; primary care physician vs. specialist) changes according to the instrument. All questions are answered on a 4-point frequency scale. Supplemental items focus on additional aspects of care (shared decisionmaking, costs, prescription medications, etc.). The survey also includes questions to obtain health status and demographic data.
• All instrument items are available online.¹
• The core instrument contains 31 questions; 9 were mapped.
• The supplement contains 64 items; 35 were mapped.
• Validated versions are available online for adult and child, in both English and Spanish.¹

Sources:

1. CAHPS Surveys and Tools. Agency for Health Research and Quality. Available at: http://www.ahrq.gov/cahps/. Accessed: 2 May 2016.
2. Agency for Health Research and Quality CAHPS Web site, CAHPS Bibliography. Available at: http://www.ahrq.gov/cahps/. Accessed: 2 May 2016.
3. Rodriguez HP, von Glanh T, Rogers WH, et al. Organizational and market influences on physician performance and patient experience measures. Health Serv Res 2009;44(3):880-901.
4. Isetts BJ, Schondelmeyer SW, Heaton AH, et al. Effects of collaborative drug therapy management on patients' perceptions of care and health related quality of life. Res Soc Adm Pharm 2006;2:129-42.

Measure #4b. Consumer Assessment of Healthcare Providers and Systems (CAHPS) — Adult Specialty Care 1.0

Care Coordination Measure Mapping Table

	Measurement Perspective:
	Patient/Family	Health Care Professional(s)	System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility	□
Communicate	■
Interpersonal communication	■
Information transfer	■
Facilitate transitions
Across settings
As coordination needs change
Assess needs and goals	□
Create a proactive plan of care
Monitor, follow up, and respond to change	□
Support self-management goals	■
Link to community resources
Align resources with patient and population needs
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination
Health care home	□
Care management
Medication management	□
Health IT-enabled coordination

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

Consumer Assessment of Healthcare Providers and Systems (CAHPS) — Adult Specialty Care 1.0

Purpose: To measure adult consumers' experiences with a specific specialty care physician and practice.

Format/Data Source: Survey comprised of 31 core items with an additional 64 supplemental items specific to adult specialty care. Supplemental items focus on additional aspects of care, including: (1) after hours care, (2) costs of care, (3) doctor role, (4) doctor thoroughness, (5) health improvement, (6) health promotion and education, (7) help with problems or concerns, (8) other doctors, (9) provider communication, (10) provider knowledge of specialist care, (11) doctor recommendation, (12) shared decisionmaking, (13) wait time, (14) care received from specialists, and (15) most recent visit. All questions were answered on a 4-point frequency scale. Responses covered experiences in the last 12 months and were compiled into a nationally available database.¹

Date: Measure released in 2008.¹

Perspective: Patient/Family

Measure Item Mapping:

• Establish accountability or negotiate responsibility: 2, DR1
• Communicate:
  • Between health care professional(s) and patient/family: 14, 15, CC1, SD1, SD2
• Interpersonal communication:
  • Between health care professional(s) and patient/family: DC1-3, SD3
• Information transfer:
  • Between health care professional(s) and patient/family: 10, 12, 22, SP2
  • Participants not specified: 18
• Assess needs and goals: SD1, SD2
• Monitor, follow up, and respond to change: 22
• Support self-management goals: 17, DC4, SP5, SP6
• Health care home: 1, 2
• Medication management: COC1, COC3

Development and Testing: The draft instrument was revised based on a literature review and feedback that was provided from extensive field tests with various health care organizations, cognitive interviews, and stakeholders.¹ The final instrument is endorsed by the National Quality Forum as well as the Ambulatory Care Quality Alliance (AQA).

Link to Outcomes or Health System Characteristics: The CAHPS survey questions and data have been used for evaluating patient experiences with care delivery.² Measure scores related to communication and care coordination were shown to be higher (more favorable) for patients seen by physicians in large, integrated medical groups compared with other practice settings.³ Study populations enrolled in care management programs also showed trends toward higher ratings of patient experience with provider communication via the CAHPS.⁴

Logic Model/Conceptual Framework: None described in the sources identified.

Country: United States

Past or Validated Applications*:

• Patient Age: Adults
• Patient Condition: General Population/Not Condition Specific
• Setting: Primary Care Facility

*Based on the sources listed below.

Notes:

• The final survey includes 3 variations of a multi-item instrument: (1) Adult Primary Care 1.0, (2) Adult Specialty Care 1.0, and (3) Child Primary Care 1.0, which has a beta adaptation (Child Primary Care 2.0). Core question items are the same across the non-beta versions, but wording (patient vs. child; primary care physician vs. specialist) changes according to the instrument. All questions are answered on a 4-point frequency scale. Supplemental items focus on additional aspects of care (shared decisionmaking, costs, prescription medications, etc.). The survey also includes questions to obtain health status and demographic data.
• All instrument items are available online.¹
• The core instrument contains 31 questions; 9 were mapped.
• The supplement contains 51 items; 21 were mapped.
• Validated versions are available online for adult and child, in both English and Spanish.¹

Sources:

1. CAHPS Surveys and Tools. Agency for Health Research and Quality. Available at: http://www.ahrq.gov/cahps/. Accessed: 2 May 2016.
2. Agency for Health Research and Quality CAHPS Web site, CAHPS Bibliography. Available at: http://www.ahrq.gov/cahps/. Accessed: 2 May 2016.
3. Rodriguez HP, von Glanh T, Rogers WH, et al. Organizational and market influences on physician performance and patient experience measures. Health Serv Res 2009;44(3):880-901.
4. Isetts BJ, Schondelmeyer SW, Heaton AH, et al. Effects of collaborative drug therapy management on patients' perceptions of care and health related quality of life. Res Soc Adm Pharm 2006;2:129-42.

Measure #4c. Consumer Assessment of Healthcare Providers and Systems (CAHPS) — Child Primary Care 1.0

Care Coordination Measure Mapping Table

	Measurement Perspective:
	Patient/Family	Health Care Professional(s)	System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility	□
Communicate	□
Interpersonal communication	■
Information transfer	■
Facilitate transitions
Across settings
As coordination needs change
Assess needs and goals	■
Create a proactive plan of care
Monitor, follow up, and respond to change	□
Support self-management goals	■
Link to community resources
Align resources with patient and population needs
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination
Health care home	□
Care management
Medication management	□
Health IT-enabled coordination

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

Consumer Assessment of Healthcare Providers and Systems (CAHPS) — Child Primary Care 1.0

Purpose: To measure consumers' experiences with a specific primary care physician and practice.

Format/Data Source: Survey comprised of 30 core items with an additional 17 supplemental items specific to child primary care. Supplemental items focus on additional aspects of care, including: (1) after-hours care, (2) behavioral health, (3) screening items for children with chronic conditions, (4) doctor communication with child, (5) doctor communication, (6) doctor thoroughness, (7) health improvement, (8) Identification of site of visit, (9) prescription medications, (10) provider knowledge of specialist care, and (11) shared decisionmaking. All questions were answered on a 4-point frequency scale. Responses covered experiences in the last 12 months and were compiled into a nationally available database.¹

Date: Measure released in 2008.¹

Perspective: Patient/Family

Measure Item Mapping:

• Establish accountability or negotiate responsibility: 2
• Communicate:
  • Between health care professional(s) and patient/family: 14, 15
• Interpersonal communication:
  • Between health care professional(s) and patient/family: DC1-DC4, SD2, SD4
  • Participants not specified: 18
• Information transfer:
  • Between health care professional(s) and patient/family: 10, 12, 22, SD3
  • Across health care teams or settings: PK2
• Assess needs and goals: DT2, SD1, SD2
• Monitor, follow up, and respond to change: 22
• Support self-management goals: 17, DC3, HI1
• Health care home: 1, 2
• Medication management: PM1

Development and Testing: Several rounds of revision of the draft instrument (all versions) were based on literature review and feedback from extensive field tests with various health care organizations, cognitive interviews, and stakeholders.¹ The final instrument is endorsed by the National Quality Forum as well as the Ambulatory Care Quality Alliance (AQA).

Link to Outcomes or Health System Characteristics: The CAHPS survey questions and data have been used for evaluating patient experiences with care delivery.²  Measure scores related to communication and care coordination were shown to be higher (more favorable) for patients seen by physicians in large, integrated medical groups compared with other practice settings.³ Study populations enrolled in care management programs also showed trends toward higher ratings of patient experience with provider communication via the CAHPS.⁴

Logic Model/Conceptual Framework: None described in the sources identified.

Country: United States

Past or Validated Applications*:

• Patient Age: Children
• Patient Condition: General Population/Not Condition Specific
• Setting: Primary Care Facility

*Based on the sources listed below.

Notes:

• The final survey includes 3 variations of a multi-item instrument: (1) Adult Primary Care 1.0, (2) Adult Specialty Care 1.0, and (3) Child Primary Care 1.0, which has a beta adaptation (Child Primary Care 2.0). Core question items are the same across the non-beta versions, but wording (patient vs. child; primary care physician vs. specialist) changes according to the instrument. All questions are answered on a 4-point frequency scale. Supplemental items focus on additional aspects of care (shared decisionmaking, costs, prescription medications, etc.). The survey also includes questions to obtain health status and demographic data.
• All instrument items are available online.¹
• The core instrument contains 31 items; 9 were mapped.
• The supplement contains 17 items; 12 were mapped.
• Validated versions are available online for adult and child, in both English and Spanish.¹

Sources:

1. CAHPS Surveys and Tools. Agency for Health Research and Quality. Available at: http://www.ahrq.gov/cahps/ Accessed: 2 May 2016..
2. Agency for Health Research and Quality CAHPS Web site, CAHPS Bibliography. Available at: http://www.ahrq.gov/cahps/. Accessed: Accessed: 2 May 2016
3. Rodriguez HP, von Glanh T, Rogers WH, et al. Organizational and market influences on physician performance and patient experience measures. Health Serv Res 2009;44(3):880-901.
4. Isetts BJ, Schondelmeyer SW, Heaton AH, et al. Effects of collaborative drug therapy management on patients' perceptions of care and health related quality of life. Res Soc Adm Pharm 2006;2:129-42.

Measure #4d. CAHPS Patient-Centered Medical Home Supplementary Survey Adult Version 2.0

Care Coordination Measure Mapping Table

	Measurement Perspective:
	Patient/Family	Health Care Professional(s)	System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility
Communicate	■
Interpersonal communication
Information transfer
Facilitate transitions
Across settings	□
As coordination needs change
Assess needs and goals	□
Create a proactive plan of care
Monitor, follow up, and respond to change	□
Support self-management goals
Link to community resources
Align resources with patient and population needs
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination
Health care home	■*
Care management
Medication management	■
Health IT-enabled coordination

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

*Indicates that the measure as a whole focuses on the health care home model.

CAHPS Patient-Centered Medical Home Supplementary Survey Adult Version 2.0

Purpose: To assess processes of care and patients’ experiences with care provided by patient-centered medical homes (PCMH). The PCMH supplementary survey consists of supplementary items designed for use with the CAHPS Clinician & Group survey adult version 2.0.

Format/Data Source: An 18-item supplemental survey that can be added to the CAHPS Clinician & Group (CG-CAHPS) Version 2.0 survey. Patients complete the survey, which addresses six domains: (1) access to care, (2) comprehensiveness, (3) self-management support, (4) shared decisionmaking, (5) coordination of care, and (6) information about care and appointments.¹ Six composites may be calculated using data from the combined CG-CAHPS with PCMH supplement.²

Date: Measure released in 2011.¹

Perspective: Patient/Family

Measure Item Mapping:

• Communicate: PCMH2, PCMH5, PCMH11
  • Between health care professional(s) and patient/family: PCMH2, PCMH5
  • Across health care teams or settings: PCMH11
• Facilitate transitions:
  • Across settings: PCMH11
• Assess needs and goals: PCMH12, PCMH13
• Monitor, follow up, and respond to change: PCMH5
• Health care home: PCMH2, PCMH5, PCMH6, PCMH7, PCMH8, PCMH9, PCMH11, PCMH12, PCMH13, PCMH15*
• Medication management: PCMH6, PCMH7, PCMH8, PCMH9, PCMH15

*The instrument as a whole focuses on the Health care home model. Only those items that map to at least one other care coordination domain are listed here.

Development and Testing: The CAHPS PCMH supplement was tested in 1,790 patients from 10 adult practices in the Boston area. The Cronbach’s alpha for composite scores ranged between 0.61 and 0.91 for the combined adult survey (core CG-CAHPS plus PCMH supplement). Practice-level reliability of individual PCMH supplement items ranged from 0.09 to 0.92. Some individual items were retained despite low practice-level reliability due to high salience to the principles of the PCMH model and evidence that they performed well in other CAHPS surveys. Items with low reliability were modified after the field test in response to qualitative feedback.²

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: The CAHPS PCMH supplementary survey is based on the principles of the patient-centered medical home.³

Country: United States

Past or Validated Applications*:

• Patient Age: Adults
• Patient Condition: General Population or Not Condition Specific
• Setting: Primary Care Facility, Other Outpatient Specialty Care Facility

* Based on the sources listed below.

Notes:

• All instrument items are located online.⁴
• Additional information about the survey is available online.¹
• This instrument consists of 18 items, of which 10 were mapped.
• A version of the PCMH Supplement Survey is also available for children. It contains 11 of the 18 items included in the adult version and is intended for inclusion in the CAHPS Clinician and Group Child Version 1.1 Survey.⁵ See measure 4e for more information.
• A Spanish language version is available online.⁶
• In addition to the CAHPS Clinical and Group Survey, ambulatory care surveys include: (1) CAHPS Health Plan Survey, (2) CAHPS Surgical Care Survey, (3) ECHO Survey, (4) CAHPS Dental Plan Survey, (5) CAHPS American Indian Survey, and (6) CAHPS Home Health Care Survey.¹
• Facility Surveys are also available, including: (1) CAHPS Hospital Survey, (2) CAHPS In-Center Hemodialysis Survey, and (3) CAHPS Nursing Home Surveys.¹

Sources:

1. Agency for Healthcare Research and Quality. About the CAHPS Patient-Centered Medical Home (PCMH) Item Set. Washington, DC: 2011. Document No. 1314.
2. Scholle SH, Vuong O, Ding L, et al. Development of and field test results for the CAHPS PCMH Survey. Med Care 2012;50 Suppl:S2-10.
3. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, et al. Joint Principles of the Patient-Centered Medical Home. Washington, DC: Patient-Centered Primary Care Collaborative; 2007.
4. Supplemental Items for the Adult Surveys 2.0. Agency for Healthcare Research and Quality.
5. Supplemental Items for the Child Surveys 1.1. Agency for Healthcare Research and Quality. 
6. CAHPS Clinician and Group Surveys. Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/index.html.

Measure #4e. CAHPS Patient-Centered Medical Home Supplementary Survey Child Version 1.1

Care Coordination Measure Mapping Table

	Measurement Perspective:
	Patient/Family	Health Care Professional(s)	System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility
Communicate	■
Interpersonal communication
Information transfer
Facilitate transitions
Across settings	□
As coordination needs change
Assess needs and goals	□
Create a proactive plan of care
Monitor, follow up, and respond to change	□
Support self-management goals
Link to community resources
Align resources with patient and population needs
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination
Health care home	■*
Care management
Medication management	□
Health IT-enabled coordination

Legend:
■ = ≥ 3 corresponding measure items
□ = 1-2 corresponding measure items

*Indicates that the measure as a whole focuses on the health care home model.

CAHPS Patient-Centered Medical Home Supplementary Survey Child Version 1.1

Purpose: To assess processes of care and patients’ experiences with care provided by patient-centered medical homes (PCMH). The PCMH supplementary survey consists of supplementary items designed for use with the CAHPS Clinician & Group survey child version 1.1.

Format/Data Source: An 11-item supplemental survey that can be added to the CAHPS Clinician & Group (CG-CAHPS) survey child version 1.1. Patients complete the survey, which addresses six domains: (1) access to care, (2) comprehensiveness, (3) self-management support, (4) shared decisionmaking, (5) coordination of care and (6) information about care and appointments.¹ Six composites may be calculated using data from the combined CG-CAHPS with PCMH supplement.²

Date: Measure released in 2011.¹

Perspective: Patient/Family

Measure Item Mapping:

• Communicate: PCMH2, PCMH5, PCMH7
  • Between health care professional(s) and patient/family: PCMH2, PCMH5
  • Across health care teams or settings: PCMH7
• Facilitate transitions:
  • Across settings: PCMH7
• Assess needs and goals: PCMH8, PCMH9
• Monitor, follow up, and respond to change: PCMH5
• Health care home: PCMH2, PCMH5, PCMH7, PCMH8, PCMH9, PCMH11*
• Medication management: PCMH11

*The instrument as a whole focuses on the Health care home model. Only those items that map to at least one other care coordination domain are listed here.

Development and Testing: The CAHPS PCMH supplement was tested in 3,129 parents of pediatric patients from 33 child practices in the Boston area. The Cronbach’s alpha for composite scores ranged between 0.57 and 0.88 for the combined child survey (core CG-CAHPS plus PCMH supplement). Practice-level reliability of individual PCMH supplement items ranged from 0.11 to 0.95. Some individual items were retained despite low practice-level reliability due to high salience to the principles of the PCMH model and evidence that they performed well in other CAHPS surveys. Items with low reliability were modified after the field test in response to qualitative feedback.²

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: The CAHPS PCMH supplementary survey is based on the principles of the patient-centered medical home.³

Country: United States

Past or Validated Applications*:

• Patient Age: Children
• Patient Condition: General Population or Not Condition Specific
• Setting: Primary Care Facility, Other Outpatient Specialty Care Facility

* Based on the sources listed below.

Notes:

• All instrument items are located online.⁴
• Additional information about the survey is available online.¹
• This instrument consists of 11 items, of which 6 were mapped.
• A version of the PCMH Supplement Survey is also available for adults. It contains the 11 items included in the child survey, plus several additional items. The adult version is intended for inclusion in the CAHPS Clinician and Group Adult Version 2.0 Survey.⁴ See measure 4d for more information.
• A Spanish language version is available online.⁵
• In addition to the CAHPS Clinical and Group Survey, ambulatory care surveys include: (1) CAHPS Health Plan Survey, (2) CAHPS Surgical Care Survey, (3) ECHO Survey, (4) CAHPS Dental Plan Survey, (5) CAHPS American Indian Survey, and (6) CAHPS Home Health Care Survey.¹
• Facility Surveys are also available, including: (1) CAHPS Hospital Survey, (2) CAHPS In-Center Hemodialysis Survey, and (3) CAHPS Nursing Home Surveys.¹

Sources:

1. Agency for Healthcare Research and Quality. About the CAHPS Patient-Centered Medical Home (PCMH) Item Set. Washington, DC: 2011. Document No. 1314.
2. Scholle SH, Vuong O, Ding L, et al. Development of and field test results for the CAHPS PCMH Survey. Med Care 2012;50 Suppl:S2-10.
3. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, et al. Joint Principles of the Patient-Centered Medical Home. Washington, DC: Patient-Centered Primary Care Collaborative; 2007.
4. Supplemental Items for the Child Surveys 1.1. Agency for Healthcare Research and Quality.
5. CAHPS Clinician and Group Surveys. Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/cahps/surveys-guidance/cg/index.html. Accessed: 2 May 2016.

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