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Care Coordination Measures Atlas Update

Chapter 6. Measure Maps and Profiles (continued, 5)

Measures 8-10

Measure #8. Breast Cancer Patient and Practice Management Process Measures Surgeon Survey

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

Breast Cancer Patient and Practice Management Process Measures Surgeon Survey

Purpose: To evaluate quality of treatment during the initial course of therapy for breast cancer patients and address variation in patient and practice management processes that may be associated with better outcomes.

Format/Data Source: Mailed, self-administered, 17-item survey addressing 5 measures: (1) multidisciplinary clinician communication, (2) availability of clinical information, (3) patient decision support, (4) access to information technology, and (5) practice feedback initiatives.

Date: Measure released in 2010.1

Perspective: Health Care Professional(s)

Measure Item Mapping:

  • Communicate:
    • Interpersonal communication:
      • Across health care teams or settings: 1-3
    • Information transfer:
      • Across health care teams or settings: 4-6
  • Create a proactive plan of care: 1-3
  • Support self-management goals: 7, 8, 10-11
  • Align resources with patient and population needs: 7, 8, 10-11

Development and Testing: The development of the measures was based on a literature review and prior research conducted by the authors. The items were all pretested on a convenience sample of 10 surgeons, and the scales were piloted on a convenience sample of 34 surgeons. Scale reliability testing was conducted, and each of the scales had a Cronbach's alpha of above 9. Confirmatory factor analysis was also conducted for all of the patient management domain items and confirmed the predominant loading of the items on their hypothesized subdomains.1

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

Logic Model/Conceptual Framework: The measures were based on the Chronic Care Model and a previously developed framework for cancer care quality measures.2

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Age Specific
  • Patient Condition: Combined Chronic Conditions, Cancer/Oncology
  • Setting: Not Setting Specific

*Based on the sources listed below and input from the measure developer.

Notes:

  • The original measure did not have individual items numbered. In order to properly reference specific items within this profile, All instrument items are found in Table 1 and 2 of the source article were consecutively numbered.1
  • This instrument contains 17 items; 10 were mapped.

Sources:

1. Katz SJ, Hawley ST, Morrow M, et al. Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer. Med Care 2010;48(1):45-51.
2. Kahn KL, Malin JL, Adams J, et al. Developing a reliable, valid, and feasible plan for quality of care measurement for cancer. How should we measure? Med Care. 2002;40(Suppl):III73-III85.

Measure #9a. Care Transitions Measure (CTM-3)

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

Care Transitions Measure (CTM-3)

Purpose: To evaluate the essential processes of care involved in successful care transitions, including information transfer, patient and caregiver preparation, self-management support, empowerment to assert preferences, from a patient-centered perspective.

Format/Data Source: 3-item written survey administered at time of discharge. All questions are answered on a 5-point Likert scale.

Date: Measure released in 2002.1

Perspective: Patient/Family

Measure Item Mapping:

  • Facilitate transitions:
    • Across settings: 1-3
  • Assess needs and goals: 16
  • Create a proactive plan of care: 1
  • Support self-management goals: 2, 3
  • Medication management: 3

Development and Testing: Key domains and measure items were developed using input from patient focus groups. Psychometric evaluation established content validity, construct validity, absence of floor and ceiling effects, and intra-item variation.1 The 3-item CTM explained 88 percent of the variance in the 15-item CTM score. No differential item difficulty by age, gender, education, self-rated health, or ethnic group was identified after differential item function analysis.2 The CTM is an NQF-endorsed measure and has been applied to a range of high-risk patient populations, including frail older adults, adults with chronic health conditions, cancer patients, and children with special health care needs. Translated Hebrew and Arabic versions of the questionnaire have also been found to be reliable and valid.3

Link to Outcomes or Health System Characteristics: Patients with lower self-rated health status had significantly lower CTM scores, a result that is consistent with previous studies, suggesting that care coordination is especially important for individuals with complex health conditions. The measure also demonstrated the power to discriminate between: (1) patients discharged from the hospital that did/did not experience a subsequent emergency visit or re-hospitalization for their index condition and (2) health care facilities with differing levels of commitment to care coordination.4

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

Country: United States; translations available for use in other countries (see notes below).

Past or Validated Applications*:

  • Patient Age: Children, Adults, Older Adults
  • Patient Condition: General Population/Not Condition Specific
  • Setting: Inpatient Facility, Primary Care Facility

*Based on the sources listed below and input from the measure developer.

Notes:

  • All instrument items are located online.4
  • This instrument contains 3 items; all 3 were mapped.
  • Finnish and French translations of the CTM-3 are available online.4
  • A validated 15-item version (CTM-15) is also available online in English, Spanish, Arabic, Hebrew, and Russian.4

Sources:

1. Coleman EA, Smith JD, Frank JC, et al. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care 2002;2(1):1-9.
2. Parry C, Mahoney E, Chalmers SA, et al. Assessing the quality of transitional care: further applications of the care transitions measure. Medical Care 2008;46(3):317-22.
3. Shadmi E, Zisberg A, Coleman EA. Translation and validation of the Care Transition Measure into Hebrew and Arabic. Int J Quality Health Care 2009;21(2):97-102.
4. The Care Transitions Program: Improving Quality and Safety During Care Hand-Offs Web site. Available at: http://www.caretransitions.org/articles.asp. Accessed: 15 September 2010.
5. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for post-hospital care from the patient's perspective: The Care Transitions Measure. Med Care 2005; 43(3):246-255.
6. Coleman EA, Parry C, Chalmers S, et al. The central role of performance measurement in improving the quality of transitional care. Home Health Care Services Quarterly. 2007; 26(4):93-104.

Measure #9b. Care Transitions Measure (CTM-15)

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

Care Transitions Measure (CTM-15)

Purpose: To evaluate the essential processes of care involved in successful care transitions, including information transfer, patient and caregiver preparation, self-management support, empowerment to assert preferences, from a patient-centered perspective.

Format/Data Source: 15-item survey administered at the time of, or immediately following, hospital discharge. The items span 4 domains: (1) information transfer, (2) patient and caregiver preparation, (3) self-management support, and (4) empowerment to assert preferences. All questions are answered on a 5-point Likert scale.

Date: Measure released in 2002.1

Perspective: Patient/Family

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 9
  • Communicate:
    • Between health care professional(s) and patient/family: 1
  • Information transfer:
    • Between health care professional(s) and patient/family: 4
  • Facilitate transitions:
    • Across settings: 1-15
  • Assess needs and goals: 1-3, 7
  • Create a proactive plan of care: 7, 12
  • Monitor, follow up, and respond to change: 12
  • Support self-management goals: 1, 4-6, 8-11
  • Medication management: 13-15

Development and Testing: Key domains and measure items were developed using input from patient focus groups. Psychometric evaluation established content validity, construct validity, absence of floor and ceiling effects, and intra-item variation..1 M plus confirmatory factor analysis supported the CTM-15 factor structure in a more diverse study population (225 patients of varying racial/ethnic background, aged 18-90, in rural settings). No differential item difficulty by age, gender, education, self-rated health, or ethnic group was identified after differential item function analysis.2 The CTM is an NQF-endorsed measure and has been applied to a range of high-risk patient populations, including frail older adults, adults with chronic health conditions, cancer patients, and children with special health care needs. Translated Hebrew and Arabic versions of the questionnaire have also been found to be reliable and valid.3

Link to Outcomes or Health System Characteristics: Patients with lower self-rated health status had significantly lower CTM scores, a result that is consistent with previous studies, suggesting that care coordination is especially important for individuals with complex health conditions. The measure also demonstrated the power to discriminate between: (1) patients discharged from the hospital that did/did not experience a subsequent emergency visit or re-hospitalization for their index condition and (2) health care facilities with differing levels of commitment to care coordination.4

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

Country: United States

Past or Validated Applications*:

  • Patient Age: Adults, Older Adults
  • Patient Condition: General Population/Not Condition Specific
  • Setting: Inpatient Facility, Primary Care Facility, Home Health Care

*Based on the sources listed below and input from the measure developer.

Notes:

  • All instrument items are located online.4
  • This instrument contains 15 items; all 15 were mapped.
  • For those interested, Spanish, Arabic, Hebrew, and Russian translations of the CTM-15 are available online.4
  • A validated 3-item version (CTM-3) is also available online in English, Finnish, and French.4

Sources:

1. Coleman EA, Smith JD, Frank JC, et al. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care 2002;2(1):1-9.
2. Parry C, Mahoney E, Chalmers SA, et al. Assessing the quality of transitional care: further applications of the care transitions measure. Medical Care 2008;46(3):317-22.
3. Shadmi E, Zisberg A, Coleman EA. Translation and validation of the Care Transition Measure into Hebrew and Arabic. Int J Quality Health Care 2009;21(2):97-102.
4. The Care Transitions Program: Improving Quality and Safety During Care Hand-Offs Web site. Available at: http://www.caretransitions.org/articles.asp. Accessed: 15 September 2010.
5. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for post-hospital care from the patient's perspective: The Care Transitions Measure. Med Care 2005; 43(3):246-255.
6. Coleman EA, Parry C, Chalmers S, et al. The central role of performance measurement in improving the quality of transitional care. Home Health Care Services Quarterly. 2007; 26(4):93-104.

Measure #10. Patient Assessment of Chronic Illness Care (PACIC)

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

Patient Assessment of  Chronic Illness Care (PACIC)

Purpose: To develop a patient self-report instrument that measures the extent to which patients receive clinical services and actions consistent with the Chronic Care Model.

Format/Data Source: A 20-item survey administered to patients with chronic conditions for evaluation of their care within the past 6 months. Scales address 5 topics: (1) Patient Activation; (2) Delivery System Design/Decision Support; (3) Goal Setting; (4) Problem-Solving/Contextual Counseling, and (5) Follow-up/Coordination.

Date: Measure released in 2005.1

Perspective: Patient/Family

Measure Item Mapping:

  • Communicate:
    • Between health care professional(s) and patient/family: B11, B15, B19, B20
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: B1
  • Information transfer:
    • Between health care professional(s) and patient/family: B3
    • Participants not specified: B9
  • Assess needs and goals: B1, B2, B7-9, B12, B13
  • Create a proactive plan of care: B1, B4, B13, B14
  • Monitor, follow up, and respond to change: B16
  • Support self-management goals: B4, B6, B7, B8, B10, B13, B14, B17
  • Link to community resources: B10, B17, B18
  • Medication management: B3

Development and Testing: Face, construct, and concurrent validity, as well as measurement performance were demonstrated, characterizing the PACIC as a reliable instrument. Test-retest reliability was moderately stable over a three-month interval. Most items strongly related to their respective subscale(s), and the overall model had moderate goodness of fit. The instrument is appropriate across a variety of chronic conditions.1

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

Logic Model/Conceptual Framework: The Chronic Care Model establishes a framework from which the Patient Assessment of Chronic Illness Care (PACIC) arises.1

Country: United States

Past or Validated Applications*:

  • Patient Age: Adults
  • Patient Condition: Combined Chronic Conditions, General Chronic Conditions, Multiple Chronic Conditions
  • Setting: Primary Care Facility

*Based on the sources listed below and input from the measure developers.

Notes:

  • Instrument items located in the Appendix of the source article.1
  • Instrument items are also located online.3
  • This instrument contains 20 items; 19 were mapped.
  • A 25-item version is also available, which can be scored according to the “5 As” model of health behavior change.3
  • Additional information regarding the measure and how to contact its developers is available online.5
  • An adapted two-factor structure version of the five-factor structure PACIC (tested in the United States and Europe) was developed and tested in Australia.6
  • Studies using the PACIC have also been applied to diabetic patient populations, assessing the level of literacy in relation to self-management support.7

Sources:

1. Glasgow RE, Wagner EH, Schaefer J, et al. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care 2005;43(5):436-44.
2. Gensichen J, Serras A, Paulitsch MA, et al. The Patient Assessment of Chronic Illness Care questionnaire: Evaluation in patients with mental disorders in primary care. Community Ment Health J 2010 Aug 24. [ePub ahead of print]. No doi number listed.
3. Robert Wood Johnson Foundation Improving Chronic Illness Care Web site. Available at: http://improvingchroniccare.org/tools/pacic.htm. Accessed: 17 September 2010.
4. Glasgow RE, Nelson CC, Whitesides H, et al. Use of the Patient Assessment of Chronic Illness Care (PACIC) with diabetic patients: Relationship to patient characteristics, receipt of care, and self-management. Diabetes Care 2005;28:2655-61.
5. National Cancer Institute Grid-Enabled Measures Database (GEM), beta. Available at: https://www.gem-beta.org/public/MeasureDetail.aspx?mid=100&cat=2&mode=m. Accessed: 24 September 2010. 6. Taggart J, Chan B, Jayasinghe UW, et al. Patients Assessment of Chronic Illness Care (PACIC) in two Australian studies: Structure and utility. J Eval Clin Pract 2010 Sep 16 [ePub ahead of print] doi:10.1111/j 1365-2753.2010.01423.x.
7. Wallace AS, Carlson JR, Malone RM, et al. The influence of literacy on patient-reported experiences of diabetes self-management support. Nurs Res 2010;59(5):356-63.
8. Schmittdiel J, Mosen DM, Glasgow RE, et al. Patient Assessment of Chronic Illness Care (PACIC) and improved patient-centered outcomes for chronic conditions. J Gen Int Med 2008;23(1):77-80.

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Publication:
14-0037-EF

Previous Publication: 11-0023-EF

Page last reviewed June 2014
Page originally created June 2014

Internet Citation: Chapter 6. Measure Maps and Profiles (continued, 5). Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6d.html

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