U.S. flag

An official website of the Department of Health and Human Services

SHARE:

FacebookXEmail AHRQPrintShare

Care Coordination Measures Atlas Update

Chapter 6. Measure Maps and Profiles (continued, 10)

Measures 20-22b

Measure #20. Family Medicine Medication Use Processes Matrix (MUPM)

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

Family Medicine Medication Use Processes Matrix (MUPM)

Purpose: To measure the perceptions of primary care' physicians (family practice) in regard to pharmacists' contributions within the practices.

Format/Data Source: 22-item Family Medicine Medication Use Processes Matrix instrument mailed to family practice physicians at 3 times: (1) 3 months, (2) 1 year, and (3) 19 months after pharmacist integration. There are response sections for 5 different health care professionals: (1) family physician, (2) family practice pharmacist, (3) nurse, (4) receptionist, and (5) community pharmacist.

Date: Measure published in 2008.1

Perspective: Health Care Professional(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 13
  • Communicate:
    • Information transfer:
      • Within teams of health care professionals: 20
      • Participants not specified: 17
  • Facilitate transitions:
    • Across settings: E9
  • Assess needs and goals: 4, 9
  • Monitor, follow up, and respond to change: 9, 11, 12
  • Support self-management goals: 9, 19
  • Align resources with patient and population needs: 19
  • Medication management: 3, 5, 7, 10, 15-18, 20

Development and Testing: The IMPACT Program was used in large scale to develop this 22-item Family Medicine Medication Use Processes Matrix (MUPM). The self-completed questionnaire was pilot tested by 11 pharmacists, nurses, and physicians. Five theoretical groupings were identified: (1) Diagnosis & Prescribing, (2) Monitoring, (3) Administrative/ Documentation, (4) Education, and (5) Medication Review. Good internal consistency and test-retest reliability were demonstrated. Preliminary validation suggested the tool can identify differences in how health professionals view their and others' roles in primary care. Cronbach's alpha coefficient was used to determine internal consistency, test-retest reliability scores were calculated using intra-class coefficients, and all were deemed sufficiently valid.1

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

Logic Model/Conceptual Framework: Development of the MUPM instrument was informed by several frameworks of medication-use processes. The MUPM was developed as part of the Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics (IMPACT) project.1

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Applicable
  • Patient Condition: Not Applicable
  • Setting: Primary Care Facility

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

Notes:

  • This instrument was provided by the corresponding author upon request (B. Farrell, personal communication, September 13, 2010).
  • This instrument contains 23 items; 15 were mapped.

Sources:

1. Farrell B, Pottie K, Woodend K, et al. Developing a tool to measure contributions to medication-related processes in family practice. J Interprof Care 2008;22(1):17-29.
2. Farrell B, Pottie K, Woodend K, et al. Shifts in expectations: Evaluating physicians' perceptions as pharmacists become integrated into family practice. J Interprof Care 2010;24(1):80-9.

Measure #21. Resources and Support for Self-Management (RSSM)

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

Resources and Support for Self-Management (RSSM)

Purpose: To measure the receipt of self-management support for chronically ill patients.

Format/Data Source: Adapted the 20-item Patient Assessment of Chronic Illness Care (PACIC) survey, adding new items that addressed domains (including followup and support for community resources) and removing others, for a finalized 17-item instrument. The RSSM portion of the survey contains 17 items spanning 5 areas: (1) individualized assessment, (2) collaborative goal setting, (3) enhancing skills, (4) ongoing followup and support, and (5) community resources.

Date: Measure published in 2008.1

Perspective: Patient/Family

Measure Item Mapping:

  • Communicate:
    • Interpersonal communication:
      • Between health care professional(s) and patient/family: 10, 15
    • Information transfer:
      • Between health care professional(s) and patient/family: 14
  • Facilitate transitions:
    • Across settings: 9
  • Assess needs and goals: 1, 2, 4, 5
  • Create a proactive plan of care: 3, 4
  • Monitor, follow up, and respond to change: 1, 2, 5, 9-15
  • Support self-management goals: 1, 6-8, 11
  • Link to community resources: 11, 16, 17
  • Care management: 1-15
  • Medication management: 12, 13

Development and Testing: Two rounds of cognitive testing on 14 participants pilot-tested the RSSM questionnaire. Further testing was performed on a sample of 957 patients with diabetes. Cronbach's alpha coefficients supported construct validity. The RSSM tool exhibited good psychometric properties and was used successfully by respondents of varying education levels.1

Link to Outcomes or Health System Characteristics: Patients with diabetes who reported higher RSSM scores also reported better self-management behaviors (more frequently checking blood sugar and feet, greater program participation, better diet and nutrition behaviors, and greater physical activity).1

Logic Model/Conceptual Framework: The Chronic Care Model provided the framework for construction of the RSSM. The model identifies 6 elements of a delivery system that lead to improved care for the chronically ill, including: (1) organization of care within the health system, (2) clinical information systems, (3) decision support, (4) delivery system design, (5) self-management support, and (6) community resources and policies.1

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Age Specific
  • Patient Condition: Combined Chronic Conditions, General Chronic Conditions
  • Setting: Primary Care Facility

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

Notes:

  • All instrument items are located in Table 2 of the source article.1
  • This instrument contains 17 items; all 17 were mapped.

Sources:

1. McCormack LA, Williams-Piehota PA, Bann CM, et al. Development and validation of an instrument to measure resources for chronic illness self-management: a model using diabetes. Diabetes Educator 2008;34(4):707-18.

Measure #22a. Continuity of Care Practices Survey — Program Level (CCPS-P)

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

Continuity of Care Practices Survey — Program Level (CCPS-P)

Purpose: To evaluate the program-level version of the Continuity of Care Practices Survey (CCPS-P) addressing continuity of care in substance use disorder (SUD) treatment programs.

Format/Data Source: The CCPS-P is a 23-item instrument that addresses 4 continuity of care practice subscales from a program-level perspective. These subscales include: (1) provider continuity, (2) maintain contact, (3) connect to resources, and (4) coordinate care. Responses provided on a Likert scale.

Date: Measure published in 2004.1

Perspective: System Representative(s)

Measure Item Mapping:

  • Communicate:
    • Within teams of health care professionals: 8D, 8E
  • Interpersonal communication:
    • Within teams of health care professionals: 8A
  • Information transfer:
    • Between health care professional(s) and patient/family: 9.2, 9.3
    • Within teams of health care professionals: 8C
  • Facilitate transitions:
    • Across settings: 4, 5A-6A, 7A-F, 8B, 9.1-9.4
    • As coordination needs change: 6B
  • Create a proactive plan of care: 8B
  • Monitor, follow up, and respond to change: 5A-6B, 8D, 8E
  • Support self-management goals: 9.1
  • Link to community resources: 7B-D
  • Care management: 10A-C, 11

Development and Testing: All Veterans Administration (VA) intensive SUD treatment programs were identified through telephone interviews. Questionnaires were mailed to directors of these programs to obtain data necessary to examine the reliability and discriminant validity of the CCPS-P. Internal consistency reliability was demonstrated via Cronbach's alpha coefficients, which were moderate to high for 117 of the 129 SUD programs on psychometric characteristics. Preliminary evidence of discriminant validity was also demonstrated. Predictive validity was assessed through regression analyses using data from both the program level and the individual level. Internal reliability of the CCPS subscales was supported across inpatient/residential and outpatient SUD programs for both the program and individual levels.1

Link to Outcomes or Health System Characteristics: Patients in outpatient, but not inpatient/residential, programs who received more continuity of care, as measured by the CCPS-P and CCPS-I, remained engaged in continuing care for longer periods of time than patients with weaker continuity of care scores.2 Continuity of care practices have also been shown to influence abstinence from substance abuse when mediated through patients' engagement in continuing care.3

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

Country: United States

Past or Validated Applications*:

  • Patient Age: Adults
  • Patient Condition: Combined Chronic Conditions, Mental Illness & Substance Use Disorders
  • Setting: Behavioral Health Care Facility

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

Notes:

  • Instrument was provided by the corresponding author upon request (J.A. Schaefer, personal communication, September 1, 2010).
  • This instrument contains 23 items; all 23 were mapped.
  • Further application and testing of the CCPS-P is available.2, 3

Sources:

1. Schaefer JA, Cronkite R, Ingudomnukul E. Assessing continuity of care practices in substance use disorder treatment programs. J Stud Alcohol 2004;65:513-20.
2. Schaefer JA, Ingudomnukul BA, Harris AHS, et al. Continuity of Care Practices and Substance Use Disorder Patients' Engagement in Continuing Care. Med Care 2005;43(12):1234-41.
3. Schaefer JA, Harris AHS, Cronkite RC, et al. Treatment staff's continuity of care practices, patients' engagement in continuing care, and abstinence following outpatient substance-use disorder treatment. J Stud Alcohol Drugs 2008;69(5):747-56.

Measure #22b. Continuity of Care Practices Survey — Individual Level (CCPS-I)

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

Continuity of Care Practices Survey — Individual Level (CCPS-I)

Purpose: To evaluate the individual-level version of the Continuity of Care Practices Survey (CCPS-I) addressing continuity of care in substance use disorder (SUD) treatment programs.

Format/Data Source: The CCPS-I was reformatted for individual patients but addresses the same 4 continuity of care practice subscales: (1) provider continuity, (2) maintain contact, (3) connect to resources, and (4) coordinate care. Responses were provided on a Likert scale.

Date: Measure published in 2004.1

Perspective: Health Care Professional(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 5B
  • Communicate:
    • Across health care teams or settings: 9E
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 7A
    • Within teams of health care professionals: 7G
  • Information transfer:
    • Between health care professional(s) and patient/family: 8.2, 8.3
    • Within teams of health care professionals: 7I
  • Facilitate transitions:
    • Across settings: 5A, 7A-I, 8.1-8.4, 9D
    • As coordination needs change: 6
  • Create a proactive plan of care: 7F, 7H
  • Monitor, follow up, and respond to change: 9A-C, 9E, 9F
  • Support self-management goals: 8.1
  • Link to community resources: 7B-E
  • Care management: 5B

Development and Testing: All Veterans Administration (VA) intensive SUD treatment programs were identified through telephone interviews. Questionnaires were mailed to directors of these programs to obtain data necessary to examine the reliability and discriminant validity of the CCPS-P. Internal consistency reliability was demonstrated via Cronbach's alpha coefficients, which were moderate to high for 117 of the 129 SUD programs on psychometric characteristics. Preliminary evidence of discriminant validity was also demonstrated. Predictive validity was assessed through regression analyses using data from both the program level and the individual level. Internal reliability of the CCPS subscales was supported across inpatient/residential and outpatient SUD programs for both the program and individual levels.1

Link to Outcomes or Health System Characteristics: Patients in outpatient, but not inpatient/residential, programs who received more continuity of care, as measured by the CCPS-P and CCPS-I, remained engaged in continuing care for longer periods of time than patients with weaker continuity of care scores.2 Continuity of care practices have also been shown to influence abstinence from substance abuse when mediated through patients' engagement in continuing care.3

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

Country: United States

Past or Validated Applications*:

  • Patient Age: Adults
  • Patient Condition: Combined Chronic Conditions, Mental Illness & Substance Use Disorders
  • Setting: Behavioral Health Care Facility

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

Notes:

  • Instrument was provided by the corresponding author upon request (J.A. Schaefer, personal communication, September 1, 2010).
  • This instrument contains 22 items; all 22 were mapped.
  • Further application and testing of the CCPS-I is available.2, 3

Sources:

1. Schaefer JA, Cronkite R, Ingudomnukul E. Assessing continuity of care practices in substance use disorder treatment programs. J Stud Alcohol 2004;65:513-20.
2. Schaefer JA, Ingudomnukul BA, Harris AHS, et al. Continuity of Care Practices and Substance Use Disorder Patients' Engagement in Continuing Care. Med Care 2005;43(12):1234-41.
3. Schaefer JA, Harris AHS, Cronkite RC, et al. Treatment staff's continuity of care practices, patients' engagement in continuing care, and abstinence following outpatient substance-use disorder treatment. J Stud Alcohol Drugs 2008;69(5):747-56.

Return to Jump Start

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, 10). Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6i.html

Click to copy citation