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Care Coordination Measures Atlas Update

Chapter 6. Measure Maps and Profiles (continued, 13)

Measures 31-34

Measure #31. Korean Primary Care Assessment Tool (KPCAT)

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

Korean Primary Care Assessment Tool (KPCAT)

Purpose: To develop and measure performance in Korean primary care practices.

Format/Data Source: 26-item instrument consisting of 4 multi-item scales and 1 composite scale with 21 items designed to measure performance within Korean primary care practices based upon 4 domains: (1) comprehensiveness, (2) coordination function, (3) personalized care, and (4) family/community orientation. Responses provided on a 5-point Likert scale.

Date: Measure published in 2009.1

Perspective: Patient/Family

Measure Item Mapping:

  • Communicate:
    • Between health care professional(s) and patient/family: 15, 17
  • Information transfer:
    • Between health care professional(s) and patient/family: 18, 21
    • Across health care teams or settings: 16
  • Facilitate transitions:
    • Across settings: 15
  • Assess needs and goals: 6, 21
  • Monitor, follow up, and respond to change: 16
  • Support self-management goals: 7, 9
  • Link to community resources: 25
  • Align resources with patient and population needs: 13

Development and Testing: The Korean Primary Care Assessment Tool (KPCAT) was pilot tested regarding content validity on 3 distinct groups of skilled experts in primary care. Three domains (comprehensiveness excluded) demonstrated sufficiently high reliability alpha coefficients. Each item-scale correlation surpassed required minimum values. Further validation was demonstrated in a recent study of 9 South Korean primary care clinics, forthcoming in the International Journal for Quality in Health Care (J.H. Lee, personal communication, September 12, 2010).

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

Logic Model/Conceptual Framework: This is an adaptation of the original PCAT measures, which were based on a framework described by Starfield, 1992. For further information on the framework and development of the PCAT, please go to Measure #17.

Country: Korea

Past or Validated Applications*:

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

*Based on the source 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 found in Table 2 of the source article were consecutively numbered.1
  • This instrument contains 26 items; 10 were mapped.

Sources:

1. Lee JH, Choi YJ, Sung NJ, et al. Development of the Korean primary care assessment tool: Measuring user experience: Tests of data quality and measurement performance. Int J Quality Health Care 2009;21(2):103-11.

Measure #32. Primary Care Multimorbidity Hassles for Veterans With Chronic Illnesses

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

Primary Care Multimorbidity Hassles for Veterans With Chronic Illnesses

Purpose: To evaluate primary care physicians as well as the health care system for veterans with chronic illnesses.

Format/Data Source: 16-item questionnaire that addresses 4 main attributes of primary care: (1) accumulated knowledge of the patient by the clinician, (2) coordination of care, (3) communication, and (4) preference for first contact with their primary care clinician. Responses were provided on a 4-point Likert scale. The items address health care hassles, defined as, “‘troubles" or "bothers" that patients experience during their encounters with the health care system.”1

Date: Measure published in 2005.1

Perspective: Patient/Family

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 13
  • Communicate:
    • Within teams of health care professionals: 15
    • Across health care teams or settings: 9, 10
  • Information transfer:
    • Between health care professional(s) and patient/family: 1-3, 5, 7, 11, 13
  • Facilitate transitions:
    • Across settings: 7
  • Assess needs and goals: 2, 3
  • Monitor, follow up, and respond to change: 13
  • Support self-management goals: 5, 13
  • Medication management: 3-6

Development and Testing: 16-item survey created through Dillman's Total Design Methodology. Original 26-item survey was pilot tested; items failing to improve item validity were removed. Several questions were added after a focus group session. Good internal consistency demonstrated (Cronbach's alpha coefficient of 0.94), and construct validity was determined with a principal component factor analysis (PCA) with a promax rotation. The previously validated Components of Primary Care Instrument (CPCI) was also included within the survey. Additional information was collected on demographic characteristics.1

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

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

Country: United States

Past or Validated Applications*:

  • Patient Age: Adults
  • Patient Condition: Combined Chronic Conditions, General Chronic Conditions, Multiple Chronic Conditions, Mental Illness & Substance Use Disorders
  • Setting: Primary Care Facility

*Based on the source 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 found in Table 3 of the source article were consecutively numbered.1
  • This instrument contains 16 items; 12 were mapped.
  • Further data analysis on a recent study in over 4,000 Veterans Administration primary care patients is forthcoming (M.L. Parchman, personal communication, September 10, 2010).

Sources:

1. Parchman ML, Hitchcock, Noël P, et al. Primary care attributes, health care system hassles, and chronic illness. Med Care 2005;43(11):1123-29.

Measure #33. Primary Care Satisfaction Survey for Women (PCSSW)

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

Primary Care Satisfaction Survey for Women (PCSSW)

Purpose: To assess patient (female) satisfaction with primary care.

Format/Data Source: 29-item, self-administered or telephone-conducted survey, both before and after a primary care visit. Two categories were established: (1) items pertaining to a specific visit and (2) items pertaining to overall health care at the site during the past 12 months. Responses were based on a 5-point Likert scale (excellent-to-poor range) and summed for a total score.

Date: Measure published in 2004.1

Perspective: Patient/Family

Measure Item Mapping:

  • Communicate:
    • Between health care professional(s) and patient/family: 11i, 11k
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 11h, 11j, 11o
  • Information transfer:
    • Between health care professional(s) and patient/family: 12h, 12i
    • Participants not specified: 11m
  • Assess needs and goals: 11o, 12d
  • Monitor, follow up, and respond to change: 11e
  • Support self-management goals: 12a, 12c
  • Link to community resources: 12e

Development and Testing: A focus group determined women's expectations and preferences in primary care, which assisted in the formation of survey items. Additional cognitive testing led to item revision. Each scale within the PCCSW had high internal consistency reliability with Cronbach's alpha coefficient of 0.96. Convergent validity was supported by correlations with the MOS Visit Satisfaction Scale and CAHPS. Discriminant validity and predictive validity were demonstrated through regression analysis.1

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

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 and input from the measure developer.

Notes:

  • All instrument items are located in Table 2 of the source article.1
  • This instrument contains 29 items; 13 were mapped.

Sources:

1. Scholle SH, Weisman CS, Anderson RT, et al. The development and validation of the Primary Care Satisfaction Survey for Women. Womens Health Issues 2004;14:35-50.
2. Scholle SH, Weisman CS, Anderson R, et al. Women's satisfaction with primary care: A new measurement effort from the PHS National Centers of Excellence in Women's Health. Womens Health Issues 2000;10(1):1-9.
3. Anderson, RT, Weisman CS, Camacho F, et al. Women's satisfaction with their on-going primary health care services: A consideration of visit-specific and period assessments. Health Serv Res 2007;42(2):663-81.

Measure #34. Personal Health Records (PHR)

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

Personal Health Records (PHR)

Purpose:To evaluate and discern areas for improvement in the patient-centeredness of personal health records (PHR).

Format/Data Source: The framework for evaluation (based on patient-centeredness) includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between health care providers; (7) physical comfort; and (8) coordination of care. For the purpose of this measure, personal health records (PHR) are defined as, “software applications that patients can use to communicate with their clinician, to enter their own health data, and to access information from their medical record and other sources.”1

Date: Measure published in 2009.1

Perspective: System Representative(s)

Measure Item Mapping:

  • Communicate:
    • Between health care professional(s) and patient/family: 9, 10
  • Information transfer:
    • Participants not specified: 5
  • Support self-management goals: 1, 5
  • Health IT-enabled coordination: 1-10

Development and Testing: Literature reviews and personal communications initially identified areas to address within PHR. In-depth, semi-structured interviews were conducted in a variety of PHR settings to develop the10-item instrument discussing personal health records. Post-interview respondent validation demonstrated sufficient accuracy. When evidence was available for patient preferences, it was compared to existing PHR policies to propose a best practice model.1

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

Logic Model/Conceptual Framework: Patient-centeredness was assessed against a framework of care defined within Format/Data Source. A patient-centered policy model was developed with the ideas of patient empowerment and full control of the personal health record.1

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Applicable
  • Patient Condition: Not Applicable
  • Setting: Not Setting Specific

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

Notes:

  • All instrument items are located in Table 1 of the source article.1
  • This instrument contains 10 items; all 10 were mapped.

Sources:

1. Reti SR, Feldman HJ, Ross SE, et al. Improving personal health records for patient-centered care. JAMIA 2010;17:192-5.

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, 13). Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6l.html

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