Care Coordination Measures Atlas Update

Measures 38f-41b

Measure #38f. PREPARED Survey — Modified Medical Practitioner Version

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

PREPARED Survey — Modified Medical Practitioner Version

Purpose: To measure qualities of hospital discharge from the outpatient physician perspective.

Format/Data Source: 8-item questionnaire covering 2 key domains: (1) timeliness of communication and (2) adequacy of discharge plan/transmission.

Date: Measure published in 1998.¹

Perspective: Health Care Professional(s)

Measure Item Mapping:

• Communicate:
  • Across health care teams or settings: 7
• Information transfer:
  • Across health care teams or settings: 1-3, 5, 6
• Facilitate transitions:
  • Across settings: 4, 8
• Assess needs and goals: 4
• Create a proactive plan of care: 8
• Support self-management goals: 8
• Medication management: 6, 7

Development and Testing: Items were selected from the PREPARED Medical Practitioner survey. All items with nominal response categories that lacked graded or ordinal characteristics were excluded. Additionally, one item that had proven to have large proportions of missing responses because respondents checked “not applicable” in past studies was also excluded. Scale analysis was conducted on a total of 8 items after item reduction was completed. The 8-item scale proved to be internally consistent with a Cronbach's alpha of 0.86. Principal component analysis identified 2 components (timeliness of communication and adequacy of discharge plan/transmission). Construct validity of the measure was also verified.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: Inpatient Facility, 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
• The PREPARED instrument is available in 6 versions: (1) Australian Patient Version, (2) Australian Carer Version, (3) Australian Residential Care Staff Version, (4) Australian Community Service Provider Version, (5) Australian Medical Practitioner Version, and (6) American Medical Practitioner Version. All of the Australian instruments can be found online.¹
• This instrument contains 8 items; all 8 were mapped.

Sources:

1. Graumlich JF, Grimmer-Somers K, Aldag JC. Discharge planning scale: Community physicians' perspective. J Hosp Med 2008;3(6):455-64.

Measure #39. Health Tracking Household 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

Health Tracking Household Survey

Purpose: To assess whether continuity of care and referral source are associated with better coordination of care from the patient perspective.

Format/Data Source: 3-item telephone survey focusing on 3 major aspects of coordination: (1) whether the primary care physician is informed of care the patient received from an outside specialist, (2) whether the primary care physician discussed with the patient what happened at the most recent visit to the specialist, and (3) whether different doctors caring for a patient's chronic condition work well together to coordinate that care.

Date: Measure administered nationally in 2007.¹

Perspective: Patient/Family

Measure Item Mapping:

• Communicate:
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 2
  • Information transfer:
    • Across health care teams or settings : 1
• Monitor, follow up, and respond to change: 1,2
• Teamwork focused on coordination: 3

Development and Testing: Coordination measures were adapted from validated surveys and underwent cognitive interview testing to ensure that respondents understood and felt capable of answering the items.¹

Link to Outcomes or Health System Characteristics: Higher ratings of care coordination were associated with (1) continuity of visits with the same primary care physician and (2) primary care physician as the referral source.¹

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, General Chronic Conditions, General Population/Not Condition Specific
• Setting: Primary Care Facility, Other Outpatient Specialty Care Facility

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

Notes:

• All instrument items are located in Figure 1 of the source article.¹
• This instrument contains 3 items; all 3 were mapped.
• This instrument was developed by The Center for Studying Health System Change (HSC). Information on the broader 2007 survey can be found online.²

Sources:

1. O'Malley AS, Cunningham PJ. Patient experiences with coordination of care: the benefit of continuity and primary care physician as referral source. J Gen Int Med 2008;24(2):170-77.
2. Health System Change (HSC) Web Site. Available at: http://www.hschange.org/CONTENT/1091/. Accessed: 20 September 2010.

Measure #40. Adapted Picker Institute Cancer 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

Adapted Picker Institute Cancer Survey

Purpose: To assess patients' experiences with cancer care, health-related quality of life, comorbid illnesses, and sociodemographic characteristics.

Format/Data Source: 34-item telephone interview covering 7 different question domains: (1) coordination of care, (2) confidence in providers, (3) treatment information, (4) health information, (5) access to cancer care, (6) psychosocial care, and (7) symptom control.

Date: Measure published in 2005.¹

Perspective: Patient/Family

Measure Item Mapping:

• Establish accountability or negotiate responsibility: 1, 5
• Communicate:
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 9, 13
  • Information transfer:
    • Between health care professional(s) and patient/family: 1, 6, 7, 14-23
    • Across health care teams or settings: 2-4
• Facilitate transitions:
• • Across settings: 16, 24-26
• Assess needs and goals: 13, 15
• Create a proactive plan of care: 7, 28, 29
• Monitor, follow up, and respond to change: 3
• Support self-management goals: 23
• Teamwork focused on coordination: 8

Development and Testing: Questions were obtained from a survey designed by the Picker Institute and were adapted for a telephone interview. The instrument was pilot tested on a sample of 50 patients. Principal factor analysis was conducted to group questions into 6 different domains of care. All domains had moderate to high internal consistency (Cronbach's alpha ranged from 0.55 to 0.82).¹

Link to Outcomes or Health System Characteristics: Worse physical, functional, and disease-specific well-being as measured by the Trials Outcomes Index were found to be associated with higher adjusted problem scores for coordination of care, confidence in providers, and health information.¹

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, Cancer/Oncology
• Setting: Inpatient Facility

*Based on the source listed below.

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 the Appendix of the source article were consecutively numbered.¹
• This instrument contains 34 items; 25 were mapped.

Sources:

1. Ayanian JZ, Zaslavsky AM, Guadagnoli E, et al. Patients' perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol 2005;23(27):6576-86.

Measure #41a. Ambulatory Care Experiences Survey (ACES)

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

Ambulatory Care Experiences Survey (ACES)

Purpose: To measure patient experiences with individual primary care physicians and their practices.

Format/Data Source: 34-item survey that covers two broad domains: (1) quality of physician-patient interactions and (2) organizational features of care.

Date: Measure developed in 2002.¹

Perspective: Patient/Family

Measure Item Mapping:

• Communicate:
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 6, 7, 10, 19
  • Information transfer:
    • Between health care professional(s) and patient/family: 9, 11, 15, 22
    • Across health care teams or settings: 21
    • Participants not specified: 12, 20, 26
• Assess needs and goals: 13, 14, 16
• Monitor, follow up, and respond to change: 22
• Support self-management goals: 11, 17

Development and Testing: ACES demonstrated high internal consistency reliability with a Cronbach's alpha >0.70. Physician-level reliability was also established with a sample size of 45 patients per physician.²

Link to Outcomes or Health System Characteristics: ACES has been used in several published studies that report its associations with important outcomes of care and organizational factors. A list of these publications may be found online.¹

Logic Model/Conceptual Framework: The Institute of Medicine definition of primary care was utilized as the measure's underlying conceptual model for measurement.²

Country: United States

Past or Validated Applications*:

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

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

Notes:

• Instrument was provided by the authors upon request (A. Li, personal communication, September 9, 2010). The 2005 version was mapped for this profile.
• This instrument contains 34 items; 16 were mapped.
• The ACES survey is administered in Massachusetts every two years and annually in California as part of the California Cooperative Healthcare Reporting Initiative.

Sources:

1. Tufts Medical Center: Institute for Clinical Research and Health Policy Studies Web site. Available at: http://160.109.101.132/icrhps/resprog/thi/aces_publist.asp Accessed: 21 September 2010.
2. Safran DG, Karp M, Coltin K, et al. Measuring patients' experiences with individual primary care physicians. J Gen Int Med 2006;21(1):13-21.

Measure #41b. Primary Care Provider Ambulatory Care Experiences Survey (PCP ACES)

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 Provider Ambulatory Care Experiences Survey (PCP ACES)

Purpose: To evaluate patients’ experiences with self-management support for chronic conditions.

Format/Data Source: This 5-item component on self-management support¹ for those patients with chronic conditions is intended for use with the Ambulatory Care Experiences Survey (ACES, measure 41a).² The self-management support items are used to create a composite measure ranging from 1 to 100, with higher scores indicating better support. (Note: Information in this profile focuses on the new self-management support composite, but is closely related to the ACES survey. See the profile for measure 41a for information on the ACES survey).

Date: Measure developed in 2002.¹

Perspective: Patient/Family

Measure Item Mapping:

• Communicate:
  • Interpersonal communication: 1,5
    • Between health care professional(s) and patient/family: 1,5
  • Information transfer: 4
    • Across health care teams or settings: 4
• Assess needs and goals: 2, 5
• Support self-management goals: 1,3

Development and Testing: Psychometric analyses demonstrated acceptable internal consistency (>0.70). Cronbach’s alpha for the self-management support composite was 0.75 among primary care respondents and 0.71 among specialist respondents. Overall Cronbach’s alpha was 0.73. The minimum sample size required for medical groups to provide a reliable and stable estimate of self-management support using this composite was 199 patients (across all chronic conditions).¹

Link to Outcomes or Health System Characteristics: Among more than 80,000 patients surveyed from 173 medical groups in California, bivariate analyses showed that self-management support scores were significantly greater when additional medical professionals were involved in care for a chronic condition (p<0.001). For example, participation of other physicians, nurses, nurse practitioners, physical therapists or nutritionists in addition to the general or specialist physician directing care. This relationship was observed for each of the eight types of chronic conditions analyzed (arthritis, asthma, back pain, cancer, cardiovascular disease, depression, diabetes and hypertension).¹

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

Country: United States

Past or Validated Applications*:

• Patient Age: Adult
• Patient Condition: Combined Chronic Conditions, General Chronic Conditions
• Setting: Primary Care Facilities; Other Outpatient Specialty Care Facilities

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

Notes:

• All instrument items are located in the text of the source article. Items are numbered sequentially in the order in which they appear.¹
• This instrument contains 5 items, of which 5 were mapped.
• The 5-item self-management support component profiled here is intended for use with the Ambulatory Care Experiences Survey (ACES). See the ACES profile (measure #41a) for further information about that instrument.

Sources:

1. Sequist TD, von Glahn T, Li A, et al. Statewide evaluation of measuring physician delivery of self-management support in chronic disease care. J Gen Intern Med 2009;24(8):939-45.
2. Safran DG, Karp M, Coltin K, et al. Measuring patients' experiences with individual primary care physicians. J Gen Int Med 2006;21(1):13-21.

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