Measures 50-53
Measure #50. Degree of Clinical Integration Measures
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.
Degree of Clinical Integration Measures
Purpose: To measure functional integration, which is defined as the extent to which patient care services are coordinated across various functions, activities, and operating units of a system.
Format/Data Source: 17 measures used to assess 6 dimensions of clinical integration: (1) clinical protocol development, (2) medical records uniformity and accessibility, (3) clinical outcomes data collection and utilization, (4) clinical programming and planning efforts, (5) shared clinical support services, and (6) shared clinical services lines.
Date: Measures published in 1994.1
Perspective: System Representative(s)
Measure Item Mapping:
- Communicate:
- Information transfer:
- Across health care teams or settings: 8,9
- Information transfer:
- Facilitate transitions:
- Across settings: 16,17
- Health IT-enabled coordination: 3-7
Development and Testing: Measures were developed based on a literature review, interaction with the study research advisory group committee, and site visits. 1
Link to Outcomes or Health System Characteristics: None described in the source identified.
Logic Model/Conceptual Framework: Builds on the work of models and frameworks of vertically integrated health systems.1
Country: United States
Past or Validated Applications*:
- Patient Age: Not Age Specific
- Patient Condition: General Population/Not Condition Specific
- Setting: Not Setting Specific
*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 Table 3 of the source article were consecutively numbered.1
- This instrument contains 17 items; 9 were mapped.
Source:
1. Devers KJ, Shortell SM, Gillies RR, et al. Implementing organized delivery systems: An integration scorecard. Health Care Manage Rev 1994;19(3):7-20.
Measure #51. National Survey for Children's Health (NSCH)
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.
National Survey for Children's Health (NSCH)
Purpose: To collect a broad range of information about children's health and well-being in order to allow for comparisons among States as well as nationally.
Format/Data Source: Telephone interview comprised of 11 sections: (1) initial demographics, (2) health and functional status, (3) health insurance coverage, (4) health care access and utilization, (5) medical home, (6) early childhood, (7) middle childhood and adolescence, (8) family functioning, (9) parental health, (10) neighborhood and community characteristics, and (11) additional demographics. The section most relevant to care coordination is Section 5 - Medical Home, which consists of 4 subdomains: (1) referrals; (2) care coordination; (3) provider communication; and (4) compassionate, culturally effective, family centered care.
Date: Measure administered nationally in 2003 and 2007.1
Perspective: Patient/Family
Measure Item Mapping:
- Communicate:
- Across health care teams or settings: K5Q30, K5Q31, K5Q32
- Interpersonal communication:
- Between health care professional(s) and patient/family: K5Q41
- Information transfer:
- Between health care professional(s) and patient/family: K5Q43
- Across health care teams or settings: K5Q30, K5Q31, K5Q32
- Facilitate transitions:
- Across settings: K5Q10, K5Q11
- Align resources with patient and population needs: K5Q42, 8K5Q45, K5Q46
- Health care home: K5Q10, K5Q11, K5Q20-22, K5Q30-32, K5Q40-46
- Care management: K5Q20, K5Q22
Development and Testing: The survey's framework, intended goals, and content was designed by a National Expert Panel consisting of State and Federal policymakers, health services researchers, survey design experts, parents, and health care practitioners. A subset of this group formed the Technical Expert Panel that met multiple times to discuss the development and testing of specific questionnaire items. A majority of the questions included in the survey were taken directly from previously validated surveys including: the National Health Interview Survey (NHIS), the national Survey of Children with Special Health Care Needs, the Consumer Assessment of Health Plans Survey (CAHPS), the National Survey of America's Families, the Promoting Healthy Development Survey, and the Living With Illness Survey. All questionnaire items were also reviewed by outside experts and the user community prior to final inclusion. A pretest of the survey instrument was conducted with approximately 1000 interviews.2
Link to Outcomes or Health System Characteristics: The NSCH survey questions and data have been used in several published studies. A list of these publications may be found online.1
Logic Model/Conceptual Framework: The Medical Home Section of the survey was based largely on the American Academy of Pediatrics medical home model of primary pediatric care, which defines medical home care as accessible, continuous, comprehensive, family-centered, compassionate, culturally effective, and coordinated with specialized services.2
Country: United States
Past or Validated Applications*:
- Patient Age: Children
- Patient Condition: General Population/Not Condition Specific
- Setting: Not Setting Specific
*Based on the sources listed below and input from the measure developers.
Notes:
- The NSCH consists of 11 sections, but only the section relevant to care coordination (Section 5 - Medical Home) was mapped for this profile. The full-length NSCH as well as a Spanish version can be found online.1
- The Measure Item Mapping portion of the profile refers to the question items found in the 2007 version of the NSCH. For those interested in the 2003 version of the NSCH, it can be found online.1
- The mapped section of the measure contains 15 items; all 15 were mapped.
- The 2003 and 2007 national and State data are publicly available for download online.1
Sources:
1. National Survey of Children's Health Web site. Available at: http://www.nschdata.org/content/Default.aspx. Accessed: 20 September 2010.
2. Blumberg SJ, Foster EB, Frasier AM, et al. Design and operation of the National Survey of Children's Health, 2007. Vital Health Stat 1. (forthcoming).
3. van Dyck P, Kogan MD, Heppel D, et al. The National Survey of Children's Health: A new data resource. Matern Child Hlth J 2004;8(3):183-8.
Measure #52. Mental Health Professional HIV/AIDS Point Prevalence and Treatment Experiences Survey Part II
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.
Mental Health Professional HIV/AIDS Point Prevalence and Treatment Experiences Survey Part II
Purpose: To assess multiple aspects of system integration within the mental health facility, and system integration between mental health, primary care, and case management for the HIV-infected patient.
Format/Data Source: Mailed questionnaire with questions divided into 4 categories: (1) mental health system integration with primary care physicians, (2) mental health system integration with care coordination sites, (3) mental health system integration with other mental health centers, and (4) internal integration of HIV care into the mental health system itself.
Date: Measure published in 2001.1
Perspective: System Representative(s)
Measure Item Mapping:
- Communicate:
- Interpersonal communication:
- Across health care teams or settings: 2, 4, 5, 7, 8, 10
- Information transfer:
- Across health care teams or settings: 1, 6, 11
- Interpersonal communication:
- Create a proactive plan of care: 3
- Link to community resources: 9, 10, 23, 27, 28
- Align resources with patient and population needs: 15-17, 24, 25, 29, 30
- Teamwork focused on coordination: 3, 12-14, 18-22, 26, 31-33
Development and Testing: Panel convened at the Indiana State Department of Health—composed of experts from the fields of medicine, public health, community mental health, medical sociology, and psychology—developed the survey instrument. Internal consistency reliability analysis was conducted. The Cronbach's alpha coefficient results for each category were: specific indicators of mental health systems integration with primary care physicians (0.80), global assessment of mental health system integration with primary care physicians (0.75), specific indicators of mental health system integration with HIV care coordination sites (0.90), global assessment of mental health system integration with HIV care coordination sites (0.74), global assessment of mental health system integration with other mental health agencies (0.57), global assessment of mental health system integration of HIV care into the mental health system (0.61). 1
Link to Outcomes or Health System Characteristics: System integration was not significantly associated with mental health service provider turnover rates.1
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, Behavioral Health Care 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 Tables 2 and 3 of the source article were consecutively numbered.1
- This instrument contains 34 items; 33 were mapped.
Source:
1. Lemmon R, Shuff M. Effects of mental health centre staff turnover on HIV/AIDS service delivery integration. AIDS Care 2001;13(5):651-61.
Measure #53. Cardiac Rehabilitation Patient Referral from an Inpatient Setting
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.
Cardiac Rehabilitation Patient Referral from an Inpatient Setting
Purpose: To measure the percentage of patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina (CSA), or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention (CR) program.1
Format/Data Source: This process measure requires administrative claims data and/or data collected from the medical record. Data from clinical registries may also be used, if available (e.g., National Cardiovascular Data Registry, ACTION-Get With the Guidelines Inpatient Registry).1
Date: Measure released in 20072 and updated in 2010.1
Perspective: System Representative(s).
Measure Item Mapping:
This measure maps to the following domains: There are no individual measure items to map.
- Communicate
- Information transfer
- Between health care professional(s) and patient/family
- Across health care teams or settings
- Information transfer
Development and Testing: The Cardiac Rehabilitation/Secondary Prevention Performance Measure Writing Committee reviewed a list of 39 elements from practice guidelines and evaluated their potential use as performance measures according to the ACC/AHA Task Force on Performance Measures guidelines. They selected those that were most evidence-based, interpretable, actionable, clinically meaningful, valid, reliable, and feasible for inclusion.2 The measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.3
Link to Outcomes or Health System Characteristics: The measure is based on clinical guidelines with the highest level of evidence, including links to clinical outcomes.2
Logic Model/Conceptual Framework: The measure is based on clinical guidelines.2
Country: United States
Past or Validated Applications*:
- Patient Age: Adults
- Patient Condition: Combined Chronic Conditions, General Chronic Conditions, Other – cardiac conditions not identified under General Chronic Conditions
- Setting: Inpatient Facility, Other Outpatient Specialty Care Facility, Long Term Care Facility
*Based on the sources listed below and input from the measure developers
Notes:
- Detailed measure specifications are included in the AACVPR/AACF/AHA 2010 Update report.1
- Because the NQF-endorsed preferred practices and performance measures for measuring and reporting care coordination were released shortly before completion of the Atlas, we were not able to contact the measure developers about any on-going measure development or testing. Additional information may become available in the future.
Sources:
1. Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). J Am Coll Cardiol 2010;56:1159-67. Also published in Circulation 2010;122:1342-50. Also published in J Cardiopulm Rehabil 2010;30:279-88.
2. Thomas RJ, King M, Lui K, et al. AACVPR/AAC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol 2007;50:1400-33. Also published in Circulation 2007;116:1611-42. Also published in J Cardiopulm Rehabil 2007;27:260-90.
3. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.
