Care Coordination Measures Atlas Update

Measures 54-58

Measure #54. Cardiac Rehabilitation Patient Referral from an Outpatient 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 Outpatient Setting

Purpose: To measure the percentage of patients evaluated in an outpatient setting who within the past 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis, who are referred to such a 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
• Monitor, follow-up, and respond to change

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: Primary Care Facility, Other Outpatient Specialty 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.

Measure #55. Patients with a Transient Ischemic Event ER Visit That Had a Follow Up Office Visit

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.

Patients with a Transient Ischemic Event ER Visit That Had a Follow Up Office Visit

Purpose: To measure the percent of patients with an emergency department visit for a transient ischemic event who had a follow-up outpatient encounter within 14 days.¹

Format/Data Source: Electronic claims data.

Date: Included in NQF preferred practices and performance measures set, released in September 2010.¹

Perspective: System Representative(s)

Measure Item Mapping:

This measure maps to the following domains: There are no individual measure items to map.

• Facilitate transitions
  • Across settings
• Monitor, follow up and respond to change

Development and Testing: This measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.¹

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: Other – Transient Ischemic Event (stroke)
• Setting: Emergency Care Facility, Primary Care Facility, Other Outpatient Specialty Care Facility

*Based on the source listed below

Notes:

• 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.

Source:

1. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

Measure #56. Biopsy Follow Up

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.

Biopsy Follow Up

Purpose: To measure the percentage of patients who are undergoing a biopsy whose biopsy results have been reviewed by the biopsying physician and communicated to the primary care physician and the patient, denoted by entering said physicians' initials into a log, as well as by documentation in the patient chart.¹

Format/Data Source: Review of medical chart.

Date: Included in NQF preferred practices and performance measures set, released in September 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

Development and Testing: This measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.¹

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

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

Country: United States

Past or Validated Applications*:

• Patient Age: Not Age Specific
• Patient Condition: Other - biopsy
• Setting: Primary Care Facility, Not Setting Specific

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

Notes:

• 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.

Source:

1. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

Measure #57. Reconciled Medication List Received by Discharged Patients

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.

Reconciled Medication List Received by Discharged Patients

Purpose: To measure the percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care, or their caregiver(s), who received a reconciled medication list at the time of discharge including, at a minimum, medications in the specified categories.¹

Format/Data Source: This process measure requires administrative claims data and data collected from the medical record.¹

Date: Measure released in 2009.¹

Perspective: System Representative(s).

Measure Item Mapping:

This measure maps to the following domains: There are no individual measure items to map.

• Establish accountability or negotiate responsibility
• Communicate
  • Information transfer
    • Between health care professional(s) and patient/family
• Facilitate transitions
  • Across settings
• Medication Management

Development and Testing: The measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.²

Link to Outcomes or Health System Characteristics: In a Swedish study, the risk of negative clinical outcomes due to medication errors was significantly reduced for elderly individuals who were given comprehensive and structured information on medications at the time discharge. In another study, 14% of older patients that experienced a medication discrepancy were readmitted within 30 days of initial discharge, compared to only 6% among those patients without a medication discrepancy.¹

Logic Model/Conceptual Framework: This measure incorporates elements from The Joint Commission's 2009 Hospital Accreditation Standards, Medication Systems Guidelines from the Institute for Healthcare Improvement, and recommendations from Institute for Healthcare Improvement, a 2008 consensus policy statement from the American College of Physicians, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Geriatrics Society, The American College of Emergency Physicians and the Society of Academic Emergency Medicine.¹

Country: United States

Past or Validated Applications*:

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

*Based on the sources listed below.

Notes:

• Detailed measure specifications are included in the Physician Consortium for Performance Improvement (PCPI) report.¹
• This measure is intended for use in conjunction with two other PCPI measures (Measure #58, Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care); and Measure #59, Timely Transmission of Transition Record) as part of a bundled set. Each measure in the bundled set is intended to be scored separately.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. American Board of Internal Medicine Foundation, American College of Physicians, Society of Hospital Medicine, Physician Consortium for Performance Improvement. Care Transitions Performance Measurement Set (Phase I: Inpatient discharges and emergency department discharges). Chicago, IL: American Medical Association; 2009.
2. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

Measure #58. Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges)

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.

Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges)

Purpose: To measure the percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements.¹

Format/Data Source: This process measure requires administrative claims data and data collected from the medical record.¹

Date: Measure released in 2009.¹

Perspective: System Representative(s)

Measure Item Mapping:

This measure maps to the following domains: There are no individual measure items to map.

• Establish accountability or negotiate responsibility.
• Communicate
  • Information transfer.
    • Between health care professional(s) and patient/family.
• Facilitate Transitions
  • Across settings.
• Create a proactive plan of care
• Monitor, follow up, and respond to change
• Medication Management

Development and Testing: The measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.²

Link to Outcomes or Health System Characteristics: One study showed that compared to patients receiving usual care, patients who received detailed instructions, medication review and help scheduling follow-up care at the time of discharge had 30% fewer re-admissions and visits to the emergency department.¹

Logic Model/Conceptual Framework: This measure incorporates elements from The Joint Commission's 2009 Hospital Accreditation Standards and a 2008 consensus policy statement from the American College of Physicians, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Geriatrics Society, The American College of Emergency Physicians and the Society of Academic Emergency Medicine.¹

Country: United States

Past or Validated Applications*:

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

*Based on the sources listed below.

Notes:

• Detailed measure specifications are included in the Physician Consortium for Performance Improvement (PCPI) report.¹
• This measure is intended for use in conjunction with two other PCPI measures (Measure #57, Reconciled Medication List Received by Discharged Patients; and Measure #59, Timely Transmission of Transition Record - Inpatients Discharged) as part of a bundled set. Each measure in the bundled set is intended to be scored separately.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. American Board of Internal Medicine Foundation, American College of Physicians, Society of Hospital Medicine, Physician Consortium for Performance Improvement. Care Transitions Performance Measurement Set (Phase I: Inpatient discharges and emergency department discharges). Chicago, IL: American Medical Association; 2009.
2. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

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