Care Coordination Measures Atlas Update

Atlas Update: New Measure Additions and Measures 62-65

The profiles that follow represent new measures added to the updated version of the Atlas.

These measures are:

#	Measure Title
	New Measures Related to Measures from Original Atlas*
4.	Consumer Assessment of Healthcare Providers and Systems (CAHPS)
	d. Patient-Centered Medical Home (PCMH) Supplementary Survey Adult Version 2.0*
	e. Patient-Centered Medical Home (PCMH) Supplementary Survey Child Version 1.1*
41.	Ambulatory Care Experiences Survey (ACES)
	b. Primary Care Provider Ambulatory Care Experiences Survey (PCP ACES)*
Measures added to the updated Atlas
62.	Team Survey for Program of All-Inclusive Care for the Elderly (PACE)
63.	Medication Reconciliation for Ambulatory Care
64.	Promoting Healthy Development Survey PLUS – (PHDS-PLUS)
65.	Canadian Survey of Experiences with Primary Health Care Questionnaire
66.	Interpersonal Processes of Care Survey
67.	Brief 5 A’s Patient Survey
68.	Patient Perceived Continuity of Care from Multiple Providers
69.	Relational and Management Continuity Survey in Patients with Multiple Long-Term Conditions
70.	Patient Perception of Integrated Care Survey (PPIC)
71.	Safety Net Medical Home Scale (SNMHS)
72.	Parents' Perceptions of Primary Care – (P3C)
73.	Primary Care Questionnaire for Complex Pediatric Patients
74.	Safety Net Medical Home Provider Experience Survey
75.	Rhode Island Physician Health Information Technology Survey
76.	The Joint Commission Patient-Centered Medical Home Self-Assessment Survey
77.	Communication with Referring Physicians Practice Improvement Module (CRP-PIM)
78.	Safe Transitions Community Physician Office Best Practice Measures
79.	National Survey of Physicians Organizations and the Management of Chronic Illness II (NSPO-2)
80.	Patient-Centered Medical Home Assessment (PCMH-A) Tool

*These measures appear near their parent measures, in the previous section of this chapter.

Measure #62. Team Survey for Program of All-Inclusive Care for the Elderly (PACE)

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.

Team Survey for Program of All-Inclusive Care for the Elderly (PACE)

Purpose: To develop an instrument that will assess interdisciplinary team performance in long-term care settings as well as PACE.

Format/Data Source: Self-administered, confidential, mailed surveys in several languages were sent to all part-time or full-time employees of the twenty-six PACE programs.¹ Responses were based on a 5-point Likert scale for all items in Sections I and II.

Date: Measure published in 2004.¹

Perspective: Health Care Professional(s)

Measure Item Mapping:

• Establish accountability or negotiate responsibility: 1A5, 1A7, 1D4, 2.12
• Communicate:
  • • Within teams of health care professionals: 1C9, 1C12, 1C14
  • Information transfer:
    • Within teams of health care professionals: 1C8, 1C9
• Create a proactive plan of care: 1C13
• Teamwork focused on coordination: 1B5

Development and Testing: The instrument was pilot tested via 3 approaches: (1) questions were reviewed by an education specialist and a specialist in English-as-a-second-language to confirm appropriateness; (2) an expert panel provided feedback, and (3) the instrument was pilot tested among 84 aides in either a PACE program or a nursing home. All domains demonstrate reliability, and regression analyses determined sufficient construct validity. Cronbach’s alpha coefficients supported internal consistency reliability.¹

Link to Outcomes or Health System Characteristics: Overall team performance had significant association with activities of daily living outcomes at 3 and 12 months, and improved urinary incontinence at 12 months. There was no significant association with survival.²

Logic Model/Conceptual Framework: The team survey for PACE stems from an adaptation of a model developed by Shortell and Rousseau to assess nurse-physician collaborative relationships within intensive care settings.³

Country: United States

Past or Validated Applications*:

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

*Based on the sources listed below.

Notes:

• Instrument was provided by the corresponding author upon request (H. Temkin-Greener, personal communication, September 1, 2010).
• This instrument contains 81 items. Only Sections I and II were mapped. Section I contains 49 items; 9 of which were mapped. Section II contains 32 items; 1 of which was mapped.
• This measure instrument was adapted from the ICU Nurse-Physician Questionnaire.⁴
• The author has revised this instrument and used it in nursing homes. For more information, see measure 23.

Sources:

1. Temkin-Greener H, Gross D, Kunitz SJ, et al. Measuring interdisciplinary team performance in a long-term care setting. Med Care 2004; 42(5):472-81.
2. Mukamel DB, Temkin-Greener H, Delavan R, et al. Team performance and risk-adjusted health outcomes in the Program of All-Inclusive Care for the Elderly (PACE). The Gerontologist 2006; 46(2) 227-237.
3. Shortell S, Rousseau DM. Excerpted from The Organization and Management of Intensive Care Units. [pamphlet] 1989.
4. Shortell SM, Rousseau DM, Gillies RR, et al. Organizational Assessment in Intensive Care Units (ICUs): Construct Development, Reliability, and Validity of the ICU Nurse-Physician Questionnaire. Med Care 1991; 29:709-727.
5. Mukamel DB, Peterson DR, Temkin-Greener H, et al. Program characteristics and enrollees’ outcomes in the Program of All-Inclusive Care for the Elderly (PACE). The Milbank Quarterly 2007; 85(3):499-531.

Measure #63. Medication Reconciliation for Ambulatory Care

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.

Medication Reconciliation for Ambulatory Care

Purpose: To measure the percentage of patients aged 65 years and older who were discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days of discharge in the office by the physician providing on-going care who had reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.¹

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

Date: Measure released in 2006.¹

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
    • Across health care teams or settings
• Facilitate transitions
  • Across settings
• Monitor, follow up, and respond to change
• Medication Management

Development and Testing: None described in the sources identified.

Link to Outcomes or Health System Characteristics: One study indicated a relationship between hospital readmissions and the quality of discharge communication, although medication management was not determined to be the causal factor.^{2, 3}

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

Country: United States

Past or Validated Applications*:

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

*Based on the sources listed below.

Notes:

• • Detailed measure specifications are included in the Physician Consortium for Performance Improvement (PCPI) Geriatrics Physician Performance Measurement Set, which is available for download from the American Medical Association website.¹
  • Current Procedural Terminology (CPT) service codes are indicated in the measure specifications within the PCPI Geriatrics Physician Performance Measurement Set.¹
  • This measure is intended for use in ambulatory care settings only.¹
  • An updated version of this measure is forthcoming at the time of this publication.

Sources:

1. American Geriatrics Society, Physician Consortium for Performance Improvement (PCPI), National Committee for Quality Assurance (NCQA). Geriatrics Physician Performance Measurement Set. Chicago, IL: American Medical Association; 2006. Available at: http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI.
2. William El and Filton F. General practitioner response to elderly patients discharged from hospital. BMJ 1990; 300:159-161.
3. Wenger NS, Young RT. Quality indicators of continuity and coordination of care for vulnerable elders. JAGS 2007; 55(S2):S285-S292.

Measure #64. Promoting Healthy Development Survey PLUS – (PHDS-PLUS)

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.

Promoting Healthy Development Survey PLUS – (PHDS-PLUS)

Purpose: To assess whether young children between 0-3 years (3 - 48 months of age) are receiving nationally recommended preventive and developmental services.¹

Format/Data Source: A 128-item telephone/interviewer-administered survey largely derived from the mail/self-administered Promoting Health Development Survey (PHDS). It takes 15-18 minutes to administer and provides a high-level summary of questions asked in the survey.¹ The core text of the survey consists of 19 sections, which include: (1) child information, (2) health care utilization, (3) access issues, (4) care coordination, (5) other health services, (6) anticipatory guidance and parental education, (7) developmental assessment, (8) follow up for children at risk for developmental/behavioral delays, (9) family-centered care, (10) health provider assessment of risks in the family, (11) health information, (12) helpfulness of care provided, (13) health of child: overall health status, (14) health of child: special health care needs, (15) child health characteristics, (16) personal doctor or nurse, (17) maternal health, (18) parenting behaviors, and (19) socio-demographic.

Date: Measure released in 2001.²

Perspective: Patient/Family

Measure Item Mapping:

• Establish accountability or negotiate responsibility: 9.4
• Communicate:
  • Interpersonal communication:
    • Between health care professional(s) and patient/family: 6.1 (3-9 month old bracket); 6.1 (10-18 month old bracket); 6.1 (19-48 month old bracket); 6.15 (3-9 month old bracket); 6.18 (10-18 month old bracket); 6.15 (19-48 month old bracket)
• Facilitate transitions:
  • Across settings: 4.1a, 8.1
• Monitor, follow up, and respond to change: 8.1
• Support self-management goals: 6.1 (3-9 month old bracket); 6.1 (10-18 month old bracket); 6.1 (19-48 month old bracket)
• Link to community resources: 5.2 (3-9month old bracket); 6.15 (3-9 month old bracket); 6.18 (10-18 month old bracket); 6.15 (19-48 month old bracket)

Development and Testing: The PHDS was designed and tested by The Child and Adolescent Health Measurement Initiative (CAHMI) using a peer-reviewed measurement development process. A rigorous six-stage process was used to develop the PHDS, beginning with focus groups with families to identify the aspects of health care quality that are important to parents in the area of preventive care for their children. A literature review of Medline informed the materials that guided development. The instrument was then tested in 3 managed care organizations. Bivariate and multivariate analyses were conducted to assess the reliability, validity and feasibility of the PHDS.² To date, more than 45,000 surveys have been collected by 10 Medicaid agencies, 4 health plans, 38 pediatric practices and nationally through the National Survey of Early Childhood Health (NSECH).¹ The PHDS has been endorsed by the National Quality Forum as a valid measure for system, plan and provider-level assessment of patients’ experiences with preventive and developmental health care.¹ Psychometric analyses of the PHDS quality measures scales have demonstrated strong construct validity and internal consistency (Cronbach’s alphas ranged from 0.63 to 0.88). Concurrent validity was also tested. Factor analysis demonstrated strong factor structure within the PHDS. ²

Link to Outcomes or Health System Characteristics: Parents who received answers to their questions from medical providers indicated higher confidence in related parenting activities with an odds ratio (OR) of 5.9 (95%CI 3.4-10.2).²

Logic Model/Conceptual Framework: A conceptual framework was developed and investigated in regards to relevance for each measure.¹

Country: United States

Past or Validated Applications*:

• Patient Age: Children
• Patient Condition: Combined Chronic Conditions, Children with Special Health Care Needs, General Population/Not Condition Specific
• Setting: Primary Care Setting

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

Notes:

• All instrument items are located online.¹
• This instrument contains 19 sections, of which 5 were mapped.
  • There are 128 items in this instrument; 10 were mapped.
• Section 6 of the instrument has three separate sections with overlapping questions based upon the age of the child. The categories were mapped by the age brackets: 3-9 months, 10-18 months and 19-48 months.
• The PHDS-PLUS was enhanced with additional items about the child and parent’s health, health care utilization and other related topics, from the original PHDS survey. The PHDS has been updated to reflect the most recent edition of the Bright Futures Guidelines (S. Stumbo, personal communication, July 26, 2011) and is available in English and Spanish versions.¹
• The instrument is also available in a reduced-item version (ProPHDS). Research with health care providers has demonstrated that for in-office survey administration to be feasible, the survey must take no longer than five minutes.¹
• This instrument is related to the National Survey for Children’s Health (NSCH) and the National Survey for Children with Special Health Care Needs (CSHCN). For more information about additional measures by The Child and Adolescent Health Measurement Initiative (CAHMI), see Measures 14 and 51.
• The Online PHDS Toolkit offers customization of survey administration materials for providers and health systems. The information can be stored to provide automated feedback reports, identifying quality improvement tips to meet needs.
• Parents who complete the survey have access to links to educational resources and receive a customized feedback report that provides guidance on questions to ask at their next well child visit. (S. Stumbo, personal communication, July 26, 2011).

Sources:

1. Preventive Services for Young Children Overview: Promoting Healthy Development Survey Web site. Available at: http://www.cahmi.org/ Accessed: 15 July 2011.
2. Bethell C, Reuland C, Schor E. Assessing health system provision of well-child care: The Promoting Healthy Development Survey. Pediatrics 2001; 107(5):1084-94.
3. Bethell CD, Carter K, Latzke B, et al. Toward Appropriate, Meaningful and Valid Measurement of Differences in Health Care Quality Across Culturally Diverse Populations Using Consumer Reported Measures of Health Care Quality. The Commonwealth Fund; March 2003.
4. Bethell C, Peck C, Abrams M, et al., Partnering with Parents to Promote the Healthy Development of Young Children Enrolled in Medicaid. The Commonwealth Fund; September 2002.
5. Bethell CD, Peck Reuland C, Halfon, N, et al. Measuring the quality of preventive and developmental services for young children: National estimates and patterns of clinicians’ performance. Pediatrics; June 2004.
6. Bethell C, Reuland C. Guidelines for pediatric office-based implementation of the Promoting Healthy Development Survey. The Commonwealth Fund; 2004.

Measure #65. Canadian Survey of Experiences with Primary Health Care Questionnaire

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.

Canadian Survey of Experiences with Primary Health Care Questionnaire (CSEPHC)

Purpose: To measure Canadians' experiences with health care, specifically, experiences with various types of doctors and clinics, access to different types of health care including emergency room and prescription medication use.

Format/Data Source: A 181-item telephone-administered survey. The survey assess 10 areas of health, health care utilization, and experiences with care: (1) health status, (2) primary health care types, (3) health care use, (4) health care utilization, (5) experiences with primary health care providers, (6) access to health care, (7) emergency room use, (8) prescription medication use, (9) chronic conditions, and (10) patient activation.¹

Date: Measure released in 2008.¹

Perspective: Patient/Family

Measure Item Mapping:

• Communicate:
  • • Between health care professional(s) and patient/family: EP_Q01, CC_Q08
    • Participants not specified: EP_Q05
  • Information transfer:
    • Across health care teams or settings: HZ_Q02, HZ_Q08B, EP_Q04, EP_Q06
• Facilitate transitions:
  • Across settings: HU_Q05
• Assess needs and goals: EP_Q03, CC_Q03, CC_Q09
• Create a proactive plan of care: CC_Q05, CC_Q09
• Monitor, follow up, and respond to change: HZ_Q02, MU_Q03
• Support self-management goals: CC_Q04, CC_Q05
• Link to community resources: CC_Q07
• Align resources with patient and population needs: CC_Q06
• Teamwork focused on coordination: HU_Q05
• Medication Management: MU_Q03

Development and Testing: The survey was developed by the Health Council of Canada and Canadian Institute for Health Information (CIHI) based on CIHI health indicators. The questionnaire was iteratively refined through expert review and field testing in the general population of Canada, as well as in patients with chronic conditions.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: Canada

Past or Validated Applications*:

• Patient Age: Not Age Specific
• Patient Condition: General Population or Not Condition Specific
• Setting: Primary Care Facility, Inpatient Care Facility, Other Outpatient Specialty, Emergency Care Facility

*Based on the sources listed below^{1, 2} and input from the measure developers.

Notes:

• English instrument items are located online.¹
• This instrument contains 181 items, of which 16 were mapped.
• A French language version is available.

Sources:

1. Canadian Survey of Experiences with Primary Health Care. Statistics Canada. Available at: http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5138&lang=en&db=imdb&adm=8&dis=2. Accessed: 2 June 2013.
2. Jesmin S, Thind A, Sarma S. Does team-based primary health care improve patients' perception of outcomes? Evidence from the 2007-08 Canadian Survey of Experiences with Primary Health. Health Policy 2012;105(1):71-83.

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