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Care Coordination Measures Atlas Update

Chapter 6. Measure Maps and Profiles (continued, 24)

Measures 70-73

Measure #70. Patient Perception of Integrated Care Survey (PPIC)

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.

Patient Perception of Integrated Care Survey (PPIC)

Purpose: To measure the integration of patient care as experienced by patients.

Format/Data Source: A 62-item paper-based survey using yes/no and 4-point Likert-type scale responses. The measure assesses six factors of integrated care as experienced by patients: (1) Information flow to your doctor, (2) Information flow to your specialist, (3) Information flow to other providers in your doctor’s office, (4) Coordination with home and community resources, (5) Post-visit information flow to the patient, and (6) Patient-centeredness.1

Date: Measure released in 2010.1

Perspective: Patient/Family

Measure Item Mapping:

  • Communicate:
      • Within teams of health care professionals: 10, 26, 28
      • Across health care teams or settings: 41, 42
    • Interpersonal communication:
      • Between health care professional(s) and patient/family: 27
      • Within teams of health care professionals: 27
    • Information transfer:
      • Between health care professional(s) and patient/family: 18, 20
      • Across health care teams or settings: 46, 47, 52
  • Facilitate transitions:
    • Across settings: 49, 50
  • Assess needs and goals: 22, 23, 24, 38
  • Monitor, follow up, and respond to change: 9, 18, 20, 35, 49
  • Support self-management goals: 29, 30, 39, 50
  • Link to community resources: 39
  • Teamwork focused on coordination: 26, 27, 28
  • Medication Management: 44

Development and Testing: Pilot testing in 1,289 patients with multiple chronic conditions from 13 primary care clinics in one Massachusetts-based delivery system demonstrated moderate to good internal reliability for the six factors identified through exploratory factor analysis (range of Cronbach’s alphas 0.62 to 0.80), as well as good model fit.1 A refined instrument was tested with 3,000 elderly patients with multiple chronic conditions from six physician practices within a different multispecialty physician group in Massachusetts. Additional measure testing and refinement of both the survey and the psychometric models is on-going, including two large, national samples of patients (S. Singer, personal communication, September 23, 2013).

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

Logic Model/Conceptual Framework: Based on a framework for measuring integrated patient care.2

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Age Specific
  • Patient Condition: Combined Chronic Conditions, General Chronic Conditions, Multiple Chronic Conditions.
  • Setting: Not Setting Specific

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

Notes:

  • The version of the instrument mapped in this profile was provided by the measure developer (S. Singer, personal communication, April 11, 2013).
  • The version of the instrument mapped in this profile contains 62 items, of which 23 were mapped.
  • Spanish and Portuguese versions of this instrument are also available.1
  • Further information about this measure and related research is available online.3

Sources:

  1. Singer SJ, Friedberg MW, Kiang MV, et al. Development and preliminary validation of the Patient Perceptions of Integrated Care survey. Med Care Res Rev 2013;70(2):143-64.
  2. Singer SJ, Burgers J, Friedberg M, et al. Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Medical Care Research & Review 2011;68(1):112-27.
  3. Patient Perceptions of Integrated Care. Available at: http://www.IntegratedPatientCare.org. Accessed: September 24, 2013.

Measure #71. Safety Net Medical Home Scale (SNMHS)

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.

*Indicates that the measure as a whole focuses on the Health care home model

Safety Net Medical Home Scale (SNMHS)

Purpose: To summarize health center capability to provide a patient-centered medical home.

Format/Data Source: An 88-item survey completed by safety net clinics (i.e., federally qualified health centers) regarding their adoption and adherence to the principles of a patient-centered medical home. Survey items are grouped together into six validated sub-scales: (1) access and communication, (2) patient tracking and registry, (3) care management, (4) test and referral tracking, (5) quality improvement, and (6) external coordination. The total scale score is calculated between 0 (poor) to 100 (best), by averaging together the six sub-scales.1

Date: Measure released in 2009.1

Perspective: System Representative(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 17a
  • Communicate:
      • Across health care teams or settings: 22a, 22b
    • Interpersonal communication:
      • Between health care professional(s) and patient/family: 16e, 17a
    • Information transfer:
      • Between health care professional(s) and patient/family: 13c
      • Across health care teams or settings: 11b, 11c, 11d, 11e, 21a, 21b, 21c, 22c, 23
  • Facilitate transitions:
    • Across settings: 17d, 19a, 19b, 19c, 20a, 20b, 21a, 21b, 21c, 22a, 22b, 22c, 23
  • Monitor, follow up, and respond to change: 13a, 13d, 17a, 21c
  • Support self-management goals: 17c
  • Health care home: 11b, 11c, 11d, 11e, 13a, 13c, 13d, 16e, 17a, 17c, 17d, 19a, 19b, 19c, 20a, 20b, 21a, 21b, 21c, 22a, 22b, 22c, 23*
  • Medication Management: 11e, 17a
  • Health IT-enabled coordination: 11b, 11c, 11d, 11e, 13c, 13d

*The instrument as a whole focuses on the Health care home model. Only those items that map to at least one other care coordination domain are listed here.

Development and Testing: In a study of 65 safety net practices across five states, internal consistency reliability was high (Cronbach’s alpha = 0.84). Convergent validity was assessed through comparisons with the two other measures of advanced primary care practice. The SNMHS was moderately correlated with both the Assessment of Chronic Illness Care (r=0.64, p < 0.001) and Patient-Centered Medical Home – Assessment Tool (r=0.56, p < 0.001).1

Link to Outcomes or Health System Characteristics: Linear regression models showed that clinics with a greater number of providers (>8 vs. <4 full-time equivalents) and that participated in financial incentive programs were positively associated with the total Safety Net Medical Home scale score (p<0.05).1

Logic Model/Conceptual Framework: The measure is based in part on the NQF-Endorsed Definition and Framework for Measuring Care Coordination.2

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Applicable
  • Patient Condition: Not Applicable
  • Setting: Primary Care Facility, Other Outpatient Specialty Care Facility, Inpatient, Emergency Department

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

Notes:

  • All instrument items are located online.3
  • This instrument contains 88 items, of which 23 were mapped.

Sources:

  1. Birnberg JM, Drum ML, Huang ES, et al. Development of a safety net medical home scale for clinics. J Gen Intern Med 2011;26(12):1418-25.
  2. National Quality Forum. National Quality Forum-endorsed definition and framework for measuring care coordination. Washington, D.C.: Forum NQ; 2006.
  3. The Commonwealth Fund 2009 Survey of Health Clinics Involved in the Safety Net Medical Home Initiative The Commonwealth Fund. Available at: http://www.commonwealthfund.org/Innovations/Tools/2011/~/media/Files/Innovations/CMWF_SurveyFinal722.pdf. Accessed: August 30 2013.

Measure #72. Parents' Perceptions of Primary Care – (P3C)

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.

Parents' Perceptions of Primary Care – (P3C)

Purpose: To measure parents’ of experiences with their child’s primary care for use as an indicator of pediatric primary care quality.

Format/Data Source: A 23-item survey completed by parents. Most questions are answered via a 5-point Likert scale indicating frequency of experience (never, sometimes, often, almost always, always). The survey focuses on 6 factors of high-quality pediatric care: (1) longitudinal continuity, (2) access, (3) communication, (4) contextual knowledge, (5) comprehensiveness, and (6) coordination of care. Higher scores on these factors indicate better care.1

Date: Measure released in 2001.1

Perspective: Patient/Family

Measure Item Mapping:

  • Communicate:
      • Between health care professional(s) and patient/family: 6, 7, 8, 9, 14, 15, 16, 17
      • Across health care teams or settings: 5, 20, 21
    • Interpersonal communication:
      • Between health care professional(s) and patient/family: 10, 11, 12, 13
  • Facilitate transitions:
    • Across settings: 18
  • Monitor, follow up, and respond to change: 19
  • Support self-management goals: 9, 14, 15, 16, 17

Development and Testing: The measure was piloted with 36 parents, who also provided feedback and suggestions, then administered to 3371 parents of students from 18 elementary schools (Kindergarten through 6th grade) from in a large, urban school district. Psychometric analyses demonstrated acceptable internal consistency for the measure total score (Cronbach’s alpha 0.95) and for each of the 6 subscales (Cronbach’s alphas ranged from 0.77 to 0.92). Factor analysis supported validity of the six subscales, each aligning with one of the factors hypothesized to be important for high-quality pediatric primary care. As expected, bivariate analyses showed that the mean total score on the measure varied significantly between three groups of parents expected to experience different quality of pediatric primary care: children with and without health insurance (those with insurance scored higher), parents completing the survey in English vs. other languages (those completing the measure in English scored higher), and children with a personal doctor (those with a personal doctor scored higher) (p<0.05 for all comparisons). Mean scores differed significantly for each of the 6 subscale scores as well using the same set of comparisons (p<0.05 for all comparisons).1

Link to Outcomes or Health System Characteristics: In bivariate analyses, children experiencing higher quality primary care, as measured by the P3C instrument, also had higher reported quality of life as measured through the validated PedsQL instrument (p<0.01).1

Logic Model/Conceptual Framework: The measure is based on the Institute of Medicine’s definition of primary care.2

Country: United States

Past or Validated Applications*:

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

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

Notes:

  • All instrument items are located in the appendix of the source article.1
  • This instrument contains 23 items, of which 17 were mapped.
  • Translations are available in Spanish, Vietnamese, and Tagolog.1

Sources:

  1. Seid M, Varni JW, Bermudez LO, et al. Parents' Perceptions of Primary Care: measuring parents' experiences of pediatric primary care quality. Pediatrics 2001;108(2):264-70.
  2. Donaldson M, Yordy K, Lohr K, et al. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press; 1996.

Measure #73. Primary Care Questionnaire for Complex Pediatric 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.

Primary Care Questionnaire for Complex Pediatric Patients

Purpose: To assess quality of care for children with complex medical conditions with respect to the patient-centered medical home framework.

Format/Data Source: This set of 35 indicators assesses quality for five domains of care for complex pediatric patients: (1) primary care – general, (2) patient/family-centered care, (3) chronic care, (4) coordination of care, and (5) transition of care. The indicators use data from a variety of sources, including the medical record (17 indicators), patient surveys (10 indicators), and practice-based surveys (8 indicators).1 Indicators using patient survey data are primarily based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) instruments (A.Y. Chen, personal communication, May 13, 2013).1

Date: Measure released in 2012.1

Perspective: Patient/Family, System Representative(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 28, 29, 35
  • Communicate:
      • Between health care professional(s) and patient/family: 4, 15, 17, 18, 19
    • Information transfer: 2
      • Between health care professional(s) and patient/family: 2
  • Facilitate transitions:
    • Across settings: 25, 27
    • As coordination needs change: 34, 35
  • Assess needs and goals: 16, 18
  • Create a proactive plan of care: 23
  • Monitor, follow up, and respond to change: 24
  • Support self-management goals: 24
  • Link to community resources: 20, 33
  • Align resources with patient and population needs: 21, 22
  • Teamwork focused on coordination: 27
  • Health IT-enabled coordination: 5

Development and Testing: A national expert panel, using the RAND/University of California Los Angeles Appropriateness Method, selected the final set of 35 quality measures from among 74 candidates.1

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

Logic Model/Conceptual Framework: The American Academy of Pediatrics Patient-Centered Medical Home model.2

Country: United States

Past or Validated Applications*:

  • Patient Age: Children
  • Patient Condition: Combined Chronic Conditions, Children with Special Health Care Needs
  • Setting: Primary Care Facility

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

Notes:

  • For the purposes of mapping to coordination domains in this profile, items were numbered consecutively in the order in which they appear in Table 2 of the source article.1
  • This instrument contains 35 quality indicators, of which 20 were mapped.
  • Additional information for some indicators is forthcoming in the National Quality Measures Clearinghouse (A.Y. Chen, personal communication, May 13, 2013).

Source:

  1. Chen AY, Schrager SM, Mangione-Smith R. Quality measures for primary care of complex pediatric patients. Pediatrics 2012;129(3):433-45.
  2. Medical Home Initiatives for Children With Special Needs Project Advisory Committee. American Academy of Pediatrics. The medical home. Pediatrics 2002;110(1 Pt 1):184-6.

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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, 24). Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6w.html

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