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Care Coordination Measures Atlas Update

Chapter 6. Measure Maps and Profiles (continued, 26)

Measures 78-80

Measure #78. Safe Transitions Community Physician Office Best Practice 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.

Safe Transitions Community Physician Office Best Practice Measures

Purpose: To measure successful communication and timely transfer of clinical information at the time of patient transitions to and from the hospital (including emergency department) and community physician offices.

Format/Data Source: A 7-item set of measures designed to reflect best practices for community-based ambulatory care physicians when facilitating high-quality patient transitions to and from their offices. The measure set includes measures of information transfer (i.e., discharge summaries, medication lists, referral information), medication reconciliation, accountability (i.e., naming primary care provider), follow-up, and other coordination activities. Data for all seven measures is derived from documentation included in patients’ medical records (chart review) or electronic clinical information (audit trails). Measure specifications include numerator and denominator definitions and exclusions.1

Date: Measure released in 2012.1

Perspective: System Representative

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 4
  • Communicate:
    • Interpersonal communication:
      • Across health care teams or settings: 2
    • Information transfer:
      • Across health care teams or settings: 1, 3, 4
  • Facilitate transitions:
    • Across settings: 1, 2, 3, 4, 5, 6, 7
  • Monitor, follow up, and respond to change: 5, 6
  • Medication Management: 7

Development and Testing: The measures set is based on evidence-based guidelines. A consensus-based stakeholder review process was utilized to refine the best practices and ensure feasibility with existing care setting workflows. The stakeholders vetted the finalize measure set, including ensuring face validity.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: Adult
  • Patient Condition: Not Condition Specific
  • Setting: Primary Care Facility, Inpatient Care Facility, Emergency Department

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

Notes:

  • All instrument items are located online.2
  • This instrument contains 7 items, of which 7 were mapped.
  • Several other related versions of this measure set exist, each tailored to transitions to and from a different setting: emergency departments, home health agencies, nursing homes, urgent care centers, and hospitals.

Sources:

  1. Baier R, Gardner R, Gravenstein S, et al. Partnering to improve hospital-physician office communication through implementing care transitions best practices. Medicine & Health / Rhode Island 2012:178-82.
  2. Healthcentric Advisors Partnering to Improve Hospital-Physician Office Communication. Available at: http://www.healthcentricadvisors.org/resources/managing-healthcare/tag/resources/Safe%20Transitions.html. Accessed: August 14, 2013.

Measure #79. National Survey of Physicians Organizations and the Management of Chronic Illness II (NSPO-2)

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

National Survey of Physicians Organizations and the Management of Chronic Illness II (NSPO-2)

Purpose: To measure the degree of adoption of primary care medical home (PCMH) infrastructure components (physician-directed care, care coordination/integration, quality and safety, and enhanced access) in large primary care practices and multispecialty medical groups.

Format/Data Source: A 221-item survey completed by medical directors, presidents, or chief operating officers of medical groups and independent practice associations with more than 20 physicians and who treat patients with specific chronic diseases (asthma, diabetes, congestive heart failure, or depression). The survey takes approximately 35 minutes to complete by telephone. Survey responses can be combined to create a PCMH index ranging from 0 to 20, where a greater score indicates greater implementation of PCMH infrastructure components.1

Date: Measure released in 2008.2

Perspective: System Representative(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: C41, C42, C43, C44, C45, C46, C47, C48, C49, D5
  • Communicate:
    • Interpersonal communication:
      • Between health care professional(s) and patient/family: B30
      • Within teams of health care professionals: C49
    • Information transfer:
      • Between health care professional(s) and patient/family: B16
      • Within teams of health care professionals: B13, B14
      • Across health care teams or settings: B17, B19, B21, B23, B25, B27, B29, D9
      • Participants not specified: G2
  • Assess needs and goals: C46, G1, H5
  • Monitor, follow up, and respond to change: C17, C18, C19, C20, C21, C22, C23, C24, D2, G3
  • Support self-management goals: C25, C26, C27, C28, C29, C30, C31, C32, D3
  • Align resources with patient and population needs: C25, C26, C27, C28, C29, C30, C31, C32, C41, C42, C43, C44, C45, C46, C47, C48, C51, D3, D5, G16
  • Teamwork focused on coordination: C49, D10
  • Care management: C41, C42, C43, C44, C45, C46, C47, C48, D5, D9, D10
  • Health IT-enabled coordination: B13, B14, B16, B18, B20, B22, B24, B26, B28, B30

Development and Testing: None described in the source identified.

Link to Outcomes or Health System Characteristics: Among 291 medical groups, larger groups (measured by number of physicians) scored higher on the PCMH Index calculated from the NSPO-2 survey, indicating greater implementation of PCMH infrastructure components.1 In a sample of 1,164 small or medium sized physician practices (<20 physicians), practices that participated in an independent practice association or a practice-hospital organization were significantly more likely to offer greater care management processes to their patients, including using a registry to track patients with chronic disease, providing reminders to patients about needed follow-up care, and using nurse care managers to coordinate with patients between office visits (p<0.05).3

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
  • Setting: Primary Care Facility, Other Outpatient Specialty Care Facility

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

Notes:

  • All instrument items are located online.2
  • This instrument contains 221 items, of which 53 were mapped.
  • Version 3 of this measure has been developed, but has not yet been publicly released.

Sources:

  1. Rittenhouse DR, Casalino LP, Gillies RR, et al. Measuring the medical home infrastructure in large medical groups. Health Affairs 2008;27(5):1246-58.
  2. University of California at Berkeley. National Study of Physician Organizations. Available at: http://nspo.berkeley.edu/Instruments.htm. Accessed: August 29, 2013.
  3. Casalino LP, Wu FM, Ryan AM, et al. Independent practice associations and physician-hospital organizations can improve care management for smaller practices. Health Aff (Millwood) 2013;32(8):1376-82.

Measure #80. Patient-Centered Medical Home Assessment (PCMH-A) Tool

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.

Patient-Centered Medical Home Assessment (PCMH-A) Tool

Purpose: To assess implementation of the patient-centered medical home model at a site of care, identify opportunities for related improvement, and track progress towards strengthening the patient-centered medical home.

Format/Data Source: A 35-item survey to be completed by multidisciplinary groups of health care professionals (i.e., physicians, nurses, medical assistants, residents, administrative staff) to assess the current level of functional implementation of the patient-centered medical home model in a practice. The survey is comprised of eight change concept subscales, including (1) engaged leadership, (2) quality improvement strategy, (3) empanelment, (4) continuous and team-based healing relationships, (5) organized, evidence-based care, (6) patient-centered interactions, (7) enhanced care, and (8) care coordination. Responses are on a 12-point scale, with quadrants of scores (1-3, 4-6, 7-9, 10-12) divided among four levels of PCMH implementation (level A-D). Higher scores (i.e., level A) indicate more advanced implementation of the PCMH model.1

Date: Measure released in 2013.1

Perspective: System Representative(s)

Measure Item Mapping:

  • Establish accountability or negotiate responsibility: 29
  • Communicate:
      • Between health care professional(s) and patient/family: 8, 21, 22, 35
      • Within teams of health care professionals: 19
      • Across health care teams or settings: 19, 32
    • Information transfer:
      • Across health care teams or settings: 28
  • Facilitate transitions:
    • Across settings: 30, 31, 32, 33
  • Assess needs and goals: 17, 20, 21
  • Create a proactive plan of care: 18
  • Monitor, follow up, and respond to change: 17, 32, 33
  • Support self-management goals: 18, 23
  • Link to community resources: 32, 34
  • Align resources with patient and population needs: 19, 22
  • Teamwork focused on coordination: 17
  • Health care home: 8, 17, 18, 19, 20, 21, 22, 23, 28, 29, 30, 31, 32, 33, 34, 35*
  • Care management: 19
  • Health IT-enabled coordination: 8

*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: None described in the sources identified.

Link to Outcomes or Health System Characteristics: In a study of 64 safety net practices from five states participating in a national demonstration project, independent observers agreed with practices’ PCMH-A scores 82% of the time. In addition, practices that earned recognition as a PCMH by the National Committee for Quality Assurance early in the demonstration had higher PCMH-A scores than other sites. In addition, sites that engaged in and completed more medical home transformation activities by the end of the demonstration were more likely to report higher PCMH-A scores (personal communication, Donna Daniel, April 3, 2013).

Logic Model/Conceptual Framework: The instrument was developed based on the Change Concepts for Practice Transformation2 and the 2008 National Committee for Quality Assurance PCMH standards.3

Country: United States

Past or Validated Applications*:

  • Patient Age: Not Applicable
  • Patient Condition: Not Applicable
  • Setting: Primary Care Facility

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

Notes:

  • All instrument items are located online.1
  • This instrument contains 35 items, of which 16 were mapped.

Sources:

  1. Patient-Centered Medical Home Assessment (PCMH-A). Safety Net Medical Home Initiative. Available at: http://www.safetynetmedicalhome.org/sites/default/files/PCMH-A.pdf.
  2. Wagner EH, Coleman K, Reid RJ, et al. The changes involved in patient-centered medical home transformation. Prim Care 2012;39(2):241-59.
  3. National Committee for Quality Assurance. PCMH Standards & Guidelines. Available at: http://www.ncqa.org/tabid/1016/Default.aspx. Accessed: August 1, 2011.

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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, 26). Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6y.html

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