Patient Element
| Potential Measure K | |
| Item | Description |
| Title | Patient has a usual source of primary care |
| Description | This measure assesses whether patients within a community have a usual source of primary care. |
| Domain | Ability to access primary care (patient). |
| Data source | Patient/individual survey |
| Calculation method | This measure may be assessed for patients of a particular clinic or community practice, or for members of the community as a whole. This measure may be reported as the percentage of patients within a community who report a usual source of care. Usual sources of primary care could include family physicians, nurses of a clinic, obstetricians, etc. |
| Notes | Principles for this measure may be adapted from 2007 Medical Expenditure Panel Survey: Percent of persons with a usual primary care provider: http://www.healthindicators.gov/Indicators/Usual-primary-care-provider-percent_372/Profile |
| Potential Measure L | |
| Item | Description |
| Title | Patient ability to achieve prevention goals |
| Description | This measure assesses the level of knowledge, capacity, skill, and support patients have to achieve prevention goals. |
| Domain | Capacity for self-management (patient) |
| Data source | Patient/individual survey |
| Calculation method | This measure may be assessed for patients of a particular clinic or community practice, or for members of the community as a whole for their ability to manage their own health to achieve prevention goals. |
| Notes | Relevant types of support include structural, familial, work, or other environmental factors. This measure should be specific to prevention goals that are the target of clinical-community relationships such as weight loss, smoking cessation, or reducing alcohol misuse |
Patient Element
| Potential Measure M | |
| Item | Description |
| Title | Patient health literacy |
| Description | This measure assesses patients’ ability to understand health information needed to manage their own health and make appropriate health care decisions. Appropriate use of health information technology may be defined in terms of CMS Meaningful Use objectives, or other ways of using technology to improve quality, reduce health disparities, or engage patients and family. |
| Domain | Health literacy (patient) |
| Data source | Patient/individual survey |
| Calculation method | This measure may be assessed for patients of a particular clinic or community resource or for members of the community as a whole. This measure may be reported as the percentage of patients achieving adequate health literacy. |
| Notes | Principles for this measure may be adapted from the Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM). The determination of reading comprehension should take into account actionable knowledge that the patient may use to improve his/her care. The meaning of “appropriate” use of health information technology depends on context, setting, and the particular evaluation goals of any study that uses the measure. |
| Potential Measure N | |
| Item | Description |
| Title | Patient health numeracy |
| Description | This measure assesses patients’ ability to understand numerical information needed to manage their own health and make appropriate health care decisions. Appropriate use of health information technology may be defined in terms of CMS Meaningful Use objectives, or other ways of using technology to improve quality, reduce health disparities, or engage patients and family. |
| Domain | Health literacy (patient) |
| Data source | Patient/individual survey |
| Calculation method | This measure may be assessed for patients of a particular clinic or community resource, or for members of the community as a whole. This measure may be reported as the percentage of patients achieving adequate health numeracy. |
| Notes | Principles for this measure may be may be adapted from the Subjective Numeracy Scale (SNS): http://cbssm.med.umich.edu/how-we-can-help/tools-and-resources/subjective-numeracy-scale The determination of mathematical skill should take into account actionable knowledge that the patient may use to improve his/her care. The meaning of “appropriate” use of health information technology depends on context, setting, and the particular evaluation goals of any study that uses the measure. |
| Potential Measure O | |
| Item | Description |
| Title | Patient appropriate use of health information technology |
| Description | This measure assesses whether patients use health information technology appropriately to achieve preventive health goals. Appropriate use of health information technology may be defined in terms of CMS Meaningful Use objectives, or other ways of using technology to improve quality, reduce health disparities, or engage patients and family. |
| Domain | Information technology infrastructure (patient) |
| Data source | Survey – A patient survey to assess the use of health information technology for achieving prevention goals such as weight loss or smoking cessation, as well as reminders to receive applicable clinical preventive services. |
| Calculation method | This measure may be reported as the percentage of patients of a clinical practice, or other relevant patient population who use health information technology appropriately to facilitate achieving preventive health goals. |
| Notes | Types of health information technology could include: personal health records, activity logs, or appointment reminder systems that may be linked to electronic health records. Principles of this measure may be adapted from Stage 3 Meaningful Use Recommendations related to Engaging patients and families in their care: The meaning of “appropriate” use of health information technology depends on context, setting, and the particular evaluation goals of any study that uses the measure. |
| Potential Measure P | |
| Item | Description |
| Title | Patient awareness of available community resources |
| Description | This measure assesses the level of awareness of patients regarding available community resources that provide preventive services. |
| Domain | Knowledge of and familiarity with community resources (patient) |
| Data source | Patient/individual survey |
| Calculation method | This measure may be assessed for patients of a particular clinic, or for members of the community as a whole. This measure may be reported as the average level of awareness about availability of community resources that provide preventive services. This measure may be specific to particular preventive services. |
| Notes | N/A |
| Potential Measure Q | |
| Item | Description |
| Title | Patient actions to learn about community resources |
| Description | This measure assesses the actions of patients within a community to learn about available preventive services offered by community resources within a community. |
| Domain | Outreach to obtain knowledge of and familiarity with community resources (patient) |
| Data source | Patient/individual survey |
| Calculation method | This measure may be based on specific survey items (patient recall of telephone calls to community resource, email inquiries, website visits, etc.) or may be reported as a composite measure that combines responses to several survey items to assess the intensity of actions reported by patients in a community to learn about available preventive services offered by community resources. |
| Notes | Similar to measure F of clinic/clinician element |
| Potential Measure R | |
| Item | Description |
| Title | Progress through that stages of behavior change (patient) |
| Description | This measure assesses how well patients have been able to initiate and sustain behavior changes necessary to achieve prevention goals. |
| Domain | Stage of behavior change (patient) |
| Data source | Patient/individual survey |
| Calculation method | This measure may be reported as the percentage of patients of a clinical practice, or other relevant patient population who have been able to initiate and sustain behavior changes over time. |
| Notes | Measure should consider principles from Prochaska’s Transtheoretical model5. Similar to measure I of clinic/clinician element and BB of community resource element |
