Potential Measures
A comprehensive list of the potential measures is provided in Table 2. A description of each of the 52 potential measures is provided following Table 2.
The letters before each potential measure correspond to the letters provided in the Master Measure Mapping Table (Table 1) which indicate the domain within the Measurement Framework in which each measure falls. The Measurement Framework is provided on Table A-1. A domain may apply to more than one element/relationship within the CCRM Measurement Framework.
The numbers within cells of the Master Measure Mapping Table correspond to the measure number for existing measures from the CCRM Atlas. Existing measures from the CCRM Atlas are provided for ease of reference in the Appendix. The Appendix also contains, in addition to the CCRM Measurement Framework, the definition for each domain (Table A-2), and a listing of CCRM Expert Panel Members.
Table 1. Master measure mapping table with potential measures
Domain | Element | Relationship | ||||
Clinic/Clinician | Patient | Community Resource | Clinic/Clinician – Patient | Clinic/Clinician – Community Resource | Patient – Community Resource | |
Ability to access primary care | K | |||||
Ability to access community resource | 3 | |||||
Accessibility | A, B | S | ||||
Assessment and goal setting | 13 | RR | ||||
Capacity for self-management | L | |||||
Clinician experience | 9, 11, 21, JJ | |||||
Communication and follow through/follow up | SS | |||||
Community resource experience | KK, LL | |||||
Cost/efficiency | DD | MM, NN | TT | |||
Delivery of service | EE | UU | ||||
Delivery system design | C | T, U | ||||
Feedback and communication | 12, 20 | |||||
Health literacy | M, N | |||||
Information technology infrastructure | D | O | V | |||
Informed and activated patient | 5 | VV | ||||
Knowledge of and familiarity with community resources | 10, 22 | P | ||||
Marketing of services | W | |||||
Marketing results | X | |||||
Nature and strength of the inter-organizational relationship | OO | |||||
Organizational infrastructure | E | Y | ||||
Outreach to obtain knowledge of and familiarity with community resources | F | Q | ||||
Patient-centeredness | FF | WW | ||||
Patient experience | GG | XX | ||||
Proactive and ready clinician | 6, 7 | |||||
Proactive and ready community resource | YY | |||||
Readiness for behavior change | G | 2, 18 | Z | |||
Referral process | 1, 4, 8, 14, 15, 17,19, 21 |
PP | 16 | |||
Self-management support | HH | ZZ | ||||
Service capacity | H | AA | ||||
Shared decision-making | II | |||||
Stage of behavior change | I | R | BB | |||
Timeliness | ||||||
Training | J | CC |
Notes
- Blank cell (gray background): the domain does not apply to the element or relationship.
- Cell with Numbers (green background): a measure exists. See CCRM Atlas.
- Cells with Letters (white background): the domain applies to the element or relationship and no measure exists.
- Number(s) in the cell correspond with measure number in CCRM Atlas.
- Letter(s) in the cell correspond with candidate measure(s) in this supplement.
Potential measures are organized according to the columns of the Master Measure Mapping Table (Table 1). The measures are listed in Table 2, followed by details for each potential measure presented in the format of the measure template.
Table 2. Potential measures
Letter | Potential measure |
A | Patient difficulty in accessing primary care |
B | Accessibility of clinic/clinical practices |
C | Clinic/clinician delivery system capability |
D | Clinic/clinician appropriate use of health information technology |
E | Financial sustainability (clinic/clinician) |
F | Clinic/clinician actions to learn about community resources |
G | Clinician readiness to change |
H | Infrastructure to maintain relationships with community resource(s) |
I | Progress through the stages of organizational change (clinic/clinician) |
J | Staff competency in providing preventive health services (clinic/clinician) |
K | Patient has a usual source of primary care |
L | Patient ability to achieve prevention goals |
M | Patient health literacy |
N | Patient health numeracy |
O | Patient appropriate use of health information technology |
P | Patient awareness of available community resources |
Q | Patient actions to learn about community resources |
R | Progress through the stages of behavior change (patient) |
S | Accessibility of community resources |
T | Community resource delivery system infrastructure |
U | Community resource capacity to deliver preventive services |
V | Community resource appropriate use of health information technology |
W | Availability of community resource marketing plans |
X | Effectiveness of community resource marketing |
Y | Financial sustainability (community resource) |
Z | Community resource readiness to change |
AA | Infrastructure to maintain relationships with clinic(s) |
BB | Progress through the stages of organizational behavior change (community resource) |
CC | Staff competency in providing preventive health services (community resource) |
DD | Clinic/clinician efficiency due to the use of clinical-community relationships |
EE | Percentage of patients who received appropriate preventive services |
FF | Patient-centeredness of care offered by clinic/clinicians |
GG | Patient experience of care with primary care clinic/clinician |
HH | Clinician supports patient self-management of prevention |
II | Patient report of shared decision making regarding prevention |
JJ | Utility of “bridging resources” / informational tools used by clinicians to foster relationships with community resources |
KK | Value of clinical-community resource relationship |
LL | Utility of “bridging resources” / informational tools used by community resources to foster relationship with clinic/clinicians |
MM | Costs to the clinic/clinician and a community resource to establish a clinical-community relationship |
NN | Costs to the clinic/clinician and a community resource to maintain a clinical-community relationship |
OO | Strength of a clinical-community resource relationship |
PP | Percentage of referrals to a community resource that are actionable |
Time to provide preventive services by a community resource. | |
RR | Prevention goal setting and action planning |
SS | Communication between client and community resource |
TT | Average total time working with client |
UU | Percentage of clients referred to a community resource who received appropriate preventive services |
VV | Client interest in accessing preventive services from community resource |
WW | Patient-centeredness of care offered by community resources |
XX | Patient experience of care with community resource |
YY | Proactive steps taken by community resources to engage and interact with patients |
ZZ | Community resource supports patient self-management of prevention |