Potential Measures for Clinical-Community Relationships

A Supplement to the Clinical-Community Relationships Atlas

 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
Page last reviewed October 2013
Internet Citation: Potential Measures for Clinical-Community Relationships: A Supplement to the Clinical-Community Relationships Atlas. October 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/resources/ccrm-atlas-suppl/ccrm-atlas3-2.html