Potential Measures for Clinical-Community Relationships

Patient-Community Resource Relationships

Community Resource Element: Patient-Community Resource Relationships

Potential Measure RR
Item Description
Title Prevention goal setting and action planning
Description This measure assesses whether there are prevention goals and a plan for achievement of those goals that were jointly developed between a client and his/her community resource organization.
Domain Assessment and goal setting (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may report the percentage of clients who receive services from a particular community resource who have a jointly developed action plan with goals and milestones.
Notes N/A

Potential Measure SS
Item Description
Title Communication between client and community resource
Description This measure assesses the level of interaction between a client and a community resource organization.
Domain Communication and follow through/follow up (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may be reported as the percentage of clients who receive services from a particular community resource that report communication with the community resource after an initial visit.
Notes This measure may further evaluate the modes of communication (e.g., in-person, telephone, texting, email, group meetings, etc.) as well as the timeliness of communication.

Potential Measure TT
Item Description
Title Average total time working with client
Description This measure assesses the average amount of time community resources spend in providing a preventive service to their clients.
Domain Cost/efficiency (patient-community resource)
Data source Audit – An auditor will use administrative management data to determine the average total time community resources spend working with clients.
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may report the average total time (including scheduling services, providing services, follow-up calls, etc.) per patient it takes community resources to provide a preventive service to their clients.
Notes Measure should consider new compensation policy for delivering preventive services and using community resources to do so.

This measure will be assessing total time working with client while the client is participating in a clinical-community relationship intervention. It may be assessed relative to specific clinical preventive services.

Potential Measure UU
Item Description
Title Percentage of clients referred to a community resource who received appropriate preventive services
Description This measure assesses whether clients referred to a community resource through a clinical-community relationship are receiving appropriate preventive services from the community resource
Domain Delivery of service (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may report the percentage of referrals from a clinic/clinician to a community resource that result in the delivery of the preventive service.
Notes Appropriate preventive services should be based on USPSTF recommendations based on a patient’s age, sex, and risk factors. This measure should focus on the delivery of preventive services for which the patients were referred by a clinic/clinician.

Supplementary data sources may include administrative client tracking data and/or electronic client record and/or paper client records.

The meaning of “appropriate” preventive services depends on context, setting, and the particular evaluation goals of any study that uses the measure. 

Potential Measure VV
Item Description
Title Client interest in accessing preventive services from community resource
Description This measure assesses the level of interest clients have in continuing to access preventive services from a community resource after their initial encounter with the community resource.
Domain Informed and activated patient (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may report the average level of interest of patients who had an encounter with a particular community resource in continuing to receive preventive services from the community resources.
Notes

Measure may be adapted from measure 5 of the CCRM Atlas - Safety Check Practitioner Post-Visit Survey. Should take into account Prochaska’s Transtheoretical model5.

This measure will be assessing client interest while the client is participating in a clinical-community relationship intervention.

Potential Measure WW
Item Description
Title Patient-centeredness of care offered by community resources
Description This measure assesses the level of patient-centered care a patient received from community resources.
Domain Patient-centeredness (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may be reported as the average level of patient-centered care received from community resources in a community. Subscale domains for this measure may include levels of the following: enabling of informed decisions, coordination of care, and patient value reflected in care.
Notes Principles of this measure may be adapted from work by CAHPS Patient Centered Medical Home survey:
http://www.ahrq.gov/cahps/surveys-guidance/cg/pcmh/index.html

This measure will be assessing patient-centeredness while the patient is participating in a clinical-community relationship intervention.

Similar to measure FF in clinic/clinician-patient relationship

Potential Measure XX
Item Description
Title Patient experience of care with community resource
Description This measure assesses aspects of a patient’s experience with a community resource to achieve a desired preventive health goal.
Domain Patient experience (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community organization or for all patients who receive services from community resources in the community as a whole.  This measure may be based on specific survey items (patient recall of interactions with community resource, experience with treatment, etc.) or may be reported as a composite measure that combines responses to several survey items to assess relevant aspects of patient experience.
Notes This measure may focus on preventive services amenable to the clinical-community relationships approach to support a comparison between the delivery of these services in the clinical setting and the community setting.

Similar to measure GG of clinic/clinician-patient relationship.

Potential Measure YY
Item Description
Title Proactive steps taken by community resources to engage and interact with patients
Description This measure assesses the degree of proactivity demonstrated by community resources in seeking out, engaging, and interacting with patients who have been referred for services.
Domain Proactive and ready community resource (patient-community resource)
Data source Audit – An auditor will assess policies and procedures, plus activities undertaken by the community resource organization to follow up on referrals received from clinicians.
Calculation method This measure may be assessed for an individual community resource or for community resource organizations in the community as a whole. This measure will be reported as a composite measure reflecting relevant aspects of community resource follow up.  
Notes This measure will be assessing community resource proactivity in working with clients who have been referred through a clinical-community relationship intervention.

Potential Measure ZZ
Item Description
Title Community resource supports patient self-management of prevention
Description This measure assesses community resource support for patient self-management of prevention activities.
Domain Self-management support (patient-community resource)
Data source Patient/individual survey
Calculation method This measure may be reported for patients of a particular community resource clinic or for patients in the community as a whole. It may be targeted to patients participating in a clinical-community relationship or be reported more generally. This measure may report the percentage of patients who report community resource support of self-management for prevention. Support may include community resource involvement in the development, implementation, and monitoring of a prevention plan, and encouraging patients to use self-support groups, programs, or tools.
Notes Principles for this measure may be adapted from the Canadian Institute for Health Information: Self-management support indicator: https://secure.cihi.ca/free_products/Pan-Canadian_PHC_Indicator_Update_Report_en_web.pdf

Measure may also be adapted from IHI self-management support measures
http://www.ihi.org/knowledge/Pages/Measures/SelfManagementSupportMeasures.aspx

This measure is most relevant in the context of a clinical-community relationship intervention.

Similar to measure HH of the clinic/clinician-patient relationship


5.James O. Prochaska and Wayne F. Velicer (1997) The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion: September/October 1997, Vol. 12, No. 1, pp. 38-48. http://ajhpcontents.org/doi/abs/10.4278/0890-1171-12.1.38

Page last reviewed October 2013
Internet Citation: Patient-Community Resource Relationships. October 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/resources/ccrm-atlas-suppl/ccrm-atlas3-6.html