Potential Measures for Clinical-Community Relationships

Potential Measures

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