Potential Measures for Clinical-Community Relationships

A Supplement to the Clinical-Community Relationships Atlas

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

DomainElementRelationship
Clinic/ClinicianPatientCommunity ResourceClinic/Clinician – PatientClinic/Clinician – Community ResourcePatient – Community Resource
Ability to access primary care K    
Ability to access community resource 3    
AccessibilityA, 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   DDMM, NNTT
Delivery of service   EE UU
Delivery system designC T, U   
Feedback and communication    12, 20 
Health literacy M, N    
Information technology infrastructureDOV   
Informed and activated patient   5 VV
Knowledge of and familiarity with community resources10, 22P    
Marketing of services  W   
Marketing results  X   
Nature and strength of the inter-organizational relationship    OO 
Organizational infrastructureE Y   
Outreach to obtain knowledge of and familiarity with community resourcesFQ    
Patient-centeredness   FF WW
Patient experience   GG XX
Proactive and ready clinician   6, 7  
Proactive and ready community resource     YY
Readiness for behavior changeG2, 18Z   
Referral process   1, 4, 8, 14,
15, 17,19, 21
PP16
Self-management support   HH ZZ
Service capacityH AA   
Shared decision-making   II  
Stage of behavior changeIRBB   
Timeliness    QQ 
TrainingJ 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

LetterPotential measure
APatient difficulty in accessing primary care
BAccessibility of clinic/clinical practices
CClinic/clinician delivery system capability
DClinic/clinician appropriate use of health information technology
EFinancial sustainability (clinic/clinician)
FClinic/clinician actions to learn about community resources
GClinician readiness to change
HInfrastructure to maintain relationships with community resource(s)
IProgress through the stages of organizational change (clinic/clinician)
JStaff competency in providing preventive health services (clinic/clinician)
KPatient has a usual source of primary care
LPatient ability to achieve prevention goals
MPatient health literacy
NPatient health numeracy
OPatient appropriate use of health information technology
PPatient awareness of available community resources
QPatient actions to learn about community resources
RProgress through the stages of behavior change (patient)
SAccessibility of community resources
TCommunity resource delivery system infrastructure
UCommunity resource capacity to deliver preventive services
VCommunity resource appropriate use of health information technology
WAvailability of community resource marketing plans
XEffectiveness of community resource marketing
YFinancial sustainability (community resource)
ZCommunity resource readiness to change
AAInfrastructure to maintain relationships with clinic(s)
BBProgress through the stages of organizational behavior change (community resource)
CCStaff competency in providing preventive health services (community resource)
DDClinic/clinician efficiency due to the use of clinical-community relationships
EEPercentage of patients who received appropriate preventive services
FFPatient-centeredness of care offered by clinic/clinicians
GGPatient experience of care with primary care clinic/clinician
HHClinician supports patient self-management of prevention
IIPatient report of shared decision making regarding prevention
JJUtility of “bridging resources” / informational tools used by clinicians to foster relationships with community resources
KKValue of clinical-community resource relationship
LLUtility of “bridging resources” / informational tools used by community resources to foster relationship with clinic/clinicians
MMCosts to the clinic/clinician and a community resource to establish a clinical-community relationship
NNCosts to the clinic/clinician and a community resource to maintain a clinical-community relationship
OOStrength of a clinical-community resource relationship
PPPercentage of referrals to a community resource that are actionable
QQTime to provide preventive services by a community resource.
RRPrevention goal setting and action planning
SSCommunication between client and community resource
TTAverage total time working with client
UUPercentage of clients referred to a community resource who received appropriate preventive services
VVClient interest in accessing preventive services from community resource
WWPatient-centeredness of care offered by community resources
XXPatient experience of care with community resource
YYProactive steps taken by community resources to engage and interact with patients
ZZCommunity resource supports patient self-management of prevention
Current as of 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.html