Potential Measures for Clinical Community Relationships

A Supplement to the Clinical-Community Relationships Measures Atlas

4. Recommended Measures and Core Steps

This report includes 52 potential measures plus 22 existing measures from the CCRM Atlas. All need additional development and refinement to ensure that the resulting measures are scientifically sound, relevant, and feasible for assessing clinical-community relationships for prevention. To help stakeholders focus resources and effort, we have selected a core set of 13 measures to prioritize for future development. The core set reflects a judgment about which measures may be the most useful and feasible for quality improvement and program evaluation. The recommended set of core measures highlights the complex interactions between patients, clinicians, and community organizations involved in clinical-community relationships.  It reflects the need for measures that are broadly applicable across settings and programs, while focusing on key aspects of the structures, processes, and outcomes that are important for any type of clinical-community relationship design. The suggested core measures are listed below, divided among Donabedian’s measure categories6 :

Structure Measures

  1. Clinic/clinician and community resource infrastructure to maintain clinical-community relationships (Potential Measures H and AA)
  2. Community resource capacity to deliver preventive services (Potential Measure U)
  3. Strength of a clinical-community resource relationship (Potential Measure OO)

Process Measures

  1. Percentage of referrals to a community resource that are actionable (Potential Measure PP)
  2. Clinician receipt of treatment plan from the service coordinator (CCRM Atlas Measure 12)

Outcome Measures

  1. Percentage of clients referred to a community resource who received appropriate preventive services (Potential Measure UU)
  2. Percentage of patients who received appropriate preventive services (Potential Measure EE)
  3. Patient experience of care with community resource (Potential Measures XX)
  4. Utility of “bridging resources”/informational tools used by clinicians and community resources to foster clinical-community relationships (Potential Measures JJ and LL)
  5. Costs to the clinic/clinician and a community resource to establish and maintain a clinical-community relationship (Potential Measures MM and NN).

Stakeholders with interest in the advancement of the clinical-community relationships approach may include integrated health systems, accountable care organizations, or safety-net providers. This research can take place within these delivery systems or may take advantage of other types of research infrastructure such as practice-based research networks.

Clinical service providers and community organizations have the potential to work together for the delivery of a range of services, including, but not limited to, the clinical preventive services that have been the focus of this project. These relationships can take a variety of forms, ranging from awareness, to cooperation, to collaboration, to partnership. Further work on refining the core set of measures can help advance the development of these relationships, and the science of designing and evaluating interventions.


6. Donabedian A. The quality of care: how can it be assessed? Archives of Pathology and Laboratory Medicine. 1997;121:1145–1150.

Current as of October 2013
Internet Citation: Potential Measures for Clinical Community Relationships: A Supplement to the Clinical-Community Relationships Measures Atlas. October 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/resources/ccrm-atlas-suppl/ccrm-atlas4.html