Chapter 5. Measure Maps and Profiles

Care Coordination Measures Atlas

In the first section of this chapter we present three Master Measure Mapping Tables, one for each perspective— Patient/Family, Health Care Professional(s), and System Representative(s). In the second section of this chapter, we present specific measure mapping tables for each individual measure and profiles detailing information about each measure.

Master Measure Mapping Tables

Tables 5, 6, and 7 are Master Measure Mapping Tables for the three care coordination perspectives— Patient/Family, Health Care Professional(s), and System Representative(s), respectively. The tables indicate which measures focus on each of the care coordination domains for each perspective. The measure numbers seen in the Master Measure Mapping Tables correspond to the numbers assigned to each measure in Table 8.

Table 5. Care Coordination Master Measure Mapping Table, Patient/Family Perspective†

Care Coordination Activities
	Measurement Perspective: Patient/Family
Establish accountability or negotiate responsibility	3, 4a, 4b, 4c, 6, 9b, 11a, 13, 14, 16c, 17a, 17b, 26, 32, 37, 40, 42, 45, 48
Communicate	3, 4a, 4b, 4c, 6, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 24, 25, 26, 29, 30, 31, 32, 33, 37, 38a, 45, 48, 51
Interpersonal communication	3, 4a, 4b, 4c, 6, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 33, 35, 36, 37, 38b, 39, 40, 41, 42, 45, 48, 51
Information transfer	3, 4a, 4b, 4c, 6, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 24, 26, 29, 30, 31, 32, 33, 35, 36, 37, 38a, 38b, 39, 40, 41, 42, 45, 48, 49, 51
Facilitate transitions‡
Across settings	9a, 9b, 13, 14, 16c, 17a, 17b, 21, 26, 31, 32, 37, 38a, 38b, 40, 42, 51
As coordination needs change	11a, 14, 24
Assess needs and goals	3, 4a, 4b, 4c, 6, 9a, 9b, 10, 11a, 13, 14, 16c, 17a, 17b, 21, 24, 25, 26, 30, 31, 32, 33, 35, 37, 38a, 38b, 40, 41, 42, 45
Create a proactive plan of care	6, 9b, 10, 11a, 16c, 21, 24, 37, 38a, 40
Monitor, follow up, and respond to change	3, 4a, 4b, 4c, 6, 9b, 10, 11a, 13, 16c, 17a, 17b, 21, 24, 25, 26, 29, 31, 32, 33, 36, 37, 39, 40, 41, 45
Support self-management goals	4a, 4b, 4c, 6, 9a, 9b, 10, 11a, 13, 16c, 17a, 17b, 21, 24, 25, 26, 29, 31, 32, 33, 35, 36, 37, 38a, 38b, 40, 41
Link to community resources	10, 11a, 16c, 17b, 21, 24, 31, 33, 38a, 38b
Align resources with patient and population needs	6, 11a, 14, 16c, 17a, 17b, 31, 38a, 38b, 51
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination	6, 11a, 16c, 24, 25, 29, 30, 35, 36, 39, 40
Health care home	4a, 4b, 4c, 16c, 17a, 17b, 45, 51
Care management	11a, 14, 21, 51
Medication management	4a, 4b, 4c, 6, 9a, 9b, 10, 17a, 17b, 21, 32, 35, 36, 37, 38a, 38b, 42, 48
Health IT-enabled coordination	4a

† A key to measure numbers can be found in Table 8: Index of Measures.
‡ All measure items addressing transitions were mapped to one of the specific transition types (across settings or as coordination needs change).

Table 6. Care Coordination Master Measure Mapping Table, Healthcare Professional(s) Perspective†

Care Coordination Activities
	Measurement Perspective: Health Care Professional(s)
Establish accountability or negotiate responsibility	5, 7a, 7b, 11b, 18, 20, 22b, 38c, 38d, 38e, 43, 46
Communicate	5, 7a, 7b, 11b, 12a, 12b, 17d, 22b, 23, 38e, 38f, 43, 46
Interpersonal communication	7a, 7b, 8, 11b, 12a, 12b, 17d, 18, 22b, 28, 43
Information transfer	5, 8, 11b, 12a, 12b, 17d, 18, 20, 22b, 23, 27, 38c, 38d, 38e, 38f
Facilitate transitions‡
Across settings	5, 17d, 22b, 27, 43, 38c, 38d, 38e, 38f
As coordination needs change	11b, 22b
Assess needs and goals	5, 11b, 12a, 12b, 17d, 20, 23, 27, 38d, 38e, 38f, 43, 46
Create a proactive plan of care	5, 7b, 8, 11b, 12a, 22b, 23, 27, 38e, 38f
Monitor, follow up, and respond to change	5, 11b, 12a, 12b, 17d, 20, 22b, 23
Support self-management goals	5, 8, 11b, 17d, 20, 22b, 38d, 38e, 38f
Link to community resources	5, 11b, 17d, 22b, 27, 38e
Align resources with patient and population needs	5, 8, 11b, 17d, 20, 38d, 38e
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination	7a, 7b, 11b, 12a, 12b, 18, 23, 27, 28, 43, 46
Health care home	17d
Care management	5, 11b, 22b, 27
Medication management	17d, 18, 20, 38c, 38e, 38f
Health IT-enabled coordination	12a, 17d

Table 7. Care Coordination Master Measure Mapping Table, System Representative(s) Perspective†

Care Coordination Activities
	Measurement Perspective: System Representative(s)
Establish accountability or negotiate responsibility	1, 2, 15, 16a, 16b, 57, 58, 59, 60
Communicate	1, 16a, 16b, 17c, 22a, 34,
Interpersonal communication	17c, 22a, 52
Information transfer	1, 2, 15, 16a, 17c, 22a, 34, 44, 49, 50, 52, 53, 54, 56, 57, 58, 59, 60
Facilitate transitions‡
Across settings	15, 16a, 17c, 22a, 49, 50, 55, 57, 58, 59, 60
As coordination needs change	16a, 16b, 22a
Assess needs and goals	1, 16a, 16b, 17c, 44, 49
Create a proactive plan of care	1, 16a, 16b, 22a, 49, 52, 55, 58, 59, 60
Monitor, follow up, and respond to change	1, 2, 3, 17c, 19, 22a, 44, 49, 54, 58, 59, 60, 61
Support self-management goals	1, 16a, 17c, 19, 22a, 34, 49
Link to community resources	1, 16a, 17c, 22a, 44, 52
Align resources with patient and population needs	1, 2, 16a, 16b, 17c, 19, 49, 52
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination	1, 44, 52
Health care home	2, 3, 16a, 16b, 17c, 19, 47
Care management	15, 16a, 16b, 22a, 49
Medication management	2, 3, 17c, 57, 58, 60
Health IT-enabled coordination	1, 16a, 17c, 19, 34, 44, 50

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Measure Profiles

This section contains measure mapping tables specific to each individual measure. Each individual measure mapping table is followed by a measure profile designed to provide more detailed information on the measure's purpose, format and data source, perspective, validation and testing, links to outcomes, applications, and key sources. The measure profiles also identify the specific measure items (i.e., survey questions or measure components) that map to each domain. Table 8 below is an index to the measure numbers (far left column) cited in the Master Measure Mapping Tables and the order in which the individual measure mapping tables and profiles appear.

Table 8. Index of Measures

Measure Number	Measure Title
1.	Assessment of Chronic Illness Care (ACIC)
2.	ACOVE-2 Quality Indicators: Continuity and Coordination of Care Coordination
3.	Coleman Measures of Care Coordination
4.	Consumer Assessment of Healthcare Providers and Systems (CAHPS)
	a. Adult Primary Care 1.0
	b. Adult Specialty Care 1.0
	c. Child Primary Care 1.0
5.	Care Coordination Measurement Tool (CCMT)
6.	Client Perception of Coordination Questionnaire (CPCQ)
7.	Collaborative Practice Scale (CPS)
	a. Nurse Scale
	b. Physician Scale
8.	Breast Cancer Patient and Practice Management Process Measures
9.	Care Transitions Measure (CTM)
	a. CTM-3
	b. CTM-15
10.	Patient Assessment of Care for Chronic Conditions (PACIC)
11.	Family-Centered Care Self-Assessment Tool
	a. Family Version
	b. Provider Version
12.	ICU Nurse-Physician Questionnaire
	a. Long Version
	b. Short Version
13.	Primary Care Assessment Survey (PCAS)
14.	National Survey of Children With Special Health Care Needs (CSHCN)
15.	Head And Neck Cancer Integrated Care Indicators
16.	Medical Home Index (MHI)
	a. Long Version (MHI-LV)
	b. Short Version (MHI-SV)
	c. Medical Home Family Index and Survey (MHFIS)
17.	Primary Care Assessment Tool (PCAT)
	a. Child Expanded Edition (PCAT-CE)
	b. Adult Expanded Edition (PCAT-AE)
	c. Facility Expanded Edition (PCAT-FE)
	d. Provider Expanded Edition (PCAT-PE)
18.	Physician-Pharmacist Collaboration Instrument (PPCI)
19.	Readiness for the Patient-Centered Medical Home
20.	Family Medicine Medication Use Processes Matrix (MUPM)
21.	Resources and Support for Self-Management (RSSM)
22.	Continuity of Care Practices Survey
	a. Program Level (CCPS-P)
	b. Individual Level (CCPS-I)
23.	Program of All-Inclusive Care for the Elderly (PACE)
24.	Measure of Processes of Care (MPOC-28)
25.	Care Evaluation Scale for End-of-Life Care (CES)
26.	Oncology Patients' Perceptions of the Quality of Nursing Care Scale (OPPQNCS)
27.	Care Coordination Services In Pediatric Practices
28.	Collaboration and Satisfaction About Care Decisions (CSACD)
29.	Follow Up Care Delivery
30.	Family Satisfaction in the Intensive Care Unit (FS-ICU 24)
31.	Korean Primary Care Assessment Tool (KPCAT)
32.	Primary Care Multimorbidity Hassles for Veterans With Chronic Illnesses
33.	Primary Care Satisfaction Survey for Women (PCSSW)
34.	Personal Health Records (PHR)
35.	Picker Patient Experience (PPE-15)
36.	Physician Office Quality of Care Monitor (QCM)
37.	Patient Perceptions of Care (PPOC)
38.	Prepared Survey
	a. Patient Version
	b. Carer Version
	c. Residential Care Staff Version
	d. Community Service Provider Version
	e. Medical Practitioner Version
	f. Modified Medical Practitioner Version
39.	Health Tracking Household Survey
40.	Adapted Picker Institute Cancer Survey
41.	Ambulatory Care Experiences Survey (ACES)
42.	Patient Perception of Continuity Instrument (PC)
43.	Jefferson Survey of Attitudes Toward Physician-Nurse Collaboration
44.	Clinical Microsystem Assessment Tool (CMAT)
45.	Components of Primary Care Index (CPCI)
46.	Relational Coordination Survey
47.	Fragmentation of Care Index (FCI)
48.	After-Death Bereaved Family Member Interview
49.	Schizophrenia Quality Indicators for Integrated Care
50.	Degree of Clinical Integration Measures
51.	National Survey for Children's Health (NSCH)
52.	Mental Health Professional HIV/AIDS Point Prevalence and Treatment Experiences Survey Part II
53.	Cardiac Rehabilitation Patient Referral from an Inpatient Setting
54.	Cardiac Rehabilitation Patient Referral from an Outpatient Setting
55.	Patients with a Transient Ischemic Event ER Visit That Had a Follow Up Office Visit
56.	Biopsy Follow Up
57.	Reconciled Medication List Received by Discharged Patients
58.	Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges)
59.	Timely Transmission of Transition Record
60.	Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges)
61.	Melanoma Continuity of Care—Recall System

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Current as of January 2011

Internet Citation: Chapter 5. Measure Maps and Profiles: Care Coordination Measures Atlas. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/chapter5.html