Chapter 5. Measure Maps and Profiles (continued, 21)

Care Coordination Measures Atlas

Measure #59. Timely Transmission of Transition Record

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care Professional(s)System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility  
Communicate   
    Interpersonal communication   
    Information transfer  
Facilitate transitions   
    Across settings  
    As coordination needs change   
Assess needs and goals   
Create a proactive plan of care  
Monitor, follow up, and respond to change  
Support self-management goals   
Link to community resources   
Align resources with patient and population needs   
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management   
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items.
□ = 1-2 corresponding measure items.

Timely Transmission of Transition Record

Purpose: To measure the percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care, for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.1

Format/Data Source: This process measure requires administrative claims data and data collected from the medical record.1

Date: Measure released in 2009.1

Perspective: System Representative(s)

Measure Item Mapping:

This measure maps to the following domains: There are no individual measure items to map.

  • Establish accountability or negotiate responsibility
  • Communicate
    • Information transfer
      • Across health care teams or settings
  • Facilitate Transitions
    • Across settings
  • Create a proactive plan of care
  • Monitor, follow up, and respond to change

Development and Testing: The measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.2

Link to Outcomes or Health System Characteristics: One study demonstrated a decreased risk of readmission when information on the index hospitalization is available during post-discharge physician visits.1

Logic Model/Conceptual Framework: This measure incorporates elements from The Joint Commission's 2009 Hospital Accreditation Standards and a 2008 consensus policy statement from the American College of Physicians, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Geriatrics Society, The American College of Emergency Physicians and the Society of Academic Emergency Medicine.1

Past or Validated Applications:

  • Setting: Inpatient facility in the United States.
  • Population: All patients being discharged from an inpatient setting.
  • Level of evaluation: System.

Notes:

  • Detailed measure specifications are included in the Physician Consortium for Performance Improvement (PCPI) report.1
  • This measure is intended for use in conjunction with two other PCPI measures (Measure #57 Reconciled Medication List Received by Discharged Patients; and Measure #58, Transition Record with Specified Elements Received by Discharged Patients - Inpatient Discharges) as part of a bundled set. Each measure in the bundled set is intended to be scored separately.1
  • Because the NQF-endorsed preferred practices and performance measures for measuring and reporting care coordination were released shortly before completion of the Atlas, we were not able to contact the measure developers about any on-going measure development or testing. Additional information may become available in the future.

Sources:

1. American Board of Internal Medicine Foundation, American College of Physicians, Society of Hospital Medicine, Physician Consortium for Performance Improvement. Care Transitions Performance Measurement Set (Phase I: Inpatient discharges and emergency department discharges). Chicago, IL: American Medical Association; 2009.
2. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

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Measure #60. Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges)

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care Professional(s)System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility  
Communicate   
    Interpersonal communication   
    Information transfer  
Facilitate transitions   
    Across settings  
    As coordination needs change   
Assess needs and goals   
Create a proactive plan of care  
Monitor, follow up, and respond to change  
Support self-management goals   
Link to community resources   
Align resources with patient and population needs   
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management  
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items.
□ = 1-2 corresponding measure items.

Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges)

Purpose: To measure the percentage of patients, regardless of age, discharged from the emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of the specified elements.1

Format/Data Source: This process measure requires administrative claims data and data collected from the medical record.1

Date: Measure released in 2009.1

Perspective: System Representative(s)

Measure Item Mapping:

This measure maps to the following domains: There are no individual measure items to map.

  • Establish accountability or negotiate responsibility.
  • Communicate
    • Information transfer.
      • Between health care professional(s) and patient/family
  • Facilitate Transitions
    • Across settings
  • Create a proactive plan of care
  • Monitor, follow up, and respond to change
  • Medication Management

Development and Testing: The measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.2

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: This measure incorporates elements from The Joint Commission's 2009 Hospital Accreditation Standards and a 2008 consensus policy statement from the American College of Physicians, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Geriatrics Society, The American College of Emergency Physicians and the Society of Academic Emergency Medicine.1

Past or Validated Applications:

  • Setting: Emergency departments in the United States.
  • Population: All patients being discharged from an emergency department (ED).
  • Level of evaluation: System.

Notes:

  • Detailed measure specifications are included in the Physician Consortium for Performance Improvement (PCPI) report.1
  • Because the NQF-endorsed preferred practices and performance measures for measuring and reporting care coordination were released shortly before completion of the Atlas, we were not able to contact the measure developers about any on-going measure development or testing. Additional information may become available in the future.

Sources:

1. American Board of Internal Medicine Foundation, American College of Physicians, Society of Hospital Medicine, Physician Consortium for Performance Improvement. Care Transitions Performance Measurement Set (Phase I: Inpatient discharges and emergency department discharges). Chicago, IL: American Medical Association; 2009.
2. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

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Measure #61. Melanoma Continuity of Care—Recall System

Care Coordination Measure Mapping Table

 Measurement Perspective:
Patient/FamilyHealth Care Professional(s)System Representative(s)
Care Coordination Activities
Establish accountability or negotiate responsibility   
Communicate   
    Interpersonal communication   
    Information transfer   
Facilitate transitions   
    Across settings   
    As coordination needs change   
Assess needs and goals   
Create a proactive plan of care   
Monitor, follow up, and respond to change  
Support self-management goals   
Link to community resources   
Align resources with patient and population needs   
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination   
Health care home   
Care management   
Medication management   
Health IT-enabled coordination   

Legend:
■ = ≥ 3 corresponding measure items.
□ = 1-2 corresponding measure items.

Melanoma Continuity of Care—Recall System

Purpose: To measure the percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: a target date for the next complete physical skin exam and a process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment.1

Format/Data Source: This process measure requires administrative claims data and data collected from the medical record.1

Date: Measure released in 20071

Perspective: System Representative(s)

Measure Item Mapping:

This measure maps to the following domains. There are no individual measure items to map.

  • Monitor, follow-up, and respond to change

Development and Testing: The measure was endorsed by NQF as part of their preferred practices and performance measures for measuring and reporting care coordination, released in September 2010.2

Link to Outcomes or Health System Characteristics: None described in the sources identified.

Logic Model/Conceptual Framework: The measure is based on clinical guidelines from both the National Comprehensive Cancer Network (NCCN) and the British National Institute for Health and Clinical Excellence (NICE).1

Past or Validated Applications:

  • Setting: Not specified.
  • Population: All patients with a current diagnosis of melanoma or a history of melanoma.
  • Level of evaluation: System.

Notes:

  • Detailed measure specifications are included in the American Academy of Dermatology/Physician Consortium for Performance Improvement/National Committee for Quality Assurance Melanoma II Physician Performance Measurement Set.1
  • Because the NQF-endorsed preferred practices and performance measures for measuring and reporting care coordination were released shortly before completion of the Atlas, we were not able to contact the measure developers about any on-going measure development or testing. Additional information may become available in the future.

Sources:

1. American Academy of Dermatology, Physician Consortium for Performance Improvement, National Committee for Quality Assurance. Melanoma II Physician Performance Measurement Set. Chicago, IL, and Washington, DC: American Medical Association and National Committee for Quality Assurance; 2007.
2. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination: a consensus report. Washington, DC: National Quality Forum; 2010.

Current as of January 2011
Internet Citation: Chapter 5. Measure Maps and Profiles (continued, 21): 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/chapter5t.html