Care Coordination Accountability Measures for Primary Care Practice
Appendix A. Atlas Perspective and Domain Definitions
The measurement perspective is the point of view for which the coordination is being measured. In survey-based measures, the perspective is the individual or team filling out the survey. The perspective of non-survey-based measures reflects the source of the data used to calculate the measure.
Patient/Family Perspective—The patient or a family member completes the survey based on his/her experience. All Atlas measures from this perspective are survey-based.
Health Care Professional Perspective—A health care professional, or team of professionals, completes the survey or collects the measure data. Health care professionals include physicians, nurses, nurse practitioners, physician assistants, or other clinical or hospital staff.
System Representative Perspective—A system administrator or someone else acting as a representative of a health care facility or system completes the survey, or the measure data source is from a health care delivery system, such as an electronic medical record or claims data. Measures based on chart review or administrative data are categorized as system representative perspective. When an individual health care professional is providing information that reflects the system experience, rather than their individual experience, that is also classified as a system representative perspective.
The Care Coordination Measures Atlas categorizes measures according to a framework of activities that have been hypothesized as important for carrying out care coordination and broad approaches that have been proposed as a means of achieving coordinated care. The activity domains from this framework were used in assessing how comprehensively care coordination is assessed by measures under consideration for the primary care practice accountability/recognition measure set.i Definitions of each activity domain are listed below. For additional information about the care coordination measurement framework and domains, see Chapter 3 of the Atlas.1
Establish Accountability or Negotiate Responsibility. Make clear the responsibility of participants in a patient's care for a particular aspect of that care. The accountable entity (whether a health care professional, care team, or health care organization) will be expected to answer for failures in the aspect(s) of care for which it is accountable. Specify who is primarily responsible for key care and coordination activities, the extent of that responsibility, and when that responsibility will be transferred to other care participants.
Communicate. Share knowledge among participants in a patient's care. Communication may occur through a wide variety of channels, but for the purposes of measurement, we distinguish two key modes of communication:
- Interpersonal Communication. The give-and-take of ideas, preferences, goals, and experiences through personal interactions. Examples include face-to-face interactions, telephone conversations, E-mail, and letters.
- Information Transfer. The flow of information, such as medical history, medication lists, test results, and other clinical data, from one participant in a patient's care to another. Examples include a written summary of laboratory results sent from a primary care practice to the patient, verbal confirmation of a laboratory value from the laboratory to a physician, or transfer of a disk containing CT images from a hospital to a primary care office.
While in practice interpersonal communication and information transfer often occur together, for the purposes of measurement, interpersonal communication is distinguished from information transfer by a two-way exchange of knowledge through personal interactions. Information transfer is characterized by the transfer of data—whether orally, in writing, or electronically—and does not necessarily involve direct interaction between sender and receiver.
Facilitate Transitions. Efforts aimed at specific transitions, which occur when information about or accountability for some aspect of a patient's care is transferred between two or more health care entities, or is maintained over time by one entity.
- Across Settings. Examples include transitions from the inpatient (hospital) setting to the outpatient setting (e.g., physicians' offices), or transitions between ambulatory care settings (e.g., primary care to specialty clinics).
- As Coordination Needs Change. Examples include the transition from pediatric to adult care, transitions over the course of a woman's changing reproductive cycle, and transitions between acute episodes of care and chronic disease management.
Assess Needs and Goals. Determine the patient's needs for care and for coordination, including physical, emotional, and psychological health; functional status; current health and health history; self-management knowledge and behaviors; current treatment recommendations, including prescribed medications; and need for support services.
Create a Proactive Plan of Care. Establish and maintain a plan of care, jointly created and managed by the patient/family and health care team, which outlines the patient's current and longstanding needs and goals for care and identifies coordination gaps. The plan is designed to fill gaps in coordination, establish patient goals for care and, in some cases, set goals for the patient's providers. Ideally, the care plan anticipates routine needs and tracks up-to-date progress toward patient goals.
Monitor, Follow Up, and Respond to Change. Jointly with the patient/family, assess progress toward care and coordination goals. Monitor for successes and failures in care and coordination. Refine the care plan as needed to accommodate new information or circumstances and to address any failures. Provide necessary followup care to patients.
Support Self-Management Goals. Tailor education and support to align with patients' capacity for and preferences about involvement in their own care. Education and support include information, training, or coaching provided to patients or their informal caregivers to promote patient understanding of and ability to carry out self-care tasks, including support for navigating their care transitions, self-efficacy, and behavior change.
Link to Community Resources. Provide information on the availability of and, if necessary, coordinate services with additional resources available in the community that may help support patients' health and wellness or meet their care goals. Community resources are any service or program outside the health care system that may support a patient's health and wellness. These might include financial resources (e.g., Medicaid, food stamps), social services, educational resources, schools for pediatric patients, support groups, or support programs (e.g., Meals on Wheels).
Align Resources with Patient and Population Needs. In the health care setting, assess the needs of patients and populations and allocate health care resources according to those needs. At the population level, this includes developing system-level approaches to meet the needs of particular patient populations. At the patient level, it includes assessing the needs of individual patients to determine whether they might benefit from the system-level approach. For example, a system-level approach to meeting the needs of patients with cancer (the population) might be to establish a multidisciplinary tumor board meeting to help coordinate cancer care among the many relevant specialties. In this scenario, aligning a particular patient's needs with available resources would include assessing whether that individual would likely benefit by having his/her case presented at the multidisciplinary tumor board meeting either for coordinating a consensus recommendation or for simplifying the patient's care pathway or both.