Care Coordination Accountability Measures for Primary Care Practice

Table C-12. Measures Under Consideration in Step 2 for Adult Measure Set

Care Coordination Activities Measurement Perspective
Patient/Family Health Care Professional(s) System Representative(s)
Establish accountability or negotiate responsibility 4a (full), 6, 17b, 37, 42, 45 7a, 7b, 18, 20, 46, 63 1, 16a, 16b
Communicate 4a (full), 6, 10, 17b, 37, 45 7a, 7b, 17d, 46 1, 16a, 16b, 17c, 34
Interpersonal communication 4a (full), 6, 10, 17b, 37, 41, 42, 45 7a, 7b, 17d, 18 17c
Information transfer 4a (full), 6, 10, 17b, 37, 41, 42, 45 17d, 18, 20, 63 1, 16a, 17c, 34, 44, 50
Facilitate transitions      
Across settings 17b, 37, 42 17d, 63 16a, 17c, 50
As coordination needs change     16a, 16b
Assess needs and goals 4a (full), 6, 10, 17b, 37, 41, 42, 45 17d, 20, 46 1, 16a, 16b, 17c, 44
Create a proactive plan of care 6, 10, 37 7b 1, 16a, 16b
Monitor, follow-up, and respond to change 4a (full), 6, 10, 17b, 37, 41, 45 17d, 20, 63 1, 17c, 19, 44
Support self-management goals 4a (full), 6, 10, 17b, 37, 41 17d, 20 1, 16a, 17c, 19, 34
Link to community resources 10 17d 1, 16a, 17c, 44
Align resources with patient and population needs 6, 17b 17d, 20 1, 16a, 16b, 17c, 19

Note: Measures in bold are highest priority (group 1). Measures in plain font are in priority group 2. Note that Measure 47 maps only to the Health Care Home broad approaches domain (broad approaches domains not considered in this report), so does not appear on this map.

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Page last reviewed October 2014
Internet Citation: Care Coordination Accountability Measures for Primary Care Practice: Table C-12. Measures Under Consideration in Step 2 for Adult Measure Set. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpacctabc12.html