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Care Coordination Accountability Measures for Primary Care Practice: A

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

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

Care Coordination ActivitiesMeasurement Perspective
Patient/FamilyHealth Care
Professional(s)
System
Representative(s)
Establish accountability or negotiate responsibility4a (full), 6, 17b, 37, 42, 457a, 7b, 18, 20, 46, 631, 16a, 16b
Communicate4a (full), 6, 10, 17b, 37, 457a, 7b, 17d, 461, 16a, 16b, 17c, 34
Interpersonal communication 4a (full), 6, 10, 17b, 37, 41, 42, 457a, 7b, 17d, 1817c
Information transfer4a (full), 6, 10, 17b, 37, 41, 42, 4517d, 18, 20, 631, 16a, 17c, 34, 44, 50
Facilitate transitions   
Across settings17b, 37, 4217d, 6316a, 17c, 50
As coordination needs change  16a, 16b
Assess needs and goals4a (full), 6, 10, 17b, 37, 41, 42, 4517d, 20, 461, 16a, 16b, 17c, 44
Create a proactive plan of care6, 10, 377b1, 16a, 16b
Monitor, follow-up, and respond to change4a (full), 6, 10, 17b, 37, 41, 4517d, 20, 631, 17c, 19, 44
Support self-management goals4a (full), 6, 10, 17b, 37, 4117d, 201, 16a, 17c, 19, 34
Link to community resources1017d1, 16a, 17c, 44
Align resources with patient and population needs6, 17b17d, 201, 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 January 2012
Internet Citation: Care Coordination Accountability Measures for Primary Care Practice: A: Table C-12. Measures Under Consideration in Step 2 for Adult Measure S. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpacctabc12.html