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 Activities	Measurement Perspective
Care Coordination Activities	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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Current as of 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