| 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.
