Updated June 2014
Prepared by: Kathryn M. McDonald, M.M.1; Ellen Schultz, M.S.1; Lauren Albin, B.A.1; Noelle Pineda, B.A.1; Julia Lonhart, B.S., B.A.1; Vandana Sundaram, M.P.H.1,3; Crystal Smith-Spangler, M.D., M.S.1,3; Jennifer Brustrom, Ph.D.2, Elizabeth Malcolm, M.D., M.S.H.S.4, Lauren Rohn, M.A.1,, Sheryl Davies, M.A.1,
Chapter 1: Background
An Evolving Field
Chapter 2. What is Care Coordination?
Perspectives on Care Coordination
Chapter 3. Care Coordination Measurement Framework
Elements of the Framework
Harmonizing Across Frameworks
Definitions of Care Coordination Domains
Chapter 4, Emerging Trends in Care Coordination Measurement
EHR-based Care Coordination Measures
Public Reporting of Health IT-enabled Care Coordination
Social Network Analysis of Care Coordination
Landscape of Core Coordination Measures
Chapter 4 References
Chapter 5. Measure Mapping
Measure Mapping Table
Measure Selection Guide
Chapter 6. Measure Maps and Profiles
Master Measure Mapping Tables
Appendix I. Measure Mapping Strategy
Appendix II. Identifying Measures
Appendix III. Advisory Group Participants
Appendixes IV and IVa. Care Coordination Measure Instruments
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The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with the material presented in this report.
For their contributions to the original Atlas development, we thank Janice Genevro, David Meyers and Mamatha Pancholi of the Agency for Healthcare Research and Quality (AHRQ) for their support, insightful comments, and enthusiasm. We thank Chris Stave for his expert guidance on literature and measures searches. We also thank Kathan Volrath for her thoughtful feedback on the framework development and Tammy Chapman for her assistance in preparing the Atlas. We thank members of our advisory panels for sharing their time and expertise to improve this work: Karen Adams, Melissa Affronti, Richard Antonelli, Anne-Marie Audet, Helen Burstin, Carol Cain, Eric Coleman, Susan Edgman-Levitan, Jinnet Fowles, Mark Friedberg, Adele Gorges, Tom Jewell, Sally Kraft, Gerri Lamb, Denise Love, Dana Safran, Sarah Scholle, Sara Singer, Vincenza Snow, Shoshana Sofaer, Scott Stumbo, Bert Vrijhoef, Eric Weil, Jonathan Weiner, and Daniel Wolfson. We also thank users who reviewed the Atlas and provided feedback: Steve Clauser, Bruce Finke, David Haggstrom, Paul Han, Diana Ordin, Sharon Pilus, and Kim Thompson. While their input guided and improved the Atlas, they are not responsible for the contents of the final product. We thank Joanne Abed and Marcía Treece, both of Battelle, for their editorial, design, and production assistance.
For their contributions to the Atlas update, we again thank Janice Genevro and David Meyers of AHRQ for their continued support, insight, and enthusiasm. We thank Jodie Ha for her assistance in updating the Atlas and Sarah Scholle, Aldo Tinoco and Susan Heil for their review of drafts of the updated Atlas. We also thank Alexandra Sharnoff Slade and the publishing team at the American Institutes for Research for their editorial, design, and production assistance. Finally, we thank all those who contributed to the original Atlas, upon which this update builds, and the many measure developers who cooperated with us in preparing information about their measurement tools.
This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders.
1Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, CA
2Battelle, Atlanta, GA
3Palo Alto Veterans Affairs Healthcare System, Palo Alto, CA
4Sutter Health, Emeryville, CA