Investigation into care coordination definitions, practices, and interventions has recently been sponsored by several national organizations including the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine, and the American College of Physicians, among others. While evidence is starting to build about the mechanisms by which care coordination contributes to patient-centered high-value, high-quality care, the health care community is currently struggling to determine how to measure the extent to which this vital activity is or is not occurring.
An AHRQ Evidence Report 1 published in 2007 demonstrated that systematic reviews of interventions to improve care coordination used a broad range of measures, with almost none that focused specifically on the structures, processes, or intermediate outcomes related to coordination. Most reports synthesized clinical and utilization measures. While these are the ultimate critical endpoints, the paucity of care-coordination-specific measurement results in limited insight about the exact mechanisms that produce better outcomes.
In response, AHRQ launched a research project with the following aim:
- To develop an atlas to help evaluators identify appropriate measures for assessing care coordination interventions in research studies and demonstration projects, particularly those measures focusing on care coordination in ambulatory care.
In developing this Care Coordination Measures Atlas (henceforth, the Atlas), we investigated currently available care coordination measurement approaches based on multiple data sources (e.g., electronic health record systems, consumer surveys, and databases of administrative claims), review of AHRQ Health Information Technology portfolio projects, information from national organizations on their care coordination measurement activities, input from expert and stakeholder/informant panels, and a comprehensive literature search.
The Atlas includes measures of patient and caregiver experiences with care coordination, as well as experiences of health care professionals and health system managers. To provide context to Atlas users and facilitate presentation of care coordination measurement approaches, we developed a care coordination measurement framework.
1 McDonald KM, Sundaram V, Bravata DM, et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, and Owens DK, eds. Closing the quality gap: A critical analysis of quality improvement strategies. Technical Review 9 (Prepared by Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). Vol. 7. Rockville, MD: Agency for Healthcare Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
The Atlas aims to support the field of care coordination measurement by:
- Providing a list of existing measures of care coordination.
- Organizing those measures along two dimensions (domain and perspective) in order to facilitate selection of care coordination measures by Atlas users.
- Developing a framework for understanding care coordination measurement, incorporating elements from other proposed care coordination frameworks whenever possible. The framework is designed to support current and future development of this field, while remaining flexible so that it may be adapted as the field matures.
The Atlas is designed with several key audiences in mind:
- Evaluators of interventions or demonstration projects that aim to improve care coordination (either as a primary or secondary goal).
- Anyone wishing to evaluate the practice of care coordination or its effects outside the context of interventions or demonstration projects, including quality improvement practitioners, recognizing a likely need for this audience to have some technical support from measurement experts or researchers in using the material presented in the Atlas.
- Researchers studying care coordination.
Selection of care coordination measures focused on:
- Those that could reasonably apply to the ambulatory care setting (e.g., a measure of care coordination focused on the transition from inpatient to outpatient care would be eligible for the Atlas but not one focused on care processes only applicable to a single hospital stay). The Atlas focuses on environments where patients already have access to health care.
- Structural measures hypothesized to reflect better coordination (e.g., presence of a patient registry with an algorithm that identifies complex patients with significant coordination needs).
- Process measures hypothesized to reflect better coordination (e.g., percent of patients asked to review their medication list during a primary care office visit).
- Intermediate outcomes of coordination (e.g., percent of test results communicated to patients within a specific timeframe).
- Those that have been tested with evidence of some valid measurement properties using National Quality Forum (NQF) standards and AHRQ Quality Indicators (QI) program methods.
- Those that at a minimum were developed in association with a logic model that has evidence of causal linkages between the activities measured and outcomes desired.
- Those that have been field tested and have shown feasibility or have had structured expert panel face validity testing. Some measures may be more helpful for research or quality improvement purposes, even if not feasible for performance measurement.
- Measures within the public domain.
The Atlas does not include commonly known endpoints, which evaluators are likely to identify easily without the aid of the Atlas. These endpoints reflect the Institute of Medicine goals for quality of care--safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. Specific examples of endpoints used in care coordination studies to date include:
- Emergency room visits
- Hospital readmissions
- Disease-specific hospital admissions
- Disease-specific mortality
- Short-term clinical outcomes (e.g., glycated hemoglobin levels for diabetic patients)
- Functional status (e.g., for congestive heart failure patients)
- Quality of life
- Other patient outcomes (e.g., missed school days for children due to illness)
- Treatment adherence
- Service adherence (e.g., remain in contact with services for mentally ill patients)
Because of concurrent timing with the completion of the Atlas and regulatory changes under way related to meaningful use of electronic medical records, the Atlas does not include the measures contained in the final rule, "Medicare and Medicaid Programs: Electronic Health Record Incentive Program" [CMS-0033-F]. This final rule was first publicly available on July 13, 2010, and is effective September 27, 2010. The final rule includes Stage 1 criteria of meaningful use for eligible providers (EP) and the proposed measures associated with them. For example, one of the core objectives for EPs related to care coordination is the capability to electronically exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results) among providers of care and patient-authorized entities. This objective's associated measure is demonstration by EP of performing at least one test of certified electronic health record technology's capacity to electronically exchange key clinical information.
Since the original Atlas was published in January 2011, interest in care coordination has continued to grow, and many new coordination measures have been developed and published. This updated version of the Atlas contains some of those new measures, with a particular focus on those that reflect coordination efforts within the primary care setting. Primary care was selected as a focus given its often central role in coordinating care across settings, particularly as accountable care organization and patient-centered medical home delivery models are more widely implemented. Furthermore, this focus aligns with the original scope of the Atlas that centered on measures that might reasonably be applied in the ambulatory care setting. Measures selected for this update are also applicable to broad groups of patients, such as the general population or patients with any chronic condition, rather than measures tailored to individuals with a single disease or condition.
This update also contains a new section on emerging trends in care coordination measurement. It focuses, in particular, on measures that utilize data from electronic health records (EHR), in addition to a brief discussion of approaches based on social network analysis. Use of EHRs both to carry out and to measure care coordination is central to the Centers for Medicare and Medicaid Services’ (CMS) EHR incentive programs. The Medicaid EHR Incentive Program and the Medicare EHR Incentive Program offer additional payments to eligible professionals and hospitals that can attest to and implement Meaningful Use of EHRs through reporting of measures established by the Office of the National Coordinator (ONC). Implementation of that program was just beginning at the time the original Atlas was published; many new EHR-based measures of care coordination have been developed in the intervening years. This update reviews and discusses those measures, including those used for Meaningful Use.
At the time it was published, the original Atlas represented the emerging field of care coordination and care coordination measures. This updated version of the Atlas reflects the tremendous growth that has occurred in this field in the intervening years, and its continuing rapid evolution. Much of the ambiguity in definitions of care coordination and lack of consensus around a single conceptual model that framed the original Atlas work still exists today. Indeed, the proliferation of measure development, improvement initiatives, and discussion around care coordination may have heightened, rather than clarified, this ambiguity. But this growth in interest also represents important progress.
The Atlas aims to systematically map the particular aspects of care coordination measured by each of its included measures, distinguishing evaluations of coordination processes from other processes of care, to the extent that logistical versus clinical processes can actually be disentangled. The scope of the Atlas is purposefully broad in an attempt not to limit, but instead to stimulate, further thinking about which measures are most salient and useful to those working to improve the coordination of care. By adopting an initially broad definition of care coordination to identify measures and then mapping measures at the level of specific coordination activities (the framework domains) and individual instrument items (i.e., survey questions), the Atlas provides users an opportunity for flexibility in how narrowly or broadly to assess coordination.
The Atlas conceptual framework is designed to evolve with the field. However, given the lack of a broader consensus and the continued rapid expansion of the care coordination field, for this update we did not see a rationale for any modifications to the Atlas framework or the way in which its domains were mapped onto measures. Rather, in this section we discuss several challenges highlighted by the experience of developing and updating the Atlas, and in so doing hope to stimulate further advances in useful tools for evaluating care coordination.
Care vs. Coordination
One challenge encountered throughout the care coordination field is the difficulty in distinguishing care coordination from other aspects or processes of care. Care coordination is a complex concept, intertwined with many other concepts relating to quality, delivery, and organization of care. In its broadest sense, almost all aspects of health care and its delivery can be understood as part of care coordination. A very narrow definition, on the other hand, might encompass only a few of the domains included in the measurement framework presented in this report.
Throughout development of the Atlas, conceptualization of its framework of coordination domains, and application of the framework while mapping measures, we have recognized the lack of a bright line between coordination and other aspects of care. Particularly challenging were decisions about whether to include within the scope of care coordination concepts such as access to care (availability of after-hours care, access to medical insurance, transportation to locations of care, ability to understand and navigate the health care system), continuity of care (a continuous relationship with a single provider over time, on-going familiarity and trust), and shared decisionmaking (engaging patients in discussions of treatment options, matching communication style to patient preferences). Each of these aspects of care has a well-established literature of its own, thereby interpreted often as distinct from coordination. But each can also involve some coordination-like processes in certain situations. Also challenging were decisions about how to map measures of communication and care planning, activities involved in many other aspects of care beyond just coordination. When these were considered coordination and when they were viewed as activities employed in the execution of other care processes depended primarily on the context of the measure.
Ultimately, this Atlas reflects an understanding of care coordination as a process that occurs most often during and in response to care transitions (e.g., transitions across settings, within care teams, among care participants, between encounters or care episodes, as patient needs change) and that involves activities or approaches that bridge gaps arising from those transitions. Applying this understanding required judgment, consideration of measure context, and often discussions among measure reviewers to debate grey areas, but was ultimately a useful lens through which to view and categorize the measures identified through this review.
The Atlas framework represents just one stage in an evolving understanding of care coordination. It reflects decisions made at the time the Atlas was initially developed, decisions oriented to measurement applications, and decisions informed by discussions among experts, stakeholders, team members and collaborators. These discussions have continued as the Atlas and its framework have been applied to other activities, including this update. We hope that the Atlas continues to stimulate discussion, and that additional voices join in the process of defining, measuring, and improving care coordination, and ultimately the quality of care delivered to all patients.