Elements of the Framework
To help organize measures of care coordination, we developed a framework diagramming key domains that are important for measuring care coordination and their relationship to potentially measurable effects (go to Figure 2). When laid out in the Measure Mapping Table (go to Chapter 5), this serves as an indexing system to map the landscape of available measures and measurement gaps for care see coordination. Because the care coordination topic is potentially quite broad, it is vital to have a way to see where measurement work has and has not been done. This indexing approach may help guide future measurement work by showing what regions of the measurement landscape are as yet unexplored or underdeveloped.
Figure 2. Care Coordination Measurement Framework Diagram
[D] Select for Text Description.
Goal. The framework starts at the top with the goal of achieving coordinated care. Chapter 2 describes through definitions, visual means, and patient scenarios ways to think about this goal. In short, care coordination is a means to help achieve care goals: it aims to meet patient needs and preferences and to facilitate delivery of high-quality, high-value care.
Mechanisms. Various mechanisms may be employed to facilitate this goal of care coordination. Coordination activities are actions that help achieve coordination, whether employed in an improvised or systematic way. Broad approaches aimed at improving the delivery of health care, including improving or facilitating coordination, often incorporate a number of coordination activities. Such approaches are often complex in intent and design. The specific activities employed when implementing the broad approaches often vary, are not always well described, and have coordination-related components that are not necessarily clearly delineated.
Table 1 lists coordination activities that have been hypothesized or demonstrated to facilitate care coordination and broad approaches commonly used to improve the delivery of health care, including improving care coordination. These mechanisms make up the domains of our care coordination measurement framework. As the knowledge base around care coordination grows, we expect this list to change. See domain definitions.
Table 1. Mechanisms for Achieving Care Coordination (Domains)
|Establish Accountability or Negotiate Responsibility
Assess Needs and Goals
Create a Proactive Plan of Care
Monitor, Follow Up, and Respond to Change
Support Self-Management Goals
Link to Community Resources
Align Resources with Patient and Population Needs
|Teamwork Focused on Coordination
Health Care Home
Health IT-Enabled Coordination
Effects. The effects of care coordination mechanisms—whether specific activities or broad approaches—will be perceived differently depending upon who is asked: patient and/or family, health care professional(s), or system representative(s).
The measurement perspective reflects the source of data used to understand the effect or experience. The data source is a function of who is asked or assessed. Table 2 shows some examples related to care coordination.
Table 2. Examples of Effects or Experiences From Three Perspectives
|Patient report of satisfaction with coordination of care
Family report of confusion or hassle (e.g., number of contacts needed to schedule a clinic visit)
Patient report of unnecessary care (e.g., unnecessary tests, procedures, emergency room visits, or hospitalizations)
|Health Care Professional(s) Perspective|
|Nurses reports of confusion or hassle (e.g., time spent coordinating referrals)
Physician survey on effectiveness of medication management process at averting drug interaction complications
|System Representative(s) Perspective|
|Quality of care (safe, effective, efficient, timely, equitable, patient-centered) measured through analysis of medical chart data, electronic health record, or administrative data
Health care utilization by a group of patients (e.g., hospital readmissions, emergency room visits)
Participants. Care coordination necessarily involves multiple participants. Chapter 2: What is Care Coordination? outlines some of the groups of participants typically involved in patient care and provides examples of gaps between participants and how they may be bridged by coordination activities. When selecting care coordination measures, it may be helpful to consider which participants are interacting in the activities of interest to be measured and from which perspectives you wish to measure those interactions. For example, measures that assess communication may focus on communication between patients/family and health care professionals, communication within teams of health care professionals, or communication across health care teams or settings. (When detailing specific measures, we provide information on types of participant interactions for items related to the Communicate domain or its subdomains).
Note that a single interaction may be measured from multiple perspectives. For example, communication between patients and physicians during office visits might be measured from the patient perspective by asking patients how much they agree that their doctor listens to their concerns about conflicting advice from different health care professionals. It might be measured from the health care professional(s) perspective by asking physicians whether they believe they have adequate time during visits to convey information about referrals and followup plans. The interaction also might be measured from a system representative(s) perspective by examining the percent of office visits where discussion of a plan of care was documented in the electronic medical record. All three measures evaluate communication between patients and health care professionals but provide different views on the effect or experience of that activity.
While participant interactions are important to consider for many coordination activities, they may be particularly important to consider for several additional framework domains, including Teamwork Focused on Coordination (Which teams? Coordination of which participants?), Establish Accountability or Negotiate Responsibility (Whose responsibility? Accountability for whom?), and Facilitate Transitions (Transitions between which participants? Across which settings?). For further discussion of types of transitions, go to Points of Transition in Chapter 2.
Coordination Measures in the Atlas. The effects noted in the Chapter 1 are the ultimate endpoints of interest (e.g., clinical outcomes, utilization-related outcomes, quality of life, etc.). However, the Atlas focuses on perspectives as they relate to whether specific activities or approaches were carried out, or what intermediate outcome these mechanisms produced, as gateways to potentially achieving the ultimate endpoint experiences desired by the different stakeholders.
Context. Care coordination measurement must also consider the context: which patient population(s), which setting(s), what timeframe. In addition, care coordination effects may be magnified or muted by facilitators and barriers of care coordination (e.g., effect modifiers). Therefore, it may be advisable, in addition to using measures from the Atlas, to examine potential facilitators and barriers to successful implementation of an intervention. Examples of factors that may facilitate or impede care coordination, depending upon the specific circumstances, include the availability of resources, payment structure, patient complexity and capacity (e.g., Chapter 2 patient scenarios), and local culture.
Harmonizing Across Frameworks
The goal in creating a care coordination framework was to develop a list of domains that are important to care coordination. Existing measures of care coordination were mapped to these domains to help users identify measures that might be of interest in relation to their measurement objectives.
To create this framework, several other proposed frameworks for care coordination were reviewed. We drew heavily on these past works and, when possible, tried to be consistent in use of terminology. However, core domains also were organized differently from other frameworks because of our goal to identify potentially measurable aspects of care coordination. Therefore, some conceptual domains were grouped that were separate in other works and some provided more granularity. Table 3 outlines key sources and their relation to our framework domains.
Care coordination is an emerging field with a rapidly growing evidence base. This framework is intended to grow with the field. Elements of the framework that define each box, and that are noted in bold in Figure 2, are core components that we do not expect to undergo much change. However it is defined, care coordination will always have goals, it will be achieved through some combination of mechanisms, and it will be experienced through effects. Those effects will likely be perceived differently from three key perspectives: that of patients and family, of health care professionals, and of system representatives. Coordination measures can be categorized using these perspectives and domains related to mechanisms. Thus, as currently presented, this framework provides a starting place for understanding care coordination and, in particular, for indexing measures of care coordination.
For an explanation of how our Care Coordination Measurement Framework might be envisioned as a subset of broader models, go to the box below. The box shows two examples of the relationship between this framework and other conceptual models, the Donabedian Model and the Organizational Design Model, discussed in Chapter 5 of the AHRQ Care Coordination Evidence Report, “Conceptual Frameworks and Their Application to Assessing Care Coordination.”7
Organizational Design Model
The Context of our framework—which includes the clinical setting and characteristics of the patient population—influence the need for care coordination. In particular, coordination needs are driven by the degree of system fragmentation, the complexity of the patient and the patient's capacity for self-management and coordination (see the clinical scenarios in Chapter 2: What is Care Coordination?). The ability of a system (whether a clinic, hospital, or integrated network) to meet those coordination needs—its coordinating capacity—is determined in part by the coordinating mechanisms in use, such as carrying out key Coordination Activities or implementing particular Broad Approaches. When there is a good fit between coordination needs and coordinating capacity, the Effect will be a system that delivers effective and efficient care coordination, which will be perceived in different ways from different Perspectives. When fit is poor, different coordinating mechanisms may be selected, or implementation of existing mechanisms modified, to try to improve the fit.
For our purposes, a key strength of the Organizational Design Model is that it acknowledges that, to be successful, care coordination mechanisms must be tailored to a particular context. An important limitation is that it does not provide insight into how to match capacity with needs or how to assess fit (short of measuring the ultimate outcomes of interest).
Donabedian A. The criteria and standards of quality. Ann Arbor, MI: Health Administration Press; 1982.
Definitions of Care Coordination Domains
The care coordination measurement framework includes activities that have been hypothesized as important for carrying out care coordination and broad approaches that have been proposed as means of achieving coordinated care. This set of domains may change as knowledge about care coordination grows. For additional details on key sources that informed development of this set of framework domains, go to Table 3.
The term ‘care coordination' is cited often in the health services literature, but is rarely clearly defined. The 2007 AHRQ Evidence Report on care coordination identified more than 40 definitions of coordination pertaining to a diverse set of patient populations, health care scenarios, and organizational situations.8 Descriptions of care coordination activities and interventions are also often ambiguous. This is particularly true of the broad approaches, which are frequently described by referring to general processes or roles without specifying who performs which actions under which circumstances. These are also usually wide in scope, with goals of improving aspects of patient care beyond just care coordination.
The working definitions for each framework domain were developed by drawing on a variety of sources. The intent is to help Atlas users understand how care coordination measures were mapped to the framework domains and to identify more easily the domains most relevant to their evaluation objectives. For details of this mapping process, go to Chapter 5—Measure Mapping.
Establish accountability or negotiate responsibility. Make clear the responsibility of participants in a patient's care for a particular aspect of that care. The accountable entity (whether a health care professional, care team, or health care organization) will be expected to answer for failures in the aspect(s) of care for which it is accountable. Specify who is primarily responsible for key care and coordination activities, the extent of that responsibility, and when that responsibility will be transferred to other care participants.
Communicate.9 Share knowledge among participants in a patient's care. Communication may occur through a wide variety of channels, but for the purposes of measurement, we distinguish two key modes of communication:
Interpersonal communication. The give-and-take of ideas, preferences, goals, and experiences through personal interactions. Examples include face-to-face interactions, telephone conversations, email, and letters.
Information transfer. The flow of information, such as medical history, medication lists, test results, and other clinical data, from one participant in a patient's care to another. For example, a written summary of laboratory results sent from a primary care practice to the patient, verbal confirmation of a laboratory value from the laboratory to a physician, or transfer of a disk containing CT images from a hospital to a primary care office.
While in practice interpersonal communication and information transfer often occur together, for the purposes of measurement, interpersonal communication is distinguished from information transfer by a two-way exchange of knowledge through personal interactions, while information transfer is characterized by the transfer of data––whether orally, in writing, or electronically––and does not necessarily involve direct interaction between sender and receiver. Many, but not all, care coordination measures include aspects of both interpersonal communication and information transfer and, as such, we expect that many measures will map to both subdomains.
Facilitate transitions. Facilitate specific transitions, which occur when information about or accountability for some aspect of a patient's care is transferred between two or more health care entities or is maintained over time by one entity. Facilitation may be achieved through activities designed to ensure timely and complete transmission of information or accountability.
Across settings. For example,transitions from the inpatient (hospital) setting to the outpatient setting (i.e., physician's offices); or transitions between ambulatory care settings (i.e., primary care to specialty clinics).
As coordination needs change.For example, the transition from pediatric to adult care; transitions over the course of a woman's changing reproductive cycle; and transitions between acute episodes of care and chronic disease management.
Assess needs and goals.10 Determine the patient's needs for care and for coordination, including physical, emotional, and psychological health; functional status; current health and health history; self-management knowledge and behaviors; current treatment recommendations, including prescribed medications; and need for support services.
Create a proactive plan of care.11 Establish and maintain a plan of care, jointly created and managed by the patient/family and health care team, which outlines the patient's current and longstanding needs and goals for care and/or identifies coordination gaps. The plan is designed to fill gaps in coordination, establish patient goals for care and, in some cases, set goals for the patient's providers. Ideally, the care plan anticipates routine needs and tracks current progress toward patient goals.
Monitor, follow up, and respond to change. Jointly with the patient/family, assess progress toward care and coordination goals. Monitor for successes and failures in care and coordination. Refine the care plan as needed to accommodate new information or circumstances and to address any failures. Provide necessary followup care to patients.
Support self-management goals. Tailor education and support to align with patients' capacity for and preferences about involvement in their own care. Education and support include information, training, or coaching provided to patients or their informal caregivers to promote patient understanding of and ability to carry out self-care tasks, including support for navigating their care transitions, self-efficacy, and behavior change.
Link to community resources. Provide information on the availability of and, if necessary, coordinate services with additional resources available in the community that may help support patients' health and wellness or meet their care goals. Community resources are any service or program outside the health care system that may support a patient's health and wellness. These might include financial resources (e.g., Medicaid, food stamps), social services, educational resources, schools for pediatric patients, support groups, or support programs (e.g., Meals on Wheels).
Align resources with patient and population needs. Within the health care setting, assess the needs of patients and populations and allocate health care resources according to those needs. At the population level, this includes developing system-level approaches to meet the needs of particular patient populations. At the patient level, it includes assessing the needs of individual patients to determine whether they might benefit from the system-level approach. For example, a system-level approach to meeting the needs of patients with cancer (the population) might be to establish a multidisciplinary tumor board meeting to help coordinate cancer care among the many relevant specialties. In this scenario, aligning a particular patient's needs with available resources would include assessing whether that individual would likely benefit by having his/her case presented at the multidisciplinary tumor board meeting either for coordinating a consensus recommendation or for simplifying the patient's care pathway or both.
Broad Approaches Potentially Related to Care Coordination
Teamwork focused on coordination.11 Integration among separate health care entities participating in a particular patient's care (whether health care professionals, care teams, or health care organizations) into a cohesive and functioning whole capable of addressing patient needs.
Health care home.12 A source of usual care selected by the patient that functions as the central point for coordinating care around the patient's needs and preferences. This includes coordination among all participants in a patient's care, such as the patient, family members, other caregivers, primary care providers, specialists, other health care services (public and private), and nonclinical services, as needed and desired by the patient. Other terms are frequently used to describe this model, such as medical home, patient-centered medical home, and advanced primary care. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality defines a medical home as not simply a place but a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses several functions and attributes: it is patient-centered and provides superb access to comprehensive and coordinated care and employs a system-based approach to quality and safety.
Care management. A process designed to assist patients and their support systems in managing their medical/social/mental health conditions more efficiently and effectively. Case management and disease management are included in this definition and further defined below.
Case management. 12 The Case Management Society of America defines case management as: “A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.”
Disease management. 12 The Disease Management Association of America defines this term as: “A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.”
Medication management.13 Reconciling discrepancies in medication use in order to avoid adverse drug events associated with transitions in care. This can involve review of the patient's complete medication regimen at the time of admission/transfer/discharge, including assessing use of over-the-counter medications and supplements; comparison across information sources and settings; or direct communication between patients and providers.
Health IT-enabled coordination. Using tools, such as electronic medical records, patient portals, or databases, to communicate information about patients and their care between health care entities (health care professionals, care teams, or health care organizations) or to maintain information over time.
7McDonald KM, Sundaram V, Bravata DM, et al. Conceptual frameworks and their application to assessing 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, Chapter 5. Rockville, MD: Agency for Healthcare Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
8McDonald 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.
9Informed by Coeira E. Guide to health informatics. 2nd ed. London, England: Hodder Arnold, a member of the Hodder Headline Group; 2003.
10Adapted from: Coordinating care for Medicare beneficiaries: Early experiences of 15 demonstration programs, their patients, and providers: Report to Congress. Princeton, NJ: Mathematica Policy Research, Inc.; May 2004.
11Adapted from 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.
12Adapted from National Quality Forum. National Quality Forum-endorsed definition and framework for measuring care coordination. Washington, DC: National Quality Forum; 2006.
13Adapted from information available at: Agency for Healthcare Research and Quality. AHRQ Patient Safety Network Glossary. http://psnet.ahrq.gov/glossary.aspx. Accessed: 26 September 2010.